Military Base Realignments and Closures
Impact of Terminating, Relocating, or Outsourcing the Services of the Armed Forces Institute of Pathology Gao ID: GAO-08-20 November 9, 2007The 2005 Base Realignment and Closure (BRAC) provision required the Department of Defense (DOD) to close the Armed Forces Institute of Pathology (AFIP). GAO was asked to address the status and potential impact of implementing this BRAC provision. This report discusses (1) key services AFIP provides to the military and civilian communities; (2) DOD's plans to terminate, relocate, or outsource services currently provided by AFIP; and (3) the potential impacts of disestablishing AFIP on military and civilian communities. New legislation requires DOD to consider this GAO report as it develops its plan for the reorganization of AFIP. GAO reviewed DOD's plans, analysis, and other relevant information, and interviewed officials from the public and private sectors.
AFIP pathologists perform three key services--diagnostic consultations, education, and research--primarily for physicians from DOD, the Department of Veterans Affairs (VA), and civilian institutions. AFIP provides consultations when physicians cannot make a diagnosis or are unsure of their initial diagnosis. About half of its 40,000 consultations in 2006 were for DOD physicians, and the rest were nearly equally divided between VA and civilian physicians. AFIP's educational services train physicians in diagnosing the most difficult-to-diagnose diseases. Civilian physicians use these services more extensively than military physicians. In addition, AFIP pathologists collaborate with others on research applicable to military operations and general medicine, often using material from AFIP's repository of tissue specimens to gain a better understanding of disease diagnosis and treatment. To implement the 2005 BRAC provision, DOD plans to terminate most services currently provided by AFIP and is developing plans to relocate or outsource others. DOD plans to outsource some diagnostic consultations to the private sector through a newly established office and use its pathologists for consultations when possible. With the exception of two courses, DOD does not plan to retain AFIP's educational program. DOD also plans to halt AFIP's research and realign the repository, which is AFIP's primary research resource. The BRAC provision allows DOD flexibility to retain services that were not specifically addressed in the provision. As a result, DOD will retain four additional AFIP services and is considering whether to retain six others. DOD had planned to begin implementation of the BRAC provision related to AFIP in July 2007 and complete action by September 2011, but statutory requirements prevent DOD from reorganizing or relocating AFIP functions until after DOD submits a detailed plan and timetable for the proposed implementation of these changes to congressional committees no later than December 31, 2007. Once the plan has been submitted, DOD can resume reorganizing and relocating AFIP. Discontinuing, relocating, or outsourcing AFIP services may have minimal impact on DOD, VA, and civilian communities because pathology services are available from alternate sources, but a smooth transition depends on DOD's actions to address the challenges in developing new approaches to obtaining pathology expertise and managing the repository. For consultations, these challenges are to determine how to use existing pathology resources, obtain outside expertise, and ensure coordination and funding of services to avoid disincentives to quality care. While DOD has begun to identify the challenges, it has not developed strategies to address them. Similarly, whether the repository will continue to be a rich resource for military and civilian research depends on how DOD populates, maintains, and provides access to it in the future, but DOD has not developed strategies to address these issues. DOD contracted for a study, due to be completed in October 2008, of the usefulness of the material in the repository. DOD plans to use this study to help make decisions about managing the repository.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-08-20, Military Base Realignments and Closures: Impact of Terminating, Relocating, or Outsourcing the Services of the Armed Forces Institute of Pathology
This is the accessible text file for GAO report number GAO-08-20
entitled 'Military Base Realignments and Closures: Impact of
Terminating, Relocating, or Outsourcing the Services of the Armed
Forced Institute of Pathology' which was released on December 10, 2007.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to the Committee on Health, Education, Labor, and Pensions, U.S.
Senate:
United States Government Accountability Office:
GAO:
November 2007:
Military Base Realignments and Closures:
Impact of Terminating, Relocating, or Outsourcing the Services of the
Armed Forces Institute of Pathology:
Armed Forces Institute of Pathology:
GAO-08-20:
GAO Highlights:
Highlights of GAO-08-20, a report to the Committee on Health,
Education, Labor, and Pensions, U.S. Senate.
Why GAO Did This Study:
The 2005 Base Realignment and Closure (BRAC) provision required the
Department of Defense (DOD) to close the Armed Forces Institute of
Pathology (AFIP). GAO was asked to address the status and potential
impact of implementing this BRAC provision. This report discusses (1)
key services AFIP provides to the military and civilian communities;
(2) DOD‘s plans to terminate, relocate, or outsource services currently
provided by AFIP; and (3) the potential impacts of disestablishing AFIP
on military and civilian communities. New legislation requires DOD to
consider this GAO report as it develops its plan for the reorganization
of AFIP. GAO reviewed DOD‘s plans, analysis, and other relevant
information, and interviewed officials from the public and private
sectors.
What GAO Found:
AFIP pathologists perform three key services”diagnostic consultations,
education, and research”primarily for physicians from DOD, the
Department of Veterans Affairs (VA), and civilian institutions. AFIP
provides consultations when physicians cannot make a diagnosis or are
unsure of their initial diagnosis. About half of its 40,000
consultations in 2006 were for DOD physicians, and the rest were nearly
equally divided between VA and civilian physicians. AFIP‘s educational
services train physicians in diagnosing the most difficult-to-diagnose
diseases. Civilian physicians use these services more extensively than
military physicians. In addition, AFIP pathologists collaborate with
others on research applicable to military operations and general
medicine, often using material from AFIP‘s repository of tissue
specimens to gain a better understanding of disease diagnosis and
treatment.
To implement the 2005 BRAC provision, DOD plans to terminate most
services currently provided by AFIP and is developing plans to relocate
or outsource others. DOD plans to outsource some diagnostic
consultations to the private sector through a newly established office
and use its pathologists for consultations when possible. With the
exception of two courses, DOD does not plan to retain AFIP‘s
educational program. DOD also plans to halt AFIP‘s research and realign
the repository, which is AFIP‘s primary research resource. The BRAC
provision allows DOD flexibility to retain services that were not
specifically addressed in the provision. As a result, DOD will retain
four additional AFIP services and is considering whether to retain six
others. DOD had planned to begin implementation of the BRAC provision
related to AFIP in July 2007 and complete action by September 2011, but
statutory requirements prevent DOD from reorganizing or relocating AFIP
functions until after DOD submits a detailed plan and timetable for the
proposed implementation of these changes to congressional committees no
later than December 31, 2007. Once the plan has been submitted, DOD can
resume reorganizing and relocating AFIP.
Discontinuing, relocating, or outsourcing AFIP services may have
minimal impact on DOD, VA, and civilian communities because pathology
services are available from alternate sources, but a smooth transition
depends on DOD‘s actions to address the challenges in developing new
approaches to obtaining pathology expertise and managing the
repository. For consultations, these challenges are to determine how to
use existing pathology resources, obtain outside expertise, and ensure
coordination and funding of services to avoid disincentives to quality
care. While DOD has begun to identify the challenges, it has not
developed strategies to address them. Similarly, whether the repository
will continue to be a rich resource for military and civilian research
depends on how DOD populates, maintains, and provides access to it in
the future, but DOD has not developed strategies to address these
issues. DOD contracted for a study, due to be completed in October
2008, of the usefulness of the material in the repository. DOD plans to
use this study to help make decisions about managing the repository.
What GAO Recommends:
GAO recommends DOD report to Congress on (1) its strategies for
organizing consultation services; (2) the repository‘s assets and their
potential use; and (3) its strategies for using the repository. DOD
generally concurred with GAO‘s findings and conclusions. GAO has
modified its recommendations to reflect concerns DOD raised about
additional steps it needs to take before it can report on its
strategies for using the repository. VA stated that GAO‘s report was
factually accurate, but believed that it did not sufficiently describe
the impact of closing AFIP. GAO believes that this report provides a
balanced assessment of AFIP‘s services and the impact of its closing.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-20]. For more information, contact
Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
AFIP's Key Services Include Consultation, Education, and Research That
Benefit DOD, VA, and Civilian Communities:
DOD Has Specific Plans to Terminate Most Services Currently Provided by
AFIP and Is Developing Plans to Relocate the Others:
Closing AFIP May Have Minimal Effect, but Management Strategy Is
Important to Address Key Challenges:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Maps of the Armed Forces Institute of Pathology's (AFIP)
2006 Consultations:
Appendix III: Description of Services Performed by the Armed Forces
Institute of Pathology (AFIP):
Appendix IV: Comments from the Department of Defense:
Appendix V: Comments from the Department of Veterans Affairs:
Appendix VI: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Number and Percentage of AFIP Consultations for Customers,
2005 and 2006:
Table 2: Consultation Outcomes Where an Initial Diagnosis Was Provided,
for 2006:
Table 3: Examples of AFIP's Research Projects:
Table 4: Services Currently Performed by AFIP That Are to Be Retained
and Relocated, or Established, or Are Awaiting Final Decisions:
Figures:
Figure 1: DOD's Proposed Timeline for BRAC Implementation Pertaining to
AFIP:
Figure 2: AFIP's DOD Consultations for 2006:
Figure 3: AFIP's VA Consultations for 2006:
Figure 4: AFIP's Civilian Consultations for 2006:
Abbreviations:
AFIP: Armed Forces Institute of Pathology:
ARP: American Registry of Pathology:
ASD(HA): Assistant Secretary of Defense for Health Affairs:
BRAC: Base Realignment and Closure:
CAP: College of American Pathologists:
CDC: Centers for Disease Control and Prevention:
CME: continuing medical education:
DNA: deoxyribonucleic acid:
DOD: Department of Defense:
DU: depleted uranium:
MTF: military treatment facility:
PMO: Program Management Office:
USUHS: Uniformed Services University of the Health Sciences: VA:
Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
November 9, 2007:
The Honorable Edward M. Kennedy:
Chairman:
The Honorable Michael B. Enzi:
Ranking Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
On May 13, 2005, the Department of Defense (DOD) recommended closing
the Armed Forces Institute of Pathology[Footnote 1] (AFIP)--an agency
within DOD--as part of the Base Realignment and Closure (BRAC)
process.[Footnote 2] This would require that the pathology services
currently provided by AFIP be discontinued, transferred to other parts
of DOD or elsewhere, or outsourced to the civilian community. AFIP
provides pathology expertise--which is based on laboratory analyses of
tissue or other specimens to diagnose diseases or other medical
conditions--to military and civilian physicians and maintains a rich
and comprehensive catalog of pathology material such as tissue
specimens, referred to as the National Pathology Repository.[Footnote
3] In addition to providing services to DOD, AFIP provides its
expertise to other physicians such as those working at the Department
of Veterans Affairs (VA) and it has statutory authority to provide
pathology services to civilian physicians.[Footnote 4] According to the
College of American Pathologists (CAP) and other pathology
organizations, AFIP is relied upon by its customers as a definitive
consult on the most difficult-to-diagnose cases and through its
research and training has advanced the knowledge and competency of the
medical profession.
In accordance with the BRAC statute, DOD must complete closure and
realignment actions within 6 years from the time the recommendations
were forwarded to Congress, which for the 2005 BRAC provisions is
September 15, 2011.[Footnote 5] In light of the BRAC provision specific
to AFIP,[Footnote 6] the Senate Committee on Health, Education, Labor,
and Pensions requested an analysis of the impact of disestablishing,
relocating, or outsourcing AFIP's key services due to concerns that
this would affect the ability of military and civilian communities to
obtain high-quality pathology services. In this report, we discuss (1)
the key services AFIP provides to the military and civilian
communities; (2) DOD's plans to terminate, relocate, or outsource
services currently provided by AFIP; and (3) the potential impacts of
disestablishing AFIP on military and civilian communities.
To accomplish these objectives, we reviewed recent reports describing
AFIP's services and business practices, including a previous GAO report
on AFIP's business plan,[Footnote 7] as well as those conducted by the
Army Audit Agency and BearingPoint--a consulting company that fulfilled
a contract from the Army Surgeon General to review AFIP. We also
reviewed other documents and legislation pertaining to AFIP and the
BRAC provision, including business plans and data related to analysis
that led to BRAC-related decisions. Additionally, we obtained data from
AFIP to describe key services it provides and we determined the data to
be sufficiently reliable for the purposes of this report. We also
interviewed officials from AFIP, VA, the American Registry of Pathology
(ARP), and pathology associations such as CAP to collect information on
the services that AFIP provides. Within DOD, we interviewed officials
from the Offices of the Surgeons General of the Army, Navy, and Air
Force; the Office of the Assistant Secretary of Defense for Health
Affairs (ASD(HA)); the TRICARE Management Activity; the Office of the
Deputy Under Secretary of Defense (Installations and Environment); the
Uniformed Services University of the Health Sciences (USUHS)--a
military medical training and research institution;[Footnote 8] and the
Office of the General Counsel. We also interviewed pathologists from
DOD military treatment facilities (MTF) and VA medical centers.
Finally, to assess the potential impacts of terminating AFIP and
relocating services, we interviewed officials as mentioned above,
civilian pathologists from major medical centers, as well as
representatives from pathology and radiology associations such as ARP,
CAP, the American Society for Investigative Pathology, the Association
of Pathology Chairs, the American College of Radiology, and the
Canadian Association of Radiologists. We conducted our work from March
2007 through November 2007 in accordance with generally accepted
government auditing standards. Further details on our scope and
methodology are described in appendix I.
Results in Brief:
AFIP pathologists perform three key services--diagnostic consultations,
education, and research--that benefit military and civilian
communities. AFIP pathologists provide diagnostic consultations when
physicians--that is, clinicians or general pathologists--at DOD, VA, or
civilian medical centers cannot make a diagnosis or are unsure of their
initial diagnosis. In 2006, AFIP provided over 40,000 diagnostic
consultations, almost half of which were for DOD. AFIP's remaining
consultations were nearly equally divided between VA and civilian
physicians. AFIP's educational services include courses, texts, and
distance learning activities that draw upon pathology material from the
repository. AFIP's educational services train physicians in diagnosing
the most difficult-to-diagnose diseases. While DOD, VA, and civilian
physicians use AFIP's educational services, civilian physicians use
AFIP's educational services more extensively than military physicians.
Regarding its research services, AFIP pathologists work individually
and in partnership with other federal and private researchers using
material from the repository to conduct research applicable to military
operations, as well as to diagnose and treat diseases affecting
military and civilian health. For example, pathologists from AFIP were
able to reconstruct the genome of the virus that caused the 1918
Spanish Flu pandemic from material in the repository. This discovery
has provided a better understanding of how an avian flu epidemic can
become deadly to humans, which in turn has affected current strategies
to address the potential of pandemic flu.
In accordance with the BRAC provision, DOD plans to terminate most
services currently provided by AFIP and is developing plans to relocate
or outsource other services. Specifically, DOD plans to outsource its
second-opinion and some initial consultations to the private sector
through a new Program Management Office (PMO), which was required to be
established by the BRAC provision. DOD has not determined whether it
would allow VA to obtain diagnostic consultations through the PMO. DOD
plans to retain and relocate only two training programs currently
offered by AFIP--the enlisted histology technician training and the DOD
Veterinary Pathology Residency Program. DOD also plans to halt AFIP's
research and realign the repository, which is AFIP's primary research
resource. The BRAC provision provided DOD with flexibility to retain
services that were not addressed in the provision. In accordance with
this statutory authority, the ASD(HA) has retained four additional AFIP
services and is considering whether to retain six others. DOD planned
to begin implementation of the BRAC provision in July 2007 and to
complete action by September 2011. However, statutory requirements
prevent DOD from reorganizing or relocating AFIP functions until after
DOD has submitted detailed plans and timetables for the proposed
reorganization and relocation to the House and Senate Appropriations
and Armed Services Committees.[Footnote 9] Once the plan has been
submitted, DOD can resume reorganizing and relocating AFIP. However,
other developments could impact the implementation of those plans.
Specifically, Congress is considering requiring or allowing DOD to
establish a new Joint Pathology Center.
Discontinuing or relocating AFIP services may have minimal impact on
DOD, VA, and civilian communities because alternative services are
available from other sources. Although AFIP is a noted center for
pathology expertise, DOD, VA, and civilian pathologists may obtain
pathology consultations from sources other than AFIP, as other medical
institutions have subspecialty pathology experts that provide this
service. Other institutions also provide pathology education and are
used by DOD, VA, and civilian pathologists to fulfill continuing
medical education (CME) requirements. Further, DOD, VA, and civilian
pathologists could continue to conduct research, using material from
the repository, and possibly through collaborations with other
institutions. However, a smooth transition in services depends on DOD's
actions to address challenges involved in developing new approaches to
obtain subspecialty pathology consultations and manage the repository
to facilitate its use for research. For consultations, these challenges
are to determine how to effectively use existing specialized pathology
resources, obtain outside expertise, and ensure coordination and
funding of services to encourage efficiency while avoiding
disincentives to quality care. While DOD has begun to identify the
challenges, it has not developed strategies to address them. Similarly,
whether the repository will continue to be a rich resource for DOD, VA,
and civilian research depends on how DOD populates, maintains, and
provides access to it in the future, but DOD has not developed its
strategies to address issues that will affect the viability and
usefulness of the repository. DOD awarded a contract to study the
usefulness of the material in the repository and will use the study, to
be completed by the end of 2008, to help make decisions on how the
repository will be managed.
We are recommending that DOD include its strategies for organizing
consultation services in its 2007 plan to Congress. Furthermore, we are
recommending that DOD provide information on the status of the
repository's assets and their potential for research within 6 months of
completing its study. We are also recommending that DOD provide a
report to Congress, prior to USUHS assuming responsibility for the
repository, on its implementation strategies for how it will populate,
manage, and use the repository.
In commenting on a draft of this report, DOD generally concurred with
the findings and recommendations. However, our draft report had
recommended that DOD provide information on its implementation
strategies for how it will populate, manage, and use the repository
within 6 months of completing its study. DOD raised concerns with
respect to steps it needs to take before it could report to Congress on
its implementation strategies for how it will populate, manage, and use
the repository. As a result, we altered our recommendations as
described above. VA agreed that GAO's report was factually accurate,
but believed it did not sufficiently describe the impact of closing
AFIP. We believe that we provided a balanced assessment of AFIP's
services and the impact of its closing.
Background:
In 1862, the Army Surgeon General established a repository in the Army
Medical Museum for disease specimens collected from Civil War soldiers.
The Army Institute of Pathology was created as a part of the museum in
1944, using the museum's extensive collection of disease specimens to
develop expertise in diagnostic pathology. In 1949, the Army Institute
of Pathology was renamed the Armed Forces Institute of Pathology, and
the museum became a unit within AFIP. In 1976, the Department of
Defense Appropriation Authorization Act for Fiscal Year 1977
established AFIP in its current form, as a joint entity of the
Departments of the Army, Navy, and Air Force, to offer pathologic
support to military and civilian medicine in consultation, education,
and research.[Footnote 10]
Role of AFIP:
Throughout the early part of the 20th century, AFIP was the only
institution in the country that maintained expertise in every major
area of anatomical pathology, attracting large numbers of
consultations, trainees, and research grants on the basis of the
institute's unique reputation. However, according to AFIP's Scientific
Advisory Board, many changes in modern medical practice over the last
several decades have altered the environment in which AFIP operates.
For example, AFIP must now compete with over one hundred civilian
medical institutions, many of which have in-house experts and
comparable subspecialty areas of pathology.
AFIP provides pathology expertise for all branches of the military.
AFIP also provides pathology expertise for VA in exchange for a
specified number of VA staff positions assigned to AFIP. Additionally,
AFIP offers pathology expertise on a reimbursable basis for its
civilian customers. To assist AFIP in this part of its mission, the
Department of Defense Appropriation Authorization Act for Fiscal Year
1977 authorized ARP to be established as a nonprofit corporation with
responsibility for encouraging and facilitating collaborative work
between AFIP and civilian medicine.[Footnote 11] As such, ARP enters
into contracts, collects fees, and accepts research grants on behalf of
AFIP, in support of cooperative enterprises and interchange between
military and civilian pathology.
From 1998 through 2006, DOD and others conducted reviews that concluded
that AFIP lacked controls over its financial operations, provided
services for the civilian medical community without adequate
reimbursement, and the costs of the services it provided to VA exceeded
the value of the paid staff positions VA provided in exchange.[Footnote
12] These reviews concluded that DOD, in effect, subsidized AFIP's work
for VA and civilian customers. In response to these concerns, AFIP
began making changes to its operations in 2000, including the
development and implementation of a business plan meant to increase
AFIP's revenue and reduce DOD's level of funding to AFIP.
DOD Examines AFIP's Future Role:
DOD examined AFIP's operations as part of the 2005 BRAC process, which
was intended to find ways to consolidate, realign, or find alternative
uses for current facilities given the U.S. military's limited
resources. In making its 2005 BRAC recommendations, DOD applied
statutory selection criteria that included military value, costs and
savings, economic impact to local communities, community support
infrastructure, and environmental impact.[Footnote 13] In applying
these criteria, the law required that priority consideration be given
to military value, and allowed the other criteria to be considered to a
lesser extent. In DOD's evaluation, AFIP received a low military value
due to its large portion of civilian-related work. Therefore, DOD
recommended disestablishing AFIP by relocating critical military
services and terminating civilian-related activities currently provided
by AFIP.
As part of the BRAC process, the Secretary of Defense issued a report
containing his realignment and closure recommendations, which were then
reviewed by the BRAC Commission.[Footnote 14] The 2005 BRAC
Commission's final report contained recommendations to disestablish
AFIP and relocate certain services that AFIP provides. These
recommendations became binding as of November 9, 2005. In accordance
with BRAC statutory authority, DOD must complete closure and
realignment actions by September 15, 2011.[Footnote 15]
AFIP's Key Services Include Consultation, Education, and Research That
Benefit DOD, VA, and Civilian Communities:
AFIP pathologists perform diagnostic consultations, education, and
research services benefiting DOD, VA, and civilian communities. In
2006, AFIP provided over 40,000 consultations, almost half of which
were for DOD physicians. AFIP's educational services include live
courses, distance learning activities, and texts that draw upon
pathology material from the repository with the goal of training
physicians in diagnosing the most difficult-to-diagnose diseases. DOD,
VA, and civilian physicians use AFIP's educational services, but the
civilian community uses AFIP's educational services more extensively
than military physicians. Regarding its research services, AFIP
pathologists work individually and in partnership with other federal
and private researchers using material from the repository to conduct
research applicable to military operations as well as to diagnose and
treat diseases affecting military and civilian health.
Providing Consultations Is AFIP's Primary Mission, and DOD Is Its Most
Frequent Customer:
AFIP's primary mission is to provide diagnostic consultations. Its
pathologists spend nearly twice as much time providing this service as
they do providing education and research services. AFIP pathologists
provide consultations for cases referred to them with and without
diagnoses. That is, when physicians--clinicians or general
pathologists--at civilian, DOD, or VA medical centers cannot make a
diagnosis or when they are unsure of their initial diagnosis and are in
need of another opinion, they can send the case to AFIP's subspecialty
pathologists[Footnote 16] for diagnostic consultation. According to the
American Board of Pathology, there are 10 different areas of
subspecialty pathology, such as dermatopathology and forensic
pathology. Additionally, pathologists are recognized as subspecialists
in other areas of pathology pertaining to particular cancers, such as
breast or prostate. Requesting physicians--those who send cases to AFIP
in search of diagnostic consultations--typically need consultations for
more complex cases that require the additional expertise of a
subspecialty pathologist.[Footnote 17] In the course of providing these
diagnostic consultations to the requesting physicians, AFIP receives
and is able to add pathology material[Footnote 18] to its repository.
As a result, consultations have been instrumental in expanding the
repository.
Over time, AFIP has increased the amount of services provided for DOD
and decreased the amount of services provided for civilians. The total
number of diagnostic consultations that AFIP provided remained
relatively stable from 2000 to 2004. However, as we previously
reported, DOD diagnostic consultations provided by AFIP increased by 30
percent from 2000 through 2004, while its civilian consultations
decreased by 28 percent.[Footnote 19] We also reported that nearly all
of the decrease in civilian consultations occurred in the 2 years after
AFIP announced that it would raise its consultation fees beginning in
January 2003. According to AFIP and civilian pathologists, this
decrease in civilian diagnostic consultations was also attributed to a
more competitive marketplace for obtaining consultations. Additionally,
these pathologists also cited the loss of nationally recognized experts
at AFIP as another possible reason for the decline in the number of
civilian diagnostic consultations being sent to AFIP.
In 2006, AFIP provided almost half of its consultations to DOD
physicians. From 2005 to 2006, AFIP decreased the total number of
consultations it provided from 44,169 to 41,582. Consistent with
earlier trends from 2000 to 2004, AFIP continued to increase the number
and percentage of consultations provided to DOD and decrease the amount
provided to the civilian community from 2005 to 2006. (See table 1.) In
2006, the largest percentage of consultations, approximately 48
percent, was conducted for DOD, followed by those for VA and civilian
physicians at nearly 27 percent and 25 percent, respectively. AFIP also
provided about 1 percent of its consultations for others, which
included other federal agencies and foreign military services. While
AFIP receives consultation requests from all over the world,
consultations are heavily concentrated from more populous states and
the East Coast. (See app. II for maps of AFIP's 2006 consultations.)
Table 1: Number and Percentage of AFIP Consultations for Customers,
2005 and 2006:
Customer type: DOD[B];
2005: Consultations: 19,464;
2005: Percentage of total: 44.1;
2006: Consultations: 19,856;
2006: Percentage of total[A]: 47.8.
Customer type: VA;
2005: Consultations: 11,520;
2005: Percentage of total: 26.1;
2006: Consultations: 11,083;
2006: Percentage of total[A]: 26.7.
Customer type: Civilian;
2005: Consultations: 12,708;
2005: Percentage of total: 28.8;
2006: Consultations: 10,287;
2006: Percentage of total[A]: 24.7.
Customer type: Other federal agencies[C];
2005: Consultations: 456;
2005: Percentage of total: 1.0;
2006: Consultations: 334;
2006: Percentage of total[A]: 0.8.
Customer type: Foreign[D];
2005: Consultations: 21;
2005: Percentage of total: 0.0;
2006: Consultations: 22;
2006: Percentage of total[A]: 0.1.
Total;
2005: Consultations: 44,169;
2005: Percentage of total: 100.0;
2006: Consultations: 41,582;
2006: Percentage of total[A]: 100.0.
Source: GAO analysis of DOD data.
[A] Does not add to 100 due to rounding.
[B] Includes the Army, Navy, and Air Force.
[C] Includes the Department of Health and Human Services, Department of
Homeland Security, and others.
[D] Includes consultation requests from physicians from other
countries, such as countries in Europe, Africa, or Asia.
[End of table]
In 2006, about 62 percent (25,621) of AFIP's cases were for
consultations where AFIP pathologists reviewed the initial diagnoses
from DOD, VA, civilian, or other physicians for confirmation or change.
For these cases, AFIP pathologists changed the initial diagnoses from
requesting physicians in 10,987 cases, or about 43 percent of the time.
For the remaining 57 percent of the cases (14,634), AFIP confirmed the
requesting physicians' initial diagnoses.[Footnote 20] When AFIP's
diagnoses differ from the requesting physicians' initial diagnoses, it
classifies the changes as either minor or major. According to AFIP, a
minor change often involves a change in severity of the condition
diagnosed or the choice of appropriate therapy. For example, the
initial diagnosis may have correctly identified a tumor as malignant
but may have assigned an incorrect type or level of aggressiveness,
which could affect treatment and prognosis. In addition, AFIP
classifies a change as major if it involves a change in the nature of
the condition diagnosed. For example, a major change would include
changing a diagnosis from malignant to benign. Both minor and major
diagnosis changes can lead to a different treatment and, ultimately, a
different outcome for the patient. As shown in table 2, most of AFIP's
changes to initial diagnoses that were provided by requesting
physicians were classified by AFIP as minor changes.
Table 2: Consultation Outcomes Where an Initial Diagnosis Was Provided,
for 2006:
Outcome: Initial diagnosis confirmed;
Consultations: 14,634;
Percentage of total[A]: 57.1.
Outcome: Minor change[B];
Consultations: 10,116;
Percentage of total[A]: 39.4.
Outcome: Major change[B];
Consultations: 871;
Percentage of total[A]: 3.4.
Total;
Consultations: 25,621;
Percentage of total[A]: 100.0.
Source: GAO analysis of DOD data.
[A] Does not add to 100 due to rounding.
[B] Minor and major changes were classified as such by AFIP.
[End of table]
The type of consultations DOD, VA, and civilian physicians seek from
AFIP differ somewhat, both in terms of the number of cases sent without
a diagnoses and the type of pathology expertise requested. For example,
47 percent of DOD's consultation requests were sent without an initial
diagnosis, compared to 27 percent from VA and 31 percent from civilian
physicians. This may be due, in part, to the type of expertise DOD and
civilian physicians most commonly need, which also differs. For
example, in 2006, almost a quarter of all DOD consultations were in the
area of forensic toxicology, which includes examining material from
autopsies and testing biological specimens for alcohol and drugs.
However, VA physicians most frequently requested AFIP's environmental
toxicology diagnostic consultations, while civilian physicians most
frequently requested hepatic consultations--involving diseases of the
liver--as well as gastrointestinal consultations. The other
consultation service most frequently requested by DOD, VA, and civilian
pathologists was for dermatopathology--or the interpretation of skin
biopsies.
AFIP Provides Varied Educational Services, Used Primarily by Civilian
Physicians:
AFIP, in conjunction with ARP, offers a variety of courses,
conferences, and other educational services, generally for physicians,
and tailors its curriculum to the most common as well as the most
difficult-to-diagnose diseases. AFIP staff design and conduct live and
distance learning courses that aid physicians in expanding their
medical knowledge as well as fulfilling their state licensure
requirements for CME credit. AFIP's educational services cover a range
of topics in the fields of pathology, radiology, and veterinary
pathology, with particular emphasis on identifying emerging diseases,
offering new insights into known diseases, and giving hands-on
experience in diagnosing difficult cases. In developing material for
conferences, courses, and texts, AFIP staff query a database of recent
consultations searching for the most common missed diagnoses--that is,
those cases in which the requesting physician misdiagnosed the case, as
well as diagnoses in which the requesting physician most frequently did
not make an initial diagnosis.
In 2006, AFIP, in conjunction with ARP, offered 28 formal courses, 24
video teleconferences, and 4 Web-based courses. These courses qualify
for CME credit, which assists DOD, VA, and civilian pathologists and
other physicians in fulfilling state requirements for maintaining their
medical licenses.[Footnote 21] Civilian physicians use AFIP's training
services more extensively than DOD and VA physicians. In 2006, 61
percent of the students attending AFIP's CME courses were civilians, 34
percent were DOD attendees,[Footnote 22] and 5 percent were from VA.
Most live CME courses are attended predominantly by civilians. For
example, in 2006, 96 percent of the residents who attended the
Radiologic-Pathologic Correlation course were civilians. However, some
courses are solely attended by military health professionals because
they involve issues specific to DOD or because AFIP does not allow
civilians to attend classes such as its Air Force Medical Forensic
Sustainment course. Overall, AFIP's courses have attracted instructors
and students from around the world. In 2006, individuals representing
over 70 institutions, including the Federal Bureau of Investigation,
the National Institutes of Health, private academic institutions and
medical centers, and MTFs participated in AFIP's CME program.
According to military pathologists, AFIP's distance learning programs
are a convenient and economical way to obtain CME requirements and
fulfill state licensure requirements. AFIP's distance learning programs
include AskAFIP, an online database maintained and operated by AFIP. To
hone diagnostic skills, AskAFIP allows users to query a database that
contains information from AFIP's collection of specific diagnoses,
texts, case materials, and images from the repository. DOD, VA, and
civilian physicians have access to AskAFIP. Also, as part of its
distance learning educational services, AFIP's pathologists review
diagnoses provided by VA pathologists--known as the Systematic External
Review of Surgicals program.[Footnote 23]
In addition to offering courses, in conjunction with ARP, AFIP
publishes examples of clinical-pathologic correlations, which describe
the relationships that exist between the clinical symptoms or
attributes exhibited by a patient and the pathological abnormalities of
a specific disease or type of tumor. These correlations are published
in texts called fascicles,[Footnote 24] which DOD, VA, and civilian
pathologists told us are a primary reference source and serve as an
important, frequently used tool as they practice pathology.[Footnote
25] The fascicles are updated to capture the more recent developments
in pathology.
AFIP's Research Benefits DOD, VA, and Civilians:
The combination of unique case material and expertise of AFIP
pathologists facilitates AFIP's research that benefits DOD, VA, and
civilian medicine and results in hundreds of publications each year.
Research is conducted by AFIP pathologists, as well as by other federal
and private researchers in collaboration with AFIP pathologists,
primarily using material from the repository.[Footnote 26] All outside
researchers are required to collaborate with an AFIP pathologist in
order to access AFIP's materials.
The repository contains over 3 million disease specimens and their
accompanying case histories dating back over 150 years. Because of the
large volume of cases in the repository, researchers can conduct
studies of considerable sample size. Since AFIP receives pathology
material for many difficult-to-diagnose diseases, the repository
contains complex and uncommon cases that have accumulated over time.
Studying these samples allows for advances in diagnosis and treatment
of diseases. For example, AFIP has accumulated a large collection of
gastrointestinal stromal tumors, a relatively uncommon tumor. Recent
studies involving this collection have led to advances in the
identification of, and therapy for, this tumor. One of the
responsibilities of AFIP pathologists is to classify the material that
AFIP receives into the repository so that researchers can access it in
the future. As medical knowledge evolves, AFIP pathologists reclassify
material in the repository to better characterize it for future use.
AFIP staff are also in the process of putting material from the
repository in digital form to expand its use for research.
AFIP conducts and collaborates on research applicable to military
operations and general medicine, so its research affects DOD, VA, and
civilian communities. Although "militarily relevant" research has not
been well-defined, AFIP staff said it generally includes subjects of
direct interest to the military. For example, according to AFIP staff,
research conducted in collaboration with the Armed Forces Medical
Examiner has led to developments such as improved body armor and acute
care of wounded personnel. Further, AFIP conducts and collaborates on
infectious disease and cancer research, which has applicability for the
civilian community as well. AFIP's infectious disease research has
focused on the characterization of potentially epidemic organisms, such
as severe acute respiratory syndrome, as well as on the development of
improved vaccines and the detection of biologic toxins, such as those
that may be used in biological warfare. AFIP's cancer research,
including breast, gynecologic, and prostate cancers, has resulted in
more accurate diagnosis and development of better treatment methods.
Table 3 provides examples of AFIP's research projects, including their
impact.
Table 3: Examples of AFIP's Research Projects:
Research project: Body armor;
Description: AFIP conducted a study examining full autopsies on U.S.
troops killed in Iraq and Afghanistan from March 2003 to mid-2005.
Investigators found that 80 percent of the fatalities could have been
prevented by better protection for the shoulder, back, chest, and side
areas. As a result, DOD decided to redesign body armor.
Research project: Thoracic needle;
Description: AFIP conducted a study examining why field medics'
procedures to treat collapsed lungs were not working. Researchers
discovered that a soldier's muscle thickness is greater than the
average person's muscle thickness. As a result, DOD now uses thicker,
longer needles to penetrate the lung.
Research project: Spanish influenza;
Description: The 1918 influenza pandemic killed more than 50 million
people worldwide. AFIP pathologists were able to decode the genetic
sequence of the 1918 strain by examining tissue samples in the
repository from World War I soldiers who had died of the disease in
1918. Understanding the genetic sequence of this influenza virus could
aid in predicting future influenza pandemics and in developing
interventions and treatment of virulent influenza viruses.
Research project: Reye syndrome;
Description: Reye syndrome primarily affects children, causing sudden
brain damage and liver function problems. AFIP pathologists found that
Reye Syndrome was associated with the use of aspirin to treat
chickenpox or upper respiratory infection in children. As a result of
understanding this association, the Food and Drug Administration issued
a package insert for aspirin warning against prescribing aspirin to
infants and children with chickenpox or flu. There has been a sharp
decline in the number of infants and children with Reye Syndrome since
this discovery, and it is now very rare.
Source: GAO analysis of DOD data.
[End of table]
The research conducted at AFIP results in hundreds of publications per
year, but it has been declining. For example, in 2005 researchers at
AFIP published 174 peer-reviewed articles and 121 abstracts, and in
2006 researchers at AFIP published 145 peer-reviewed articles and 73
abstracts. In a previous GAO report, we found that from 2000 through
2004, the number of research protocols at AFIP declined from 371 to
296.[Footnote 27] AFIP staff said that they began to focus on
increasing militarily relevant research and reducing DOD-funded
civilian-focus research as early as 2001.
DOD Has Specific Plans to Terminate Most Services Currently Provided by
AFIP and Is Developing Plans to Relocate the Others:
The 2005 BRAC provision specifies that AFIP be disestablished.
Accordingly, most services currently provided by AFIP will be
terminated and other services will be relocated or outsourced.
Specifically:
* DOD plans to outsource second-opinion consultations and some initial
diagnostic consultations to the private sector through a newly
established PMO.
* With the exception of two educational courses, DOD does not plan to
retain and relocate the educational programs currently offered by AFIP.
* DOD plans to halt AFIP's research and realign the repository, which
is AFIP's primary research resource, to the Forest Glen Annex,
Maryland, under the management of USUHS.
The BRAC provision allows DOD the flexibility to retain capabilities
that were not specifically addressed in the provision. In accordance
with this statutory authority, the ASD(HA) has retained four additional
AFIP services and is considering whether to retain six others.
According to DOD's most recently developed implementation plan, dated
February 2007, DOD had planned to begin implementation of the BRAC
provision relating to AFIP in July 2007 and to complete action by
September 2011. However, a provision from the 2007 supplemental
appropriations act prevents DOD from reorganizing or relocating any
AFIP functions until after DOD has submitted detailed plans and
timetables for the proposed reorganization and relocation to
Congress.[Footnote 28] Once the reorganization plan has been submitted,
DOD can resume reorganizing and relocating AFIP.
Most of AFIP's Services Will Be Terminated, but Some Will Be Relocated:
DOD plans to terminate AFIP's provision of diagnostic consultations and
outsource certain DOD diagnostic consultations to the private sector
through a newly established PMO. More specifically, the BRAC provision
requires that the PMO be established at the new Walter Reed National
Military Medical Center in Bethesda, Maryland,[Footnote 29] to
coordinate pathology results, contract administration, quality
assurance, and control of DOD second-opinion consults worldwide. DOD
plans to relocate sufficient personnel from AFIP to the new PMO to
conduct its activities.[Footnote 30] Further, DOD's justification for
this provision states that DOD will also rely on the civilian market
for providing initial diagnoses when the local pathology labs'
capabilities are exceeded.
In determining the legal implications of the BRAC provision with
respect to consultation services, DOD's Office of General Counsel
concluded that military second-opinion consultations as currently
provided by AFIP would not be subject for retention because the PMO
would be required to outsource these consultations. Initial diagnoses
would either be provided by military pathologists or possibly military
subspecialty pathologists at MTFs when possible or outsourced through
the PMO. Although the PMO would not coordinate civilian diagnostic
consultations, DOD has not determined whether it would allow VA or
other federal agencies to obtain diagnostic consultations--either
initial or second-opinion--through the PMO. The PMO working group,
including DOD and VA officials, met in August 2007 to discuss the
establishment of the PMO.
Regarding the retention of educational services, DOD does not plan to
relocate any educational services currently offered by AFIP with the
exception of the enlisted histology technician training and the DOD
Veterinary Pathology Residency Program. The BRAC provision requires DOD
to relocate the enlisted histology technician training to Fort Sam
Houston, Texas. The DOD Veterinary Pathology Residency Program would be
relocated to Forest Glen Annex, Maryland.
With respect to the research, DOD plans to realign the repository,
which is AFIP's primary research resource, to Forest Glen Annex,
Maryland, to be managed by USUHS. USUHS issued a Request for Proposal
in May 2007, for the purpose of contracting for a review of the quality
of the pathology material and associated case records contained in the
repository. USUHS officials told us that they will make further
decisions regarding laboratory and storage facility requirements for
the repository, as well as plans for staffing and research uses, when
the evaluation is complete. Pending the outcome of this review, USUHS
may employ 10-12 pathologists who would spend the majority of their
time on research; these pathologists would also be responsible for
classifying pathology material in the repository.
Aside from the AFIP services discussed above, the BRAC provision
required that some of AFIP's other services be retained by DOD and
relocated into other facilities. For example, the provision requires
relocating Legal Medicine to the Walter Reed National Military Medical
Center in Bethesda, Maryland, and the relocation of the Armed Forces
Medical Examiner, DNA (deoxyribonucleic acid) Registry, and Accident
Investigation to Dover Air Force Base, Delaware.
As part of its review regarding the disestablishment of AFIP, the BRAC
Commission found that the medical professional community regarded AFIP
and its services as integral to the military and civilian medical and
research community. The commission also found that DOD substantially
deviated from its selection criteria by failing to sufficiently address
several AFIP functions. As a result, the commission amended DOD's
initial recommendation to add that AFIP capabilities not specified in
the final recommendation would be absorbed into other DOD, federal, or
civilian facilities, as necessary. The revised language was approved by
the President as part of the final BRAC provision. As revised, DOD has
the flexibility to review AFIP capabilities or services not
specifically addressed in the BRAC provision to determine which
functions to retain.
As a result of the amendment, the ASD(HA) informed key DOD
officials[Footnote 31] in a November 16, 2006, memorandum that he had
approved the retention of four services--the DOD Veterinary Pathology
Residency Program, Automated Central Tumor Registry, Center for
Clinical Laboratory Medicine, and Patient Safety Center. He also
informed them that the remaining AFIP services would be disestablished
unless any of the key officials identified the need to retain specific
services. Based on responses from the key officials, an additional six
AFIP services were recommended for retention. As of September 2007, the
ASD(HA) had not made a final decision on them. These six services
include diagnostic telepathology, two biodefense projects, reserve
biological select agent inventory, depleted uranium (DU) testing, and
cystic fibrosis testing. In addition, VA expressed an interest in
having DOD retain the DU testing capability. Table 4 summarizes AFIP
services that will be relocated or established as specified in the BRAC
provision, those that were subsequently added by the ASD(HA) to be
retained, and those that were recommended for retention by the DOD
officials and are awaiting final decision. (See app. III for a
description of services currently performed by AFIP that are to be
retained and relocated, or newly established, or are awaiting final
decisions.)
Table 4: Services Currently Performed by AFIP That Are to Be Retained
and Relocated, or Established, or Are Awaiting Final Decisions:
Service: Services required to be retained by the BRAC provision: Legal
Medicine;
Proposed locations[A]: Walter Reed National Military Medical Center,
Md.
Service: Services required to be retained by the BRAC provision:
National Museum of Health and Medicine;
Proposed locations[A]: Walter Reed National Military Medical Center,
Md., managed by Uniformed Services University of the Health Sciences
(USUHS), Md.
Service: Services required to be retained by the BRAC provision:
Repository;
Proposed locations[A]: Forest Glen Annex, Md., managed by Uniformed
Services University of the Health Sciences (USUHS), Md.
Service: Services required to be retained by the BRAC provision: Armed
Forces Medical Examiner, DNA Registry, and Accident Investigation;
Proposed locations[A]: Dover Air Force Base, Del.
Service: Services required to be retained by the BRAC provision:
Enlisted histology technician training;
Proposed locations[A]: Fort Sam Houston, Tex.
Service: Service to be established as specified by BRAC provision:
Program Management Office (PMO);
Proposed locations[A]: Walter Reed National Military Medical Center,
Md.
Service: Services designated for retention by ASD(HA): DOD Veterinary
Pathology Residency Program;
Proposed locations[A]: Forest Glen Annex, Md.
Service: Services designated for retention by ASD(HA): Automated
Central Tumor Registry;
Proposed locations[A]: Forest Glen Annex, Md. managed by Uniformed
Services of the Health Sciences (USUHS), Md.
Service: Services designated for retention by ASD(HA): Center for
Clinical Laboratory Medicine;
Proposed locations[A]: Walter Reed National Military Medical Center,
Md.
Service: Services designated for retention by ASD(HA): Patient Safety
Center;
Proposed locations[A]: Walter Reed National Military Medical Center,
Md.
Service: Services being considered for retention by key DOD officials
and awaiting a final decision: Diagnostic telepathology;
Proposed locations[A]: Walter Reed National Military Medical Center,
Md., or Fort Belvoir, Va.[B].
Service: Services being considered for retention by key DOD officials
and awaiting a final decision: Biodefense Project - Joint Biological
Agent Identification and Diagnostic System;
Proposed locations[A]: Fort Detrick, Md.
Service: Services being considered for retention by key DOD officials
and awaiting a final decision: Biodefense Project - Critical Reagent
Program;
Proposed locations[A]: Aberdeen Proving Ground, Md.[B].
Service: Services being considered for retention by key DOD officials
and awaiting a final decision: Reserve Biological Select Agent
Inventory;
Proposed locations[A]: Aberdeen Proving Ground, Md.[B].
Service: Services being considered for retention by key DOD officials
and awaiting a final decision: Depleted uranium testing;
Proposed locations[A]: Aberdeen Proving Ground, Md.[B].
Service: Services being considered for retention by key DOD officials
and awaiting a final decision: Cystic fibrosis testing;
Proposed locations[A]: Outsourced.
Source: GAO analysis of DOD data.
[A] The new locations of Legal Medicine; the Armed Forces Medical
Examiner, DNA Registry, and Accident Investigation; and enlisted
histology technician training were specified in the BRAC provision.
[B] As of September 2007, DOD had not finalized decisions regarding the
locations of these services.
[End of table]
Planned Implementation to be Completed by 2011:
According to DOD's most recently developed implementation
plan,[Footnote 32] execution of the BRAC provision regarding AFIP was
scheduled to begin in July 2007 and be complete by September 2011.
Figure 1 summarizes DOD's plans to terminate AFIP's three key services
by December 2010. It also illustrates DOD's timeline that would have
relocated other AFIP services that were designated to be retained by
the BRAC provision. Several rounds of staff reductions were anticipated
to occur as DOD terminated or relocated AFIP services. As figure 1
shows, DOD's plans left a lag time between when AFIP DOD diagnostic
consultations ended in December 2010 and when the PMO was expected to
be operational in September 2011.
Figure 1: DOD's Proposed Timeline for BRAC Implementation Pertaining to
AFIP:
This figure is a timeline for BRAC implementation pertaining to AFIP.
[See PDF for image]
Source: GAO summary of AFIP data.
[End of figure]
Implementation of these plans were put on hold by the requirements of
section 3702 of the fiscal year 2007 supplemental appropriations act,
which suspended all BRAC actions affecting AFIP until after DOD submits
detailed plans to the House and Senate Appropriations and Armed
Services Committees, which are due by December 31, 2007. DOD officials
acknowledge that the timeline as envisioned in their February 2007
implementation plan can no longer be met and the full amount of onetime
savings from disestablishment of AFIP will not be realized, although
they believe that they may still be able to complete all actions
required by the BRAC provision by 2011.
While DOD is required to share more information regarding its plans
with Congress before the end of the year, other developments could
impact the implementation of those plans. Specifically, on May 17,
2007, the House passed H.R. 1585, a bill for the National Defense
Authorization Act for Fiscal Year 2008, which contains a provision that
would require DOD to establish a "Joint Pathology Center" at the
National Naval Medical Center in Bethesda. On October 1, 2007, the
Senate passed its version of the same bill. However, the Senate-passed
version contains a provision that would authorize, rather than require,
DOD to establish a Joint Pathology Center at Bethesda, "to the extent
consistent with the final recommendations of the 2005 [BRAC] Commission
as approved by the President." If a new Center is established under
either provision, it would be required to provide diagnostic pathology
consultation, pathology education, and diagnostic pathology research.
In addition, the Senate bill would require that the Center, if
established, provide maintenance and continued modernization of the
tissue repository. As of the publication of this report, the House and
Senate had not reached agreement at conference on any provision related
to a new Joint Pathology Center.
Closing AFIP May Have Minimal Effect, but Management Strategy Is
Important to Address Key Challenges:
Although AFIP is a noted center for pathology expertise, closing AFIP
may have minimal effect on DOD, VA, and civilian communities because
pathology services are available to them elsewhere. However, a smooth
transition depends on DOD's actions to address key challenges involved
in developing new approaches to obtaining subspecialty pathology
consultations and managing the repository to facilitate its use for
research. DOD and VA officials have begun to identify the challenges,
but have not decided upon strategies to address them.
DOD, VA, and Civilian Physicians May Be Able to Obtain Key Services
from Other Institutions:
In large part, DOD, VA, and civilian pathologists may be able to obtain
services elsewhere to replace those currently provided by AFIP.
Diagnostic consultations: Other medical institutions currently provide
diagnostic consultations that require subspecialty expertise. For
example, Massachusetts General Hospital (Boston, Massachusetts) and M.
D. Anderson Cancer Center (Houston, Texas) each provide about 60,000 or
more pathology consultations per year. While AFIP has many different
subspecialty areas, major civilian medical institutions, such as The
Johns Hopkins Hospital (Baltimore, Maryland) and Memorial Sloan-
Kettering Cancer Center (New York, New York) have from 10 to 17
different subspecialty areas, respectively.[Footnote 33] Pathologists
we interviewed emphasized the importance of being able to obtain
consultations from expert pathologists, wherever they may work. They
also stated that pathologists with particular expertise who move from
AFIP to the private sector may be able to continue to provide
consultations from whichever institutions they may join. Most DOD and
VA pathologists noted that even though MTFs and VA medical centers can
readily access AFIP consultations without incurring additional fees,
they already use subspecialty pathologists from civilian medical
institutions on occasion for consultations due to their needs for
particular subspecialty expertise and concerns about obtaining a
diagnosis in a timely manner. In addition, some MTFs have subspecialty
pathologists who can provide consultations for other military
physicians. For example, Brooke Army Medical Center and Wilford Hall
Medical Center--both located in San Antonio, Texas--each have over
seven different subspecialty areas. According to pathologists from the
five MTFs we interviewed, subspecialty pathologists from their centers
currently provide consultations to other nearby MTFs.
Pathology education: Other institutions also provide pathology
education. For example, CAP offers educational courses covering a range
of topics such as histotechnology and molecular pathology. DOD, VA, and
civilian pathologists that we interviewed told us that they have
fulfilled CME requirements through other institutions and could
continue to do so. Pathologists we interviewed said that DOD and VA
pathologists generally make independent decisions about which classes
to attend and how to meet accreditation requirements. Military
pathologists we interviewed also said that due to limited budgets,
pathologists generally do not travel to AFIP to attend courses because
other pathology organizations, such as CAP, offer CMEs that are
accessible without the need to travel. Most DOD, VA, and civilian
pathologists we interviewed said that AFIP's Radiologic-Pathologic
Correlation course is unique and valuable to the radiology profession.
Some of the pathologists we interviewed said that this is because the
course utilizes the expertise of physicians who work with pathology
material from a large volume of difficult-to-diagnose cases, requires
attendees to bring unique specimens for class analysis and discussion,
and utilizes material from AFIP's repository, which houses a
comprehensive collection of specimens. Further, many pathologists and
representatives from radiology organizations told us that it is the
most common way radiology residents fulfill a requirement to have
specific training in pathology. Although the course is recognized as
being unique, according to guidance set forth by the Accreditation
Council for Graduate Medical Education, radiologists could fulfill
their accreditation requirements through avenues other than AFIP. In
addition, according to DOD officials, it is not DOD's mission to train
civilian radiology residents, although we believe that DOD could be in
a position to assist outside groups if any expressed interest in
becoming responsible for maintaining the course.
Research services: The type of research historically conducted by AFIP
could be conducted at other institutions or by pathologists who remain
with DOD. USUHS will continue to perform militarily relevant,
biomedical research, focusing on health promotion and disease
prevention, as it gains responsibility for the repository--AFIP's
primary research tool. Additionally, the Office of the Armed Forces
Medical Examiner has also been responsible for conducting research
applicable to military operations. Because it is being retained, it
could continue to do so. Also, AFIP has partnered with other
government, academic, and private sector institutions to carry out
research services. Specifically, AFIP staff have conducted research
affecting general medicine through collaborations with external
organizations, such as The Johns Hopkins Hospital and the Mayo Clinic.
These organizations will likely continue to fund medical research and
could possibly continue to conduct research using pathology material
from the repository. Although USUHS has not finalized its plans
regarding the repository, its intent is to make the pathology material
accessible to others including civilian researchers, to the extent it
is approved by DOD, practicable, and legally feasible.
DOD Faces Challenges in Ensuring That Military Physicians' Access to
Subspecialty Consultation Services Is Maintained at a Reasonable Cost:
Given that AFIP is a central source that provides its customers with
definitive consults on the most difficult-to-diagnose cases, DOD and VA
pathologists face challenges in obtaining similar consultative
expertise once AFIP is disestablished. These challenges include
determining how to effectively use existing subspecialty pathology
resources, obtain outside expertise, and ensure coordination and
funding of services to encourage efficiency while avoiding
disincentives to quality care. In addition, DOD must decide whether VA
could obtain consultation services through the PMO and whether VA will
be able to provide some subspecialty pathology expertise for DOD. While
DOD and VA officials have begun the process to identify these
challenges, as of mid-August 2007, they had not yet developed
management strategies to mitigate them.
Effective utilization of existing resources: While DOD officials told
us that they might be able to perform some in-house diagnostic
consultations for MTFs, they have not evaluated their existing medical
resources to determine the extent to which such consultation services
can be performed. According to DOD officials, some large MTFs have
subspecialty expertise and might be able to absorb some of the demand
for consultations, but DOD has not identified the potential volume and
type of consultations that these large MTFs could absorb. Further, DOD
pathologists expressed concerns that MTFs would not be able to absorb
many additional consultations without increasing the number of
subspecialty pathologists staffed at MTFs. This could be challenging,
they said, because it is difficult to retain pathologists within the
military. Because DOD is retaining some of its pathology capabilities
from AFIP under the BRAC provision, such as the Armed Forces Medical
Examiner, it will continue to have expertise available to provide
services in the area of forensic toxicology--DOD's most frequently used
consultation service in 2006. Further, several DOD officials were
concerned that the DOD General Counsel's interpretation of the BRAC
provision requiring outsourcing through the PMO would preclude DOD from
providing second-opinion consultations from expertise within its MTFs.
In addition, although VA may be able to absorb some of its own
consultations using its subspecialty pathologists, including those who
are currently assigned to AFIP, VA pathologists told us that VA is
limited in how many additional consultations its current subspecialty
pathologists could provide.
The PMO process: How the PMO functions and obtains diagnostic services
from medical centers outside DOD and VA has important implications,
both from a quality of care and a cost standpoint. DOD and VA officials
we interviewed indicated that DOD faces challenges in developing the
new PMO that can outsource for quality pathology services; such
challenges involve issues related to the timeliness of consultations
and the ability to obtain appropriate expertise at a reasonable cost.
As of August 2007, DOD has not formulated its management strategies for
addressing the following issues concerning how the PMO will function.
* Assisting other federal agencies with obtaining consultations.
Although DOD has discussed the possibility that the PMO could include
VA in outsourced diagnostic consultations, no decisions had been made
as of mid-August 2007. Since VA has received over a quarter of AFIP's
total consultations, VA officials have expressed an interest in
continuing to receive consultations through the PMO once DOD
discontinues offering AFIP consultations. VA officials also expressed
concerns about the cost of obtaining consultations outside of AFIP,
which they estimated to be much greater than the financial support it
currently provides to AFIP for its services. In addition, the officials
stated that AFIP has been responsible for VA's DU program,[Footnote 34]
and as of June 2007, VA officials were uncertain about the extent to
which staff and equipment providing these services would be sufficient
to meet the future needs. VA officials stated that their agency did not
have the equipment or expertise to conduct the analyses needed for this
program, and for testing of other types of embedded fragments, such as
cobalt, nickel, and tungsten. VA officials indicated that testing for
DU and other potentially harmful embedded fragments plays an important
role in providing high quality health care to recently injured combat
veterans. As we previously discussed in this report, DOD officials are
considering the possibility of retaining DU testing.
* Obtaining consultation services. Several military pathologists
expressed concerns about the challenges DOD and VA would face in
identifying and obtaining needed subspecialty expertise from
pathologists. These concerns stem, in part, from their understanding of
AFIP's capabilities to provide consultations for difficult-to-diagnose
cases by involving different types of subspecialty pathologists as
needed. Within AFIP, cross-consultation among experts is available
under one roof. As DOD will have to determine a new method for
obtaining consultations using the PMO, military pathologists expressed
concerns that it might be more difficult to access expertise dispersed
among different institutions to obtain accurate diagnostic information.
DOD and VA pathologists also expressed concerns regarding whether
continuity of patient care would be maintained for retired military
personnel if pathology specimens from active duty personnel and
veterans are no longer sent to one central laboratory, such as AFIP. At
present, if a patient has had a previous consultation, the material is
available from the repository for comparison if AFIP is requested to
conduct another consultation at a later date for the same patient. This
can be important for the patient's care--for example, in determining if
a patient's cancer is metastasizing or if a precancerous condition is
worsening. AFIP pathologists expressed concern that patient care could
be compromised if the pathologists providing consultations could no
longer obtain their patients' previous specimens, slides, or case notes
from the repository. In addition, according to an AFIP pathologist, the
repository is particularly valuable for AFIP's consultation services
because it can serve as a reference tool to compare pathology material
from one patient to that of many others to confirm a diagnosis. VA and
AFIP pathologists have raised concerns about whether alternate sources
of consultation services obtained through the PMO will be able to
provide the same continuity or quality of service unless pathologists
from these alternate sources can use the repository as a reference.
Further, DOD pathologists expressed concern about whether private
sector institutions with the best subspecialty pathology expertise can
absorb the 40,000 consultations that have been conducted by AFIP
annually. DOD pathologists also indicated that as of August 2007, DOD
had not yet developed a management strategy to address this challenge.
* Timeliness of consultation services. DOD pathologists we interviewed
are also concerned that obtaining consultations may take longer than it
does under AFIP because it is unclear how DOD will identify and obtain
needed pathology expertise. Timeliness of consultation services is
important. For example, understanding the aggressiveness and particular
stage of a cancer in a given point in time can influence patient
treatments and outcomes. Some pathologists also anticipate that
turnaround time for DOD's consultations may increase due to difficulty
coordinating among pathologists with varied subspecialty expertise that
are dispersed among different institutions and that this could impair
the quality of services that DOD obtains. As of August 2007, DOD had
not outlined the management strategy that it will pursue to ensure
timely access to consultative services.
* Funding mechanisms. DOD pathologists' access to subspecialty
pathology expertise can also be impacted depending on how DOD plans to
mitigate funding incentives related to centralization or
decentralization of the budget. According to DOD officials, as of July
2007, DOD had not made decisions regarding whether the budget for
consultations would be maintained centrally at the PMO or if each MTF
would receive a separate budget for outsourced consultations. Because
DOD pathologists did not have to pay for AFIP's consultation services,
there was no financial disincentive to use them. Several pathologists
we interviewed expressed concern that decentralized funding for
consultation services would create disincentives to obtaining
consultations and could ultimately affect the quality of the medical
care the military would receive for such services. More specifically,
these officials asserted that a decentralized funding system would
require a Department of Pathology Chair within an MTF to scrutinize the
department's competing demands for resources and make decisions about
whether to obtain outside pathology expertise or spend financial
resources on other patient care needs. VA pathologists also expressed
concern that funding issues could contribute to increasing the
difficulty of obtaining subspecialty consultations. If pathologists
cannot obtain subspecialty consultations when they are unsure of their
diagnosis, patients might be misdiagnosed. This is particularly
relevant since, as we discussed earlier in this report, AFIP has
changed requesting physicians' initial diagnoses for about 43 percent
of the cases it reviews.
* Minimizing costs of services through volume discounts. By working
with VA, DOD could further increase its economies of scale by
purchasing a higher volume of consultation services. However, several
DOD and VA pathologists expressed concerns that if DOD chooses to
obtain services from the lowest bidder, the quality of consultations
could be compromised. They informed us that large national laboratories
would likely be the lowest bidders, but these institutions might lack
the subspecialty expertise to provide the best services. In fact, such
large national laboratories currently use AFIP consultation services.
Further, DOD pathologists we interviewed expressed concern for their
patients' care with respect to whether DOD would obtain the best
subspecialty consultations possible.
DOD has formed a working group, which met for the first time in August
2007, to address issues pertaining to obtaining consultations. This
group includes representatives from the Offices of the Surgeons General
of the Army, Navy, and Air Force, as well as other DOD and VA
officials. According to DOD officials, the workgroup spent its first
meeting identifying the challenges faced by DOD in obtaining needed
expertise but had not yet developed specific options to address the
challenges.
Research Could Be Affected Depending on How DOD Plans to Populate,
Maintain, and Use the Repository in the Future:
Because DOD has not developed its strategy regarding how it will
populate, maintain, and use the repository, some pathologists we
interviewed were concerned about the future of the repository and
whether it would continue to be a viable research tool. Recently, USUHS
awarded a contract to study the usefulness of the pathology material in
the repository.[Footnote 35] According to DOD, once that study is
completed in October 2008, USUHS plans to convene a panel of experts to
develop a blueprint on how to use the repository for research, and then
will likely contract for development of a detailed plan on how to best
populate, manage, and use the repository. USUHS does not intend to
finalize key decisions until that process is complete.
USUHS officials told us that one of the challenges they face in the
future is how they will populate pathology material in the repository
in order to maintain its viability as a research tool. They explained
that AFIP generally populates its repository through pathology material
obtained from its consultation services. As a result, the repository
includes material from the DOD, VA, and civilian populations.
Additionally, AFIP's Radiologic-Pathologic Correlation course has
historically contributed to the growth of pathology material in the
repository because students, who are primarily civilians, are required
to submit samples to AFIP that have pathologic significance. We
estimate that the repository gains approximately 1,200 to 2,400 samples
per year from students attending this course. Pathologists we
interviewed explained that the value of the material in the repository
is related to the number of cases it accumulates for a particular
disease. That is, in order for a researcher to be able to identify the
characteristic patterns of a disease allowing for its diagnosis and
treatment, there must first be a sufficient number of cases of the
particular disease. USUHS officials told us that due to the large
volume of cases that AFIP accumulated in the repository, including
complex cases, researchers can currently conduct studies of
considerable sample size. Thus, the manner in which USUHS plans to
continue to accumulate material in the repository can influence the
pace of research.
Because USUHS does not provide pathology consultations, in the absence
of civilian consultations it will need to develop other strategies to
populate the repository. The strategy that USUHS officials discussed
with us was to populate the repository with specimens from military
hospitals. Populating the repository in this manner, however, could
skew the repository since military hospitals generally draw patients
that are largely young, male, and active. This could decrease the
usefulness of the repository, ultimately affecting the breadth of
research. As a result, it is important that USUHS develop a strategy to
determine how it will populate the repository, considering both the
quantity of pathology material for each disease as well as the quality
and type of material from which it draws.
DOD, VA, and civilian pathologists we interviewed also recognize that
proper maintenance of pathology material is necessary for retaining the
repository's optimal usefulness. Specifically, as medical knowledge of
tumors and other conditions evolves, material requires reclassification
by pathologists with subspecialty expertise in order to be useful. As
such, repositories can become useless without continuous update and
evaluation. Officials from academic centers that we spoke with said
that the failure to preserve, maintain, and update the repository would
be a tremendous loss to pathology, and general medicine overall. USUHS
officials said that having staff pathologists with subspecialty
expertise responsible for properly classifying pathology material is
important to the repository's viability. USUHS discussed with us that
it may employ about 10 to 12 pathologists with subspecialty expertise
who would be responsible for reclassifying material in the repository
as needed.
USUHS officials expressed a desire to expand the use of the repository
to others outside of DOD--such as pharmaceutical companies and
cooperative ventures with other academic institutions--so that the
repository's role in general medical research could continue and
benefit the general population. However, USUHS officials said that they
first need to determine policy, financial, and legal ramifications,
such as patient privacy issues, before they make any decisions
regarding research access to the repository assets. USUHS officials
also told us that the pathologists they hire would have access to
pathology material in the repository and would also be responsible for
conducting militarily relevant research.
Conclusions:
AFIP is a noted institution that has provided pathology expertise in a
range of subspecialty areas, and its customers value the services that
it provides. Congress has mandated that DOD provide a detailed plan on
disestablishing AFIP by December 2007, which gives DOD an opportunity
to address potential challenges involved with closing the facility. DOD
awarded a contract to study the usefulness of the material in the
repository, which it anticipates to be completed by the end of 2008.
DOD anticipates using the study, a subsequent panel of experts, and a
possible second contract to develop a detailed implementation plan to
help make decisions on how the repository will be managed. As part of
its planning process, it is critical for DOD's plan to go beyond the
steps to terminate, relocate, or outsource AFIP's services and include
implementation strategies that detail how it will organize consultation
services and manage the repository in the future. DOD has not yet
developed these strategies--strategies that could help mitigate
potential negative impacts of disestablishing AFIP and facilitate a
smooth transition as DOD looks to other sources for obtaining high-
quality pathology services.
Recommendations for Executive Action:
As part of DOD's initiative to develop a plan for disestablishing AFIP,
we are making three recommendations to the Secretary of Defense that
could help mitigate potential negative impacts of disestablishing AFIP.
* We recommend that the Secretary of Defense include in the December
2007 plan to Congress implementation strategies for how DOD will use
existing in-house pathology expertise available within MTFs, identify
and obtain needed consultation services from subspecialty pathologists
with appropriate expertise through the PMO in a timely manner, and
solidify the source and organization of funds to be used for outsourced
consultation services.
* Within 6 months of completion of DOD's study regarding the usefulness
of the pathology material in the repository that is to be finished in
October 2008, the Secretary should require USUHS to provide Congress
with information on the status of the repository's assets and their
potential for research use.
* Prior to USUHS assuming responsibility for the repository, the
Secretary should provide a report to Congress on its implementation
strategies for how it will populate, manage, and use the repository in
the future. The implementation strategies should include information on
how USUHS intends to use pathology expertise to manage the material,
obtain pathology material from a wide variety of individuals, maximize
availability of the repository for research through cooperative
ventures with other academic institutions, and assist interested
groups--if any--in supporting the continuation of educational services,
such as the Radiologic-Pathologic Correlation course.
Agency Comments and Our Evaluation:
DOD and VA provided written comments on a draft of this report,
included in appendix IV and appendix V. In commenting on a draft of
this report, DOD concurred with the report's findings and conclusions
and fully concurred with our recommendation for DOD to include its
implementation strategies for organizing future pathology consultation
services in its December 2007 plan to the Congress. However, DOD
partially concurred with the recommendation to report to the Congress
within 6 months of completing its study on the viability of the
repository. Specifically, DOD indicated that USUHS would not be in a
position to report its strategies on managing the repository until
further work was completed. As a result, we modified our recommendation
to limit the reporting requirement to information on the viability of
material in the repository and its usefulness for research. We also
added another recommendation that DOD should report to Congress at a
later date on USUHS's planned strategies for managing the repository.
In its written comments, VA agreed that the draft report was factually
accurate, but indicated that it did not fully capture the essential
nature of AFIP's services to VA and DOD or fully address the impact of
its closing. We believe that we provided a balanced assessment of
AFIP's services and the impact of its closing.
In its comments, DOD agreed with the description of the challenges it
faces in developing new approaches to obtaining pathology expertise
through the PMO and managing the repository to ensure that it remains a
rich resource for civilian and military research. DOD emphasized that
it was in the process of developing alternative strategies that would
be coordinated internally and with VA to ensure that the strategies
would meet DOD's needs, assist the VA, and be in accordance with BRAC
recommendations. DOD concurred with our recommendation that the
Secretary of Defense should include in the December 2007 plan to
Congress implementation strategies for how DOD will use existing in-
house pathology expertise available within MTFs, identify and obtain
needed consultations from subspecialty pathologists with appropriate
expertise through the PMO in a timely manner, and solidify the source
and organization of funds to be used for outsourced consultation
services. In addition, DOD agreed that the Secretary of Defense should
submit a plan to Congress within 6 months of completion of the
repository evaluation contract to provide information on the status of
pathology material in it and its research potential. However, DOD
indicated that the results of the evaluation contract will likely
result in another contract to help develop a detailed strategy on how
USUHS will populate, manage, and use the repository. Therefore, DOD
will not be able to report on how USUHS will populate, manage, and use
the repository within 6 months of completion of the repository
evaluation contract and did not concur with that portion of the draft
recommendation. Given this, we modified our recommendations in this
report to reflect the steps DOD anticipates taking. Specifically, we
separated the recommendations to address reporting on the viability of
the repository material and the strategies for its maintenance and use.
In commenting on a draft of this report, VA indicated that the report
was factually accurate, but did not sufficiently describe the potential
impact associated with closing AFIP. VA focused on five concerns--DU
testing, stagnation of the repository, difficulties in replacing AFIP's
consultation services and obtaining them through the PMO, potential
impact on patient care, and the potential costs to replace existing
services.
* VA commented that AFIP's testing of DU and other types of potentially
harmful embedded fragments was essential to providing quality health
care to recently injured veterans. VA indicated that our report did not
sufficiently emphasize the importance of these AFIP services. While the
report clearly states that DOD is considering retaining DU testing, we
added additional text in this report to highlight VA's concerns,
including those about testing other types of potentially harmful
embedded fragments.
* VA also indicated that the repository contained a large archive of
veterans' pathology specimens that would be invaluable for future
clinical and research endeavors and expressed concern that DOD will
allow the repository to stagnate upon closure of AFIP. Our report
acknowledges the importance of the repository to veterans' care. This
is why we discussed the challenges of maintaining a viable repository
in the report and made a specific recommendation that DOD provide
information on future plans for it.
* Regarding consultation services, VA expressed concerns that other
institutions may not have the capacity to absorb AFIP's workload; some
types of services might not be available; and obtaining services
through the PMO may adversely affect timeliness and make it more
complex and inefficient for local facilities to obtain pathology
services. In our report, we discussed such concerns and stated that DOD
faces challenges in obtaining expertise similar to what AFIP offered.
As a result, we recommended that DOD report to the Congress on how it
would address these challenges and obtain pathology services in the
future.
* VA stated that the report did not fully discuss the impact of closing
AFIP on patient care--especially the significance of changing diagnoses
and of providing timely services. We disagree. The draft report clearly
states that changing a diagnosis can lead to different treatment and,
ultimately, a different outcome for the patient. The report also states
that timeliness is important because it can affect patient treatment
and outcomes. VA appears to assume that DOD will not be able to obtain
timely and quality consultative services through the PMO. In the
report, we stated that obtaining quality consultation services in a
timely manner through the PMO is one of the challenges that DOD would
have to address. Until DOD develops its strategies, we would not have a
basis to determine whether it would be likely to meet this challenge.
* VA commented on the potential high cost in procuring alternative
sources for AFIP's services. We did not conduct an overall assessment
of whether it would cost DOD more to obtain consultations from other
sources than it would to maintain AFIP. DOD considered costs when
developing its recommendation to the BRAC commission to outsource
consultations. However, as we have reported previously, implementing
other BRAC recommendations has led to lower cost savings than DOD had
estimated.[Footnote 36] Regarding the costs for VA, we state in our
report that earlier studies had found that the costs of the services
that AFIP provided to VA exceeded the value of the paid positions VA
provided in exchange. AFIP officials indicated that this continued to
be true in fiscal year 2007. As a result, depending on how and where VA
obtains consultation services, its costs could increase.
As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
from this date. At that time, we will send copies of this report to the
Secretary of Defense, the Secretary of VA, appropriate congressional
committees, and other interested parties. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov]. If you or your staff have any questions about this
report please contact me at (202) 512-7114 or williamsonr@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff who
made major contributions to this report are listed in appendix VI.
Signed by:
Randall B. Williamson:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
To describe key services that the Armed Forces Institute of Pathology
(AFIP) provides to the Department of Defense (DOD), the Department of
Veterans Affairs (VA), and civilian communities, we reviewed recent
reports describing AFIP's services and business practices, including a
previous GAO report[Footnote 37] and an Army Audit Agency report on
AFIP's business plan[Footnote 38] and a BearingPoint report on AFIP's
capabilities,[Footnote 39] and other relevant reports, including some
from VA. We also interviewed officials from AFIP, DOD, VA, the American
Registry of Pathology (ARP), pathology associations such as the College
of American Pathologists (CAP), the American Society for Investigative
Pathology, and the Association of Pathology Chairs, as well as
radiology associations, such as the American College of Radiology and
the Canadian Radiology Association, to collect information on AFIP's
core services. Additionally, we obtained data from AFIP on the services
it provides. To assess the reliability of these data, we interviewed
knowledgeable agency officials and reviewed related documentation. We
determined that the data were sufficiently reliable for the purposes of
this report.
To describe DOD's plans to terminate, relocate, or outsource services
currently provided by AFIP, as required by the Base Realignment and
Closure (BRAC) provision, we interviewed officials from DOD's Offices
of the Surgeons General of the Army, Navy, and Air Force; the Office of
the Assistant Secretary of Defense for Health Affairs; the Office of
the General Counsel; the TRICARE Management Activity; the Office of the
Deputy Under Secretary of Defense (Installations and Environment);
AFIP; and the Uniformed Services University of the Health Sciences
(USUHS). We also interviewed pathologists from military treatment
facilities (MTF) and VA medical centers. In addition, we reviewed the
BRAC business plan for the Walter Reed Army Medical Center and related
assumptions and analysis that led to the BRAC decisions.
To assess the potential impacts of disestablishing AFIP on the military
and civilian communities, we interviewed pathologists from AFIP, ARP,
five MTFs and five VA medical centers, as well as civilian pathologists
from four major medical centers. We interviewed representatives from
pathology and radiology associations, including ARP, CAP, the American
Society for Investigative Pathology, the Association of Pathology
Chairs, the American College of Radiology, and the Canadian Association
of Radiologists, to obtain their views regarding the potential impact
of discontinuing AFIP's core services. In addition, we reviewed data
from various reports and other documents to assess the potential impact
of discontinuing the three key services as AFIP currently provides. We
performed our work from March 2007 through November 2007 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II: Maps of the Armed Forces Institute of Pathology's (AFIP)
2006 Consultations:
In 2006, AFIP provided almost half of its consultations for DOD, with
the rest predominantly for VA and civilian physicians. (See fig. 2 for
the 2006 distribution of AFIP's DOD consultations, fig. 3 for its VA
consultations, and fig. 4 for its civilian consultations.)
Figure 2: AFIP's DOD Consultations for 2006:
This figure is a map of the United States, AFIP's DOD consultations for
2006.
[See PDF for image]
Source: GAO summary of AFIP data; Copyright Corel Corp. All rights
reserved; MapArt (map).
[End of figure]
Figure 3: AFIP's VA Consultations for 2006:
This figure is a map of the United States, AFIP's VA consultations for
2006.
[See PDF for image]
Source: GAO summary of AFIP data; Copyright Corel Corp. All rights
reserved; MapArt (map).
[End of figure]
Figure 4: AFIP's Civilian Consultations for 2006:
This figure is a map of the United States, AFIP's civilian
consultations for 2006.
[See PDF for image]
Source: GAO summary of AFIP data; Copyright Corel Corp. All rights
reserved; MapArt (map).
[End of figure]
[End of section]
Appendix III: Description of Services Performed by the Armed Forces
Institute of Pathology (AFIP):
Legal Medicine: Legal Medicine provides consultation, education, and
research on medical legal, quality assurance, and risk management
issues to the Department of Defense (DOD); manages a registry of closed
DOD medical malpractice cases; manages the DOD Centralized Credentials
Quality Assurance System; assists the Uniformed Services University of
the Health Sciences (USUHS) with the masters degree program in Forensic
Sciences; awards continuing medical education (CME) credits in medical
legal, quality assurance, and risk management to nurses and physicians;
and publishes the journals Legal Medicine and Nursing Risk Management.
National Museum of Health and Medicine: The National Museum of Health
and Medicine was established during the Civil War as the Army Medical
Museum. The Museum promotes the understanding of medicine from past,
present, and future, with a special emphasis on American military
medicine. It has five major collections: Anatomical, Historical, Otis
Historical Archives, Human Developmental Anatomy Center, and
Neuroanatomical, which are estimated to contain more than 24 million
objects.
Repository: The National Pathology Repository contains approximately 3
million case files and associated paraffin blocks, microscopic glass
slides, and formalin-fixed tissue specimens. Tens of thousands of cases
are added to the repository each year. Staff code all material for
future research use.
The Office of the Armed Forces Medical Examiner, DNA (deoxyribonucleic
acid) Registry, and Accident Investigation: The Office of the Armed
Forces Medical Examiner conducts scientific forensic investigations for
determining the cause and manner of death of members of the Armed
Forces and of civilians whose deaths come under exclusive federal
jurisdiction. The office provides consultative services in forensic
pathology, forensic toxicology, forensic anthropology, and DNA
technology, as well as on-site medical legal investigations of military
accidents. It is the only federal resource of its kind, so other
federal agencies frequently use its services. The DOD DNA Registry is
at the forefront of nuclear and mitochondrial DNA technology, supports
the Office of the Armed Forces Medical Examiner in identification, and
serves as the repository for specimens obtained from military personnel
to be used for identification.
Enlisted histology technician training: The Tri-Service School of
Histotechnology is the only military histopathology training program,
according to a DOD official. It consists of 180 training days in the
technical operations of anatomic pathology. Training includes
instruction in the theory and application of histotechnology and
practical training in the fixation, processing, embedding, microtomy,
and staining of tissue specimens prior to examination by a pathologist.
The curriculum also includes instruction and practical experience as a
postmortem examination (autopsy) assistant.
Program Management Office (PMO): The PMO will be newly established to
coordinate pathology results, contract administration, and quality
assurance and control of DOD second-opinion consults worldwide.
DOD Veterinary Pathology Residency Program: The DOD Veterinary
Pathology Residency Program is a 3-year postdoctoral training program.
Residents are involved in consultation, education, and research during
the program. The residency culminates in a 2-day examination given by
the American College of Veterinary Pathologists, and successful
completion of this examination results in board certification in
veterinary anatomic pathology.
Automated Central Tumor Registry: The Automated Central Tumor Registry
provides the uniformed services MTFs with the capability to compile,
track, and report cancer data on DOD beneficiaries. The objective of
the registry is to maintain a research quality database for cancer
reporting that supports outcome analysis, referral patterns, trend
analysis, statistical reporting, health care analysis, epidemiology,
and uniform data collection and tracking.
Center for Clinical Laboratory Medicine: The Center for Clinical
Laboratory Medicine directs the operation of the DOD Clinical
Laboratory Improvement Program, as defined by DOD Instruction 6440.2
and Public Law No. 100-578; administers law and federal policy for
military medical laboratory operations in peace, contingency, and
wartime, ensuring that no restrictions or cessation of laboratory
services impedes DOD mission requirements; and acts as gatekeeper for
DOD and Centers for Disease Control and Prevention (CDC) initiatives to
develop a biological warfare detection and response system, that is,
National Laboratory Response Network.
Patient Safety Center: The Patient Safety Center manages a
comprehensive patient safety data registry for DOD. The DOD Patient
Safety Registry is a database that gathers standardized clinically
relevant information about all instances and categories of actual
events and close calls. This registry is used to identify and provide
feedback on systemic patterns and practices that place DOD patients at
risk, and thereby it stimulates, initiates, and supports local
interventions designed to reduce risk of errors and to protect patients
from inadvertent harm. The Patient Safety Center publishes DOD Patient
Safety Alerts, and it produced the first Patient Safety Toolkit
targeting patient fall reduction.
Diagnostic telepathology: The practice of pathology involves using
telecommunications to transmit data and images between two or more
sites remotely located from each other, according to a DOD official.
The data include clinical information about the patient, such as signs,
symptoms, treatment, and response; gross description of the surgical
specimen(s); and digital images of the processed specimen. These data
are transmitted electronically, allowing a pathologist practicing in a
geographically distant site to consult another pathologist for a second
opinion, or to consult other pathologists who are experts on particular
disease processes.
Biodefense Project - The Joint Biological Agent Identification and
Diagnostic System: The Joint Biological Agent Identification and
Diagnostic System pertains to a rapid identification and diagnostic
confirmation of biological agent exposure or infection, according to a
DOD official. The standalone system consists of a portable unit to
perform sample analysis, a laptop computer for readout display and
assay reagent test kits to identify multiple biological warfare agents,
infectious disease agents, and biological toxins.
Biodefense Project - The Critical Reagent Program: The Critical Reagent
Program provides bulk quantities of DNA extracted from selected
biological threat agents, according to a DOD official. These are then
used to develop validated, high-quality immunological and DNA-based
biodetection reagents to support different biological warfare agent
detector platforms.
Reserve Biological Select Agent Inventory: The Reserve Biological
Select Agent Inventory is registered with CDC and with the Army Medical
Command, and includes over 1,500 strains of controlled biological
select agents and toxins, according to a DOD official. These are stored
in freezers in secure Biosafety Laboratory level 3 areas of AFIP.
Storage, use, and transfer of any agents or toxins is strictly
controlled and regulated by CDC and Army regulations.
Depleted uranium (DU) testing: DU Urine Testing supports medical
surveillance programs by measuring the levels of uranium in patients'
urine and identifies the specific source of exposure by accurately
measuring uranium isotopic ratios, according to a DOD official. DU
Testing in Body Fluids and Tissue provides chemical analysis of
embedded DU fragments in tissues removed from shrapnel wounds.
Cystic fibrosis testing: A test for cystic fibrosis is one of several
tests for genetically inherited diseases that are recommended by the
Department of Health and Human Services' Health Resources and Services
Administration and the American College of Medical Genetics. AFIP
ceased cystic fibrosis testing on June 1, 2007. All DOD cystic fibrosis
tests are currently being performed by commercial labs or other DOD
labs.
[End of section]
Appendix IV: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
1200 Defense Pentagon:
Washington. DC 20301-1200:
October 26, 2007:
Mr. Randall Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, N.W.:
Washington, DC 20548:
Dear Mr. Williamson:
This is the Department of Defense's (DoD) response to the Government
Accountability Office (GAO) draft report, GAO 08-20, "Military Base
Closures: Impact of Terminating, Relocating, or Outsourcing the
Services of the Armed Forces Institute of Pathology," dated October 5,
2007 (GAO Code 290622).
Thank you for the opportunity to review and comment on the draft
report. Overall, the Department concurs with the report's findings and
conclusions. Our response to the recommendations is enclosed. DoD
concurs with Recommendation 1, and partially concurs with
Recommendation 2- Input was obtained from the Armed Forces Institute of
Pathology (AFIP), the Uniformed Services University of Health Sciences
(USUHS), the Military Departments, and the DoD Office of the General
Counsel.
The GAO's overall finding was that discontinuing, relocating, or
outsourcing AFIP services may have minimal impact on DoD, VA, and
civilian communities because pathology services are available from
alternate sources. A smooth transition depends on DoD's actions to
address the challenges in developing new approaches to obtaining
pathology expertise and managing the repository. The report states that
while DoD has begun to identify the challenges, it has not developed
strategies to address them. In addition, DoD has not developed its
strategies to determine whether the repository will continue to be a
rich resource for civilian and military research.
While we agree with the description of the challenges, we would like to
emphasize that we are actively pursuing alternatives to develop the
best courses of action for the Program Management Office and the Tissue
Repository- These will be coordinated across the Department, and with
the Veterans Administration, to ensure we develop a strategy that will
meet the Department's needs, assist the VA as much as possible, and be
in accordance with the BRAC recommendations.
My points of contact on this audit are Dr. Benedict Diniega
(Functional) at (703) 681-1703 and Mr. Gunther Zimmerman (Audit
Liaison) at (703) 681-4360.
Sincerely,
Signed by:
S. Ward Casscells, MD:
Enclosure:
As stated:
GAO Draft Report–dated October 5, 2007 (GAO CODE 290622/GAO-08–20)
"Military Base Closures: Impact of Terminating, Relocating, or
Outsourcing the Services of the Armed Forces Institute of Pathology"
Department Of Defense Comments To The Gao Recommendations:
Recommendation 1: The GAO recommends that the Secretary of Defense
include in his December 2007 plan to the Congress implementation
strategies for how DoD will use existing in-house pathology expertise
available within MTFs, identify and obtain needed consultation services
from subspecialty pathologists with appropriate expertise through the
PMO in a timely manner, and solidify the source and organization of
funds to be used for outsourced consultation services.
DOD Response: Concur. The AFIP established a work group to develop
courses of action for optimal utilization of in-house pathology
expertise and the PMO. After legal review of the initial concepts, the
members of the work group continue to refine their concept for
consideration by the senior medical leadership. The approved strategy
will be included in the December 2007 report to Congress.
Recommendation 2: The GAO recommends that the Secretary of Defense
within six months of completion of its study regarding the usefulness
of the pathology material in the repository that is to be finished by
2008, should require USUHS to provide its implementation strategies on
how it will populate, manage, and use the repository to the Congress.
The implementation strategies should include information on how USUHS
intends to use pathology expertise to manage the material, obtain
pathology material from a wide variety of individuals, maximize
availability of the repository for research through cooperative
ventures with other academic institutions and assist interested groups
if any, in supporting the continuation of educational services such as
the Radiologic-Pathologic Correlation course.
DOD Response: Partially Concur. The Department agrees with providing a
report six months after completion of the evaluation contract, to
provide information on the status of the repository assets and their
research utility potential. The content of the report, however, will
not include an implementation strategy. USUHS awarded a contract to
evaluate the usefulness of the pathology material in the repository and
the results will be available October 2008. At that time, USUHS plans
to convene a panel of experts to develop a blueprint for a roadmap on
how to use the repository for research. This will most likely result in
another contracting action to develop a strategy with details as to how
USUHS will populate, manage, and use the repository. Therefore, a
report submitted within six months of completion of the current
contract will not include the implementation strategies and detail
contained in Recommendation 2. USUHS will develop implementation
strategies, based on the results of the panel and the necessary
studies, to optimize populating the repository. For example, an
agreement with the Veterans Administration could provide specimens for
the repository. However, USUHS does not anticipate continuing the
Radiologic-Pathologic Correlation course, or any other educational
courses, as a means of populating the repository. In addition, based
upon the evaluation results, and recommendations from the panel of
experts, USUHS may pursue cooperative ventures not just with other
academic organizations, but with federal and non-federal research
organizations, and other public and private organizations as well.
[End of section]
Appendix V: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
October 25, 2007:
Mr. Randall B. Williamson:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Williamson:
The Department of Veterans Affairs (VA) has reviewed your draft report,
Military Base Closures: Impact of Terminating, Relocating, or
Outsourcing the Services of the Armed Forces Institute of Pathology
(GAO-08-20).
While the draft report is in general factually accurate, it does not
underscore that maintenance of the Armed Forces Institute of
Pathology's (AFIP) services and expertise are essential for both VA and
the Department of Defense (DoD). Neither does the report fully address
the impact of closing the AFIP on patient care, which is paramount for
both VA and DoD.
The enclosure provides more detailed comments on VA's concerns with
GAO's report as currently written. Thank you for the opportunity to
comment on your draft report.
Sincerely yours,
Signed by:
Gordon H. Mansfield:
Acting:
Enclosure:
Department of Veterans Affairs (VA) Comments to the
Government Accountability Office (GAO) draft report, Military Base
Closures: Impact of Terminating, Relocating, or Outsourcing the
Services of the Armed Forces Institute of Pathology (GAO-08-20):
The Department of Veterans Affairs (VA) believes GAO's draft report
insufficiently describes some of the considerable losses associated
with the closing of the Armed Forces Institute of Pathology (AFIP).
This discusses briefly some of those limitations.
The AFIP support in the Depleted Uranium (DU) testing program, as well
as the toxicological testing related to other potentially harmful
embedded fragments (e.g. cobalt, nickel, tungsten) are not emphasized
in GAO's draft report. These testing services are essential to provide
high quality health care to recently injured combat veterans- AFIP
maintains a large archive of veteran pathology specimens that could be
invaluable for historical comparative purposes in future clinical and
research endeavors. Stagnation of this repository, and the disbandment
of key technical staff with broad expertise that will be extremely
difficult to replicate, are likely to occur upon closure of AFIP. The
report also does not address sufficiently the potential cost impact of
this change, which may or may not be minimal.
In addition, some of the other services the AFIP provides are not
presently available from any other source (e.g. the uranium studies).
The report cites Massachusetts General, M D Anderson, and Johns Hopkins
as institutions that have multi and subspecialty pathology expertise,
and that these institutions handle 60,000 consultations a year.
However, the report does not address if any of these institutions have
the excess capacity to absorb the AFIP workload. Other than the casual
allusion to these academic centers, the draft report does not identify
(or suggest the requirements of) any potential replacement resource for
the AFIP's services. Due to the potential high cost in procuring
alternative sources for the consultative services as well as the
limited availability of some of the other services the AFIP provides,
we believe the impacts to both the Department of Defense (DoD) and VA
are significant.
The report also does not fully discuss the impact of the closure of the
AFIP on patient care. The report documents the large percentage of
cases that the AFIP reviews and how the AFIP review changes the
diagnosis. However, the report is silent on the significance of this
finding for proper patient care. The report mentions that the
"timeliness" of services is of critical concern to DoD and VA, but
again is silent on the significance of this finding for proper patient
care.
Further, the report does not address the significant changes in
business practices that the closure of the AFIP will cause at the local
facility level. The Program Management Office (PMO) specified in the
Base Realignment and Closure (BRAG) law will just add another
administrative entity that does not currently exist- Adding an
additional administrative layer increases costs and has the potential
to impact adversely the timeliness of consultations, which ultimately
results in degrading patient care. The loss of "one stop shopping" and
the addition of an intermediate entity, the PMO, will make
administrative processes at the local level more complex and reduce
efficiency.
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Acknowledgments:
In addition to the contact named above, Sheila Avruch, Assistant
Director; Adrienne Griffin; Cathy Hamann; Nora Hoban; Jasleen Modi;
Carolina Morgan; and Andrea Wysocki made key contributions to this
report.
[End of section]
Related GAO Products:
Military Base Realignments and Closures: Transfer of Supply, Storage,
and Distribution Functions from Military Services to Defense Logistics
Agency. GAO-08-121R. Washington, D.C.: October 26, 2007.
Defense Infrastructure: Challenges Increase Risks for Providing Timely
Infrastructure Support for Army Installations Expecting Substantial
Personnel Growth. GAO-07-1007. Washington, D.C.: September 13, 2007.
Military Base Realignments and Closures: Plan Needed to Monitor
Challenges for Completing More Than 100 Armed Forces Reserve Centers.
GAO-07-1040. Washington, D.C.: September 13, 2007.
Military Base Realignments and Closures: Observations Related to the
2005 Round. GAO-07-1203R. Washington D.C.: September 6, 2007.
Military Base Closures: Projected Savings from Fleet Readiness Centers
Likely Overstated and Actions Needed to Track Actual Savings and
Overcome Certain Challenges. GAO-07-304. Washington, D.C.: June 29,
2007.
Military Base Closures: Management Strategy Needed to Mitigate
Challenges and Improve Communication to Help Ensure Timely
Implementation of Air National Guard Recommendations. GAO-07-641.
Washington, D.C.: May 16, 2007.
Military Base Closures: Opportunities Exist to Improve Environmental
Cleanup Cost Reporting and to Expedite Transfer of Unneeded Property.
GAO-07-166. Washington, D.C.: January 30, 2007.
Military Bases: Observations on DOD's 2005 Base Realignment and Closure
Selection Process and Recommendations. GAO-05-905. Washington, D.C.:
July 18, 2005.
Military Bases: Analysis of DOD's 2005 Selection Process and
Recommendations for Base Closures and Realignments. GAO-05-785.
Washington, D.C.: July 1, 2005.
Armed Forces Institute of Pathology: Business Plan's Implementation Is
Unlikely to Achieve Expected Financial Benefits and Could Reduce
Civilian Role. GAO-05-615. Washington, D.C.: June 30, 2005.
Military Base Closures: Updated Status of Prior Base Realignments and
Closures. GAO-05-138. Washington, D.C.: January 13, 2005.
Military Base Closures: Assessment of DOD's 2004 Report on the Need for
a Base Realignment and Closure Round. GAO-04-760. Washington, D.C.: May
17, 2004.
Military Base Closures: Observations on Preparations for the Upcoming
Base Realignment and Closure Round. GAO-04-558T. Washington, D.C.:
March 25, 2004.
[End of section]
Footnotes:
[1] Pathology is the study of bodily changes due to disease, injury, or
other medical conditions, and it can lead to advancements in diagnosis
and treatment.
[2] Through the BRAC process, DOD can recommend closing or realigning
military facilities to reorganize its structure and facilitate new ways
of doing business. These recommendations are reviewed by the
independent BRAC Commission. The BRAC Commission then issues its
recommendations to the President. After the President approves the
recommendations, they are forwarded to Congress, which has 45 days to
disapprove the recommendations on an all-or-none basis; if Congress
does not act, the recommendations become binding.
[3] The National Pathology Repository, located at AFIP, stores material
coded by pathologic diagnosis. The National Pathology Repository
currently stores over 2.8 million cases coded since 1917. The material
includes written records and over 50 million microscopic slides, 30
million paraffin tissue blocks, and 12 million preserved wet tissue
specimens. Cases represent the entire spectrum of human disease,
including both sexes, all races/ethnicities, all ages, as well as
animal disease, and come from contributors worldwide. Hereafter, the
National Pathology Repository is referred to as the repository.
[4] See 10 U.S.C. § 176(b)(1)(A).
[5] See Defense Base Closure and Realignment Act of 1990, Pub. L. No.
101-510, § 2904(a)(5), codified as amended at 10 U.S.C. § 2687, note.
[6] In this report, we refer to this as the BRAC provision.
[7] GAO, Armed Forces Institute of Pathology: Business Plan's
Implementation Is Unlikely to Achieve Expected Financial Benefits and
Could Reduce Civilian Role, GAO-05-615 (Washington, D.C.: June 30,
2005).
[8] USUHS consists of a military medical school and graduate nursing
school and provides doctoral and masters degrees in biomedical and
public health. It is affiliated with major military teaching hospitals,
such as Walter Reed Army Medical Center and Wilford Hall Medical
Center. Additionally, USUHS is affiliated with the Washington Hospital
Center, a major civilian teaching hospital.
[9] See U.S. Troop Readiness, Veterans' Care, Katrina Recovery and Iraq
Accountability Appropriations Act, Pub. L. No. 110-28, § 3702, 121
Stat. 112, 144-45 (2007). This law requires DOD to take into account
this GAO report as it develops its detailed plan and timetable for the
proposed reorganization and relocation of AFIP, if the GAO report is
available on or before November 16, 2007. DOD is required to submit its
plan no later than December 31, 2007.
[10] See Pub. L. No. 94-361, § 811, 90 Stat. 923, 933-34 (codified at
10 U.S.C. § 176).
[11] Id. at 90 Stat. 934-36 (codified at 10 U.S.C. § 177).
[12] From 1998 to 2002, AFIP was the subject of three program decision
memorandums (documents used by DOD for planning and managerial
oversight), four major DOD reviews, and two DOD Inspector General
reviews.
[13] See Pub. L. No. 107-107, § 3002, 115 Stat. 1012, 1344-45 (2001)
(codified at 10 U.S.C. § 2687, note). This law authorized the 2005 BRAC
round and revised some of the BRAC procedures. The law also required
DOD to publish its final selection criteria in the Federal Register,
which DOD did in February 2004. See 69 Fed. Reg. 6948-52 (Feb. 12,
2004).
[14] The BRAC Commission is an independent body that has the authority
to change the Secretary's recommendations if it determines that the
Secretary deviated substantially from the selection criteria. See Pub.
L. No. 101-510, § 2903 (codified as amended at 10 U.S.C. § 2687, note).
The commission then makes recommendations to the President for approval
or disapproval. After the President approves the recommendations, he
transmits them to Congress. The recommendations become binding 45
legislative days after presidential transmission or at the adjournment
of Congress, unless Congress enacts a joint resolution disapproving the
recommendations.
[15] See Pub. L. No. 101-510, § 2904 (codified as amended at 10 U.S.C.
§ 2687, note).
[16] Unlike general pathologists, subspecialty pathologists specialize
in a particular organ system and gain additional exposure, experience,
and expertise in diseases and conditions affecting the tissues of that
system than general pathologists.
[17] When AFIP receives a case for consultation, staff assign the case
to the appropriate subspecialty department based on the requesting
physician's indications. AFIP's structure allows pathologists to
consult with their colleagues who have expertise in different
subspecialties as needed.
[18] Pathology material includes paraffin blocks that enclose preserved
tissue, gross tissue samples, microscopic glass slides, and clinical
records such as X-rays and photographs.
[19] GAO-05-615, 22-27.
[20] According to AFIP pathologists, confirmation of an initial
diagnosis is important because physicians seeking a consultation
generally do not begin treating a patient until another pathologist
confirms that the initial diagnosis is correct.
[21] In 2006, AFIP offered six courses, including the Radiologic-
Pathologic Correlation course, targeted to medical residents.
Practicing physicians are permitted to attend any of AFIP's courses for
residents and may earn CME credit for attendance.
[22] DOD attendees include both active duty military personnel and
physicians employed by DOD as federal government employees.
[23] Unlike the consultation process, the Systematic External Review of
Surgicals program is a peer review or quality assurance process. VA
policy requires its pathologists to submit cases--in which the VA
pathologist already rendered a diagnosis--to AFIP. Then, AFIP
subspecialty pathologists review the rendered diagnosis for quality
review purposes and provide feedback to the pathologist who submitted
the case in an effort to improve the practice of pathology.
[24] ARP holds the copyright for these fascicles.
[25] There are different types of fascicles, for example Tumors of the
Kidney, Bladder, and Related Urinary Structures and Non-Neoplastic
Disorders of the Lower Respiratory Tract.
[26] AFIP also maintains, in conjunction with ARP, over 30
international registries, such as Depleted Uranium, Agent Orange, and
tumor registries. A comprehensive database of disease diagnoses and
patient demographic data, incorporating all cases ever reviewed at
AFIP, is available to researchers.
[27] See GAO-05-615. A research protocol is a detailed proposal,
approved by AFIP's research committee, which describes the research
that will be completed.
[28] Section 3702 of the appropriations act requires DOD to take into
account this GAO report as it develops its detailed plan and timetable
for the proposed reorganization and relocation of AFIP, if this GAO
report is available on or before November 16, 2007. This effectively
suspends the disestablishment and relocation of AFIP services until DOD
submits its plan to Congress; the deadline for submission is December
31, 2007.
[29] The BRAC Commission recommended that DOD realign Walter Reed Army
Medical Center, Washington, D.C., as follows: relocate all tertiary
(subspecialty and complex care) medical services to National Naval
Medical Center, Bethesda, Maryland, establishing it as the new Walter
Reed National Military Medical Center, Bethesda, Maryland.
[30] These key DOD officials include the Surgeon General of the Army,
Surgeon General of the Navy, Surgeon General of the Air Force,
President of USUHS, and Deputy Director of TRICARE Management Activity.
[31] DOD's most recent BRAC implementation plan pertaining to AFIP was
developed in February 2007.
[32] The American Board of Pathology recognizes 10 different areas of
subspecialty pathology such as cytopathology, dermatopathology, and
forensic pathology. Other areas of specialty expertise are recognized
by military and civilian pathologists from major medical centers we
interviewed such as genitourinary, gynecology, and breast pathology.
Thus, military and civilian medical centers determine the number of
subspecialties they have in accordance with the different
subspecialties recognized by the American Board of Pathology as well as
those that focus on particular cancers.
[33] The VA DU program is responsible for providing clinical
surveillance to veterans and active duty personnel who have the highest
risk of DU exposure (primarily those with retained DU fragments).
Currently, the DU program relies on AFIP to perform analyses of
specimens from veterans and active duty personnel potentially exposed
to DU. The AFIP laboratory is one of the few facilities nationwide that
are able to measure very low concentrations of uranium in urine, blood,
and semen specimens with a high degree of accuracy and to discriminate
between natural uranium and depleted uranium based on isotopic
analysis.
[34] The study of the material in the repository would include a review
of the physical tissue samples (i.e., clinical records, blocks of
tissue embedded in paraffin, slides, and gross samples of tissue) and
the quality of the linkage between the medical record and tissue
samples.
[35] GAO, Military Base Realignments and Closures: Observations Related
to the 2005 Round, GAO-07-1203R (Washington, D.C.: Sept. 6, 2007).
[36] GAO, Armed Forces Institute of Pathology: Business Plan's
Implementation Is Unlikely to Achieve Expected Financial Benefits and
Could Reduce Civilian Role, GAO-05-615 (Washington, D.C.: June 30,
2005).
[37] U.S. Army Audit Agency, Armed Forces Institute of Pathology, Audit
Report: A-2006-0170-FFH (Alexandria: August 2006).
[38] BearingPoint, Review of Armed Forces Institute of Pathology
Capabilities Recommended for Disestablishment by the Defense Base
Closure and Realignment Commission 2005, May 2006.
[39] Emphasis would be placed on preserving AFIP consultation services
to military and other federal customers until the PMO is operational,
with earlier disestablishment of AFIP research and education
activities.
GAO's Mission:
The Government Accountability Office, the audit, evaluation, and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, DC 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, DC 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, DC 20548:
