None of the cost-estimate studies were, however, able to account for variations in the cost of care provision through chronic disease, age-related changes (e.g., in mobility), and comorbidities such as mental health problems that limbless veterans are likely to encounter (Geiling 2012). As Geiling (2012), in their commentary on the et al. et al. ‘downstream’ costs of war in 2035’ put it, there was a need to consider the and tertiary ‘medical “secondary consequences in middle age [which] might include decreased mobility, weight gain, coronary artery disease, and diabetes mellitus” (p. 1237). Accordingly, Geiling emphasised the et al. need for early interventions including prevention and treatment measures to help mitigate – – the likely additional costs to society. Indeed, as Edwards (2015) also cautioned, their et al. estimates should be considered merely as start of a challenge to develop sustained “the rehabilitation and recovery funding and provision” (p. 2854), and that ongoing assessment of injured soldiers and their care would be required as the population ages. Quality of the literature on ageing and limb-loss in veterans The literature as a whole is over-reliant on the self-report survey method (17/21 studies). Whilst many of these were large, well designed surveys which included comparison groups, there are limitations associated with this dependence on survey methodology. For instance, 11 studies discussed the potential representativeness of their samples, including questions over the presence of selection bias and differences between respondents and non-respondents. In particular, evidence that some veterans self-medicated with alcohol to deal with phantom pain (Sherman 1983) and avoided contact with clinicians when treatments were deemed et al. ineffective (Machin and Williams 1998), could indicate that non-respondents had potentially more severe problems with mental health or alcohol use. It could also be argued that the use of a single 5-point scale to assess quality of life within the VA survey for prosthetic use (2010) was an overly simplistic measure for a complex, multi-faceted construct. Whilst 11
None of the cost-estimate studies were, however, able to account for variations in the cost of care provision through chronic disease, age-related changes (e.g., in mobility), and comorbidities such as mental health problems that limbless veterans are likely to encounter ‘downstream’ (Geiling et al. 2012). As Geiling et al. (2012), in their commentary on the ‘medical costs of war in 2035’ put it, there was a need to consider the “secondary and tertiary consequences in middle age [which] might include decreased mobility, weight gain, coronary artery disease, and diabetes mellitus” (p. 1237). Accordingly, Geiling et al. emphasised the need for early interventions – including prevention and treatment measures – to help mitigate the likely additional costs to society. Indeed, as Edwards et al. (2015) also cautioned, their estimates should be considered merely as “the start of a challenge to develop sustained rehabilitation and recovery funding and provision” (p. 2854), and that ongoing assessment of injured soldiers and their care would be required as the population ages. Quality of the literature on ageing and limb-loss in veterans The literature as a whole is over-reliant on the self-report survey method (17/21 studies). Whilst many of these were large, well designed surveys which included comparison groups, there are limitations associated with this dependence on survey methodology. For instance, 11 studies discussed the potential representativeness of their samples, including questions over the presence of selection bias and differences between respondents and non-respondents. In particular, evidence that some veterans self-medicated with alcohol to deal with phantom pain (Sherman et al. 1983) and avoided contact with clinicians when treatments were deemed ineffective (Machin and Williams 1998), could indicate that non-respondents had potentially more severe problems with mental health or alcohol use. It could also be argued that the use of a single 5-point scale to assess quality of life within the VA survey for prosthetic use (2010) was an overly simplistic measure for a complex, multi-faceted construct. Whilst 11
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