BACKGROUND/RATIONALE:
In 2007, VA implemented a national clinical reminder (CR) to screen for mild traumatic brain injury (mTBI). Veterans who have positive results on the mTBI CR are then referred for a comprehensive TBI evaluation (CTE). There is limited information available about the associations between patient characteristics and facility characteristics and receipt of screening, or subsequent healthcare utilization.

OBJECTIVE(S):
To describe characteristics associated with completion of the mTBI CR; describe screening results on the mTBI CR; examine healthcare utilization after screening among Veterans who complete the mTBI CR; and examine characteristics associated with receipt and results of the CTE. Additional objectives included cost-identification analysis to estimate the cost of the CR, CTE, and follow-up care, and primary data collected from polytrauma care team members regarding factors that influence coordination of care for mTBI.

METHODS:
This was a retrospective study of OEF/OIF Veterans eligible for the mTBI screen utilizing national mTBI CR and CTE data and VA utilization data. Patient characteristics and healthcare utilization was examined using VA Medical SAS datasets and DSS. We used multilevel regression models to examine the association between receipt of screen, screening results, and health care utilization following the screen. We described the results of the CTE and the association between patient characteristics, elements of the mTBI CR, and the results of the CTE. We also conducted a cost identification analysis utilizing DSS data, administered an online survey, and conducted semi-structured interviews with polytrauma care team members.

FINDINGS/RESULTS:
Over 91% of eligible Veterans completed the mTBI CR. Being older, service connected, multiple deployments, a PTSD diagnosis, or more outpatient visits increased odds of completing the CR whereas being Hispanic, higher copay priority, service in the navy and separation greater than one year decreased the likelihood of completing the CR. Additionally, CBOCs were more likely to complete the CR than other facility types. Of those screened, 20.5% had positive results. For veterans with a positive CR who attend the CTE, almost half had a result indicating the findings were consistent with mild TBI. There was a substantial association between PTSD and mild TBI. The majority of Veterans (91%) reported pain symptoms within the last 30 days during CTE. Veterans with positive CR and/or CTE had substantially more primary, secondary and mental healthcare utilization. Visits for CRs and CTEs cost $400-$470, $665-$710, respectively. Total annual VA costs were higher for patients with positive, negative, or no CR ($9300, $5500, $3400, respectively) and CTE ($12,000, $10,000, $8300, respectively), due primarily to higher outpatient costs. Survey/interview data collected from polytrauma care team members revealed that coordination of care was complicated by a variety of system and individual-level factors, particularly the ability to access non-VA medical records, lack of time, Veteran missed appointments, and Veteran concurrent mental health issues.

IMPACT:
Identifying similarities/differences between Veterans screened and not screened for mTBI provides valuable feedback to VHA that can improve screening/evaluation compliance. Insights regarding the associations between the mTBI CR and the CTE are crucial for developing effective programs to screen and treat mTBI.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Evans CT, St Andre JR, Pape TL, Steiner ML, Stroupe KT, Hogan TP, Weaver FM, Smith BM. An evaluation of the Veterans Affairs traumatic brain injury screening process among Operation Enduring Freedom and/or Operation Iraqi Freedom veterans. PM & R : the journal of injury, function, and rehabilitation. 2013 Mar 1; 5(3):210-20; quiz 220. [view]
2. Oleksiak M, Smith BM, St Andre JR, Caughlan CM, Steiner M. Audiological issues and hearing loss among Veterans with mild traumatic brain injury. Journal of rehabilitation research and development. 2013 Aug 12; 49(7):995-1004. [view]
3. Smith BM, Martinez RN, Evans CT, Saban KL, Balbale S, Proescher EJ, Stroupe K, Hogan TP. Barriers and strategies for coordinating care among veterans with traumatic brain injury: a mixed methods study of VA polytrauma care team members. Brain injury. 2018 Mar 14; 32(6):755-762. [view]
4. Saban KL, Hogan TP, Defrino D, Evans CT, Bauer ED, Pape TL, Steiner M, Proescher EJ, Vlasses FR, Smith BM. Burnout and coping strategies of polytrauma team members caring for veterans with traumatic brain injury. Brain injury. 2013 Aug 21; 27(3):301-9. [view]
5. Hogan T, Martinez R, Evans C, Saban K, Proescher E, Steiner M, Smith B. Clinical information seeking in traumatic brain injury: a survey of Veterans Health Administration polytrauma care team members. Health information and libraries journal. 2018 Mar 1; 35(1):38-49. [view]
6. Stroupe KT, Smith BM, Hogan TP, St Andre JR. Healthcare utilization and costs of Veterans screened and assessed for traumatic brain injury. Journal of rehabilitation research and development. 2013 Nov 1; 50(8):1047-68. [view]

HSR&D or QUERI Articles

1. Smith BM, Evans (Mayfield) C. Mild Traumatic Brain Injury: Screening and Comorbidities. FORUM. 2013 Aug 1; 5. [view]

Conference Presentations

1. Evans (Mayfield) C, Pape TL, St. Andre JR, Steiner M, Li K, Miskevics SA, Stroupe KT, Hogan TP, Smith BM. An evaluation of the VA TBI screening clinical reminder among OEF/OIF Veterans and active duty service members. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD. [view]
2. Smith BM, Hogan TP, Saban KL, Evans (Mayfield) C, Stroupe KT, St. Andre JR, Steiner ML. Communicating to increase coordination of care for traumatic brain injury. Poster session presented at: International Conference on Communication in Healthcare; 2011 Oct 17; Chicago, IL. [view]
3. Herrold AA, Babcock-Parziale J, High WB, Smith BM, Evans (Mayfield) C, Urban A, Noblett K, Pape TL. Effects of Alcohol Use in Veterans with Mild TBI and/or Behavioral Health Conditions. Poster session presented at: American Congress of Rehabilitation Medicine / American Society of Neuroradiology Annual Meeting; 2011 Oct 12; Atlanta, GA. [view]
4. Herrold AA, High WM, Smith BM, Evans (Mayfield) C, Urban A, Noblett K, Pape TL, Babcock-Parziale JL. Effects Of Alcohol Use On Patient Outcomes In Veterans With Mild TBI and/or Behavioral Health Symptoms. Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 13; Washington, DC. [view]
5. Smith BM. Evaluation of TBI Screening Processes and Healthcare Utilization. Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 13; Washington, DC. [view]
6. Hogan TP, Saban KL, Evans (Mayfield) C, Stroupe KT, St. Andre JR, Urban A, Smith BM. Provider information seeking and communication about traumatic brain injury. Paper presented at: International Conference on Communication in Healthcare; 2011 Oct 17; Chicago, IL. [view]
7. Smith BM, Evans (Mayfield) C, Hogan TP, Stroupe KT, St. Andre JR, Moll K, Pape TL, Saban KL, Steiner M. Results of the Comprehensive TBI Evaluation for Veterans Returning From OEF/OIF. Paper presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD. [view]

DRA: Military and Environmental Exposures, Health Systems, Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders
DRE: Prevention
Keywords: Traumatic Brain Injury, Utilization patterns
MeSH Terms: none