2012 HSR&D/QUERI National Conference Abstract
1091 — Experts’ Uncertainty about Diagnostic Criteria for a Remote Mild Traumatic Brain Injury
Babcock-Parziale JL, Southern AZ VA Healthcare System; McKnight PE, George Mason Univeristy; Pape TL, Hines VAMC; High WM, Lexington VAMC;
A systematic review (1990 – 2011) of diagnostic studies for Mild Traumatic Brain Injury (mTBI) identified 13 studies examining the accuracy of nine diagnostic instruments. These studies examined instruments for acute mTBI; no studies investigated historic mTBI where a patient presents for care months or years after the mTBI exposure(s). The primary study aim was to determine whether a multidisciplinary panel of mTBI experts could reach consensus on diagnostic criteria.
We conducted an online Delphi survey with ten experts (5 VA, 5 non-VA) and 24 questions representing mTBI issues. The structured, interactive survey presented 14 diagnostic and 10 treatment preference questions. Questions were administered sequentially to experts blinded to each other’s identity. The process allowed participants to see how closely they responded to the other experts. Each question was allowed a maximum of eight iterations unless consensus occurred sooner. Experts provided written justifications for their final ratings for questions that lacked consensus.
Experts converged on 8 of the 14 diagnostic questions but remained neutral on their importance. None of the ten treatment questions reached consensus. Fifty-percent endorsed loss of consciousness (LOC) and 30% endorsed alteration of consciousness (AOC) as sufficient to diagnose mTBI. Although these items reached consensus, some experts agreed that LOC and AOC were sufficient criteria while 40% remained undecided about the importance of these criteria. Only 10% agreed that it is possible to determine if confusion or poor memory for an event is due to mTBI or psychological reasons. All experts agreed that it is unlikely a person would not notice cognitive functioning changes several months after an mTBI.
Experts lacked consensus about diagnostic criteria for a historic mTBI and their uncertainty mimics that seen in the field and the literature. While the experts recognized the lack of certainty regarding the importance of the diagnostic criteria, they could not agree on treatments.
Experts’ opinions lack consensus and clinical certainty for diagnosing a historic mTBI. This uncertainty, combined with current variation in the implementation of VA’s mTBI screening and evaluation process, is likely to affect the diagnostic precision and accuracy.