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2023 HSR&D/QUERI National Conference Abstract

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4037 — Comparing Specialty Service Utilization Associated with Veterans Health Administration’s Traumatic Brain Injury and Mental Health Screening Programs

Lead/Presenter: Hari Venkatachalam,  Research Service, James A Haley Veterans’ Hospital
All Authors: Venkatachalam HH (Research Service, James A Haley Veterans’ Hospital, Tampa, FL), Miles SR (Mental Health and Behavioral Sciences, James A Haley Veterans’ Hospital, Tampa, FL) Sayer NA (Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN) Belanger H (Department of Psychology, University of South Florida, Tampa, FL) Kozel FA (Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Florida State University, Tallahassee, FL) Toyinbo PA (Research and Development Service, James A Haley Veterans’ Hospital, Tampa, FL) McCart JA (Research and Development Service, James A Haley Veterans’ Hospital, Tampa, FL) Luther SL (Research and Development Service, James A Haley Veterans’ Hospital, Tampa, FL)

Objectives:
In 2007, the Veterans’ Health Administration (VHA) added a post-deployment traumatic brain injury (TBI) screen for recent combat veterans to identify possible TBI exposure. However, symptoms after mild TBI overlap with Mental Health (MH) disorders, making it unclear whether the TBI screen facilitated access to specialty care services over and beyond existing MH screens, specifically screens for PTSD (PC-PTSD), alcohol abuse (AUDIT-C), and depression (PHQ-2). The objective of this study was to determine whether TBI screening is associated with increased utilization of specialty services (MH, Physical Medicine and Rehabilitation [PMR], and Neurology) compared to MH screens alone.

Methods:
A retrospective cohort design was employed to examine specialty care utilization patterns of veterans who were screened for both TBI and MH disorders contemporaneously (i.e., screened for both within seven days) between Fiscal Year (FY) 2007 and 2018 (N = 241,136). Primary and secondary stop codes for MH, PMR, and Neurology for the cohort of Veterans were obtained from the corporate data warehouse (CDW) for the 6 months post-TBI screen as measures for service utilization. Veterans were excluded from the analysis if they were found to have pre-existing conditions that would impact service utilization (i.e., alcohol abuse, anxiety, depression, PTSD, substance abuse, or TBI) or if they were not enrolled in VA healthcare services at the time of screening or within 14 days of their screen. Zero-inflated negative binomial regression models for service utilization were fit for each specialty care type, and the summated values. Additional subgroup models were run among only individuals who screened positive for MH disorders.

Results:
After accounting for demographic covariates, those who screened positive for TBI had 2.38 times more specialty service encounters (CI: 2.33-2.42) than those who screened negative. Among the subgroup of individuals that had screened positive for MH, the TBI screen resulted in 1.78 times more specialty service encounters (CI: 1.75-1.82), with 1.33 times more encounters specifically from the MH domain of services (CI: 1.30-1.36).

Implications:
The TBI screen was found to have an impact on connecting Veterans to specialty care services in MH, PMR, and Neurology above and beyond the existing MH screens. Surprisingly, the impact on connecting Veterans to MH services beyond MH screens suggests that the TBI screen provides a mechanism for connecting Veterans to services, possibly through increased acceptability and decreased stigmatization. Findings cautiously encourage the use of targeted screenings such as the TBI screen in making healthcare more accessible for Veterans, while weighing the impact of additional screening against provider and patient burden.

Impacts:
This was the first study to comprehensively examine VHA specialty care utilization after the TBI screen compared against the MH screens. The findings suggest that the TBI screen facilitates access to PMR, Neurology, and MH services over and above the MH screens, encouraging its continued use in the VHA systems. This study provides insights that may inform future VHA screening programs and suggests further research into the impact of TBI screens on clinical outcomes.