Health Services Research & Development

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Traumatic Brain Injury Research

April 2017


Traumatic brain injury (TBI) occurs when an object or explosive force comes into contact with the head. As a result of the impact, the brain moves suddenly and is compressed against the inside of the skull, which can cause damage to delicate brain tissue and blood vessels. Traumatic brain injury is classified in categories of mild (concussion), moderate, severe, and penetrating.[1]

For those engaged in active military service, TBI from blast-related causes is a significant concern. According to recent estimates from the Defense and Veterans Brain Injury Center—a joint collaboration between VA and the Department of Defense—approximately 22 percent of all combat casualties from Iraq and Afghanistan are brain injuries. Worldwide, more than 350,000 service members have been diagnosed with TBI in some form since 2000.[2] Even mild TBI can have far-reaching impact, with symptoms ranging from headaches, irritability, and sleep disorders to memory problems, slower thinking, and depression. Many of these symptoms can lead to long-term mental and physical health problems that affect Veterans' employment and family relationships, and may negatively impact their reintegration into their communities.

Studies funded by VA's Health Services Research & Development Service (HSR&D) address many aspects of care for Veterans with TBI, including how care is organized and delivered to support for informal caregivers of those with TBI. The following summaries represent just a few of the completed and ongoing HSR&D-funded investigations into TBI.

Prevalence of Alcohol Misuse and Follow-Up Care in a National Sample of OEF/OIF VA Patients With and Without TBI

Approximately 10% to 15% of Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have sustained at least one traumatic brain injury (TBI) during their deployment—and a significant percentage report persisting, post-concussive symptoms, even many years post-injury. Additionally, up to 40% of OEF/OIF Veterans enrolled in VA care screen positive for alcohol misuse. Most OEF/OIF patients with TBI have a comorbid psychiatric diagnosis or chronic pain, and those conditions may increase risk of alcohol misuse; however, information on prevalence and management of alcohol misuse among OEF/OIF Veterans with TBI is limited.

This study used national VA healthcare utilization data to compare the prevalence of alcohol misuse, documented brief alcohol intervention (BAI), and VA addiction treatment attendance among OEF/OIF Veterans with and without TBI. The study sample included Veterans ages 18 and older who were screened with the Alcohol Use Disorders Identification Test alcohol consumption questions (AUDIT-C) in 2012, and who received VA healthcare in the prior year (N=358,417). Overall and age-specific estimates of alcohol misuse (AUDIT-C score > 5) were compared for men and women with and without TBI. BAI and addiction treatment attendance after screening were compared between the two groups.

Results showed that alcohol misuse was common among OEF/OIF Veterans with TBI, especially men, with 20% of men and 7% of women with TBI screening positive for alcohol misuse. The risk of screening positive for alcohol misuse was highest among younger men and women (age <30). The prevalence of documented BAI for OEF/OIF men and women who screened positive was high (70%−80%), regardless of TBI status. Addiction treatment attendance for men and women with severe alcohol misuse was higher among those with than without TBI (men, 20% vs. 15%; women, 37% vs. 21%).

Implications: Given that TBI is the hallmark injury of the OEF/OIF conflicts, this work has important implications throughout VA. Early recognition and management of alcohol misuse among young Veterans with TBI is critical—particularly given research that suggests alcohol use may impair neurologic recovery and magnify cognitive deficits among TBI patients. Timely intervention may support reintegration and recovery, and reduce the health burden of both alcohol misuse and TBI.

Grossbard J, Malte C, Lapham G, et al. Prevalence of alcohol misuse and follow-up care in a national sample of OEF/OIF VA patients with and without TBI. Psychiatric Services. January 2017;68(1):48-55.

The research described in this article was supported, in part, by HSR&D's Quality Enhancement Research Initiative (QUERI). Co-authors Katherine Bradley, MD; Andrew Saxon, MD; and Eric Hawkins, PhD, are with HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA.

The Cost of TBI and Co-Occurring PTSD

The primary objective of this study was to examine whether a TBI diagnosis was associated with increased outpatient service utilization and associated costs among Veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) with PTSD who used VA healthcare over a one-year period. Investigators also sought to describe patterns of use and costs in order to inform policy and planning, and sought to explore specific types of services that were used more frequently among Veterans with co-occurring PTSD and TBI than among Veterans with either PTSD or TBI.

Using VA administrative data, investigators identified all OEF/OIF/OND Veterans who utilized VA services (outpatient, inpatient, or pharmacy) from October 1, 2011 to September 30, 2012, and who had diagnostic codes indicating PTSD or TBI. Results of this study showed that Veterans in the comorbid PTSD/TBI group had significantly more total outpatient appointments than Veterans with PTSD but no TBI. This pattern held for all categories of care except orthopedics. The comorbid TBI/PTSD group ($5,769) incurred greater median outpatient healthcare costs than the PTSD ($3,168) or TBI-alone ($2,815) group.

Implications: Based on this study, investigators conclude that co-occurring TBI increases the already high level of healthcare utilization by Veterans with PTSD, suggesting that OEF/OIF/OND Veterans with comorbid PTSD/TBI have complex and wide-ranging healthcare needs. Data from this study contribute to the evidence base supporting administrators and clinicians in providing for the complex needs of those with both PTSD and TBI diagnoses. Further, study results may help policymakers in better allocating resources and staffing to best meet the needs of this high-priority group of Veterans.

Kehle-Forbes SM, Campbell EH, Taylor BC, Scholten J, Sayer N. Does co-cccurring traumatic brain injury affect VHA outpatient health service utilization and associated costs among veterans with post-traumatic stress disorder? An examination based on VHA administrative data. The Journal of Head Trauma Rehabilitation. January 1, 2017; 32(1):E16-E23.

The research described in this article was supported, in part, by HSR&D's Quality Enhancement Research Initiative (QUERI). Co-authors Shannon Kehle-Forbes, PhD; Brent Taylor, PhD, MPH; Nina Sayer, PhD; and Emily Campbell are part of HSR&D's Center for Chronic Disease Outcomes Research in Minneapolis, MN.

Organizational and Patient Factors Related to Polytrauma/TBI Patient Outcomes

VA defines polytrauma as injury to the brain and other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disabilities. Traumatic brain injury (TBI)—recognized as a signature wound of the conflicts in Iraq and Afghanistan—often occurs in combination with multiple health conditions that require coordinated, individualized, comprehensive medical and psychosocial treatment across the continuum of care. VA established a Polytrauma/TBI System of Care (PSC) to provide expertise in evaluating and treating TBI and other physical and psychological conditions, such as post-traumatic stress disorder (PTSD). Establishing the PSC was a major advance, but coordination of care across multiple specialties remains a challenge.

In this recently concluded study, investigators sought to identify which VA organizational and Veterans' personal characteristics are associated with better outcomes for community reintegration in Iraq and Afghanistan war Veterans evaluated for TBI. Investigators also sought to determine whether patient outcomes are different for women Veterans as compared to men.

Researchers looked at two types of PSC Polytrauma/TBI outpatient facilities: Polytrauma Network Sites (PNSs) and Polytrauma Support Clinic Teams (PSCTs), and surveyed VA employees who work with Veterans who had experienced TBI. Within each facility, investigators examined the size and composition of the Polytrauma/TBI core team, and coordination of care between TBI providers. Investigators also conducted a review of administrative data for 895 Veteran survey respondents to examine patient characteristics, including TBI diagnosis, physical and mental health symptoms, and utilization of TBI-related services since the TBI evaluation.

Findings for organizational and provider characteristics indicated that Polytrauma/TBI clinic directors at PNSs reported higher numbers of staff considered as polytrauma/TBI clinic "core" providers, and more weekly clinic hours. During the 7-month survey period (January-July 2013), clinicians at PNSs completed fewer comprehensive TBI evaluations than those at PSCTs; however, both PNSs and PSCTs had a similar number of clinician-confirmed TBIs and similar perceptions of their level of staffing adequacy to perform clinic functions. Clinicians at PNSs and PSCTs did not differ in their perceived coordination of care with their local VA medical center's polytrauma/TBI core team as a whole. However, compared to "non-core" team providers, core team providers rated their relational coordination to be better with other core team providers.

Findings for Veterans' personal characteristics showed that 69% were diagnosed with deployment-related mild TBI (mTBI), 5% with moderate/severe TBI, and 26% with no TBI history. Nearly two-thirds had a PTSD diagnosis. Individuals with moderate/severe TBI reported more difficulty with community reintegration than those with no TBI history. However, those with mTBI reported the same level of community reintegration difficulty as these other groups.

Implications: knowledge gained from this study may be used to inform successful organizational and team structures and practices, including those that foster provider-to-provider and provider-to-Veteran coordination and communication. Additionally, as overall findings indicate that poorer community reintegration was significantly associated with a range of Veterans' socio-economic factors, results may also help providers identify Veterans with the particular characteristics that make them vulnerable to readjustment difficulties. Such identification can allow for further evaluation and services to facilitate better community reintegration outcomes.

Pogoda T, Stolzmann K, Iverson K, et al. Associations between traumatic brain injury, suspected psychiatric conditions, and unemployment in Operation Enduring Freedom/Operation Iraqi Freedom Veterans. The Journal of Head Trauma Rehabilitation. May 1, 2016; 31(3):191-203.

Iverson, KM, Dardis, CM, & Pogoda, TK. Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence among women veterans, Comprehensive Psychiatry January 2017 (E-pub ahead of print.) 74: 80-87.

Principal Investigator: Terri K. Pogoda, PhD is part of HSR&D's Center for Healthcare Organization and Implementation Research in Boston, MA

Telephone Assessment and Skill-Building Intervention for Informal Caregivers

Stroke and traumatic brain injury (TBI) are leading causes of long-term disability among Veterans, and both conditions may result in the need for assistance from informal caregivers in a home-based setting. There are very few evidence-based, easy-to-deliver, follow-up programs to train Veterans and their informal caregivers across multiple domains post-injury. The "Acquiring New Skills While Enhancing Remaining Strengths for Veterans (ANSWERS-VA)" intervention aims to provide Veterans and their primary caregivers with a practical skill-set each can use in coping with and managing symptoms of a brain injury.

In this ongoing, randomized controlled trial, investigators are evaluating the efficacy of the ANSWERS-VA intervention with Veterans who have sustained a stroke and/or TBI and their informal caregivers.

The ANSWERS-VA intervention group is being compared with an educational intervention that will serve as an attention control group. The study has been ongoing at two VA Medical Centers and includes Veterans with stroke (N = 222) or TBI (N = 108) and their informal caregivers. Both the intervention and control involve 8 telephone sessions delivered over 8 weeks, with a booster session at 12 weeks. Data collection occurs at baseline, 8 weeks (short-term intervention effect), 12 weeks (after booster), 24 weeks, and 1 year after baseline (long-term sustainability of intervention effect). To date, investigators have enrolled 88 teams (dyads) of Veterans and caregivers at the two study sites.

Implications: With the combination of an aging Veteran population at risk for stroke, and a considerable number of OEF/OIF/OND Veterans impacted by TBI, implementing efficacious and cost-effective interventions for informal caregivers of Veterans with these conditions is critical. Building informal caregiver skills through dyadic interventions such as ANSWERS-VA should improve both Veterans caregivers' support and Veterans' health outcomes. Investigators also expect that study results will positively impact readmission costs, skilled nursing care, and premature long-term institutionalization.

Principal Investigator: Ginger S. Daggett, PhD, MSN, RN is part of HSR&D's Center for Health Information and Communication in Indianapolis, IN.



References

[1] DoD Worldwide Numbesr for Brain Injury, Defense and Veterans Brain Injury Center website. Updated: 3/9/2017. http://dvbic.dcoe.mil/files/tbi-numbers/DoD-TBI-Worldwide-Totals_2016_Q3_Nov-10-2016_v1.0_508_2016-12-27.pdf

[2] ibid