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Mild Traumatic Brain Injury: Screening and Comorbidities

Approximately 15 to 20 percent of military personnel deployed to Iraq or Afghanistan—Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)—have experienced a mild traumatic brain injury (TBI). 1, 2 Symptoms that occur following a mild TBI may include headaches, sleep problems, irritability, sensitivity to light, and dizziness. While symptoms resolve shortly after injury for the majority of individuals who experience a mild TBI, some Veterans experience long-term symptoms. In addition to experiencing mild TBI, a substantial number of OEF/OIF Veterans have comorbid mental health conditions such as PTSD and depression. To identify Veterans who might benefit from additional evaluation of their symptoms, VA implemented a national clinical reminder in 2007 to screen for TBI. The reminder includes four questions that address TBI-related exposure and symptoms.

In our HSR&D-funded study, "Evaluation of TBI Screening Processes and Healthcare Utilization" (SDR 08-409), we used VA administrative data to examine the association between Veterans' characteristics, including their comorbidities, and their likelihood of completing the clinical reminder for TBI screening and achieving a positive result. The study identified comorbidities including PTSD, depression, and other mental health conditions. We also examined VA health care utilization and costs for a one-year period. Our sample included approximately 170,000 OEF/OIF Veterans who used VA care between 2007 and 2008.

The majority of Veterans in our study were white and male, with a mean age of 33 years. A substantial number of study participants had a diagnosis of a mental health condition. Among Veterans who received a screen, 18 percent had a PTSD diagnosis, 12 percent had depression, and 4 percent had a substance-related disorder. Overall, 92 percent of OEF/OIF Veterans received the TBI screen. Veterans with PTSD, depression, or substance abuse were more likely to receive a TBI screen than Veterans without such diagnoses. Of the Veterans receiving a TBI screen, almost 21 percent had a positive result. During the screen, the most frequently reported symptoms included sleep problems, irritability, and headaches. For Veterans with comorbid mental health conditions, those with PTSD, depression, anxiety disorders, adjustment disorders, or substance-related disorders were likely to have a positive TBI screen. Other characteristics associated with a positive screen included male gender, service in the army, and several deployments. 3

Veterans who received a positive TBI screen experienced more health care utilization than patients who screened negative or did not receive the TBI screen. Veterans who screened positive averaged 3.3 primary care visits compared with 2.6 visits for Veterans who screened negative and 1.6 visits for Veterans with no TBI screen. The most common inpatient admitting diagnosis among all three TBI screening groups was PTSD, followed by alcohol dependence. Veterans who screened positive also received more medications from VA pharmacies than Veterans who screened negative or had no screening. Average total health care costs per patient for a year were nearly double for Veterans who screened positive ($9,610) compared to the mean cost for Veterans who screened negative ($5,184) and nearly three times the costs for Veterans who did not have the TBI screening ($3,399). Approximately 80 percent of total health care costs were related to outpatient visits. Among Veterans who had the TBI screen, total health care costs to VA for treating those patients exceeded $918 million during the 12-month period following the TBI screening. While 21 percent of Veterans receiving the TBI screen received a positive result, they accounted for 33 percent of the total cost (nearly $304 million).

Veterans with comorbidities use more VA services and at higher cost than other Veterans in this study. Among the comorbidities, psychoses and substance use disorder had the greatest association with costs, followed by depression and PTSD. Veterans with psychoses were 222 percent more likely to be hospitalized, with costs $5,094 higher than for Veterans without this condition. Veterans with substance use disorder had a 220 percent greater likelihood of hospitalization, with costs $2,690 higher than for Veterans without this condition.

The TBI screening rate in VA is high. The results demonstrate the continued importance of screening both for intervention to treat symptoms and for planning to provide for ongoing health care needs. We found that a substantial portion of care during a 12-month period was directly mental health-related, particularly for patients screening positive for TBI. Over 40 percent of their inpatient days in VA facilities were for mental health care. The most common admission codes of PTSD and alcohol dependence suggest the importance of mental health and substance use treatment for affected patients. Understanding health care utilization and cost patterns following TBI screening is important for policymakers as they address the ongoing and future health care needs of returning OEF/OIF Veterans.

  1. Hoge, C.W. et al. "Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq," New England Journal of Medicine 2008; 358:453-63.
  2. Tanielian, T. et al. "Invisible Wounds of War: Psychological and Cognitive Injuries: Their Consequences and Services to Assist Recovery." Santa Monica, CA: RAND Corporation, Center for Military Health Policy Research, 2008.
  3. Evans, C.T. et al. "An Evaluation of the Veterans Affairs Traumatic Brain Injury Screening Process among Operation Enduring Freedom and/or Operation Iraqi Freedom Veterans," PM&R 2013; 5:210-20.