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Findings from an HSR&D Funded Study of Traumatic Brain Injury

Traumatic Brain Injury (TBI) is a leading injury among forces deployed since 2001 to combat areas such as Afghanistan and Iraq. Deployed service members are currently eligible for up to five years of health care services through the Veterans Health Administration (VHA), with no co-payments regardless of income or disability. In recent years, 20 percent to 25 percent (400,000 or more) of these eligible service members have used VHA care.¹ Therefore, identifying TBI among VHA patients is essential, so that timely and appropriate treatment can alleviate its physical, emotional, and cognitive effects.

Screening for TBI

To identify patients who may have had TBI, VHA policy is to screen all individuals who report OEF/OIF deployment, using sets of questions about events (e.g., blast, fall, vehicle accident) associated with increased risk for TBI, immediate symptoms after the event, new or worsening symptoms following the event, and symptoms in the past week. A screen is positive if a person responds positively to any question within each set.

Not all patients who screen positive have TBI. Positive screens may be due to other conditions, such as PTSD or inner ear injury. Based on its experience with Veterans from past conflicts, VHA screening aims to be inclusive, referring patients with lower probability of having TBI for comprehensive evaluations to ensure that those needing care receive appropriate assessment and treatment. Using a defined protocol administered by a clinician, the Comprehensive TBI Evaluation collects information about the origin of the injury, assesses neurobehavioral symptoms, includes a targeted physical examination and psychiatric history, confirms or rules out a diagnosis of TBI, and lists possible follow-up care.

Our HSR&D-funded, service-directed research study examined the screening, evaluation, and utilization records for more than 216,000 patients seeking VHA services between April 2007 and March 2009. The proportions with positive screens, by gender, were 10.5 percent for women (who comprised one eighth of the patients) and 21.3 percent for men.² Approximately 5 percent of women (n = 1,912) and 11 percent of men (n = 31,873) who were screened for TBI subsequently participated in a Comprehensive TBI Evaluation. Of these, nearly equivalent proportions of women (34 percent) and men (37 percent) were confirmed to have deployment-related TBI. Of note, blast exposure (compared to non-blast events such as vehicle accidents) increased the odds of having PTSD, alcohol-related disorders, or PTSD with comorbid depression. Blast exposure also increased the odds of having severe affective (e.g., irritability, frustration) and cognitive (e.g., forgetfulness, poor ability to concentrate) neurobehavioral symptoms.

We found that women with deployment-related TBI report more severe postconcussive symptoms, especially if they have experienced blast exposure. In terms of PTSD, although women had lower odds of having a PTSD diagnosis in univariate analyses between gender and PTSD (59.6 percent of the women had a PTSD diagnosis compared to 67.8 percent of the men), this difference was not maintained after controlling for blast exposure.

Sensory Impairment and TBI

Among those with TBI, self-reported sensory impairment rates were: 34.6 percent for dual sensory (both hearing and vision) impairment, 31.3 percent for hearing impairments only, 9.9 percent for vision impairments only, and 24.2 percent for none/mild sensory impairment.³ Patients with TBI and blast exposure had the highest rate of dual sensory impairment, suggesting that for these patients in particular, VA clinicians should collaborate to maximize rehabilitation for these senses.

In the year following screening, the vast majority of screened patients received VHA health care services (from 88 percent to 98 percent). Amounts or intensity of services were higher for those with TBI and PTSD. Women tended to receive more outpatient care (about four visits) than men, but men received more inpatient care (about nine more days for the approximately 9 percent of men and women who received any inpatient care).

Our study found that VHA's TBI screening and evaluation process succeeded in being inclusive, providing follow-up care for service members who screened positive for possible TBI. Because the study population was large, we identified important differences between injured men and women in the services as well as establishing that those with mild deployment-related TBI report high rates of dual sensory impairments. The study does not generalize to all OEF/OIF-deployed service members, just to those who seek VHA health care. Future analyses will examine factors related to variations across VHA medical centers regarding specific diagnoses or conditions, types of referrals and follow-up care for specific conditions (e.g., PTSD), as well as differences by gender, military services (e.g., Army, Navy) and the number of events (both blasts and non-blasts).

References

1. Hendricks A, et al. Screening for Mild Traumatic Brain Injury in OEF-OIF Deployed Military: An Empirical Assessment of the VA Experience. Research paper presented at the February 2011 National HSR&D Conference, Washington, D.C.
2. Baker E, et al The Differential Pattern of Post-Concussive Symptoms Among Female Compared to Male OEF/OIF Veterans with Deployment-Related TBI, Plenary presentation at the February 2011 National HSR&D Conference, Washington, D.C.
3. Lew HL, Pogoda TK, Baker E, et al. Prevalence of Dual Sensory Impairment and Its Association with Traumatic Brain Injury and Blast Exposure in OEF/OIF Veterans. Journal of Head Trauma Rehabilitation 2011 (e-Published ahead of print March 7).