HSR&D Home » Research » SDR 08-409 – HSR&D Study
Evaluation of TBI Screening Processes and Healthcare Utilization
Bridget M. Smith, PhD MPA BA
Edward Hines Jr. VA Hospital, Hines, IL
Charlesnika Evans PhD MPH BS
Edward Hines Jr. VA Hospital, Hines, IL
Funding Period: April 2009 - March 2011
In 2007, VA implemented a national clinical reminder (CR) to screen for mild traumatic brain injury (mTBI). Veterans who have positive results on the mTBI CR are then referred for a comprehensive TBI evaluation (CTE). There is limited information available about the associations between patient characteristics and facility characteristics and receipt of screening, or subsequent healthcare utilization.
To describe characteristics associated with completion of the mTBI CR; describe screening results on the mTBI CR; examine healthcare utilization after screening among Veterans who complete the mTBI CR; and examine characteristics associated with receipt and results of the CTE. Additional objectives included cost-identification analysis to estimate the cost of the CR, CTE, and follow-up care, and primary data collected from polytrauma care team members regarding factors that influence coordination of care for mTBI.
This was a retrospective study of OEF/OIF Veterans eligible for the mTBI screen utilizing national mTBI CR and CTE data and VA utilization data. Patient characteristics and healthcare utilization was examined using VA Medical SAS datasets and DSS. We used multilevel regression models to examine the association between receipt of screen, screening results, and health care utilization following the screen. We described the results of the CTE and the association between patient characteristics, elements of the mTBI CR, and the results of the CTE. We also conducted a cost identification analysis utilizing DSS data, administered an online survey, and conducted semi-structured interviews with polytrauma care team members.
Over 91% of eligible Veterans completed the mTBI CR. Being older, service connected, multiple deployments, a PTSD diagnosis, or more outpatient visits increased odds of completing the CR whereas being Hispanic, higher copay priority, service in the navy and separation greater than one year decreased the likelihood of completing the CR. Additionally, CBOCs were more likely to complete the CR than other facility types. Of those screened, 20.5% had positive results. For veterans with a positive CR who attend the CTE, almost half had a result indicating the findings were consistent with mild TBI. There was a substantial association between PTSD and mild TBI. The majority of Veterans (91%) reported pain symptoms within the last 30 days during CTE. Veterans with positive CR and/or CTE had substantially more primary, secondary and mental healthcare utilization. Visits for CRs and CTEs cost $400-$470, $665-$710, respectively. Total annual VA costs were higher for patients with positive, negative, or no CR ($9300, $5500, $3400, respectively) and CTE ($12,000, $10,000, $8300, respectively), due primarily to higher outpatient costs. Survey/interview data collected from polytrauma care team members revealed that coordination of care was complicated by a variety of system and individual-level factors, particularly the ability to access non-VA medical records, lack of time, Veteran missed appointments, and Veteran concurrent mental health issues.
Identifying similarities/differences between Veterans screened and not screened for mTBI provides valuable feedback to VHA that can improve screening/evaluation compliance. Insights regarding the associations between the mTBI CR and the CTE are crucial for developing effective programs to screen and treat mTBI.
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DRA: Military and Environmental Exposures, Health Systems, Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders
Keywords: Traumatic Brain Injury, Utilization patterns
MeSH Terms: none