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SDR 08-405 – HSR&D Study

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SDR 08-405
TBI Evaluation Instruments and Processes for Clinical Follow-up
Ann M. Hendricks PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: April 2009 - March 2011

BACKGROUND/RATIONALE:
To identify Veterans with traumatic brain injury (TBI) and provide better care, VA implemented mandatory screening of all patients reporting OEF/OIF deployment. The VA Boston research team undertook this project to describe the comprehensive TBI evaluations received by patients screening positive for deployment-related injuries and relate the evaluation process to subsequent VA care patterns.

OBJECTIVE(S):
Specific aims are:
1: Measure the impact of patient and medical facility factors on rates of progression to comprehensive TBI evaluations for veterans with a "positive" screening for TBI.
2: Measure the impact of patient- and medical facility factors on differential rates of clinical impression of TBI at comprehensive evaluations.
3: Measure the impact of patient and medical facility factors on differential rates of participation in follow-up care recommended at comprehensive evaluations.

METHODS:
For all objectives, analyses used data on Screening & Comprehensive Evaluations available from Patient Care Services Office of Strategic Planning and Measurement to identify the study population of VA patients screened for the risk of TBI. We also used VA utilization data to track the number and type of VA services used by those veterans who have been through the TBI screening process. The entire study population comprised over 180,000 veterans who were screened in FY 2008 or quarters 1-3 of FY 2009. About 20% of this population reportedly had a Level 2 confirmation that symptoms were consistent with TBI. A panel of 8 national TBI clinical and research experts provided clinical and analytic oversight to this project. Analyses included factor analyses of elements from the evaluations, ANOVAs, MANOVAs or hierarchical and linear regression (as appropriate) to test correlations between evaluation outcomes and patient or facility characteristics.

FINDINGS/RESULTS:
Of 208,589 VHA patients screened from October 2007 through March 2009, 21.5% screened positive for an event that affected consciousness or memory and could be related to persistent symptoms such as headaches, dizziness, etc. About 55% of these patients with positive screens had records of a comprehensive TBI evaluation. Among this subgroup, patients with a confirmed brain injury more likely to have referrals for additional care (82% compared to 64%), but lack of referrals did not prevent the patients from getting VHA care. In the year after screening, 96% of evaluated patients with referrals received outpatient care, while 90% of those with no referral did so. Our best estimate of the rate of confirmed TBI among the total screened population is 12.6%, a rate consistent with or lower than rates reported elsewhere.

IMPACT:
This evaluation provides information that could help restructure VA's TBI evaluation process by adding clarifying questions and eliminating inconsistencies in recorded answers. The project established 4 domains for the evaluation's neurobehavioral symptom inventory (somato-sensory, affective, cognitive and vestibular). We have identified differences in symptom severity by gender and multiple injuries and differences in VA utilization by gender and PTSD co-morbidity. This research has established rates of dual and multiple sensory impairments in the patient population with mild TBI.

PUBLICATIONS:

Journal Articles

  1. Amara J, Pogoda TK, Krengel M, Iverson KM, Baker E, Hendricks A. Determinants of utilization and cost of VHA care by OEF/OIF Veterans screened for mild traumatic brain injury. Military medicine. 2014 Sep 1; 179(9):964-72.
  2. Pogoda TK, Iverson KM, Meterko M, Baker E, Hendricks AM, Stolzmann KL, Krengel M, Charns MP, Amara J, Kimerling R, Lew HL. Concordance of clinician judgment of mild traumatic brain injury history with a diagnostic standard. Journal of rehabilitation research and development. 2014 Jun 1; 51(3):363-75.
  3. Pogoda TK, Hendricks AM, Iverson KM, Stolzmann KL, Krengel MH, Baker E, Meterko M, Lew HL. Multisensory impairment reported by veterans with and without mild traumatic brain injury history. Journal of rehabilitation research and development. 2013 Aug 12; 49(7):971-84.
  4. Hendricks AM, Amara J, Baker E, Charns MP, Gardner JA, Iverson KM, Kimerling R, Krengel M, Meterko M, Pogoda TK, Stolzmann KL, Lew HL. Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience. Brain injury. 2013 Aug 8; 27(2):125-34.
  5. Iverson KM, Pogoda TK, Gradus JL, Street AE. Deployment-related traumatic brain injury among Operation Enduring Freedom/Operation Iraqi Freedom veterans: associations with mental and physical health by gender. Journal of women's health (2002). 2013 Mar 1; 22(3):267-75.
  6. Meterko M, Baker E, Stolzmann KL, Hendricks AM, Cicerone KD, Lew HL. Psychometric assessment of the Neurobehavioral Symptom Inventory-22: the structure of persistent postconcussive symptoms following deployment-related mild traumatic brain injury among veterans. The Journal of head trauma rehabilitation. 2012 Jan 1; 27(1):55-62.
  7. Lew HL, Pogoda TK, Baker E, Stolzmann KL, Meterko M, Cifu DX, Amara J, Hendricks AM. Prevalence of dual sensory impairment and its association with traumatic brain injury and blast exposure in OEF/OIF veterans. The Journal of head trauma rehabilitation. 2011 Nov 1; 26(6):489-96.
Journal Other

  1. Pogoda TK, Vanderploeg RD, Cifu DX, Tun CG, Lew HL. Re: separating deployment-related traumatic brain injury and posttraumatic stress disorder in veterans: preliminary findings from the VA TBI screening program. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2009 Dec 1; 88(12):1043-4; author reply 1044-5.
Conference Presentations

  1. Pogoda TK, Stolzmann KL, Iverson KM, Baker E, Krengel MH, Lew HL, Meterko MM. Associations between traumatic brain injury, suspected psychiatric conditions, and unemployment in returning Veterans. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 10; San Diego, CA.
  2. Meterko MM, Pogoda TK, Stolzmann KL, Iverson KM, Krengel MH, Nealon Seibert M, Sayer N, Gormley K, Baker E. Are there symptom groupings associated with mild TBI? A cluster analysis of neurobehavioral symptom data among Operation Enduring Freedom/Operation Iraqi Freedom Veterans. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA.
  3. Pogoda TK, Iverson KM. Traumatic Brain Injury Among Women Veterans: An Invisible Wound of Intimate Partner Violence. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 1; San Diego, CA.
  4. Iverson KM, Kimerling, R, Stolzman KL, Meterko MM, Baker E, Krengel MH, Hendricks AM, Pogoda TK. Do OEF/OIF Veterans who experience both MST and deployment-related TBI face more mental health problems that those with deployment-related TBI only? Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2011 Nov 16; Baltimore, MD.
  5. Iverson KM, Hendricks A, Meterko M, Stolzmann K, Krengel M, Baker E, Lew HL. Gender differences in PTSD, Depression and Neurobehavioral Symptoms Among OEF/OIF Veterans Diagnosed with Mild TBI. Paper presented at: VA Women's Health Research Conference; 2011 Jul 15; Arlington, VA.
  6. Pogoda TK, Baker EH, Gardner JA, Iverson KM, Krengel MH, Meterko MM, Stolzman KL, Lew HL, Hendricks AM. Concordance rates of clinician assessment of TBI history with ACRM criteria in OEF/OIF Veterans. Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 22; Washington, DC.
  7. Krengel MH, Baker EH, Meterko MM, Stolzman KL, Iverson KM, Pogoda TK, Hendricks AM. Examination of NSI-22 symptoms in OEF/OIF Veterans with a history of multiple concussion. Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 13; Washington, DC.
  8. Meterko MM, Baker EH, Stolzman KL, Cicerone KD, Hendricks AM, Lew HL. Evaluating the Impact of Traumatic Brain Injury: Psychometrics of the Neurobehavioral Symptom Inventory-22. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  9. Stolzman KL, Baker EH, Meterko MM, Hendricks AM. Neurobehavioral Symptomatology and Traumatic Brain Injury Among OEF/OIF Veterans: A Discriminant Analysis. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  10. Stolzman KL, Meterko MM, Baker EH, Hendricks AM, Iverson KM, Krengel MH, Charns MP, Pogoda TK, Lew HL. The Association Between Neurobehavioral Symptoms and Postinjury Employment Status Among OEF/OIF Veterans Who Screen Positive for Traumatic Brain Injury. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  11. Amara JH, Hendricks AM, Gardner JA, Lew HL. Determinants of cost and utilization of VA health care services by OEF/OIF Veterans with a focus on TBI. Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 11; Washington, DC.
  12. Meterko MM, Baker EH, Stolzman KL, Hendricks AM, Cicerone KD, Lew HL. Psychometric Assessment of the Neurobehavioral Symptom Inventory (NSI-22). Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 11; Washington, DC.
  13. Fitzharris KL, Pogoda TK, Lew HL. Auditory Findings in OEF/OIF Veterans at a PNS. Presented at: Joint Defense / Veteran Audiology Annual Conference; 2011 Mar 11; San Diego, CA.
  14. Baker EH, Iverson KM, Meterko MM, Stolzman KL, Hendricks AM. The differential pattern of post-concussive symptoms among female as compared to male OEF/OIF veterans with deployment-related TBI. Presented at: AcademyHealth Annual Research Meeting; 2011 Feb 17; Seattle, WA.
  15. Baker EH, Iverson KM, Adams EA, Meterko MM, Stolzman KL, Hendricks AM. The Differential pattern of post-concussive symptoms among female compared to male OEF/OIF Veterans with deployment-related TBI. Presented at: VA HSR&D National Meeting; 2011 Feb 14; Washington, DC.
  16. Iverson KM, Hendricks A, Kimerling R, Meterko M, Stolzmann K, Krengel M, Baker E, Lew H. Gender differences in PTSD, depression and neurobehavioral symptoms among OEF/OIF Veterans diagnosed with mild TBI. Paper presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 1; Arlington, VA.
  17. Pogoda TK, Cramer IE, Resnick SG. Stigma-related barriers to supported employment implementation. Poster session presented at: Association for Psychological Science Annual Convention; 2010 May 27; Boston, MA.
  18. Lew HL, Pogoda TK, Hsu PT, Cohen S, Amick MM, Baker EH, Meterko MM, Vanderploeg RD. Impact of the “Polytrauma Clinical Triad” on sleep disturbance in a VA outpatient rehabilitation setting. Poster session presented at: Association of Academic Physiatrists Annual Meeting; 2010 Apr 9; Bonita Springs, FL.
  19. Krengel MH, Baker EH, Meterko MM, Stolzman KL, Iverson KM, Pogoda TK, Hendricks AM. Impact of Post-Deployment Brain Injury on NSI-Symptom Domains. Paper presented at: Federal Interagency Conference on Traumatic Brain Injury; 2001 Jun 11; Washington, DC.


DRA: Military and Environmental Exposures, Brain and Spinal Cord Injuries and Disorders, Health Systems, Acute and Combat-Related Injury
DRE: Diagnosis, Prevention
Keywords: Clinical Diagnosis and Screening, PTSD, Quality of Care, TBI, Traumatic Brain Injury
MeSH Terms: none

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