In April 2007 VHA Directive 2007-013 was issued establishing policy and procedures for screening and evaluation of traumatic brain injury (TBI) in OEF/OIF Veterans. Yet the variations in clinical practices to support this directive are not known.
The purpose of this study was to examine current practices associated with TBI screening and evaluation as outlined in the VHA Directive. Specific objectives of this two year study were to: (1) Describe the level of provider and patient adherence (defined as timeliness and quality of assessments and evaluations) to five key clinical processes in TBI screening and management: a) TBI Screening, b) TBI Evaluation (History & Physical and Neuropsychiatric Symptom Inventory), c) Referrals to Specialists, d) Specialist Evaluation, and e) Treatments prescribed. (2) Identify actionable factors that contribute to performance gaps associated with TBI screening and management; and (3) Determine interventions to address identified performance gaps.
1. What percentage of OEF/OIF-era patients, who are screened for TBI, screened positive as specified in the VHA Directive by level of care (PRC, PNS, PSCT, POC)?
2. How timely were key processes completed (e.g., screening, TBI evaluation, referrals to specialists, specialist evaluation, and treatments prescribed)?
3. What patient characteristics and clinical evaluation findings best predicted successful screening, referrals to specialists and specialist evaluation, and treatments prescribed?
4. Did quality and timeliness of care vary by level of care (PRC, PNS, PSCT, POC) and patient characteristics?
5. What were the barriers, facilitators and strategies for overcoming barriers for implementing each the five clinical processes across levels of care, as perceived by clinicians, OEF/OIF veterans, and key informants?
6. Having reviewed study findings, what recommendations did a panel of experts identify to reduce unnecessary practice variations associated with TBI screening and management? (This activity was not accomplished)
This study used mixed methods, including quantitative and qualitative approaches. For all objectives, this study used a sample of all VHA Polytrauma Rehabilitation Centers (PRC Level 1) in Tampa, Richmond, Minneapolis, Palo Alto, and sampled 5 Polytrauma Network Sites (PNS Level 2), 6 Polytrauma Support Clinical Teams (PSCT Level 3), and 6 Polytrauma Points of Contact (POC Level 4), yielding a total of 21 sites across the United States. For Objective 1, quantitative data were abstracted from a random sample of 50 chart reviews per site by trained data abstractors using a structured data collection. Descriptive statistics were used to characterize practice patterns, bivariate analyses and multiple regression analyses were used to explore associations and outcomes. For Objective 2, data were derived from semi-structured interviews from a total of 64 patients, providers, and key informants volunteers from 15 geographically diverse VA facilities out of the 21 study sites. The participants had first-hand experience of the VHA mild TBI (mTBI) screening program at the four levels of the Polytrauma System of Care. Content analysis of interview transcripts were used to identify barriers and facilitators that contribute to performance gaps. To meet the intent of Objective 3, we will work with Polytrauma/Blast QUERI to report study findings to VHA Rehabilitation Service.
- Participants were an average age of 29.6; 95.5% male; 61.44% Never Married; 67% Army
- Most common pre-existing diagnoses were: Musculoskeletal pain (72%), Pain (70%), PTSD (56%)
- Primary Care performed 47% of all TBI screens
- 73% of Veterans had a single TBI screen
- Veterans with Comprehensive evaluation (n=614; 79%)
o 65% completed within 30 days of the screen
o For evaluations completed in >30 days: 71% (n=205) attributed to
unknown factors; 27.8% missed appointments; 358 phone call attempts
made to contact Veterans
o Timeliness did not vary by level of polytrauma care
o 50.5% of comprehensive evaluations were conducted by teams of providers
o 48% of symptoms were attributed to behavioral health conditions (e.g.,
depression, PTSD, anxiety); 31% to combination of TBI and behavioral
health conditions; 10% to conditions unrelated to TBI or behavioral health
o NSI symptom domains endorsed: Affective (97%); Cognitive (95%);
Headache (49%); Hearing (89%).
o Follow-up and timeliness was best for affective symptoms
o Referrals rates to specialists: Affective (46%); Cognitive (21%); Headache
(21%); Hearing (41%).
o Visits to specialists: Affective (57%); Cognitive (65%); Headache (71%);
- Multiple regression found only one statistically significant association by level of care: days between initial healthcare visit and first TBI screen was significantly greater for facilities with Points-of-Contact (36.2 128.7) versus those with Polytrauma Support Clinic Teams (15.5 47.5).
Qualitative. Participant-perceived included insufficient staff, limited time and space in some facilities, certain computer system and administrative obstacles, and screening tool limitations. Perceived barriers specific to Veterans included limited understanding of mTBI and related VA programs and competing demands for Veteran time. Perceived barriers specific to Providers included limited understanding of mTBI injuries, as well as limited understanding of the administration of mTBI screening and evaluation tools as related to VA policy. Perceived Programmatic facilitators included extended and weekend appointment hours for Veterans, use of case managers to facilitate Veterans' progression through program levels, and education on mTBI. Perceived Provider facilitators included improved communication with impaired Veterans, cross-discipline communications and team-building, and demonstration of patient-centered attitudes.
Our findings generally supported other's findings and reinforce the complexity of delivering care to Veterans with arrays of symptoms that suggest overlapping diagnoses and treatment plans. Additionally, lack of variation in quality and timeliness by level of care suggest that Veterans are receiving similar levels of care for TBI diagnosis and treatment regardless of where they live. Study findings may be used for educational materials and may lead to modification of the TBI Clinical Reminder System and follow-up care.
- Belanger HG, Powell-Cope G, Spehar AM, McCranie M, Klanchar SA, Yoash-Gantz R, Kosasih JB, Scholten J. The Veterans Health Administration's traumatic brain injury clinical reminder screen and evaluation: Practice patterns. Journal of rehabilitation research and development. 2016 Oct 1; 53(6):767-780.