BACKGROUND/RATIONALE:
A substantial number of Veterans of Operation Enduring Freedom (OEF) and Iraqi Freedom have experienced mild traumatic brain injury (TBI). To identify Veterans who may benefit from treatment and services, VA implemented a national clinical reminder. Veterans who have a positive screen are then referred for a Comprehensive TBI Evaluation (CTBIE). Despite these referrals, recent data suggests that as many as 25% of Veterans do not have a CTBIE to determine a diagnosis and develop a plan to treat symptoms. While understanding and implementing approaches to improve the CTBIE is a focus of PT/TBI QUERI, little is known about how facilities are using telehealth to enhance access to CTBIEs or about implementation issues associated with this use.

OBJECTIVE(S):
Our specific aims were to: (1) To characterize approaches to using telehealth to provide CTBIEs; (2) Examine the association between patient characteristics and use of telehealth to perform the CTBIE and outcomes associated with telehealth (i.e., cost and utilization).

METHODS:
The Veterans Health Administration (VHA) Office of Physical Medicine and Rehabilitation (PM&R) set up a number of facilities as pilot locations for administering the CTBIE using clinical video telehealth (CVT). Using a list of names provided by the Office of PM&R, we recruited providers involved in piloting the CTBIE via CVT to participate in a semi-structured interview and short background questionnaire. We conducted semi-structured interviews with 26 providers and telehealth clinical technicians (TCT) from Veterans Affairs Medical Centers (VAMCs) and Community Based Outpatient Clinics (CBOCs). Transcribed interviews were coded using a qualitative content analysis to identify barriers, facilitators, perceived advantages and disadvantages, strategies, and training needs in utilizing CVT to administer comprehensive traumatic brain injury evaluations (CTBIE). In addition to primary data collection, we conducted chart reviews of 837 Veterans who were flagged in the administrative data as having their CTBIE performed using Telehealth (DSS stop codes: 197 AND 690 or 692 or 693). We also examined the results of the CTBIE examinations database. In addition, we used the VA MedSAS Inpatient/Outpatient and Decision Support System (DSS) cost datasets to analyze healthcare cost and utilization before and after the CTBIE.

FINDINGS/RESULTS:
Interviews
Twenty six providers-including thirteen physicians, eleven telehealth clinical technicians (TCT), and two facility telehealth coordinators (FTC)-agreed to take part in the study. From the semi-structured interviews with providers, a few of the top barriers to implementing CVT for TBI screening and management included challenges with scheduling (e.g., coordinating the schedules between two different sites), setting up the clinic (e.g., equipment issues), and conducting a physical exam over a virtual modality (i.e., the provider must rely on the TCT to be their hands). In addition to listing the challenges associated with implementing CVT, providers also discussed strategies that help them workaround these issues to enhance implementation of CVT. A few of the top strategies included establishing good relationships and communication with staff, making a personal connection and establishing rapport with patients over CVT, and providing accessible resources to both patients and providers. Moreover, providers' responses indicated that there are far more advantages to utilizing CVT-including travel convenience, cost-effectiveness, and patient satisfaction-than there are disadvantages (e.g., limitations in assessing comorbid conditions besides TBI).

CTBIE Data
Among Veterans who had a telehealth CTBIE, the most common etiology of TBI was from a blast (72.3%). Approximately 354 (42.3%) lost consciousness as a result of TBI. Slightly less, 287 (34.3%), experienced post traumatic amnesia after the TBI. Ten percent (n=98) had injuries from the TBI that were severe enough to require evacuation from theater. Nearly one quarter (193, 23.1%) indicated that they had been previously treated for TBI. Since the incident the patients reported a number of symptoms such as acting difference since injury (743, 88.8%) and pain (777, 92.8%). Of those who said they experienced pain 592 (76.2%) indicated that the pain was causing difficulties in their day to day lives. Of those who were given the CTBIE the healthcare providers found that 582 (69.5%) had symptoms and etiologies consistent with TBI. According to the CTBIE administrative data 754 (90.1%) patients should have had VA consults ordered.

Chart Reviews
We conducted 837 chart reviews of patients in which the administrative data indicated that the CTE was performed using Telehealth methods. The mean age was 33.1 (SD=8.1). The majority of the Veterans in the sample were white (72.4%) and male (91.5%). Upon further review of patients' medical records we were only able to confirm that the CTE was indeed performed via CVT in 475 (57.1%) of the sample. There were a total of 1703 consults ordered in those across 622 patients, with an average of 2.7 (SD=1.6) consults per patient. The most common requested consults were for speech/language pathology (15.4%), audiology (14.7%), ophthalmology/optometry (10.7%) and physical therapy (10.7%).

Cost/Utilization Data
We calculated the difference in healthcare use and costs during the 12 month periods before and after the CTBIE and compared this difference for Veterans with CTBIEs conducted with telehealth vs. in-person. These healthcare use and cost differences were similar between patients who had the CTBIE through telehealth vs. in-person.Total costs were $4,855 higher during the 12 months following the CTBIE for patients who received this evaluation through telehealth vs. $4,889 higher for those who received this evaluation in-person (p=0.95).

IMPACT:
We have worked closely with the PT/TBI QUERI and with our partners from PM&R to share the results of our study to inform the ongoing implementation of telehealth to increase access to care for Veterans with TBI. We are currently developing a study to examine the spread of use of CVT to provide follow-up services to Veterans with TBI to enhance the foundation for a future SDP to enhance implementation of CVT in PM&R.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Martinez RN, Hogan TP, Lones K, Balbale S, Scholten J, Bidelspach D, Musson N, Smith BM. Evaluation and Treatment of Mild Traumatic Brain Injury Through the Implementation of Clinical Video Telehealth: Provider Perspectives From the Veterans Health Administration. PM & R : the journal of injury, function, and rehabilitation. 2017 Mar 1; 9(3):231-240. [view]

Conference Presentations

1. Hogan TP, Smith BM, Balbale SN, Bartle B, Lones K, Scholten J, Bidelspach D. Examining Telehealth Applications for Evaluation and Treatment of Veterans with possible Mild TBI. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 10; San Diego, CA. [view]

DRA: Brain and Spinal Cord Injuries and Disorders
DRE: Technology Development and Assessment
Keywords: Access, Operation Enduring Freedom, Operation Iraqi Freedom, Telemedicine
MeSH Terms: none