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IIR 11-078 – HSR&D Study

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IIR 11-078
Organizational and Patient Factors Related to Polytrauma/TBI Patient Outcomes
Terri Krangel Pogoda PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: March 2013 - August 2016

BACKGROUND/RATIONALE:
The Veterans Health Administration (VHA) defines polytrauma as injury to the brain and other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disabilities. Traumatic brain injury (TBI), recognized as a signature wound of the Iraq and Afghanistan wars, often occurs in combination with multiple health conditions that require coordinated, individualized, comprehensive medical and psychosocial treatment across the continuum of care. VHA established a Polytrauma/TBI System of Care (PSC) that provides expertise in evaluating and treating TBI and other physical and psychological conditions, such as posttraumatic stress disorder (PTSD). Establishing the PSC was a major advance, but coordination of care across multiple specialties is recognized as a challenge.

OBJECTIVE(S):
Our primary aim was to identify VHA organizational and Veteran characteristics that are associated with community reintegration for Iraq and Afghanistan war Veterans who were evaluated for TBI. A secondary aim was to examine community reintegration outcomes in women Veterans.

METHODS:
We interviewed and/or surveyed VHA clinicians and Veterans receiving care from two types of PSC polytrauma/TBI interdisciplinary outpatient rehabilitation clinics: Polytrauma Network Sites (PNSs) and Polytrauma Support Clinic Teams (PSCTs). Phase 1's survey to clinicians identified organizational characteristics of interest, including size and composition of each VHA medical center's polytrauma/TBI core team and perceived coordination of care for Veterans with polytrauma/TBI. For Phase 2, we sent surveys to 6,000 Iraq and Afghanistan war Veterans who were evaluated for TBI to examine current health symptoms, community reintegration, and satisfaction with VHA health care. Phase 2 also included a review of VHA administrative data to examine TBI diagnosis, physical and mental health symptoms/diagnoses, and VHA utilization since the initial TBI evaluation. In Phase 3, we aimed to conduct interviews with approximately 100 VHA clinicians across 16 PNSs and PSCTs to better understand organizational factors that are associated with Veteran outcomes. Primary analyses included analysis of variance, multiple linear regression, and qualitative analysis.


FINDINGS/RESULTS:
Phase 1.
Polytrauma/TBI clinic directors at PNSs (19/23; 82.6%) and PSCTs (46/80; 57.5%) were surveyed between January 2013 and July 2013. They reported different numbers of staff considered as polytrauma/TBI clinic core providers (M± SD = 9.6 ± 1.9 vs. 7.2 ± 2.7,
respectively, p = 0.001) and number of weekly clinic hours (24.4 ± 13.9 vs. 14.9 ± 11.5, respectively, p < 0.02). During that 7-month period, clinicians at PNSs completed fewer comprehensive TBI evaluations than those at PSCTs (86.9 ± 42.4 vs. 113.9 ± 71.3, respectively, p < 0.0001), but PNSs and PSCTs had a similar number of clinician-confirmed TBIs (67.5 ± 37.5 vs. 71.0 ± 46.6, respectively, p = 0.23), and similar perceptions on their level of staffing adequacy to perform clinic functions (p = .14), ranging, on average, from sometimes too few to usually the right amount.

Clinicians at PNSs (n = 355) and PSCTs (n = 690) did not differ in their perceived coordination of care with their local VA medical center's polytrauma/TBI core team as a whole (p = .80). However, compared to non-core team providers (2.9 ± 1.4), core team providers (4.3 ± .9) rated their relational coordination to be better with other core team providers, (p < 0.0001). On a scale from 0 (no coordination) to 10 (perfect coordination), perceived coordination of care for Veterans with TBI during a 6-month period was rated to be higher by clinicians at PNSs (6.1 ± 2.8) than at PSCTs (5.3 ± 2.9), p < 0.0001, and by core staff (7.2 ± 2.2) compared to non-core staff (5.1 ± 2.9), p < 0.0001, but there was no Site X Staff interaction.

Phase 2.
Administrative record review of the 895 Veteran survey respondents indicated that 69% were diagnosed with deployment-related mild TBI, 5% with moderate/severe TB, and 26% with no TBI history. Nearly two-thirds (64.3%) had a PTSD diagnosis. In unadjusted analyses, on a scale from 0 (no difficulty) to 4 (extreme difficulty), individuals with moderate/severe TBI (2.57 ± .87) reported more difficulty with community reintegration than those with no TBI history (2.05 ± 1.09) (p < .05). However, those with mild TBI (2.33 ± .93) reported the same level of community reintegration difficulty as these other groups (all p > .05).

A multiple regression analysis that modeled organizational, demographic/military, and health factors associated with community reintegration found that poorer community reintegration was significantly associated with: receiving care at a PNS versus a PSCT (p < .05), polytrauma/TBI clinics having fewer staff (p < .02), being unemployed/not looking for work vs. being employed full-time (p <.01), being divorced/separated/widowed vs. married/partnered (p < .02), lower satisfaction with VHA mental health services (p < .04), a PTSD diagnosis (p < 0.0001), and higher utilization of VHA services during the two-year period following the TBI evaluation (p < .02).

In a separate analysis, we examined women Veterans' (n = 127) experiences with lifetime intimate partner violence (IPV), such as emotional mistreatment, being afraid of, physically hurt, or forced or threatened into sexual activity by a partner or ex-partner. Approximately two-thirds of women who completed the survey endorsed a lifetime history of IPV, but IPV was not associated with TBI diagnosis status. Compared to those who had not experienced any IPV, women with lifetime IPV history reported significantly higher levels of somatosensory and vestibular symptoms (all p < .05), and marginally more problems with cognition (p < .06) within the past 30 days. Women with IPV were also more likely to have documented back pain (48.6% vs. 30.0%) and substance abuse (12.2% vs. 0%) issues (all p < .05). Notwithstanding, women Veterans with and without lifetime IPV reported similar levels of community reintegration (2.32 ± .98 vs. 2.05 ± .99, p = .13).

Phase 3.
Interviews with providers of care to Veterans with polytrauma/TBI identified different types of successes and challenges. Successes included clinic flexibility for scheduling Veterans with polytrauma/TBI, such as establishing walk-in clinics and using tele-health; sending Veterans appointment reminders via text message, thus reducing no-show rates; and clinicians from different services integrating with the polytrauma/TBI core team to facilitate interdisciplinary communication. Challenges included multiple health conditions that can make diagnosis and treatment difficult; not having more services co-located at the VA medical center to meet health and psychosocial needs (e.g., substance abuse treatment; vocational rehabilitation, acupuncture); and provider-to-provider and provider-to-Veteran communication barriers, such as not having the ability to read provider notes from other VA medical centers or restrictions to electronic communications with Veterans.

IMPACT:
Knowledge gained from this study may inform successful team structures and practices that foster provider-to-provider and provider-to-Veteran coordination and communication. Findings may also help providers to identify Veterans with particular sociodemographic and health characteristics that make them vulnerable to readjustment difficulties. Such identification can allow for further evaluation and services to facilitate community reintegration.

PUBLICATIONS:

Journal Articles

  1. Amara JH, Stolzmann KL, Iverson KM, Pogoda TK. Predictors of Employment Status in Male and Female Post-9/11 Veterans Evaluated for Traumatic Brain Injury. The Journal of head trauma rehabilitation. 2019 Jan 1; 34(1):11-20.
  2. Suri P, Stolzmann K, Williams R, Pogoda TK. Deployment-Related Traumatic Brain Injury and Risk of New Episodes of Care for Back Pain in Veterans. The journal of pain : official journal of the American Pain Society. 2019 Jan 1; 20(1):97-107.
  3. Pogoda TK, Levy CE, Helmick K, Pugh MJ. Health services and rehabilitation for active duty service members and veterans with mild TBI. Brain injury. 2017 Jan 1; 31(9):1220-1234.
  4. Pogoda TK, Stolzmann KL, Iverson KM, Baker E, Krengel M, Lew HL, Amara JH, Meterko M. Associations Between Traumatic Brain Injury, Suspected Psychiatric Conditions, and Unemployment in Operation Enduring Freedom/Operation Iraqi Freedom Veterans. The Journal of head trauma rehabilitation. 2016 May 1; 31(3):191-203.
Conference Presentations

  1. Pogoda TK. VHA Vocational Rehabilitation for Veterans with TBI. Paper presented at: Traumatic Brain Injury Annual Conference; 2015 Aug 24; Washington, DC.
  2. Pogoda TK, Carlson K., Pilver C, Gormley K, Resnick, SG. Department of Veterans Affairs provider perceptions of supported employment services to Veterans with traumatic brain injury. Poster session presented at: VA Traumatic Brain Injury Research State-of-the-Art Conference; 2015 Aug 24; Washington, DC.
  3. Pogoda TK, Carlson KF, Pilver C, Gormley KE, Resnick SG. Department of Veterans Affairs Provider Perceptions of Supported Employment Services to Veterans with Traumatic Brain Injury. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  4. Pogoda TK, Carlson KF, Pilver C, Gormley KE, Resnick SG. Department of Veterans Affairs Provider Perceptions of Supported Employment Services to Veterans with Traumatic Brain Injury. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.
  5. 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.


DRA: Health Systems, Brain and Spinal Cord Injuries and Disorders
DRE: none
Keywords: Care Coordination, Organizational Structure, Outcomes - Patient, Patient Preferences, Reintegration Post-Deployment
MeSH Terms: none