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Study Suggests Low Follow-Up Rates for Positive TBI Screens

Traumatic brain injury (TBI) has been described as the “signature injury” in the wars in Iraq and Afghanistan. Most combat-related TBI cases are mild in severity, but individuals with a history of mild TBI may fail to receive medical attention because their injury is not visible and because the symptoms are non-specific and may be attributed to other problems (e.g., psychiatric disorders). Left untreated, these persistent symptoms may contribute to significant levels of distress and disability. In 2007, VA implemented national TBI screening for all Iraq and Afghanistan war Veterans, in the form of a computerized clinical reminder. The TBI screen is activated for all Veterans enrolled in VA for medical services who separated from active duty after 9/11/01. As of June 2010, more than 426,000 Veterans had been screened. This retrospective study evaluated VA’s TBI screening program in terms of predictors of screening and positive-screen follow-up. Using VA data, investigators focused on 13,153 Iraq and Afghanistan war Veterans who were treated in a healthcare clinic in one of the 12 VAMCs and 44 community-based outpatient clinics (CBOC) that are part of the upper Midwest VISN between April 2007 and October 2008. Veterans did not have a TBI diagnosis prior to screening.


  • Almost 90% of Iraq and Afghanistan war Veterans in this study were offered TBI screening, and 17% screened positive; 52% of those screening positive had subsequent appointments in a TBI/polytrauma specialty clinic during the 18-month study period.
  • Of 1,185 patients evaluated in a TBI/polytrauma clinic following a positive screen, 55% were given a TBI diagnosis, and of 92 patients not evaluated in a TBI/polytrauma clinic following a positive screen, 8.5% were given a TBI diagnosis.
  • Screening likelihood increased with time since implementation of the TBI screening program and was greater at the first clinic encounter.
  • There was considerable variation by facility; for example, Veterans seen in a VAMC were more likely to be screened than those seen in a CBOC. Screening was particularly likely to occur during TBI/polytrauma and primary care clinic appointments.
  • Younger, male, Army Veterans without psychiatric diagnoses were more likely to be screened compared with women Veterans, Iraq/Afghanistan Veterans from other branches of the military, and those who were at least 40 years old.


  • This study was based on administrative data from one VISN that did not include information on: military rank, education, date of exposure or injury, and distance to the closest VA facility. Race and ethnicity information also was missing for a significant proportion of the study sample. The study was not designed to address the relationship between TBI and psychiatric disorders.

This study was funded through VA/HSR&D’s Quality Enhancement Research Initiative (QUERI). Dr. Sayer is Director of the Polytrauma/Blast-Related Injuries QUERI; she and Dr. Nelson are part of HSR&D’s Center for Chronic Disease Outcome Research in Minneapolis, MN.

PubMed Logo Sayer N, Nelson D, and Nugent S. Evaluation of the Veterans Health Administration Traumatic Brain Injury Screening Program in the Upper Midwest. Journal of Nursing Care Quarterly 2011 Feb 11;e-pub ahead of print.

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