Study Finds VA's Traumatic Brain Injury Screening Process is Inclusive and Effective in Referral for Further Services
BACKGROUND:
Traumatic brain injury (TBI) is relatively frequent among US forces deployed since 2001 to combat areas such as Afghanistan and Iraq (OEF/OIF/OND). More than 233,000 diagnoses of TBI have been made by military clinicians for U.S. forces from 2000 through 2011, and mild TBI (mTBI), commonly referred to as concussion, characterizes most TBI cases among OEF/OIF/OND service members and Veterans. Identifying mTBI is complicated because it can occur with no visible head wound, and because it is difficult to document key determinants of TBI severity (e.g. duration of altered consciousness) during combat. Moreover, mTBI symptoms are similar to characteristics of other conditions common in this cohort, such as PTSD. VA's policy is to use its national electronic medical record system to remind clinicians to screen all individuals who report OEF/OIF/OND deployment for TBI when they present at a VAMC for healthcare, regardless of the reason for their visit. This study evaluated VA's TBI screening and evaluation program and documented follow-up care and demographics of Veterans who do and do not receive care, so that VA can improve outreach and healthcare delivery. Using VA and DoD data, investigators identified all Veterans (n=208,589) screened for TBI in VA between 10/1/07 and 3/31/09 — the first cohort for which VA electronic records for both TBI screening and comprehensive TBI evaluation are available. The main variables measured included a diagnosis of TBI and referrals for follow-up care with any of 13 clinical services (e.g., audiology, physical therapy, and psychology).
FINDINGS:
- VA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of Veterans who were evaluated received further VA healthcare, and evaluations confirming TBI were associated with significantly higher healthcare use.
- Of the OEF/OIF/OND service members who were screened for TBI between 10/07 and 10/09, 44,781 (22%) screened positive. Of these Veterans, 24,461 (55%) received a comprehensive TBI evaluation. Of the Veterans with comprehensive evaluations, TBI was confirmed in 58%, yielding a best estimate that 7% of those screened were confirmed to have TBI.
- Patients with a positive screen were more likely to be male (94% vs. 88%) and enlisted (96% vs. 93%) than the screened patient population overall. Those who screened positive also had less education, were about half as likely to be in the Air Force or Navy, and were less likely to have more than eight years of service. Characteristics were similar for those with confirmed TBI.
LIMITATIONS:
- Knowledge about the actual brain injuries came from patients' self-reports
- There was no measure of symptom validity or malingering, so investigators could not comment on the extent to which Veterans exaggerated their symptoms when they presented to VA clinicians.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (SDR 08-405). During this study, Dr. Hendricks (retired) was Director of Health Care Financing & Economics, Boston VA Healthcare System. Drs. Charns (Director) and Baker are part of HSR&D's Center for Organization, Leadership and Management Research, also part of the Boston VA Healthcare System.
Hendricks A, Amara J, Baker E, Charns M, et al. Screening for Mild Traumatic Brain Injury in OEF/OIF Deployed U.S. Military: An Empirical Assessment of VHA’s Experience. Brain Injury February 2013;27(2):125-34.
