Factors Associated with Comprehensive TBI Evaluation Completion

About This Grant

Significance to VA: Post-9/11 Veterans who screen positive for mild traumatic brain injury (mTBI) and do not complete a Comprehensive TBI Evaluation (CTBIE) may be at risk of “falling through the cracks” by not having a mTBI diagnosed and referrals to appropriate health and rehabilitation services. MTBI is associated with increased risk of posttraumatic stress disorder, depression, sleep problems, and substance use. Therefore, it is critical to identify Veterans with mTBI history to intervene and mitigate any negative downstream effects. All Post-9/11 Veterans receiving Veterans Health Administration (VHA) services are screened for previously undiagnosed mTBI at their first VHA visit and offered a referral to a CTBIE if they screen positive. However, about 85,000 (23.4%) of Veterans with a positive TBI screen have not received a CTBIE, leaving their TBI status clinically unknown in VHA. The CTBIE is a pathway to interdisciplinary care for ongoing symptoms regardless of whether they are related to mTBI. Increasing CTBIE completion is a priority. Innovation and Impact: This work is innovative because it (1) integrates administrative data to characterize Veterans who screen positive for TBI with first-hand narratives of these Veterans and the VHA staff responsible for ensuring CTBIE completion and (2) accounts for differences in Veteran characteristics that may otherwise confound analyses of health-related factors by linking to multiple VA and Department of Defense (DoD) datasets. Including DoD data allows us to control for Veterans’ objective (and “pre-VHA”) injury characteristics, the measurement of which might otherwise be biased by limited Veterans’ VHA health services use and diagnoses at time of TBI screening. The result of this work will lead to work that impacts VHA’s delivery of healthcare and rehabilitation services. The synthesized administrative and interview data will identify challenges and, more importantly, best practices for overcoming them that are feasible and acceptable for the CTBIE clinics and acceptable to Veterans. This will inform actionable approaches to developing interventions to increase the CTBIE completion rate for Veterans with a positive TBI screen, a current VHA priority. Specific Aims: (1) Describe and model demographic, military, health, and VHA facility characteristics associated with CTBIE completion status among Veterans who screened positive for mTBI; (2) Identify facilitators and best practices associated with CTBIE completion, from the perspective of VHA staff, (3) Understand Veterans’ perceptions of and experiences with the TBI screening and CTBIE process and assess acceptable ways to improve it. Methodology: This is a 2-year, mixed-methods study. In Aim 1, using VA and DoD administrative data, we will quantify and model Veterans’ CTBIE completion status (CTBIE offer: Agreed vs. Declined; Among agreed: Completed vs. Not Completed) by accounting for sociodemographic, military history, health factors, and VHA facility characteristics. For Aim 2, we will interview 20 VHA staff knowledgeable about the CTBIE scheduling and completion process from VHA facilities that are high- and low-performing for CTBIE completion to understand factors, including facilitators and best practices, associated with CTBIE completion. We will identify current practices that VHA facilities follow when a Veteran screens positive for TBI and the feasibility and acceptability of other practices that could help facilitate CTBIE completion. For Aim 3, we will select 30 Veterans with a positive TBI screen based on their CTBIE completion status from sites where Aim 2 interviews occurred, to identify their perceived facilitators and barriers to CTBIE completion and have them evaluate practices that may increase the likelihood of CTBIE completion. Path to Translation/Implementation: Future research will translate this study’s findings into practical interventions to increase CTBIE completion. In collaboration with VHA TBI leadership, VHA pilot sites will be identified, and interventions will be implemented, monitored, and evaluated in a future study.