The Veterans Health Administration’s Traumatic Brain Injury Screen and Evaluation: Service Delivery Insights

The Veterans Health Administration’s Traumatic Brain Injury Screen and Evaluation: Service... Abstract Background In recognition of the incidence of traumatic brain injuries (TBIs) in the Iraq and Afghanistan conflicts, the Department of Veterans Affairs (VA) has, since 2007, examined returning U.S. service members for symptoms of TBI, a pre-condition for VA treatment of TBI. This study characterizes “Traumatic Brain Injury screen” service delivery, according to the barrier and facilitator viewpoints of those experiencing the delivery. Methods The purposeful sample comprised both Veteran patient and VA staff participants in the TBI screen program (n = 64), including patients (n = 14), health care providers (n = 38), and key informants (n = 12). Telephone interviews were conducted per standardized, semi-structured interview scripts; respondent narratives recorded and transcribed verbatim; natural emergence of key themes of discourse fostered through conventional content analysis; themes coded by meaning and meaning units organized by nature of influence on service delivery. Results A wide variety of structural, administrative, and communications barriers impede TBI screen service delivery, and certain case management and other functions promote delivery. Conclusions The value of VA TBI screen service delivery is appreciated by its participants, but delivery is perceived as vulnerable to failure; the extent of such failure and short- and long-term effects on patient health and well-being outcomes is incompletely understood and merits investigation. Evaluating VA TBI screen service delivery under alternate modes of delivery, e.g., one-stop visits, expanded hours of delivery, shared appointment sessions, telehealth, and intensified case management is suggested. INTRODUCTION Traumatic brain injury (TBI) is an “alteration of brain function, or other evidence of brain pathology, caused by an external force.”1 TBIs account for a larger proportion of combat-related casualties today compared with the previous eras of U.S. military conflict. For example, 22% of Iraq/Afghanistan casualties are attributed to TBI whereas 12–14% of Vietnam casualties are attributed to TBI.2 Among the present day, U.S. Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) combat cohort, the majority of TBIs occurred secondary to improvised explosive device blasts. Among all U.S. citizens, the majority of TBIs are caused by falls, being hit by an object, and vehicle crashes.3,4 TBI is commonly described as mild, moderate, or severe. Of all individuals sustaining mild TBI (mTBI), 85–90% recover within 30 d,5 however in some, cognitive, physical, and/or emotional symptoms occur more chronically.6 Since timely treatment can ameliorate TBI symptoms,7 and given that TBI is a signature injury of the U.S. Iraq/Afghanistan conflicts,8 in 2007, the U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA) began a system-wide TBI screening initiative. This program examines U.S. service members who return from the Iran and Afghanistan conflicts for deployment-related TBI history and symptoms; positively identified TBI can result in a referral for VA treatment of TBI. The VA defines health screening as “an examination or testing of a person without apparent symptoms to detect disease at an early stage when treatment performed on Veterans may be more effective or to detect or injury.”9 Thus the TBI screen aims to ensure that Veterans potentially affected by TBI are offered appropriate post-deployment follow-up. The TBI screen has been characterized according to classificatory accuracy,10 or the extent to which screened individuals are appropriately identified as TBI positive and TBI negative. Other TBI screen research explicates numbers served and cost of care. For example, we know that most returning OEF/OIF/OND combat Veterans who enroll for VA care do in fact receive initial mTBI screening.11,12 Of these, approximately 1 out of 5 screen positive for potential TBI12,13 and are referred for a secondary, diagnostic evaluation. According to a VA source, from April 13, 2007, through September 30, 2015, over 984,000 Veterans underwent the initial mTBI screening; 185,000 screened positive and 82,468 were ultimately diagnosed with TBI and received treatment.14 We also know that, during the 12 mo following initial TBI screening, the total median VA cost per Veteran with a positive screen is nearly double that for Veterans with a negative screen.13 The entire TBI screen program, including the timeframes within which examinations should occur, is governed by VA policy. In brief, the TBI screen comprises two levels or graduated tiers of examination: The TBI Clinical Reminder and a second-level, comprehensive TBI evaluation (CTBIE) (Figs 2 and 3). Beyond the need to comply with appointments as scheduled, a patient’s progression through examinations to potential receipt of TBI treatment (Fig. 1) is contingent upon: (1) a Veteran’s “yes” answer to each of 4 screening questions: “During any of your OIF/OEF/OND deployment(s), did you experience a blast or explosion?” “Did you lose consciousness or have a concussion immediately afterwards?” “Did any problems (such as headache, memory problems) begin or get worse afterwards?” and “In the past week, did you have symptoms such as headaches, memory problems, or sleep problems?” and (2) a positive CTBIE, an examination that consists of a detailed assessment of blast exposures and injurious events, a targeted review of symptoms, a physical examination, a definitive diagnoses or other explanation for symptoms, and a treatment plan. In general, treatment of TBI is centered on symptom management, supervised rest, and recovery. In addition to medical specialty care, ancillary services, neuropsychological testing, and other therapeutic services may be offered. FIGURE 1. View largeDownload slide Veterans Health Administration process since 2007 to diagnose and treat TBI. FIGURE 1. View largeDownload slide Veterans Health Administration process since 2007 to diagnose and treat TBI. The TBI screen program is important to investigate as a gateway to VA identification and treatment of TBI. Herein, we report the results of a study that was the qualitative arm of a larger mixed methods study on VA TBI screen practice patterns.10 Complex health care delivery programs such as the TBI screen demand complex understanding; qualitative studies add depth and nuance to quantitative studies. This study provides a unique window into subjective perceptions of TBI screen service delivery. The question posed is, “To what extent do program participants perceive the program’s delivery of services as successful?” To our knowledge, only one additional source, a 2008 U.S. General Accountability Office (GAO) Congressional Report,15 characterizes the TBI screen in terms of subjective perceptions of service delivery. Whereas the GAO identifies TBI screen barriers to such delivery only from a staff perspective only, this study identifies both barriers and facilitators according to a combined, VA patient/staff perspective. Despite these differences and acknowledging the non-equivalency of formal investigation and program auditing, redundancy of our barrier findings with those of the GAO increases our confidence in our barrier findings. METHODS With the approval of each site’s institutional review board, a convenience sample of TBI screen participants was recruited across 21 VA medical facilities located in geographically diverse regions of the USA. The study sample included patients, i.e., service members who have been deployed in OEF/OIF/OND conflicts and have screened positive on the initial mTBI screening (patients, n = 14); VA clinical staff delivering screenings (health care providers, n = 38); and VA staff not delivering screenings but possessing in-depth knowledge about administrative or other aspects of screening (key informants, n = 12). Veteran patient participants were recruited by VA clinician referral. Providers and key informant participants were identified by leadership at each VA medical facility and were recruited by e-mail, personal invitation, word of mouth, flyers, and brochures. Members of the three patient, provider, and key informant groups, henceforth referenced as “study respondents” or simply “respondents”, were interviewed using three nearly identical standardized, semi-structured interview scripts; the wording of scripts varied slightly by group to reflect the differing roles of group members relative to the TBI screen program. To influence a more natural flow of interviewer/respondent discourse, after each interviewer had conducted an initial few interviews, and as based on discussion and consensus between the two interviewers, study investigators slightly modified the original wording of the three scripts.16 As no limit was set on the length of responses to queries, the interviews ranged in length from 15 to 60 min (average, 35 min). The interviews were conducted by telephone during 2012–2013. All the interviews were audio-recorded and later transcribed exactly as spoken to allow for accountable coding. Two study interviewers independently conducted each interview as follows: after obtaining verbal informed consent and permission for audio-recording, interviewers gave a brief study overview, instructions to freely express personal viewpoints and opinions, and verbal assurance that narrative data would be aggregated and thus responses anonymous. Respondents were then queried specifically and in turn on barriers and facilitators, in their view applicable to each the four clinical procedures (TBI Clinical Reminder, the CTBIE, two referral processes) that comprise the TBI screen. To elicit greater detail or to clarify a point, interview staff sometimes followed up the standardized queries with more informal prompts and probes. After posing the main body of queries, interviewers would summarize the respondent’s main points of barrier and facilitator perception and ask: (1) Had the interviewer accurately summarized the respondent’s main points? (2) Did the respondent wish to change or add to the summary of points? (3) Did the respondent wish to add or say about anything additional about their TBI screen experience? and (4) If limited to one word or a brief phrase, how would the respondent summarize personal perceptions of the TBI screen? After interview sessions concluded, interview staff recorded age, gender, and ethnicity of the respondent, education of Veterans, and VA position and duration of employment of clinicians/key informants. Analysis We chose conventional content analysis to support a natural, unfettered emergence of themes from original narrative data.17 Each interview was selected as the unit of analysis. The lead qualitative interviewer made a preliminary identification of meaning units through: (1) reading each interview transcript several times; (2) condensing and labeling meaning units; (3) assigning each unit a code, and (4) comparing and streamlining codes for differences and similarities. The entire investigative team then reviewed, discussed, and occasionally modified themes for presentation according to specific rationales (see below).18 Organization of Themes of Perception First, the team collapsed the TBI screen’s two clinical examination procedures (TBI Clinical Reminder, CTBIE) into a single clinical examination category and the two referral procedures (post initial screening and post-secondary evaluation) into a single referral category. Second, in reflection of the barrier/facilitator format of the interview queries, we grouped themes of perception into domains (barrier, facilitator) of influence on screening delivery. Third, we grouped barrier domain themes into subdomains (structural, administrative/clinical, communication), then grouped themes within each of the three barrier subdomains into categories: (1) structural barriers, into “intrinsic” and “extrinsic to TBI screen” categories; (2) administrative/clinical barriers, into “determining initial screening eligibility”, “determining mild TBI” and other categories; and (3) communications, into staff-to-patient and staff-to-staff categories. Finally, we grouped facilitator themes of perception within coordination, training, and information dissemination subdomains. As used here, “coordination” signifies offering guidance and making special provisions for individuals to aid them in accessing treatment; “training”, delivering educational sessions, and “information dissemination”, widely dispersing knowledge. Finally, to illustrate research findings and based on representativeness of findings, we excerpted certain quotations directly from narrative data; we denoted Veteran quotations with a “V” and, based on their indistinguishable content, grouped provider/key informant quotations together and denoted these with a “P/KI”. RESULTS Table I describes the gender and race of the 64 respondents, and Table II lists the titles of provider and key informant respondents. The volume of respondent barrier commentary was far greater than facilitator commentary. Table I. Veterans and Veterans Health Administration Staff Involved in Screening, Evaluation, and Referral for Treatment for TBI Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Table I. Veterans and Veterans Health Administration Staff Involved in Screening, Evaluation, and Referral for Treatment for TBI Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Table II. Veterans Health Administration Staff Conducting Screening, Evaluation, and/or Referral for Treatment of TBI. Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 aIncludes titles such as Case or Program Manager, Polytrauma Support Team member, Primary Care or Mental Health provider, Physical Therapist, Polytrauma Coordinator, Psychology Technician. Table II. Veterans Health Administration Staff Conducting Screening, Evaluation, and/or Referral for Treatment of TBI. Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 aIncludes titles such as Case or Program Manager, Polytrauma Support Team member, Primary Care or Mental Health provider, Physical Therapist, Polytrauma Coordinator, Psychology Technician. Barriers to VA TBI Screen Operations Structural Barriers Structural barriers intrinsic to VA TBI screen delivery Service delivery design: Sequential, non-contiguous delivery of services renders appointment keeping challenging for patients: P/KI – “The biggest challenge, and this is probably more true for TBI patients, is just getting them here [for multiple screening appointments].” Infrastructure factors: Patient-to-staff ratios and other resource disparities across VAs influence long Veteran wait times (up to 6 wk) for initial medical/TBI screening appointments: P/KI – “At certain VA facilities, their TBI clinic is so overburdened that there are access to care issues.” Documents: The Neurobehavioral Symptom Inventory, described by respondents as lengthy and difficult to read, is non-ideal for transmitting patient information across VA providers: P/KIs – “Level 2 is very cumbersome. I don’t administer it, I just read it, and it’s not an easy read”; “As the provider reading the chart, if I’m looking to see what his TBI story is, I don’t walk away with a good understanding”; “I don’t think it’s a good document, it does not communicate clearly. I want to be specific so the next person that reads it will understand the evaluation. So, if we could fix the tool.” TBI Screen Clinical Reminder: Many VA staff do not have a good understanding of how to properly enter data into the VA TBI screen computerized system, or how to respond to messages that this system generates: P/KIs – “I was doing what I thought was correct, and I was never even entering the consults, because [the TBI Clinical Reminder] automatically said “consult entered”; “Even without manually going to the consult section, [the process] is not self-explanatory”; “It’s easy to make errors unintentionally. No one told me”. Structural barriers extrinsic to VA TBI screen delivery Lifestyle factors: Patient work, family, and school demands, and lack of transportation or other issues/problems such as Veteran homelessness, reduce appointment keeping: V – “I was working, I had a full-time job and a part-time job, so it was kind of hard for me to get off.” Cultural factors: Certain values common to members of military communities, such as personal resiliency and toughness, reduce patient motivation to follow-up on referrals: P/KI – “That’s just [the Veterans’] choice [not to pursue treatment] because the actual treatment part is not high on their priorities”, and “[Veterans] tend to no- show for polytrauma appointments because they don’t see that as an essential for them…” Administrative/Clinical Barriers to VA TBI Screen Delivery Establishing initial screen eligibility Patients previously screened by the VA for TBI in conjunction with a given deployment are ineligible for a second TBI screening for that deployment. However, “previously screened status” often goes undetected by VA staff, and duplicative screenings are delivered, due to: (1) Veteran faulty recall for previous TBI screening for a given deployment and (2) the time-consuming nature of staff performing medical records searches to confirm the accuracy of Veteran recall: P/KI – “Some providers are conducting screens without attempting to confirm previous deployment-related screenings.” Detecting mild TBI Initial TBI screening results are perceived to vary by: Screener discipline: P/KI – “You have LPNs to physicians doing the screens, so their interpretation of what the Veteran says is different.” Screening duration: V – “At ___ VA, the doctor knows he has a lot of time to sort of explain everything to you, at other VAs, they have less time.” Screener attitude: PKI – “Some providers do it (initial mTBI screening) because it’s a requirement, and I don’t think put a lot of thought into it.” Screener agenda: P/KI – “How they present it to the Veteran is different.” V – “So at ____ VA, they sort of look at it, looking for a positive so that they can send you to a specialist to find out, rather than looking for a negative to try to avoid the consult.” Patient agenda: Patients undergoing screening sometimes over- or under-represent TBI symptoms as influenced by personal agendas that include: (1) attaining a VA disability benefit or (2) retaining National Guard or Reserves eligibility: P/KI – “[Veterans] talk to each other, and their friend will say, “All you have to do [to receive Veteran benefits] is answer the questions like this.”” Scheduling patient appointments The VA TBI screen scheduling policy – two telephone calls followed by a mailed certified letter – is viewed as ineffectual, frustrating for staff to conduct, and as potentially off-putting for patients to receive: P/KIs – “[Veterans] screen positive on an initial screen, and then they change their phone number, their address, their contact information and you can’t locate them”; “From my perspective it’s almost a bit of a, sort of harassment of trying to get [patients] scheduled.” Communication Barriers to VA TBI Screen Delivery Providers interacting with patients VA staff sometimes communicate TBI information to patients in a way that is unintelligible to patients. V – “I just sat there and watched [the health care provider] and thought to myself ‘What is he saying to me?’” Staff interacting with staff Some provides resist conducting initial mTBI screenings. P/KIs -- “For some [providers] it’s just a blatant, ‘I’m not doing [the initial screening]’ kind of response” and “Mental health folks refuse to do [the screening], other clinicians refuse to do it. Nurses forget to do it and doctors forget or they just don’t do it.” Facilitators to VA TBI Screen Operations Coordination Care or case management, formal assistance provided to patients, assists patients in negotiating/complying with the VA TBI screen policies: V – “My nurse case managers at __ and at __ were great, I mean, they always call me up, following up about appointments. They ask me if I have any other questions. They’re always checking on me.” P/KI – “So recollection of things may be difficult, and I always encourage [Veterans] to bring their spouse of family members to provide additional information.” Training Staff training improves staff adherence to TBI screen clinical and administrative protocols: P/KIs – “Providers who don’t have the education, they don’t have training and they’re not provided that”; “The four-question screening training has been less stellar;” “Especially the new doctors that receive inadequate training, aren’t even completing the screens and the consults aren’t even entered.” Information Dissemination Conveying information, particularly about the benefit of TBI treatment, increases patient follow through on VA TBI screen referrals. P/KIs – “I would love to be able to offer some education to explain what does it mean to have a TBI”; We give [Veterans] things that are written to reinforce what we’ve said”; “We try and make sure that they understand; if we sense they aren’t getting a clue, we’ll repeat it.” DISCUSSION We conducted a study on the VA TBI screen to characterize this program’s service delivery from a subjective, insider perspective. In our analysis, a host of barriers jeopardize the effectiveness of this program’s service delivery to patients; the jeopardizing factors are wide-ranging. For example, many patients simply no-show, i.e., fail to attend, TBI screen examinations, for reasons as varied as lack of access to transportation, inability to secure leave from work, or lack of interest in or motivation to pursue second-level examinations or treatment. Study respondents referenced patient no-show rates as high as 50%. More generally, we learned that examinations are influenced by some patients over- or under-reporting TBI symptoms and some staff conveying to patients a rushed or dismissive attitude toward the screening process. In the opinion of study respondents, such factors can skew test results and can thus influence service delivery. We also learned that inexpert staff/patient and staff/staff communications can jeopardize service delivery. According to our analysis, most barriers originate within, i.e., are intrinsic to, the VA system and to the TBI screen program. For example, the program’s model or design of delivering services – non-contiguously over days or weeks of time in differing locales – increases the patient time/effort costs of appointment keeping and thus can inhibit appointment keeping. Moreover, serialized appointment keeping is likely to be disproportionally disadvantageous to individuals who sustain symptoms of TBI. It is also important to note the highly contingent nature of TBI screen service delivery (Figs 2 and 3). Another type of barrier involves cross-facility infrastructure differences, e.g., in facility size, number of staff, and the intensity of workload. In the respondent view, such disparities influence patient wait times and can even influence the tone of TBI screenings: “So at ____VA, they sort of look at it, looking for a positive so that they can send you to a specialist to find out, rather than looking for a negative to try to avoid the consult”. Moreover, we learned that, because second-level TBI evaluations are typically scheduled over the phone after a patient’s departure from an initial clinic visit, and because this particular cohort of patients is noted for frequent changes of address and phone number, many patients are lost to second-level evaluations. We also learned that, whereas VA clinicians are required by the VA to undergo TBI screen trainings, some staff are conducting TBI screenings prior to such training. Other service delivery barriers correspond with those that the previously cited GAO report documents: many VA clinical staff inaccurately identify patients as eligible/ineligible for initial screening interviews, improperly log screening results into a computerized system, and/or, fail to respond or erroneously respond to computerized “clinical reminders.” The consequences of such simple administrative errors can be serious, ranging from squandered staff effort, to inaccurate registry of Veterans receiving/not receiving initial TBI screening, to failed generation of consults/loss of eligible patients to TBI second-level evaluation, and ultimately, loss of patients to TBI treatment. FIGURE 2. View largeDownload slide Initial steps of Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom /Operation Iraqi Freedom (OIF). Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. FIGURE 2. View largeDownload slide Initial steps of Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom /Operation Iraqi Freedom (OIF). Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. FIGURE 3. View largeDownload slide Final steps in Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom/Operation Iraqi Freedom. Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. FIGURE 3. View largeDownload slide Final steps in Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom/Operation Iraqi Freedom. Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. As for facilitators, these study respondents perceive case management, particularly if tailored to a patient’s individual circumstances, to promote successful service delivery: “All the TBI teams, they really should, ideally have a case manager to follow-up those types of [memory] impaired patients.” Case managers establish rapport with patients that can bolster patient appointment keeping resolve; case managers, moreover, help coordinate appointments for patients who may be challenged in doing so themselves. For example, case managers can help patients with benefits or transportation to facilitate appointment keeping. In addition to case management, the bulk of respondent opinion validates VA-mandated TBI trainings as essential, endorses the importance of communications and teamwork trainings to support services delivery, and emphasizes the importance of consistently and repeatedly disseminating TBI- and TBI screen-specific information: “We must ensure that [Veterans] get a consistent message, a correct message, and that they understood the message, particularly about the fact that with mild TBI, the expectation is recovery.” CONCLUSION In this qualitative study, inquiry was limited to presently operational barriers and facilitators. Accordingly, study results peripherally suggest how services might be more effectively delivered in the future, or how policies or procedures might be altered to better promote such delivery. However, results suggest the need for related research, including evaluating TBI screen service delivery under alternate modes of delivery, e.g., one-stop visits, expanded hours of delivery, shared appointment sessions, telehealth, and intensified case management. The longer term effect of truncated TBI service delivery on patient health outcomes is also an extremely important research topic, particularly considering new findings that concussive blast TBI appears to lead to considerable decline after 5 yr.19 Thus prospectively following patients initially identified as positive and negative for potential TBI is warranted. Another, shorter term investigation might include evaluating the relationship between VA site of TBI screening and rates of service delivery. Finally, whereas the TBI Clinical Reminder tool is worded to capture combat-acquired TBI symptoms, civilian-acquired TBI symptoms are far more common and thus likely to be reported along with or in lieu of combat symptoms. Potentially challenging, related research invites pursuit: perhaps comparing examination results under different conditions of verbal introduction (explicit, emphatic/less explicit, emphatic stressing of the combat-related intent of VA TBI screen) would be productive. Or perhaps the better route is sequentially testing the same sample of OEF/OIF/OND combat Veterans, first for civilian-, and then for combat-acquired TBI symptoms. Going forward, study results should be considered in view of study limitations. Because of their wide-ranging nature, organizing themes of perception was unusually challenging, heavily dependent on the analytical skills of the researchers, and potentially influenced by researcher biases. Another limitation is that results are marginally generalizable to other disease screening programs. Moreover, we were far more successful in recruiting VA staff for study participation than in recruiting patients for participation. Such disparity is likely due to the work, family, and other demands typically confronting individuals returning from military deployment, or by the fact that staff participated in interviews as part of a routine work day, whereas patients participated during their personal hours. The relatively small number of patient respondents represents a major study weakness. Additionally, it is possible that both patient and staff respondents, due to TBI screen vested interests, were less than candid when answering interview questions. Finally, the fact that we concluded interview sessions by asking respondents to supply a one-word or brief phrase summary of their VA TBI screen experience was limiting; however, in conjunction with the more in-depth responses, such summaries augment service delivery insights: “I consider it to be excellent, I’m very positive about it”; “It’s better than nothing”; “It’s an incredible honor”; “It’s a moving target”; and “I think it’s getting better”. Despite limitations, this study and others19,20 underscore the need for robust evidence to inform improvement of the VA TBI screen. Such evidence is critical to motivating the re-vamping of the TBI screen program likely required to assure more effective delivery of screening and evaluation services to Veterans potentially eligible for TBI treatment. Funding This research was supported by Health Services Research and Development Service, Office of Research and Development, Veterans Health Administration, Department of Veterans Affairs, IAC 08-101: “Existing Practice Patterns for Screening Mild TBI in OEF/OIF Veterans”; by the Defense and Veterans Brain Injury Center (DVBIC); and by James A. Haley Veterans’ Hospital. Acknowledgements We would like to thank the following VA employees: Lynn Dirk, MAMC, who edited early versions of this paper; Sandra Mutolo, MSW, who conducted a portion of the qualitative interviews; and Andrea Spehar, PhD, who served as the study coordinator for the SDR HSR&D #08-411 grant. Conflict of Interest No work resembling the enclosed article has been published or is being submitted for publication elsewhere. All authors have certified in writing that they have read the final version of the manuscript and have made a substantial contribution to the research and final manuscript in accordance with the guidelines of the Uniform Requirements. All authors declare that the answer to the questions on your competing interest form are all “No” and therefore have nothing to declare. No author has any financial, funding, or other conflicts of interest that might bias this work. 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Google Scholar CrossRef Search ADS PubMed 12 Evans CT , St Andre JR , Pape TL-B , Steiner ML , Stroupe KT , Hogan TP , et al. : An evaluation of the Veterans Affairs traumatic brain injury screening process among Operation Enduring Freedom and/or Operation Iraqi Freedom veterans . PM R 2013 ; 5 : 210 – 20 ; quiz 220. Google Scholar CrossRef Search ADS PubMed 13 Stroupe KT , Smith BM , Hogan TP St , Andre JR , Pape T , Steiner ML , et al. : Healthcare utilization and costs of Veterans screened and assessed for traumatic brain injury . J Rehabil Res Dev 2013 ; 50 : 1047 – 68 . Google Scholar CrossRef Search ADS PubMed 14 Donnelly KT , Donnelly JP , Dunnam M , Warner GC , Kittleson CJ , Constance JE , et al. : Reliability, sensitivity, and specificity of the VA traumatic brain injury screening tool . J Head Trauma Rehabil 2011 ; 26 : 439 – 53 . Google Scholar CrossRef Search ADS PubMed 15 Government Accountability Office (GAO) . VA Health Care. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain [Internet]. Washington, DC: US Government Accountability Office; 2008 . Available at http://www.gao.gov/new.items/d08276.pdf 16 Crabtree BF , Miller WL : Doing Qualitative Research . Thousand Oaks, Calif , Sage Publications , 1999 . 17 Hsieh H-F , Shannon SE : Three approaches to qualitative content analysis . Qual Health Res 2005 ; 15 : 1277 – 88 . Google Scholar CrossRef Search ADS PubMed 18 Donabedian A : The quality of care. How can it be assessed? 1988 . Arch Pathol Lab Med 1997 ; 121 : 1145 – 50 . Google Scholar PubMed 19 Sayer NA , Nelson D , Nugent S : Evaluation of the veterans health administration traumatic brain injury screening program in the upper midwest . J Head Trauma Rehabil 2011 ; 26 : 454 – 67 . Google Scholar CrossRef Search ADS PubMed 20 Arriola VD , Rozelle JW : Traumatic brain injury in United States Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) hispanic veterans – a review using the PRISMA method . Behav Sci Basel Switz 2016 ; 6 , article 3. Author notes The views expressed herein are those of the authors and do not represent the views of the Department of Army, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government. Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

The Veterans Health Administration’s Traumatic Brain Injury Screen and Evaluation: Service Delivery Insights

Military Medicine , Volume 183 (9) – Sep 1, 2018

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Oxford University Press
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Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018.
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0026-4075
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Abstract

Abstract Background In recognition of the incidence of traumatic brain injuries (TBIs) in the Iraq and Afghanistan conflicts, the Department of Veterans Affairs (VA) has, since 2007, examined returning U.S. service members for symptoms of TBI, a pre-condition for VA treatment of TBI. This study characterizes “Traumatic Brain Injury screen” service delivery, according to the barrier and facilitator viewpoints of those experiencing the delivery. Methods The purposeful sample comprised both Veteran patient and VA staff participants in the TBI screen program (n = 64), including patients (n = 14), health care providers (n = 38), and key informants (n = 12). Telephone interviews were conducted per standardized, semi-structured interview scripts; respondent narratives recorded and transcribed verbatim; natural emergence of key themes of discourse fostered through conventional content analysis; themes coded by meaning and meaning units organized by nature of influence on service delivery. Results A wide variety of structural, administrative, and communications barriers impede TBI screen service delivery, and certain case management and other functions promote delivery. Conclusions The value of VA TBI screen service delivery is appreciated by its participants, but delivery is perceived as vulnerable to failure; the extent of such failure and short- and long-term effects on patient health and well-being outcomes is incompletely understood and merits investigation. Evaluating VA TBI screen service delivery under alternate modes of delivery, e.g., one-stop visits, expanded hours of delivery, shared appointment sessions, telehealth, and intensified case management is suggested. INTRODUCTION Traumatic brain injury (TBI) is an “alteration of brain function, or other evidence of brain pathology, caused by an external force.”1 TBIs account for a larger proportion of combat-related casualties today compared with the previous eras of U.S. military conflict. For example, 22% of Iraq/Afghanistan casualties are attributed to TBI whereas 12–14% of Vietnam casualties are attributed to TBI.2 Among the present day, U.S. Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) combat cohort, the majority of TBIs occurred secondary to improvised explosive device blasts. Among all U.S. citizens, the majority of TBIs are caused by falls, being hit by an object, and vehicle crashes.3,4 TBI is commonly described as mild, moderate, or severe. Of all individuals sustaining mild TBI (mTBI), 85–90% recover within 30 d,5 however in some, cognitive, physical, and/or emotional symptoms occur more chronically.6 Since timely treatment can ameliorate TBI symptoms,7 and given that TBI is a signature injury of the U.S. Iraq/Afghanistan conflicts,8 in 2007, the U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA) began a system-wide TBI screening initiative. This program examines U.S. service members who return from the Iran and Afghanistan conflicts for deployment-related TBI history and symptoms; positively identified TBI can result in a referral for VA treatment of TBI. The VA defines health screening as “an examination or testing of a person without apparent symptoms to detect disease at an early stage when treatment performed on Veterans may be more effective or to detect or injury.”9 Thus the TBI screen aims to ensure that Veterans potentially affected by TBI are offered appropriate post-deployment follow-up. The TBI screen has been characterized according to classificatory accuracy,10 or the extent to which screened individuals are appropriately identified as TBI positive and TBI negative. Other TBI screen research explicates numbers served and cost of care. For example, we know that most returning OEF/OIF/OND combat Veterans who enroll for VA care do in fact receive initial mTBI screening.11,12 Of these, approximately 1 out of 5 screen positive for potential TBI12,13 and are referred for a secondary, diagnostic evaluation. According to a VA source, from April 13, 2007, through September 30, 2015, over 984,000 Veterans underwent the initial mTBI screening; 185,000 screened positive and 82,468 were ultimately diagnosed with TBI and received treatment.14 We also know that, during the 12 mo following initial TBI screening, the total median VA cost per Veteran with a positive screen is nearly double that for Veterans with a negative screen.13 The entire TBI screen program, including the timeframes within which examinations should occur, is governed by VA policy. In brief, the TBI screen comprises two levels or graduated tiers of examination: The TBI Clinical Reminder and a second-level, comprehensive TBI evaluation (CTBIE) (Figs 2 and 3). Beyond the need to comply with appointments as scheduled, a patient’s progression through examinations to potential receipt of TBI treatment (Fig. 1) is contingent upon: (1) a Veteran’s “yes” answer to each of 4 screening questions: “During any of your OIF/OEF/OND deployment(s), did you experience a blast or explosion?” “Did you lose consciousness or have a concussion immediately afterwards?” “Did any problems (such as headache, memory problems) begin or get worse afterwards?” and “In the past week, did you have symptoms such as headaches, memory problems, or sleep problems?” and (2) a positive CTBIE, an examination that consists of a detailed assessment of blast exposures and injurious events, a targeted review of symptoms, a physical examination, a definitive diagnoses or other explanation for symptoms, and a treatment plan. In general, treatment of TBI is centered on symptom management, supervised rest, and recovery. In addition to medical specialty care, ancillary services, neuropsychological testing, and other therapeutic services may be offered. FIGURE 1. View largeDownload slide Veterans Health Administration process since 2007 to diagnose and treat TBI. FIGURE 1. View largeDownload slide Veterans Health Administration process since 2007 to diagnose and treat TBI. The TBI screen program is important to investigate as a gateway to VA identification and treatment of TBI. Herein, we report the results of a study that was the qualitative arm of a larger mixed methods study on VA TBI screen practice patterns.10 Complex health care delivery programs such as the TBI screen demand complex understanding; qualitative studies add depth and nuance to quantitative studies. This study provides a unique window into subjective perceptions of TBI screen service delivery. The question posed is, “To what extent do program participants perceive the program’s delivery of services as successful?” To our knowledge, only one additional source, a 2008 U.S. General Accountability Office (GAO) Congressional Report,15 characterizes the TBI screen in terms of subjective perceptions of service delivery. Whereas the GAO identifies TBI screen barriers to such delivery only from a staff perspective only, this study identifies both barriers and facilitators according to a combined, VA patient/staff perspective. Despite these differences and acknowledging the non-equivalency of formal investigation and program auditing, redundancy of our barrier findings with those of the GAO increases our confidence in our barrier findings. METHODS With the approval of each site’s institutional review board, a convenience sample of TBI screen participants was recruited across 21 VA medical facilities located in geographically diverse regions of the USA. The study sample included patients, i.e., service members who have been deployed in OEF/OIF/OND conflicts and have screened positive on the initial mTBI screening (patients, n = 14); VA clinical staff delivering screenings (health care providers, n = 38); and VA staff not delivering screenings but possessing in-depth knowledge about administrative or other aspects of screening (key informants, n = 12). Veteran patient participants were recruited by VA clinician referral. Providers and key informant participants were identified by leadership at each VA medical facility and were recruited by e-mail, personal invitation, word of mouth, flyers, and brochures. Members of the three patient, provider, and key informant groups, henceforth referenced as “study respondents” or simply “respondents”, were interviewed using three nearly identical standardized, semi-structured interview scripts; the wording of scripts varied slightly by group to reflect the differing roles of group members relative to the TBI screen program. To influence a more natural flow of interviewer/respondent discourse, after each interviewer had conducted an initial few interviews, and as based on discussion and consensus between the two interviewers, study investigators slightly modified the original wording of the three scripts.16 As no limit was set on the length of responses to queries, the interviews ranged in length from 15 to 60 min (average, 35 min). The interviews were conducted by telephone during 2012–2013. All the interviews were audio-recorded and later transcribed exactly as spoken to allow for accountable coding. Two study interviewers independently conducted each interview as follows: after obtaining verbal informed consent and permission for audio-recording, interviewers gave a brief study overview, instructions to freely express personal viewpoints and opinions, and verbal assurance that narrative data would be aggregated and thus responses anonymous. Respondents were then queried specifically and in turn on barriers and facilitators, in their view applicable to each the four clinical procedures (TBI Clinical Reminder, the CTBIE, two referral processes) that comprise the TBI screen. To elicit greater detail or to clarify a point, interview staff sometimes followed up the standardized queries with more informal prompts and probes. After posing the main body of queries, interviewers would summarize the respondent’s main points of barrier and facilitator perception and ask: (1) Had the interviewer accurately summarized the respondent’s main points? (2) Did the respondent wish to change or add to the summary of points? (3) Did the respondent wish to add or say about anything additional about their TBI screen experience? and (4) If limited to one word or a brief phrase, how would the respondent summarize personal perceptions of the TBI screen? After interview sessions concluded, interview staff recorded age, gender, and ethnicity of the respondent, education of Veterans, and VA position and duration of employment of clinicians/key informants. Analysis We chose conventional content analysis to support a natural, unfettered emergence of themes from original narrative data.17 Each interview was selected as the unit of analysis. The lead qualitative interviewer made a preliminary identification of meaning units through: (1) reading each interview transcript several times; (2) condensing and labeling meaning units; (3) assigning each unit a code, and (4) comparing and streamlining codes for differences and similarities. The entire investigative team then reviewed, discussed, and occasionally modified themes for presentation according to specific rationales (see below).18 Organization of Themes of Perception First, the team collapsed the TBI screen’s two clinical examination procedures (TBI Clinical Reminder, CTBIE) into a single clinical examination category and the two referral procedures (post initial screening and post-secondary evaluation) into a single referral category. Second, in reflection of the barrier/facilitator format of the interview queries, we grouped themes of perception into domains (barrier, facilitator) of influence on screening delivery. Third, we grouped barrier domain themes into subdomains (structural, administrative/clinical, communication), then grouped themes within each of the three barrier subdomains into categories: (1) structural barriers, into “intrinsic” and “extrinsic to TBI screen” categories; (2) administrative/clinical barriers, into “determining initial screening eligibility”, “determining mild TBI” and other categories; and (3) communications, into staff-to-patient and staff-to-staff categories. Finally, we grouped facilitator themes of perception within coordination, training, and information dissemination subdomains. As used here, “coordination” signifies offering guidance and making special provisions for individuals to aid them in accessing treatment; “training”, delivering educational sessions, and “information dissemination”, widely dispersing knowledge. Finally, to illustrate research findings and based on representativeness of findings, we excerpted certain quotations directly from narrative data; we denoted Veteran quotations with a “V” and, based on their indistinguishable content, grouped provider/key informant quotations together and denoted these with a “P/KI”. RESULTS Table I describes the gender and race of the 64 respondents, and Table II lists the titles of provider and key informant respondents. The volume of respondent barrier commentary was far greater than facilitator commentary. Table I. Veterans and Veterans Health Administration Staff Involved in Screening, Evaluation, and Referral for Treatment for TBI Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Table I. Veterans and Veterans Health Administration Staff Involved in Screening, Evaluation, and Referral for Treatment for TBI Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Provider (n = 38) Veterans (n = 14) Key lnformant (n = 12) All (n = 64) n % n % n % n % Recruitment method Personal contact 19 29.7 13 20.3 5 7.8 37 57.8 Email 19 29.7 1 1.6 7 10.9 27 42.2 Gender Female 29 45.3 1 1.6 9 14.1 39 60.9 Male 9 14.1 12 18.6 3 4.7 24 37.5 Missing data 0 0 1 1.6 0 0 1 1.6 Race White 27 42.2 10 15.6 11 17.2 4a 75 Asian 6 9.4 0 0 0 0 5 7.8 African American 2 3.1 1 1.6 1 1.6 4 6.2 Hispanic 1 1.6 2 3.1 0 0 2 3.1 Declined to answer or missing data 2 3.1 1 1.6 0 0 2 3.1 Table II. Veterans Health Administration Staff Conducting Screening, Evaluation, and/or Referral for Treatment of TBI. Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 aIncludes titles such as Case or Program Manager, Polytrauma Support Team member, Primary Care or Mental Health provider, Physical Therapist, Polytrauma Coordinator, Psychology Technician. Table II. Veterans Health Administration Staff Conducting Screening, Evaluation, and/or Referral for Treatment of TBI. Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 Staff Title Provider (N = 38) Key Informant (N = 12) All (N = 50) n n n % Physician 9 2 11 22 ARNP 5 0 5 10 Psychologist 3 2 5 10 Social Work 9 2 11 22 Nurse 6 3 9 18 Othera 6 3 9 18 aIncludes titles such as Case or Program Manager, Polytrauma Support Team member, Primary Care or Mental Health provider, Physical Therapist, Polytrauma Coordinator, Psychology Technician. Barriers to VA TBI Screen Operations Structural Barriers Structural barriers intrinsic to VA TBI screen delivery Service delivery design: Sequential, non-contiguous delivery of services renders appointment keeping challenging for patients: P/KI – “The biggest challenge, and this is probably more true for TBI patients, is just getting them here [for multiple screening appointments].” Infrastructure factors: Patient-to-staff ratios and other resource disparities across VAs influence long Veteran wait times (up to 6 wk) for initial medical/TBI screening appointments: P/KI – “At certain VA facilities, their TBI clinic is so overburdened that there are access to care issues.” Documents: The Neurobehavioral Symptom Inventory, described by respondents as lengthy and difficult to read, is non-ideal for transmitting patient information across VA providers: P/KIs – “Level 2 is very cumbersome. I don’t administer it, I just read it, and it’s not an easy read”; “As the provider reading the chart, if I’m looking to see what his TBI story is, I don’t walk away with a good understanding”; “I don’t think it’s a good document, it does not communicate clearly. I want to be specific so the next person that reads it will understand the evaluation. So, if we could fix the tool.” TBI Screen Clinical Reminder: Many VA staff do not have a good understanding of how to properly enter data into the VA TBI screen computerized system, or how to respond to messages that this system generates: P/KIs – “I was doing what I thought was correct, and I was never even entering the consults, because [the TBI Clinical Reminder] automatically said “consult entered”; “Even without manually going to the consult section, [the process] is not self-explanatory”; “It’s easy to make errors unintentionally. No one told me”. Structural barriers extrinsic to VA TBI screen delivery Lifestyle factors: Patient work, family, and school demands, and lack of transportation or other issues/problems such as Veteran homelessness, reduce appointment keeping: V – “I was working, I had a full-time job and a part-time job, so it was kind of hard for me to get off.” Cultural factors: Certain values common to members of military communities, such as personal resiliency and toughness, reduce patient motivation to follow-up on referrals: P/KI – “That’s just [the Veterans’] choice [not to pursue treatment] because the actual treatment part is not high on their priorities”, and “[Veterans] tend to no- show for polytrauma appointments because they don’t see that as an essential for them…” Administrative/Clinical Barriers to VA TBI Screen Delivery Establishing initial screen eligibility Patients previously screened by the VA for TBI in conjunction with a given deployment are ineligible for a second TBI screening for that deployment. However, “previously screened status” often goes undetected by VA staff, and duplicative screenings are delivered, due to: (1) Veteran faulty recall for previous TBI screening for a given deployment and (2) the time-consuming nature of staff performing medical records searches to confirm the accuracy of Veteran recall: P/KI – “Some providers are conducting screens without attempting to confirm previous deployment-related screenings.” Detecting mild TBI Initial TBI screening results are perceived to vary by: Screener discipline: P/KI – “You have LPNs to physicians doing the screens, so their interpretation of what the Veteran says is different.” Screening duration: V – “At ___ VA, the doctor knows he has a lot of time to sort of explain everything to you, at other VAs, they have less time.” Screener attitude: PKI – “Some providers do it (initial mTBI screening) because it’s a requirement, and I don’t think put a lot of thought into it.” Screener agenda: P/KI – “How they present it to the Veteran is different.” V – “So at ____ VA, they sort of look at it, looking for a positive so that they can send you to a specialist to find out, rather than looking for a negative to try to avoid the consult.” Patient agenda: Patients undergoing screening sometimes over- or under-represent TBI symptoms as influenced by personal agendas that include: (1) attaining a VA disability benefit or (2) retaining National Guard or Reserves eligibility: P/KI – “[Veterans] talk to each other, and their friend will say, “All you have to do [to receive Veteran benefits] is answer the questions like this.”” Scheduling patient appointments The VA TBI screen scheduling policy – two telephone calls followed by a mailed certified letter – is viewed as ineffectual, frustrating for staff to conduct, and as potentially off-putting for patients to receive: P/KIs – “[Veterans] screen positive on an initial screen, and then they change their phone number, their address, their contact information and you can’t locate them”; “From my perspective it’s almost a bit of a, sort of harassment of trying to get [patients] scheduled.” Communication Barriers to VA TBI Screen Delivery Providers interacting with patients VA staff sometimes communicate TBI information to patients in a way that is unintelligible to patients. V – “I just sat there and watched [the health care provider] and thought to myself ‘What is he saying to me?’” Staff interacting with staff Some provides resist conducting initial mTBI screenings. P/KIs -- “For some [providers] it’s just a blatant, ‘I’m not doing [the initial screening]’ kind of response” and “Mental health folks refuse to do [the screening], other clinicians refuse to do it. Nurses forget to do it and doctors forget or they just don’t do it.” Facilitators to VA TBI Screen Operations Coordination Care or case management, formal assistance provided to patients, assists patients in negotiating/complying with the VA TBI screen policies: V – “My nurse case managers at __ and at __ were great, I mean, they always call me up, following up about appointments. They ask me if I have any other questions. They’re always checking on me.” P/KI – “So recollection of things may be difficult, and I always encourage [Veterans] to bring their spouse of family members to provide additional information.” Training Staff training improves staff adherence to TBI screen clinical and administrative protocols: P/KIs – “Providers who don’t have the education, they don’t have training and they’re not provided that”; “The four-question screening training has been less stellar;” “Especially the new doctors that receive inadequate training, aren’t even completing the screens and the consults aren’t even entered.” Information Dissemination Conveying information, particularly about the benefit of TBI treatment, increases patient follow through on VA TBI screen referrals. P/KIs – “I would love to be able to offer some education to explain what does it mean to have a TBI”; We give [Veterans] things that are written to reinforce what we’ve said”; “We try and make sure that they understand; if we sense they aren’t getting a clue, we’ll repeat it.” DISCUSSION We conducted a study on the VA TBI screen to characterize this program’s service delivery from a subjective, insider perspective. In our analysis, a host of barriers jeopardize the effectiveness of this program’s service delivery to patients; the jeopardizing factors are wide-ranging. For example, many patients simply no-show, i.e., fail to attend, TBI screen examinations, for reasons as varied as lack of access to transportation, inability to secure leave from work, or lack of interest in or motivation to pursue second-level examinations or treatment. Study respondents referenced patient no-show rates as high as 50%. More generally, we learned that examinations are influenced by some patients over- or under-reporting TBI symptoms and some staff conveying to patients a rushed or dismissive attitude toward the screening process. In the opinion of study respondents, such factors can skew test results and can thus influence service delivery. We also learned that inexpert staff/patient and staff/staff communications can jeopardize service delivery. According to our analysis, most barriers originate within, i.e., are intrinsic to, the VA system and to the TBI screen program. For example, the program’s model or design of delivering services – non-contiguously over days or weeks of time in differing locales – increases the patient time/effort costs of appointment keeping and thus can inhibit appointment keeping. Moreover, serialized appointment keeping is likely to be disproportionally disadvantageous to individuals who sustain symptoms of TBI. It is also important to note the highly contingent nature of TBI screen service delivery (Figs 2 and 3). Another type of barrier involves cross-facility infrastructure differences, e.g., in facility size, number of staff, and the intensity of workload. In the respondent view, such disparities influence patient wait times and can even influence the tone of TBI screenings: “So at ____VA, they sort of look at it, looking for a positive so that they can send you to a specialist to find out, rather than looking for a negative to try to avoid the consult”. Moreover, we learned that, because second-level TBI evaluations are typically scheduled over the phone after a patient’s departure from an initial clinic visit, and because this particular cohort of patients is noted for frequent changes of address and phone number, many patients are lost to second-level evaluations. We also learned that, whereas VA clinicians are required by the VA to undergo TBI screen trainings, some staff are conducting TBI screenings prior to such training. Other service delivery barriers correspond with those that the previously cited GAO report documents: many VA clinical staff inaccurately identify patients as eligible/ineligible for initial screening interviews, improperly log screening results into a computerized system, and/or, fail to respond or erroneously respond to computerized “clinical reminders.” The consequences of such simple administrative errors can be serious, ranging from squandered staff effort, to inaccurate registry of Veterans receiving/not receiving initial TBI screening, to failed generation of consults/loss of eligible patients to TBI second-level evaluation, and ultimately, loss of patients to TBI treatment. FIGURE 2. View largeDownload slide Initial steps of Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom /Operation Iraqi Freedom (OIF). Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. FIGURE 2. View largeDownload slide Initial steps of Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom /Operation Iraqi Freedom (OIF). Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. FIGURE 3. View largeDownload slide Final steps in Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom/Operation Iraqi Freedom. Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. FIGURE 3. View largeDownload slide Final steps in Veterans Health Administration screening program to diagnose and treat TBI in Veterans. VA, Department of Veteran Affairs; OEF/OIF, Operation Enduring Freedom/Operation Iraqi Freedom. Reproduced from US Government Accountability Office. Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. Report to Congressional Requesters. 2008 Feb. As for facilitators, these study respondents perceive case management, particularly if tailored to a patient’s individual circumstances, to promote successful service delivery: “All the TBI teams, they really should, ideally have a case manager to follow-up those types of [memory] impaired patients.” Case managers establish rapport with patients that can bolster patient appointment keeping resolve; case managers, moreover, help coordinate appointments for patients who may be challenged in doing so themselves. For example, case managers can help patients with benefits or transportation to facilitate appointment keeping. In addition to case management, the bulk of respondent opinion validates VA-mandated TBI trainings as essential, endorses the importance of communications and teamwork trainings to support services delivery, and emphasizes the importance of consistently and repeatedly disseminating TBI- and TBI screen-specific information: “We must ensure that [Veterans] get a consistent message, a correct message, and that they understood the message, particularly about the fact that with mild TBI, the expectation is recovery.” CONCLUSION In this qualitative study, inquiry was limited to presently operational barriers and facilitators. Accordingly, study results peripherally suggest how services might be more effectively delivered in the future, or how policies or procedures might be altered to better promote such delivery. However, results suggest the need for related research, including evaluating TBI screen service delivery under alternate modes of delivery, e.g., one-stop visits, expanded hours of delivery, shared appointment sessions, telehealth, and intensified case management. The longer term effect of truncated TBI service delivery on patient health outcomes is also an extremely important research topic, particularly considering new findings that concussive blast TBI appears to lead to considerable decline after 5 yr.19 Thus prospectively following patients initially identified as positive and negative for potential TBI is warranted. Another, shorter term investigation might include evaluating the relationship between VA site of TBI screening and rates of service delivery. Finally, whereas the TBI Clinical Reminder tool is worded to capture combat-acquired TBI symptoms, civilian-acquired TBI symptoms are far more common and thus likely to be reported along with or in lieu of combat symptoms. Potentially challenging, related research invites pursuit: perhaps comparing examination results under different conditions of verbal introduction (explicit, emphatic/less explicit, emphatic stressing of the combat-related intent of VA TBI screen) would be productive. Or perhaps the better route is sequentially testing the same sample of OEF/OIF/OND combat Veterans, first for civilian-, and then for combat-acquired TBI symptoms. Going forward, study results should be considered in view of study limitations. Because of their wide-ranging nature, organizing themes of perception was unusually challenging, heavily dependent on the analytical skills of the researchers, and potentially influenced by researcher biases. Another limitation is that results are marginally generalizable to other disease screening programs. Moreover, we were far more successful in recruiting VA staff for study participation than in recruiting patients for participation. Such disparity is likely due to the work, family, and other demands typically confronting individuals returning from military deployment, or by the fact that staff participated in interviews as part of a routine work day, whereas patients participated during their personal hours. The relatively small number of patient respondents represents a major study weakness. Additionally, it is possible that both patient and staff respondents, due to TBI screen vested interests, were less than candid when answering interview questions. Finally, the fact that we concluded interview sessions by asking respondents to supply a one-word or brief phrase summary of their VA TBI screen experience was limiting; however, in conjunction with the more in-depth responses, such summaries augment service delivery insights: “I consider it to be excellent, I’m very positive about it”; “It’s better than nothing”; “It’s an incredible honor”; “It’s a moving target”; and “I think it’s getting better”. Despite limitations, this study and others19,20 underscore the need for robust evidence to inform improvement of the VA TBI screen. Such evidence is critical to motivating the re-vamping of the TBI screen program likely required to assure more effective delivery of screening and evaluation services to Veterans potentially eligible for TBI treatment. Funding This research was supported by Health Services Research and Development Service, Office of Research and Development, Veterans Health Administration, Department of Veterans Affairs, IAC 08-101: “Existing Practice Patterns for Screening Mild TBI in OEF/OIF Veterans”; by the Defense and Veterans Brain Injury Center (DVBIC); and by James A. Haley Veterans’ Hospital. Acknowledgements We would like to thank the following VA employees: Lynn Dirk, MAMC, who edited early versions of this paper; Sandra Mutolo, MSW, who conducted a portion of the qualitative interviews; and Andrea Spehar, PhD, who served as the study coordinator for the SDR HSR&D #08-411 grant. Conflict of Interest No work resembling the enclosed article has been published or is being submitted for publication elsewhere. All authors have certified in writing that they have read the final version of the manuscript and have made a substantial contribution to the research and final manuscript in accordance with the guidelines of the Uniform Requirements. All authors declare that the answer to the questions on your competing interest form are all “No” and therefore have nothing to declare. No author has any financial, funding, or other conflicts of interest that might bias this work. 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Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain [Internet]. Washington, DC: US Government Accountability Office; 2008 . Available at http://www.gao.gov/new.items/d08276.pdf 16 Crabtree BF , Miller WL : Doing Qualitative Research . Thousand Oaks, Calif , Sage Publications , 1999 . 17 Hsieh H-F , Shannon SE : Three approaches to qualitative content analysis . Qual Health Res 2005 ; 15 : 1277 – 88 . Google Scholar CrossRef Search ADS PubMed 18 Donabedian A : The quality of care. How can it be assessed? 1988 . Arch Pathol Lab Med 1997 ; 121 : 1145 – 50 . Google Scholar PubMed 19 Sayer NA , Nelson D , Nugent S : Evaluation of the veterans health administration traumatic brain injury screening program in the upper midwest . J Head Trauma Rehabil 2011 ; 26 : 454 – 67 . Google Scholar CrossRef Search ADS PubMed 20 Arriola VD , Rozelle JW : Traumatic brain injury in United States Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) hispanic veterans – a review using the PRISMA method . Behav Sci Basel Switz 2016 ; 6 , article 3. Author notes The views expressed herein are those of the authors and do not represent the views of the Department of Army, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government. Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Journal

Military MedicineOxford University Press

Published: Sep 1, 2018

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