VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain
Released: 2008-02-08T00:00:00

Letter

Background

In the military setting, mild TBI has become an increasing concern in recent years with respect to OEF/OIF servicemembers and veterans. Blasts due to IEDs and other explosive devices have been one of the leading causes of injury for those serving in OEF and OIF—and in particular have been a leading cause of TBI. TBI has been a frequent diagnosis among OEF/OIF servicemembers medically evacuated to Walter Reed Army Medical Center or the National Naval Medical Center. Mild TBI can also be present in servicemembers whose injuries do not result in medical evacuation out of the combat theater. According to DOD, TBI screening and assessments conducted from 2004 to 2006 for several groups of Army and Marine Corps servicemembers returning from OEF/OIF to selected military bases found that about 10 to 20 percent of those servicemembers had sustained a mild TBI, although those groups are not necessarily representative of the overall Army and Marine Corps populations returning from OEF/OIF or of the Air Force and Navy populations returning from OEF/OIF, who in general have much less combat exposure than other servicemembers.

Mild TBI

In the absence of a consensus definition of mild TBI among clinicians and medical associations, VA has adopted a definition for mild TBI that is consistent with the one developed by the American Congress of Rehabilitation Medicine (ACRM). The ACRM—and thus, VA—defines a person as having a mild TBI if the person had a traumatically-induced physiological disruption of brain function as demonstrated after an event by at least one of the following: (1) any period of loss of consciousness; (2) any loss of memory for events immediately before or after the event; (3) any alteration in mental state at the time of the event, for example feeling dazed, disoriented, or confused; and (4) a focal neurological deficit or deficits that may or may not have been transient, for example loss of coordination, speech difficulties, or double vision. ACRM’s definition further specifies that a person may be designated as having a mild TBI only if the severity of the injury does not include a loss of consciousness that lasted longer than approximately 30 minutes, post-traumatic amnesia lasting longer than 24 hours, and, after 30 minutes from the event, an initial Glasgow Coma Score of less than 13. Such symptoms may indicate a TBI more severe than mild TBI.

Mild TBI can result in symptoms that can be categorized as physical, cognitive, emotional, or sleep-related, and can cause short- or long-term difficulties that affect an individual’s ability to function, according to CDC guidance. (See table 1 for examples of symptoms associated with mild TBI as categorized by CDC.) The symptoms of mild TBI can be subtle and may not appear for days or weeks after the injury. According to literature on mild TBI in the civilian population, the duration of mild TBI symptoms can vary. Most with mild TBI have symptoms that resolve within hours, days, or weeks. Others, however, experience persistent symptoms that last for several months or longer.

Although symptoms of mild TBI may appear to be mild in nature, they can lead to significant long-term impairments that affect an individual’s ability to function. For example, individuals may have difficulty returning to routine daily activities and may be unable to return to work for weeks or months. Individuals with mild TBI may also have multiple co-occurring physical injuries, such as orthopedic injuries, depending on the event that caused the mild TBI.

According to CDC, treatment for individuals who have sustained a mild TBI may include increased rest, refraining from participation in activities that are likely to result in additional head injury, management of existing symptoms, and education about mild TBI symptoms and what to expect during recovery. For some cases, rehabilitative or cognitive therapies, counseling, or medications might be used. Currently, there are no evidence-based clinical practice guidelines that address treatment of mild TBI.

VA Health Care Services for OEF/OIF Veterans and DOD Servicemembers

Veterans who have served in combat in certain conflicts, including OEF/OIF veterans, are presumed to be eligible for VA health care services for any condition for a period of up to 5 years, even if there is insufficient medical evidence to conclude that the condition is attributable to military service. This presumptive eligibility includes those National Guard and Reserve members who have left active duty and returned to their units. If veterans do not enroll until after the presumptive period, they will be subject to the same eligibility and enrollment rules as other veterans, who generally have to prove that a medical problem is connected to their military service or that they have incomes below certain thresholds. As of October 2007, according to VA, about 260,000 or over one-third of veterans who had returned from service in OEF or OIF, including National Guard and Reserve members, had accessed VA for various health care needs.

In some circumstances, VA also provides health care to active duty OEF/OIF servicemembers. Under existing DOD-VA agreements, OEF/OIF servicemembers may obtain health care services, such as rehabilitative care, from VA facilities while the servicemembers are still on active duty. DOD determines whether servicemembers receive care from VA, at one of DOD’s own military treatment facilities (MTF), or from a TRICARE civilian provider. OEF/OIF servicemembers may be referred by MTFs to VA for care on an inpatient or outpatient basis.

OEF/OIF veterans and in some cases OEF/OIF servicemembers may obtain VA health care through VA’s national health care system, which provided health care services to nearly 5.5 million patients in 2006. VA’s health care system is organized into 21 regional health care networks that comprise VA medical facilities, community-based outpatient clinics (CBOC), and Vet Centers. VA medical facilities offer services that range from primary care to complex specialty care, such as cardiac or spinal cord injury care. VA’s CBOCs, which are associated with VA medical facilities, mainly provide primary care services. Vet Centers offer readjustment and family counseling, employment services, bereavement counseling, and a range of social services to assist veterans in readjusting from wartime military service to civilian life.

VA has classified its medical facilities into a four-tiered polytrauma system of care to help address the medical needs of returning OEF/OIF veterans, in particular those who have suffered polytraumatic injuries—that is, injuries to more than one part of the body or organ system, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. Veterans with polytraumatic injuries may have injuries or conditions such as TBI, amputations, multiple fractures, and burns to the body. Each of the four tiers in VA’s polytrauma system of care, referred to by VA as components, represents medical facilities that offer different levels of specialty services. Medical facilities in the first three tiers have designated polytrauma teams to care for polytrauma patients.

Component I sites, Polytrauma Rehabilitation Centers, are four regional medical facilities that provide acute comprehensive medical and rehabilitative care for the severely injured. These facilities have a team of rehabilitation professionals and consultants from other specialties related to polytrauma and serve as resources for other VA medical facilities and DOD MTFs.

Component II sites, Polytrauma Network Sites, are 21 medical facilities that provide specialized, post-acute rehabilitation services. There is one Polytrauma Network Site in each of VA’s 21 regional health care networks, including one at each of the four Component I sites.

Component III sites, Polytrauma Support Clinic Teams, are medical facilities that have facility-based teams of providers with rehabilitation expertise who deliver follow-up services to veterans and assist in the management of stable polytrauma conditions that are a consequence of the injuries sustained by veterans.

Component IV sites, Polytrauma Points of Contact, are present at medical facilities that do not have Component I, II, or III services. Each of these medical facilities has a point of contact whose role is to ensure that veterans are referred to a facility capable of providing the services they require.

VA Has Implemented a TBI Screening Tool at Its Medical Facilities but Has Not Determined the Clinical Validity and Reliability of the Tool

In April 2007, VA implemented in its medical facilities a computer-based screening tool to identify OEF/OIF veterans who may have a mild TBI. VA’s screening tool consists of a series of questions that VA providers must ask OEF/OIF veterans when the veterans come to a VA medical facility for care. Although VA’s TBI policy does not require VA medical facilities to conduct outreach to veterans who have not been seen at the medical facility since the TBI screening tool was implemented, we found that a majority of the nine medical facilities we reviewed were conducting various forms of outreach to encourage OEF/OIF veterans to come to the medical facility for TBI screening. While VA’s screening efforts depend on its TBI screening tool, VA has not determined the clinical validity and reliability of the screening tool—that is, respectively, how effective the tool is in identifying those who are and are not at risk for mild TBI and whether the screening tool would yield consistent results if administered to the same veteran more than once.

VA Has Implemented a TBI Screening Tool to Be Used in VA Medical Facilities

To screen OEF/OIF veterans for mild TBI, VA has implemented a TBI screening tool to be used when OEF/OIF veterans seek care at VA medical facilities. The screening tool, which VA implemented across its medical facilities in April 2007, can be used to screen for TBIs of varying severities, but is primarily intended to identify those OEF/OIF veterans at risk for mild TBI given that more severe forms of TBI are more easily identified. VA’s screening tool consists of a series of questions asked of OEF/OIF veterans who come to a VA medical facility for care. VA requires its medical facilities to use the TBI screening tool to screen every OEF/OIF veteran who presents for care at any clinic in the medical facility, including primary care, dental, and urgent care clinics, CBOCs, or specialty clinics, such as cardiology or orthopedic clinics. When a VA provider accesses a veteran’s electronic VA medical record during a clinic appointment, the provider is prompted by a computer-based clinical reminder to complete the TBI screening tool.

In order to complete the TBI screening, VA providers are required to ask OEF/OIF veterans a series of questions to identify those who are experiencing symptoms that may indicate a mild TBI. After prompting the provider to ask initial screening questions designed to confirm that the veteran is an OEF or OIF veteran, the screening tool then prompts the VA provider to ask whether the veteran has been previously diagnosed with a TBI. If the veteran has been previously diagnosed with a TBI, the screening is considered to be completed and the provider should ask whether the OEF/OIF veteran would like to obtain care from a VA specialty provider. The provider is to document any refusal of specialty care in the veteran’s electronic VA medical record. A depiction of VA’s TBI screening process is provided in figure 1.

For OEF/OIF veterans who have not been previously diagnosed with a TBI, VA’s TBI screening tool prompts the provider to continue the screening process by asking four sequential sets of questions that are used to identify OEF/OIF veterans who are at risk for a mild TBI. The first set of questions asks whether the veteran has experienced an event that could increase the risk of a possible mild TBI—specifically blasts or explosions, a vehicle accident or crash, a fragment wound or bullet wound above the shoulders, or a fall. If the veteran reports experiencing any of these events, a second set of questions asks about the immediate effects after the event, including a loss of consciousness, being dazed or confused, not remembering the event, a concussion, or a head injury. If the veteran reports experiencing any of these effects, then a third set of questions asks the veteran about symptoms that may have begun or gotten worse after the event, specifically memory problems or lapses, balance problems or dizziness, sensitivity to bright light, irritability, headaches, or sleep problems. Finally, if the veteran reports experiencing any of these symptoms, a fourth set of questions asks whether the veteran has experienced, within the week prior to the TBI screening, any of the symptoms listed in the third set of questions.

Under VA’s policy for its TBI screening tool, if the OEF/OIF veteran answers “no” to all of the questions in any of the four sections of the TBI screening tool, VA considers the veteran to have screened negative for a possible mild TBI. However, if the veteran answers “yes” to one or more questions in each of the four sections, then VA considers the veteran to have screened positive for a possible mild TBI. In guidance issued on the use of the TBI screening tool, VA directs providers to not diagnose a patient with a mild TBI based solely on the results of the TBI screening tool because it is possible to respond positively to all four sections and not have a mild TBI, due to the presence of conditions such as PTSD that present similar symptoms. Instead, VA policy requires that veterans who screen positive on VA’s TBI screening tool be offered a follow-up evaluation with a specialty provider who can determine whether the veteran has a mild TBI. VA officials reported that as of August 2007 about 61,000 OEF/OIF veterans had been screened for TBI and of those, nearly 20 percent had screened positive for possible TBI.

Although VA has a requirement that its facilities screen OEF/OIF veterans for mild TBI, veterans can refuse to participate in the screening. While VA’s policy does not specify what steps facility providers should take if a veteran refuses to be screened for TBI, according to a VA headquarters official, the provider must document the refusal in the veteran’s electronic VA medical record. This official also stated that the clinical reminder for TBI screening should continue to appear at subsequent clinic visits. Seven of the nine facilities we reviewed estimated that 2 percent or less of the OEF/OIF veterans offered TBI screening refused. The remaining two facilities did not provide estimates of the number of OEF/OIF veterans that had refused the TBI screening tool.

According to VA’s policy for its TBI screening tool, the TBI screening tool may be administered by physicians or other clinical providers, such as nurse practitioners, physician’s assistants, and nurses, who have the clinical background to review results with the veteran. Across the nine VA facilities we reviewed, we found variation in the types of VA providers who were responsible for administering the TBI screening tool to OEF/OIF veterans. At three facilities, we found that physicians or nurse practitioners were administering the TBI screening tool, and at the remaining six facilities, providers such as registered nurses or social workers in addition to physicians and nurse practitioners were administering the TBI screening tool. Further, in two of those six facilities, medical facility officials told us that dental technicians and licensed practical nurses were able to administer the TBI screening tool.

VA’s policy on TBI screening includes a requirement that all VA clinical staff who administer the TBI screening tool complete VA’s TBI training module. This training module—an online course produced by VA in January 2004—is designed to provide an overview of TBI, in order to help providers identify veterans at risk for a TBI. At seven of the nine VA facilities we reviewed, VA facility officials reported that VA providers administering the TBI screening tool had completed VA’s required training. At one of the two remaining facilities, officials reported that many providers had completed VA’s required training and that officials at the facility were reviewing providers’ completion of VA’s TBI training module to ensure that all providers administering the TBI screening tool had completed VA’s required training. At the remaining facility, officials reported that nurses at the facility had just recently begun administering the TBI screening tool and had not yet completed VA’s TBI training module at the time of our visit.

In addition to the required TBI training module, VA has also developed other training related to TBI screening for providers who administer the screen to OEF/OIF veterans. VA has provided training on TBI and the TBI screening tool to its medical facilities through satellite broadcasts and educational materials about TBI, including pamphlets and brochures, and held national conferences in April and August 2007 that focused in part on how to administer the TBI screening tool and who should be screened using it. In addition, VA has also conducted national conference calls between VA headquarters and VA medical facilities to address concerns facilities had in implementing and using the TBI screening tool.

In an effort to ensure that all VA medical facilities are utilizing the tool to screen OEF/OIF veterans for mild TBI, VA has implemented a TBI screening performance measure for fiscal year 2008. The performance measure is designed to assess the extent to which OEF/OIF veterans who seek care at VA medical facilities are being screened for TBI. Performance measures are routinely used by VA to hold managers accountable for the quality of health care provided to veterans at their medical facilities and to track facilities’ progress in meeting performance goals established by VA.

VA Medical Facilities We Reviewed Conducted Various Forms of Outreach to OEF/OIF Veterans to Increase Participation in TBI Screening

To increase awareness of and participation in TBI screening of OEF/OIF veterans, the nine VA medical facilities we reviewed were conducting various outreach efforts to OEF/OIF veterans, even though VA’s TBI policy does not require VA medical facilities to conduct outreach. Specifically we found that five of the nine facilities we reviewed were in the process of contacting veterans who had received care at the facility before the medical facility had implemented VA’s TBI screening tool in order to encourage the veterans to be screened for mild TBI. Medical facility officials reported that they were contacting these veterans by telephone or mail. Officials from two of the five facilities reported administering the screening tool to OEF/OIF veterans over the phone, while medical officials at three of the five facilities reported encouraging OEF/OIF veterans to return to the medical facility to be screened for TBI.

Some VA medical facilities were providing outreach to OEF/OIF veterans through TBI-related education efforts. For example, VA medical facility officials told us they attend DOD post-deployment events to provide OEF/OIF veterans—and OEF/OIF servicemembers who in the future will become OEF/OIF veterans—information about VA’s health care system, including information about VA’s TBI screening efforts. VA officials told us that they hope the information provided at the post-deployment events encourages those eligible for VA health care benefits to be screened for mild TBI at a VA medical facility. Moreover, two medical facilities we reviewed had administered the TBI screening tool during these post- deployment events.

Facility officials also told us they reach out to veterans through Vet Centers by providing information on TBI rather than waiting for veterans to come into a VA medical facility for care. In addition, two facilities reported that they made TBI-related information available through community resources in order to reach out to OEF/OIF veterans. For example, one facility asked businesses and organizations such as doctors’ offices, stores, churches, and schools to share information about TBI and VA health care services with community members. The other facility shared TBI-related information using media outlets such as television broadcasts, radio broadcasts, and newspapers to increase awareness of TBI in the community.

Although VA’s TBI Screening Efforts Depend on the Screening Tool, VA Has Not Determined the Tool’s Clinical Validity and Reliability

The key component of VA’s efforts to screen OEF/OIF veterans for mild TBI is VA’s requirement that VA medical facilities administer the TBI screening tool to these veterans when they seek care at VA facilities. However, VA has not assessed the clinical validity and reliability of the screening tool—that is, respectively, how effective the tool is in identifying those who are and are not at risk for mild TBI, and whether the screening tool would yield consistent results if the tool was administered to the same veteran more than once.

VA based its screening tool largely on a TBI screening tool developed and used by the DVBIC—the Brief Traumatic Brain Injury Screen (BTBIS). The BTBIS has been used at select military bases to screen returning OEF/OIF servicemembers for TBI and has been shown to be clinically valid, according to the DVBIC. When developing its screening tool, VA made some changes to the questions contained in the BTBIS. These changes were based on a review of other TBI screening instruments, published reports of the symptoms that follow a mild TBI, and the experience of MTFs with using modified versions of the BTBIS. The goal of VA’s changes was to develop a highly sensitive screening tool that would err on the side of being overly-inclusive in identifying veterans who may be at risk for having a TBI. VA recognized that using a highly sensitive TBI screening tool would result in some veterans who screen positive for possible TBI later being found after follow-up evaluation to not have a TBI. According to VA officials, VA specifically chose to develop a highly sensitive TBI screening tool to reduce the risk of not identifying those veterans who have a TBI.

A study of the validity and reliability of VA’s TBI screening tool is important for several reasons. First, because VA’s TBI screening tool is a modified version of the BTBIS and is being used to screen a slightly different population, the results from DVBIC’s validity study of the BTBIS would not be directly applicable to VA’s screening tool. In addition, a study of the validity of VA’s screening tool would provide information on how well the TBI screening tool distinguishes between OEF/OIF veterans who are at risk for a mild TBI and those who are not, according to VA officials. Like other screening tools, VA’s TBI screening tool may result in some false positives—OEF/OIF veterans who screen positive for possible mild TBI but do not have the condition—and some false negatives— OEF/OIF veterans who screen negative on VA’s TBI screening tool but actually have a mild TBI. One consequence of false positives is that OEF/OIF veterans who screen positive for possible mild TBI on VA’s TBI screening tool but do not have a mild TBI may worry that they have the condition when they do not. Also, because veterans who screen positive are to receive a follow-up evaluation by a specialty provider to determine whether they actually have a mild TBI, false positives affect specialty providers’ workload and may affect their capacity to see other veterans. In contrast, OEF/OIF veterans who screen negative for possible mild TBI but actually have the condition are at risk for not being evaluated and treated for their symptoms. Knowing both the validity and reliability of the TBI screening tool would help VA providers and OEF/OIF veterans understand the significance of the TBI screening results, including the likelihood of veterans having the same screening results if they were screened again by the same provider or a different provider.

VA officials recognize the need to conduct a study to assess the clinical validity and reliability of the TBI screening tool. VA officials decided to begin implementing TBI screening for OEF/OIF veterans before conducting such a study in order to avoid delaying the start of VA’s TBI screening efforts. According to VA officials, VA planned to study the TBI screening tool after its medical facilities had begun using the tool to screen OEF/OIF veterans. Officials informed us in September 2007 that a validity and reliability study was in the development phase and would assess issues such as the likelihood that an OEF/OIF veteran who screens positive for possible mild TBI actually has a mild TBI and the likelihood that an OEF/OIF veteran who screens negative for possible mild TBI does not have a mild TBI. At that time, VA had not yet determined when the study would take place, which researchers would conduct it, how it would be performed, or what funding mechanism would be used. As of December 2007, VA had not begun the study.

VA Has Implemented a Protocol to Help Ensure Evaluation and Treatment of OEF/OIF Veterans Who Screen Positive for Possible TBI; However, Some Medical Facilities Had Difficulties Fully Following the Protocol

VA has implemented a national protocol to help ensure that OEF/OIF veterans who screen positive on its TBI screening tool are evaluated by a specialty provider and receive treatment, if necessary, for mild TBI. VA requires providers at its facilities to follow the evaluation and treatment protocol, which reminds providers to offer follow-up evaluations, establishes requirements for setting evaluation appointments, and provides guidance for evaluating and treating veterans’ symptoms. VA has established training for its providers to enhance providers’ use of the protocol and thereby help ensure veterans are evaluated and treated for mild TBI. However, providers at some VA facilities have had difficulties fully following the protocol. Specifically, some providers reported difficulties implementing electronic requests for follow-up evaluations and did not always use a symptom checklist—used to assess the presence and severity of symptoms associated with mild TBI—during follow-up evaluations. VA medical facilities have taken steps to resolve these difficulties, and VA has put in place measures to help ensure that all VA providers follow the protocol. At the VA medical facilities we reviewed, providers stated that conducting VA’s TBI follow-up evaluations was not currently causing significant capacity problems for their specialty departments responsible for conducting the follow-up evaluations. However, specialty providers at some facilities we reviewed reported that an increased need for follow-up evaluations could cause increases in specialty providers’ workloads and that additional specialty providers could be needed in order to expand the specialty departments’ capacity to evaluate OEF/OIF veterans for mild TBI.

VA Has Implemented a Protocol to Help Ensure Evaluation and Treatment of OEF/OIF Veterans Who Screen Positive on VA’s TBI Screening Tool

To help ensure that OEF/OIF veterans who screen positive on VA’s TBI screening tool are evaluated for a possible mild TBI and treated if necessary, VA has implemented a national evaluation and treatment protocol for its medical facility providers to follow. One way the protocol helps ensure that OEF/OIF veterans are evaluated for mild TBI is by requiring the provider administering the TBI screening tool to discuss positive results with veterans and offer them the opportunity for a follow- up evaluation with a specialty provider. The purpose of the follow-up evaluation is to further evaluate the veteran’s symptoms and to determine whether the veteran has a mild TBI. If the veteran refuses to participate in the follow-up evaluation, the protocol requires the provider to document the refusal in the veteran’s electronic VA medical record. Providers are encouraged to provide education on TBI and to maintain an open door for veterans refusing to participate in the follow-up evaluation by advising them to return if they want care at a later date.

Another way VA’s evaluation and treatment protocol helps to ensure that OEF/OIF veterans receive follow-up evaluations for mild TBI is by establishing requirements for scheduling appointments for these evaluations with specialty providers. For veterans who have agreed to participate in the follow-up evaluation, providers are to send an electronic request for consultation to a specialty department designated by the VA medical facility as responsible for the evaluations. According to the protocol, the specialty department receiving the consultation request must contact the veteran within 1 week to set up an appointment for the follow- up evaluation. If the contact effort is unsuccessful, the protocol states that subsequent efforts are to include two telephone calls 1 week apart and, if still unsuccessful, a certified letter sent to the veteran. According to the protocol, efforts to contact the veteran to schedule a follow-up evaluation are to be documented in the veteran’s electronic VA medical record.

Under VA’s evaluation and treatment protocol, VA medical facilities can designate, within VA headquarters guidelines, which specialty department—and thus which type of provider—should conduct the follow- up evaluations. VA medical facilities we reviewed varied as to which types of specialty providers were designated to conduct the follow-up evaluation following a positive TBI screen. Five VA medical facilities we reviewed referred OEF/OIF veterans to an interdisciplinary team of specialists affiliated with the facility’s polytrauma team, while the four other facilities referred veterans to a neurologist, physical medical and rehabilitation physician, or psychiatrist for the follow-up evaluation. One of the medical facilities we reviewed made these referrals for a follow-up evaluation to a local specialty provider practicing in the community, while the remaining eight medical facilities utilized specialty providers within their facility. Furthermore, as part of the follow-up evaluation at one facility, all OEF/OIF veterans who screened positive on the TBI screening tool were being seen by a vision specialist and some vision problems had been identified through that process.

In addition to helping ensure that appointments for follow-up evaluations are made, VA’s evaluation and treatment protocol also provides guidance for VA specialty providers on evaluating and treating veterans for mild TBI. VA requires that the VA specialty providers who conduct the follow- up evaluations and the providers who provide treatment for mild TBI use VA’s protocol to help determine if a diagnosis of mild TBI should be made and, if so, what course of treatment should be followed. According to the protocol, providers conducting the follow-up evaluations should obtain a complete history of the veteran’s injury and current symptoms, conduct a physical examination targeted to the veteran’s symptoms, and use a symptom checklist to assess the presence and severity of various symptoms associated with mild TBI. (VA’s TBI follow-up evaluation process is depicted in fig. 2.) The symptom checklist lists 22 neurobehavioral symptoms associated with mild TBI, such as headaches, dizziness, memory problems, irritability problems, and poor concentration. (See app. II for VA’s symptom checklist.) For each symptom on the checklist the OEF/OIF veteran reports experiencing, VA’s protocol provides recommendations on additional physical examinations and tests that should be conducted and guidance on creating an individualized treatment plan for the veteran. If the veteran’s symptoms persist, the protocol includes guidance on when the veteran should be referred to other VA medical facilities for more intensive evaluation or treatment.

As allowed by VA’s evaluation and treatment protocol, medical facilities we reviewed varied in how they used the symptom checklist, including which type of provider administered the symptom checklist, when the symptom checklist was administered, and how the symptom checklist results were utilized. Some facilities reported that specialty providers administered the symptom checklist during the course of their evaluation. Another facility reported that a nonspecialist provider, such as a nurse or social worker, administered the symptom checklist prior to the specialty provider meeting with the veteran. Afterwards, the specialty provider used the responses to guide the follow-up evaluation or treatment plan. Still other facilities reported that a multidisciplinary team used the symptom checklist as a tool to help determine which specialty provider in the facility would be best to conduct the follow-up evaluation of the veteran.

To help VA monitor the extent to which its medical facilities are following the evaluation and treatment protocol, VA has implemented for fiscal year 2008 two TBI performance measures related to the follow-up evaluation. One of the two VA performance measures is designed to track whether facility staff contacted veterans who screened positive on the TBI screening tool within 1 week of screening to schedule the follow-up evaluation and, if unsuccessful, made subsequent attempts to contact the veteran. The other TBI performance measure is designed to track whether specialty providers completed the follow-up evaluation for veterans who screened positive on VA’s TBI screening tool within 30 days of VA’s initial contact with the veterans. In addition, VA implemented in November 2007 a computer-based template intended to help ensure providers follow the protocol when conducting a follow-up evaluation. The template will also provide a standardized method to document the results of this evaluation.

VA Has Established Training for Its Providers to Help Enhance Their Use of the Protocol

VA has established nationwide training to help enhance its providers’ use of the evaluation and treatment protocol and thereby help ensure veterans are evaluated and treated for mild TBI. Under VA policy, VA providers conducting the follow-up evaluations are required to complete training VA developed on its protocol for evaluating and treating veterans with mild TBI. The training consists of VA’s online TBI training module, which is also required of providers conducting VA’s TBI screening, and three satellite broadcasts providing information on the TBI screening tool and on the evaluation and treatment protocol. While the TBI training module provides an overview of TBI, the satellite broadcasts—produced in 2007 and aired to VA medical facilities periodically—are designed to provide information and guidance on using the protocol for evaluation and treatment efforts related to mild TBI. In particular, the satellite broadcasts provide information on how to perform the follow-up evaluation, how to confirm a mild TBI diagnosis, how to establish a treatment plan, and when to make referrals to a higher level of VA care. According to VA officials, the non-VA specialty providers that medical facilities may use to conduct the follow-up evaluations are not required to complete VA’s online TBI training module and the training VA developed on the evaluation and treatment protocol. A VA official told us this was the case because VA expects that referrals for follow-up evaluations will be made to specialty providers with TBI expertise. A VA official also noted that VA is willing to provide training on VA’s evaluation and treatment protocol to non-VA providers.

In addition to the training VA requires, VA has provided other training to help its providers use the evaluation and treatment protocol. At two national training conferences held in April and August of 2007, VA provided training on evaluating and treating veterans with mild TBI, including training on using the protocol. In addition, through conference calls between staff at VA headquarters and VA medical facilities and through educational materials contained on VA’s internal Web site, VA has also provided training on using the protocol. According to a VA official, VA decided to provide some of its training, such as the second satellite broadcast, after learning during conference calls between VA headquarters and VA medical facilities that some providers conducting follow-up evaluations focused on using the symptom checklist and did not always obtain a detailed medical history and conduct a targeted physical examination.

Two VA Medical Facilities We Reviewed Had Difficulty Fully Following VA’s Protocol

Although VA has implemented its evaluation and treatment protocol across its facilities, we found one of the VA medical facilities we reviewed had difficulty following the part of the protocol that specifies how facilities should contact OEF/OIF veterans who screened positive to schedule the follow-up evaluation. According to the protocol, if a veteran screens positive, the TBI screening tool should automatically prompt the VA provider administering the screen to electronically send a request for consultation to the specialty department that will conduct the follow-up evaluation. However, providers at this facility identified cases where OEF/OIF veterans had screened positive on VA’s TBI screening tool, but the specialty department responsible for completing the follow-up evaluation did not receive the electronic consultation request, as specified by VA’s protocol. As a result, 27 veterans that screened positive on the TBI screening tool at this medical facility had not been contacted by the specialty department responsible for conducting the follow-up evaluation to schedule an appointment.

During the period of our review, officials at the facility recognized the problem with the electronic notification and took corrective action. Because of the potential for this problem at other VA medical facilities, we notified a VA headquarters official about this problem. When asked if this problem had been discussed with VA medical facilities systemwide, VA officials told us that the problem had not been specifically addressed or investigated at other VA medical facilities, but that facilities generally had not reported this type of problem during conference calls between VA headquarters and VA medical facilities held to discuss potential problems. In the future, similar problems scheduling follow-up evaluations may be identified through one of VA’s new performance measures related to the TBI follow-up evaluation process. The performance measure, which was implemented in the first quarter of fiscal year 2008, is designed to retrospectively track whether veterans who screened positive on the TBI screening tool—including those who screened positive on the TBI screening tool in fiscal year 2007—were contacted by the specialty department in a timely manner to schedule the follow-up evaluation as required by VA’s evaluation and treatment protocol. However, because this performance measure was not implemented until the first quarter of fiscal year 2008, veterans who screened positive in fiscal year 2007 who were not contacted by the specialty department may not be identified until the performance measure results are made available to the medical facilities in fiscal year 2008, unless the medical facilities identify these veterans through their own tracking mechanisms.

At two of the VA medical facilities we reviewed, including the facility that reported problems with the electronic notification, we also found that providers were not fully following VA’s evaluation and treatment protocol at the time of our site visit, though they were doing so several months later. For example, at one facility we reviewed in July 2007, three months after national implementation of the protocol, one of two specialty providers designated to conduct the follow-up evaluation at the medical facility had not learned about the protocol or the symptom checklist until the day before our site visit. At another VA medical facility we reviewed in July 2007, the designated specialty providers were familiar with the protocol, including the symptom checklist, but facility staff told us that they were not yet using the symptom checklist as part of the follow-up evaluations due to staff workload and clinic capacity issues. Facility staff told us that they planned to fully implement the protocol, by using the symptom checklist once an additional provider had been hired and trained. When we followed up with the facilities in September and October 2007, the facilities told us that the specialty providers are now using the symptom checklist. Both facilities told us that they had created a template in the computerized medical record system that helps specialty providers ensure they are following the protocol and completing the symptom checklist in the course of their follow-up evaluation.

Some VA Specialty Providers Reported That an Increased Need for Follow-up Evaluations Could Create a Need to Expand Specialty Departments’ Capacity

At the VA medical facilities we reviewed, providers stated that conducting VA’s TBI follow-up evaluations was not currently causing significant capacity problems for their specialty departments. However, according to providers at some facilities, an increased need for such evaluations could result in increases in specialty providers’ workloads. At the time of our review, VA medical facilities were just beginning to screen and evaluate OEF/OIF veterans for mild TBI using VA’s new screening and evaluation processes, and providers reported no significant capacity problems in their specialty departments caused by the TBI follow-up evaluations. However, VA providers and officials at several facilities told us that as VA screens more OEF/OIF veterans over time, the resulting demand for follow-up evaluations is likely to increase. In addition, DOD is planning to but has not yet begun to routinely screen OEF/OIF servicemembers for possible TBI after their return from combat theaters as part of DOD’s post- deployment health assessment process. Once DOD begins its screening efforts, VA facilities could see an increase in demand for TBI-related evaluations for OEF/OIF veterans, including those veterans who are deactivated members of the National Guard and Reserves and—like other OEF/OIF veterans—are presumptively eligible for VA care at no cost for up to 5 years. According to VA specialty providers at some facilities, an increase in demand for follow-up evaluations could result in VA’s specialty departments needing to add more providers in order to expand specialty departments’ capacity to provide follow-up TBI evaluations for OEF/OIF veterans.

VA Faces Clinical and Cultural Challenges in Screening and Evaluating OEF/OIF Veterans for Mild TBI

VA faces a number of clinical and cultural challenges in its efforts to screen and evaluate OEF/OIF veterans for mild TBI. The lack of objective diagnostic tests that can identify mild TBI, and the fact that many symptoms of mild TBI are similar to those of other conditions, such as PTSD, represent clinical challenges to VA’s screening and evaluation efforts. In addition, several characteristics of the OEF/OIF veteran population create cultural challenges to VA’s efforts to the extent that the characteristics make OEF/OIF veterans unwilling to report experiencing TBI-related symptoms or unwilling to seek care for such symptoms.

Lack of Objective Diagnostic Tests and Overlap of Mild TBI Symptoms with Those of Other Conditions Present Clinical Challenges

VA faces a number of clinical challenges in its efforts to screen OEF/OIF veterans for mild TBI and evaluate those who screen positive on the TBI screening tool. One challenge is that there are currently no objective diagnostic tests—such as laboratory tests or neuroimaging tests like MRI and computed tomography (CT) scans—that can definitively and reliably identify mild TBI. While neuroimaging tests yield information about injury to the brain for some patients with mild TBI, most patients with mild TBI have normal neuroimaging test results. Similarly, there are no laboratory tests such as blood tests that can detect whether an OEF/OIF veteran has a mild TBI.

In the absence of objective diagnostic tests that definitively determine if an OEF/OIF veteran has a mild TBI, VA providers must screen and evaluate veterans using the veterans’ own descriptions of their exposures to incidents that might have caused a mild TBI as well as their descriptions of past and current symptoms that could indicate a mild TBI. However, using self-reported information to screen and evaluate in order to make a clinical diagnosis can be challenging. Self-reported information can reflect the veteran’s own recollections of the incident and symptoms but can also reflect what the veteran was told by others who observed the incident if the veteran had lost consciousness or had memory loss. According to officials we interviewed at several VA medical facilities, it can be difficult to obtain from veterans a clear history of the veteran’s exposure to incidents as well as symptoms. One reason officials cited was the lapse of time between the incident that could have caused a mild TBI and the screening for TBI. Officials explained that in many instances, months or even years have passed between an incident and the time a veteran undergoes TBI screening and subsequent evaluation, and that amount of time can complicate the veteran’s ability to accurately and completely recall the incident and the symptoms experienced afterwards. At one VA medical facility, for example, officials reported that it could be 2 to 3 years after the initial injury before VA providers see veterans for their initial TBI screening. Finally, medical facility officials also noted that memory problems due to the mild TBI itself can adversely affect the accuracy of the information that an OEF/OIF veteran provides.

Another clinical challenge VA faces in its TBI screening and evaluation effort is the fact that many symptoms of mild TBI are similar to the symptoms associated with other conditions, which makes a definitive diagnosis of mild TBI more difficult to reach. Many symptoms of mild TBI—such as insomnia and irritability—are similar to those of PTSD. Officials at all nine medical facilities we reviewed reported that this overlap in symptoms posed a challenge for them. They noted that OEF/OIF veterans may have symptoms that could indicate either PTSD or mild TBI, or both, and that it can be difficult to determine which condition or conditions the OEF/OIF veteran has. Deployment to a combat theater can put OEF/OIF veterans at risk for other mental health conditions as well— such as anxiety or depression. These mental health conditions may be symptoms of mild TBI themselves and may also lead to additional symptoms—such as difficulty sleeping or memory problems—that overlap with those of mild TBI. Complicating this challenge is the fact that certain combat experiences, such as exposure to an explosive blast, can put OEF/OIF veterans at risk for mental health conditions as well as for mild TBI. In addition, some symptoms of mild TBI—such as headaches and anxiety—are commonly found in the general population or may predate the injury, which can make it difficult to determine whether these symptoms can be attributed specifically to a mild TBI.

An additional clinical challenge reported by VA medical facility officials is that OEF/OIF veterans with mild TBI might not realize that they have an injury and should seek health care. VA officials and TBI experts stated that for some OEF/OIF veterans, their mild TBI symptoms may be subtle and easy to overlook, while other OEF/OIF veterans may not realize they have an injury because they do not have an obvious physical injury, such as a head wound. In addition, OEF/OIF veterans with mild TBI might be aware that they are experiencing symptoms such as headaches or difficulties completing tasks, but they might not connect those problems to a specific deployment-related incident or realize that the problems indicate a physical injury that needs to be evaluated and treated. For example, officials at several VA medical facilities reported that many OEF/OIF veterans notice problems after they attempt to resume their regular activities after deployment. Officials also noted that difficulties such as memory or concentration problems may arise once veterans return to work or school. These veterans may not, however, connect these difficulties to a possible injury and realize that they need to seek care.

Facility officials have found that OEF/OIF veterans’ family members are often recognizing the veterans’ behavioral or emotional changes or symptoms and encouraging them to seek VA care. This has led several facilities to take steps to educate their local communities about TBI symptoms and VA services, to help OEF/OIF veterans, their families, and community members learn more about the condition and to facilitate veterans being screened and evaluated for TBI.

Memory problems that can occur in OEF/OIF veterans with mild TBI can create a challenge when OEF/OIF veterans forget that they are due to come to a VA medical facility for screening and evaluation appointments. Officials at several facilities we reviewed have observed that many OEF/OIF veterans with mild TBI need help remembering when they have appointments. Officials have found that hand-held computers and reminder phone calls can be effective in helping to ensure that OEF/OIF veterans keep their appointments and receive needed care.

Characteristics of Military Culture and of OEF/OIF Veterans Create Cultural Challenges to VA’s Mild TBI Screening and Evaluation Efforts

Several characteristics of the OEF/OIF veteran population create cultural challenges to VA’s effort to screen OEF/OIF veterans for mild TBI and evaluate those who screen positive. For example, several aspects of military culture may discourage OEF/OIF veterans from seeking care for TBI-related symptoms, even though the veterans have returned to civilian life. According to VA officials, some OEF/OIF veterans may have concerns about being perceived as physically weak, and these concerns may stem in part from the military culture that emphasizes being strong and self- sufficient. In addition, VA officials stated that OEF/OIF veterans may not want to risk being labeled with a condition that could be perceived as a mental illness, due to the stigma associated with mental illness. Finally, according to staff at several of the VA facilities we reviewed, some OEF/OIF veterans have expressed concerns that reporting symptoms associated with a TBI could compromise their ability to remain in the National Guard or Reserves or to obtain law enforcement or security jobs after their military obligation is completed. Such veterans are concerned that documentation in their medical record regarding TBI-related symptoms could adversely affect their future employment plans.

Another cultural challenge to screening and evaluating OEF/OIF veterans for TBI is that these veterans may not schedule appointments or keep existing appointments for VA care in a timely manner due to work and family priorities or constraints. OEF/OIF veterans tend to be younger than other VA patients and often work or are in school full-time or have young children to care for, according to VA medical facility officials. OEF/OIF veterans may be returning to the jobs they held prior to deployment or starting new jobs. Facility officials have found that some employed OEF/OIF veterans are concerned with the possible consequences of taking too much time off from work to seek care and have difficulty coming to VA facilities to be screened and evaluated for mild TBI due to their work schedules. Other OEF/OIF veterans are enrolled in school and have difficulties making it to appointments because of their class schedules. Facility officials also noted that some veterans do not have available childcare and must miss appointments to stay home with their children. Facility staff also reported that OEF/OIF veterans often want to return to their lives in the community after their deployment and, as a result, may not make their own health care needs a priority when they first return home. Lastly, according to officials at several VA facilities, OEF/OIF veterans who screen positive for a possible TBI may have to travel a substantial distance to reach VA facilities for their follow-up evaluations. At one facility we reviewed, officials reported that the area it serves is characterized by small towns and farms and that some OEF/OIF veterans may have to drive 100 miles to reach the VA facility. These factors have contributed to VA facilities having high rates of no-shows for appointments for OEF/OIF veterans. For example, two facilities we reviewed reported a 50 percent or greater clinic no-show rate for OEF/OIF veterans.

In order to address these cultural challenges related to screening and evaluating OEF/OIF veterans for TBI, officials at the medical facilities we reviewed reported using various strategies. For example, in order to facilitate veterans coming to the appointments or rescheduling appointments they were unable to keep, some facilities sent reminder letters to or called OEF/OIF veterans to inform them about the day and time of their upcoming follow-up evaluation. At some facilities we reviewed, social workers, case managers, or nurses used phone calls and letters to contact OEF/OIF veterans who did not show up for follow-up evaluations or other appointments, to encourage them to come in for care. Several facilities we reviewed arranged for the follow-up evaluation to take place on the same day that the OEF/OIF veteran was screened for TBI, or have scheduled multiple appointments on one day so the OEF/OIF veteran does not have to miss multiple days of work or school for appointments.

Another characteristic of OEF/OIF veterans that creates a cultural challenge for VA is that OEF/OIF veterans may not want to seek care, such as TBI screening and evaluation services, at VA medical facilities due to their perceptions about VA health care or the population served by VA facilities. Officials at some VA medical facilities told us that some OEF/OIF veterans saw VA facilities as serving an elderly veteran population and not the younger OEF/OIF population—or thought that VA providers did not want to treat younger veterans. These impressions made some OEF/OIF veterans hesitant to seek VA care. Facility officials reported that they sought to counter these impressions by educating OEF/OIF veterans about VA’s health care system and emphasizing that VA is providing care for the OEF/OIF population.

Conclusions

With TBI a leading injury among U.S. forces serving in military operations in Afghanistan and Iraq, VA has taken positive steps in its efforts to ensure that veterans from these conflicts who are still experiencing the effects of mild TBI are identified, evaluated, and treated when they seek care at VA medical facilities. Our work during the start-up phase of VA’s efforts shows that VA facilities have made progress implementing VA’s TBI screening tool and VA’s national TBI evaluation and treatment protocol. Although we found that there were difficulties following some of the protocol’s requirements at two VA medical facilities, those facilities had taken steps to address those issues. VA has implemented new TBI-related performance measures for fiscal year 2008 as well as a computer-based template to be used with the follow-up evaluation, which are both designed to help ensure that VA providers are following the TBI protocol.

As VA moves beyond the start-up phase of its TBI efforts, one of VA’s remaining challenges is ensuring that the basis of its efforts—its TBI screening tool—is valid and reliable. VA recognizes the importance of evaluating the screening tool’s validity and reliability—and is planning to do so. However, VA has not yet begun its evaluation. Until VA evaluates the TBI screening tool’s validity and reliability, VA providers will continue to use the screening tool without knowing how effective the tool is in identifying which veterans are and are not at risk for having mild TBI.

Recommendation for Executive Action

To establish whether the use of VA’s TBI screening tool is effective in identifying OEF/OIF veterans at risk for mild TBI, we recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to expeditiously evaluate the clinical validity and reliability of VA’s TBI screening tool.

Agency Comments

In commenting on a draft of this report, VA concurred with our findings, conclusions, and recommendation to expedite the evaluation of the validity and reliability of the TBI screening tool. In its comments, VA updated its plans to finalize a validation study of the TBI screening tool and agreed to fast-track the validation study, with preliminary results expected by the end of 2008. VA noted that it also plans to study the health needs and outcomes of veterans with TBI and to look for more accurate methods of diagnosing TBI, with a particular focus on veterans who may have coexisting conditions such as PTSD, substance abuse, and physical trauma. VA also noted that more time and research may be needed to ensure consensus in the medical community about the diagnosis of TBI and the implications for recovery. VA further commented that the lack of any objective diagnostic test to definitively and reliably identify mild TBI is not unique to VA. We agree and have included clarifying language in the report to indicate that this is not a limitation unique to VA. VA’s written comments are reprinted in appendix III. VA also provided technical comments, which we have incorporated as appropriate.

We provided a draft of this report to DOD for comment. DOD declined to provide comments on the draft report.

We are sending copies of this report to the Secretary of Veterans Affairs and the Secretary of Defense. We will also provide copies to others upon request. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or kanofm@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff that made major contributions to this report are listed in appendix IV.

Appendix I: List of VA Medical Facilities, by Type of Polytrauma Component Site

Component I sites, Polytrauma Rehabilitation Centers, are four regional medical facilities that provide acute comprehensive medical and rehabilitative care for the severely injured. These centers have a team of rehabilitation professionals and consultants from other specialties related to polytrauma and serve as resources for other Department of Veterans Affairs (VA) medical facilities.

Component II sites, Polytrauma Network Sites, are 21 medical facilities that provide specialized, post-acute rehabilitation services. There is one Polytrauma Network Site in each of VA’s 21 regional health care networks, including one at each of the four Component I sites.

Component III sites, Polytrauma Support Clinic Teams, are medical facilities that have facility-based teams of providers with rehabilitation expertise who deliver follow-up services to veterans and assist in the management of stable polytrauma conditions that are a consequence of the injuries sustained by veterans.

Component IV sites, Polytrauma Points of Contact, are present at medical facilities that do not have Component I, II, or III services. Each of these medical facilities has a point of contact whose role is to ensure that veterans are referred to a facility capable of providing the services they require.

Appendix II: Symptom Checklist Included in VA’s National Traumatic Brain Injury Evaluation and Treatment Protocol

Appendix II: Symptom Checklist Included in VA’s National Traumatic Brain Injury Evaluation and Treatment Protocol Please rate the following symptoms with regard to how much they have disturbed you SINCE YOUR INJURY.

Appendix III: Comments from the Department of Veterans Affairs

Appendix IV: GAO Contact and Staff Acknowledgments

Acknowledgments

In addition to the contact named above, Marcia Mann, Assistant Director; Robin Burke; Sarah Burton; Krister Friday; Adrienne Griffin; Kelli Jones; Giao N. Nguyen; and Jessica Cobert Smith made key contributions to this report.

Related GAO Products

VA and DOD Health Care: Administration of DOD’s Post-Deployment Health Reassessment to National Guard and Reserve Servicemembers and VA’s Interaction with DOD. GAO-08-181R. Washington, D.C.: January 25, 2008.

DOD and VA: Preliminary Observations on Efforts to Improve Health Care and Disability Evaluations for Returning Servicemembers. GAO-07-1256T. Washington, D.C.: September 26, 2007.

VA and DOD Health Care: Efforts to Provide Seamless Transition of Care for OEF and OIF Servicemembers and Veterans. GAO-06-794R. Washington, D.C.: June 30, 2006.