Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons With Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project.

OBJECTIVE: To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. SETTING: Community. PARTICIPANTS: Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. DESIGN: Descriptive, qualitative study. MAIN MEASURES: Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. RESULTS: Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. CONCLUSION: This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.

Initial Evidence for Reliable and Valid Use of Scores on the 8-Item Econ-QOL Short Form to Measure Economic Quality of Life in Caregivers of Persons With Traumatic Brain Injury.

OBJECTIVE: To provide reliability and validity data to support the clinical utility of Economic Quality of Life Measure (Econ-QOL) scores in caregivers of civilians and service members/veterans with traumatic brain injury (TBI). DESIGN: Cross-sectional survey study. SETTING: Three academic medical centers and a Veterans Affairs treatment facility. PARTICIPANTS: 376 caregivers of civilians (n=213) and service members/veterans (n=163) with TBI (N=376). INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Econ-QOL and several patient-reported outcome measures (Traumatic Brain Injury Caregiver Quality of Life Caregiver-Specific Anxiety and Caregiver Strain, Patient-Reported Outcomes Measurement Information System sleep-related impairment, Neurological Quality of Life Measurement System positive affect and well-being) and measures of financial status (self-reported income). RESULTS: Internal consistency reliability of the Econ-QOL Short Form scores were excellent (all Cronbach's alphas ≥.92). There were no floor or ceiling effects for scores. There was evidence of convergent and discriminant validity, with the Econ-QOL scores having the strongest relationships with self-reported income (convergent validity evidence) and weak relationships with the other measures (discriminant validity evidence). Individuals with scores that were "below or possibly below" the poverty line (according to 2016 federal government poverty level thresholds) reported worse economic quality of life relative to those individuals who were definitely above the poverty line, supporting known-groups validity. CONCLUSIONS: This article establishes the clinical utility of scores on the Econ-QOL Short Form in caregivers of persons with TBI and provides evidence that it is valid and appropriate to use such scores not only in a variety of different disability populations (eg, spinal cord injury, stroke) but also in caregivers.

Performance validity assessment using response time on the Warrington Recognition Memory Test.

OBJECTIVE: The present study tested the incremental utility of response time (RT) on the Warrington Recognition Memory Test - Words (RMT-W) in classifying bona fide versus feigned TBI. METHOD: Participants were 173 adults: 55 with moderate to severe TBI, 69 healthy comparisons (HC) instructed to perform their best, and 49 healthy adults coached to simulate TBI (SIM). Participants completed a computerized version of the RMT-W in the context of a comprehensive neuropsychological battery. Groups were compared on RT indices including mean RT (overall, correct trials, incorrect trials) and variability, as well as the traditional RMT-W accuracy score. RESULTS: Several RT indices differed significantly across groups, although RMT-W accuracy predicted group membership more strongly than any individual RT index. SIM showed longer average RT than both TBI and HC. RT variability and RT for incorrect trials distinguished SIM-HC but not SIM-TBI comparisons. In general, results for SIM-TBI comparisons were weaker than SIM-HC results. For SIM-HC comparisons, classification accuracy was excellent for all multivariable models incorporating RMT-W accuracy with one of the RT indices. For SIM-TBI comparisons, classification accuracies for multivariable models ranged from acceptable to excellent discriminability. In addition to mean RT and RT on correct trials, the ratio of RT on correct items to incorrect items showed incremental predictive value to accuracy. CONCLUSION: Findings support the growing body of research supporting the value of combining RT with PVTs in discriminating between verified and feigned TBI. The diagnostic accuracy of the RMT-W can be improved by incorporating RT.

Development and Calibration of the TBI-QOL Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction With Social Roles and Activities Item Banks and Short Forms.

OBJECTIVE: To develop traumatic brain injury (TBI)-optimized versions of the Quality of Life in Neurological Disorders (Neuro-QoL) Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities item banks, evaluate the psychometric properties of the item banks developed for adults with TBI, develop short form and computer adaptive test (CAT) versions, and report information to facilitate research and clinical applications. DESIGN: We used a mixed methods design to develop and evaluate Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities items. Focus groups defined the constructs, cognitive interviews guided item revisions, and confirmatory factor analysis and item response theory methods helped calibrate item banks and evaluate differential item functioning related to demographic and injury characteristics. SETTING: Five TBI Model Systems centers in the United States. PARTICIPANTS: Community-dwelling adults with TBI (N=556). INTERVENTIONS: None. OUTCOME MEASURES: Traumatic Brain Injury-Quality of Life (TBI-QOL) Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction with Social Roles and Activities item banks. RESULTS: Forty-five Ability to Participate in Social Roles and Activities and 41 Satisfaction with Social Roles and Activities items demonstrated good psychometric properties. Although some of the items are new, most were drawn from analogous banks in the Neuro-QoL measurement system. Consequently, the 2 TBI-QOL item banks were linked to the Neuro-QoL metric, and scores are comparable with the general population. All CAT and short forms correlated highly (>0.90) with the full item banks and demonstrate comparable construct coverage and measurement error. CONCLUSION: The TBI-QOL Ability to Participate in Social Roles and Activities and TBI-QOL Satisfaction with Social Roles and Activities item banks are TBI-optimized versions of the Neuro-QoL Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities item banks and demonstrate excellent measurement properties in individuals with TBI. These measures, particularly in CAT or short form format, are suitable for efficient and precise measurement of social outcomes in clinical and research applications.

Outcomes after Concussion Recovery Education: Effects of Litigation and Disability Status on Maintenance of Symptoms.

This study examined the hypothesis that people who receive concussion recovery education would have better outcomes than those who received usual discharge paperwork from the emergency department (ED) and tested whether participants who were in litigation or seeking disability compensation had more symptoms than individuals not engaged in these activities. Two hundred and fifty-five persons with a diagnosis of concussion were assigned randomly to a brief education group (one-page double-sided document), a longer education group (10-page document), and usual care (standard ED discharge instructions), and were these documents in the ED. A (non-concussion) trauma comparison group was enrolled to determine the symptom rate unrelated to brain injury. The Concussion Symptom Checklist (CSC) and litigation and disability status questions were completed by telephone at one week, three months, and six months. Neither long nor brief information handouts had a significant impact on symptoms over time; the standard form had an average decrease of 1.20 symptoms compared with the brief instructional intervention group (p = 0.031). Litigation status and disability seeking status were significant predictors of symptoms on CSC over time: disability seeking (p = 0.017) and litigation status (p = 0.05). Persons seeking Social Security disability or legal compensation endorsed more symptoms over time than those who were not. Number of symptoms on the CSC for the trauma control group was the same as those who sustained concussion. Type of recovery material was not as important as noting that concussion symptoms resolve over time, and that remaining symptoms are not specific to brain injury. Litigation and disability seeking behavior accounted for maintained symptoms, rather than the concussion itself.

Sociocultural Factors Influencing Caregiver Appraisals Following Traumatic Brain Injury.

OBJECTIVE: To investigate the association of the sociocultural variables race/ethnicity, education, and poverty level to caregivers' positive and negative appraisals following traumatic brain injury. DESIGN: Survey. SETTING: Community. PARTICIPANTS: Caregivers (N=344; 216 white; 69 black; 39 Hispanic) of persons with complicated mild to severe TBI at least 1-year postinjury. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Modified Caregiver Appraisal Scale (M-CAS); Zarit Burden Interview (ZBI). RESULTS: Black caregivers reported lower levels of perceived burden on both the M-CAS and the ZBI. Black and Hispanic caregivers reported more traditional caregiver ideology (caregiving as a responsibility) than did whites. Greater poverty was associated with higher burden on the M-CAS, lower caregiver satisfaction, and less mastery. Higher education was associated with higher burden on the ZBI and with lower caregiver mastery. CONCLUSIONS: Treatment professionals should be culturally sensitive to the different perspectives that caregivers may have based on sociocultural factors. Sociocultural factors should be considered in research investigating caregiver outcomes, including appraisals.

Key dimensions of impairment, self-report, and environmental supports in persons with traumatic brain injury.

PURPOSE/OBJECTIVES: To determine key dimensions relevant to recovery in the postacute period for persons with traumatic brain injury (TBI) and to determine the ability of scores on these dimensions to predict participation outcomes for persons with TBI. RESEARCH METHOD/DESIGN: This was a prospective cohort, observational study of 504 persons with medically documented TBI. Participants completed a comprehensive battery of measures including cognitive tests; questionnaires assessing self-report of physical, cognitive, and emotional symptoms and strengths; environmental supports; and a measure of participation outcome. RESULTS: Participants were a predominantly male, ethnically/racially diverse sample of persons with complicated mild, moderate, and severe TBI. Variable cluster analysis identified 12 key dimensions of cognitive function, neurobehavioral complaints, personal strengths, physical symptoms and function, environmental supports, and performance validity. In unadjusted analyses, all 12 dimensions were predictive of participation outcome. In multivariable regression analysis with adjustment of all predictors for all other predictors, dimensions measuring memory, independence and self-esteem, resilience, emotional distress, physical functioning, and economic and family support made unique contributions to predicting participation outcome. CONCLUSIONS/IMPLICATIONS: Findings add to our understanding of key aspects of functioning and self-perception for persons with TBI. Knowledge of the profile of an individual patient on these 12 dimensions may assist with development of a treatment approach for the person with TBI. (PsycINFO Database Record

Role of character strengths in outcome after mild complicated to severe traumatic brain injury: a positive psychology study.

OBJECTIVE: To examine the effects of character strengths on psychosocial outcomes after mild complicated to severe traumatic brain injury (TBI). DESIGN: Prospective study with consecutive enrollment. SETTING: A Midwestern rehabilitation hospital. PARTICIPANTS: Persons with mild complicated to severe TBI (N=65). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community Integration Measure, Disability Rating Scale, Modified Cumulative Illness Rating Scale, Positive and Negative Affect Schedule, Satisfaction with Life Scale, Values in Action Inventory of Strengths, and Wechsler Test of Adult Reading. RESULTS: Character virtues and strengths were moderately associated with subjective outcomes, such that there were fewer and less strong associations between character virtues/strengths and objective outcomes than subjective outcomes. Specifically, positive attributes were associated with greater life satisfaction and perceived community integration. Fewer and less strong associations were observed for objective well-being; however, character strengths and virtues showed unique value in predicting physical health and disability. Positive affectivity was not meaningfully related to objective outcomes, but it was significantly related to subjective outcomes. In contrast, negative affectivity was related to objective but not subjective outcomes. CONCLUSIONS: Given the strength of the associations between positive aspects of character or ways of perceiving the world and positive feelings about one's current life situation, treatments focused on facilitating these virtues and strengths in persons who have experienced TBI may result in better perceived outcomes and potentially subsequently lower comorbidities.

Comorbidity and insurance as predictors of disability after traumatic brain injury.

OBJECTIVE: To examine the unique contribution of self-reported medical comorbidity and insurance type on disability after traumatic brain injury (TBI). DESIGN: Inception cohort design at 1-year follow up. SETTING: A university affiliated rehabilitation hospital. PARTICIPANTS: Adults with mild-complicated to severe TBI (N=70). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Self-reported medical comorbidities were measured using the Modified Cumulative Illness Rating Scale, while insurance type was classified as commercial or government-funded; disability was measured using the Disability Rating Scale. RESULTS: Two models were run using multiple linear regression, and the best-fitting model was selected on the basis of Bayesian information criterion. The full model, which included self-reported medical comorbidity and insurance type, was significantly better fitting than the reduced model. Participants with a longer duration of posttraumatic amnesia, more self-reported medical comorbidities, and government insurance were more likely to have higher levels of disability. Meanwhile, individual organ systems were not predictive of disability. CONCLUSIONS: The cumulative effect of self-reported medical comorbidities and type of insurance coverage predict disability above and beyond well-known prognostic variables. Early assessment of medical complications and improving services provided by government-funded insurance may enhance quality of life and reduce long-term health care costs.

Self-assessment of driving ability and the decision to resume driving following stroke.

The decision to resume driving after stroke can be complicated by the sequelae of stroke as well as the established finding that even healthy adults overestimate their driving ability. This study evaluated whether stroke survivors (n = 67) disproportionately overestimated their driving ability as compared to healthy significant others (n = 67). Comparison to a known target reduced self-bias among both groups, but shift toward enhanced accuracy was significantly greater among survivors than significant others. Additionally, self-bias may reflect a pervasive trait of cognitive ability, as overestimation of driving ability was paralleled on a cognitive estimation task. Use of a specific criterion can facilitate accurate self-ratings of driving ability among survivors; however, actual decisions regarding driving status may be unrelated to self-view.

Long-term medical care utilization and costs among traumatic brain injury survivors.

OBJECTIVE: To examine billing patterns and predictors of healthcare utilization and costs associated with traumatic brain injury. DESIGN: Retrospective cohort study of healthcare billings for 63 survivors of traumatic brain injury, over a 19-mo period, using a state-sponsored Medicaid program. The relationship of indicators of injury severity and disability to billings and payments was investigated. Mean age at time of injury was 33 yrs. Mean highest Glasgow Coma Scale rating immediately after brain injury was 8. RESULTS: A total of 795,635 US dollars was billed to Medicaid for 3,950 services and medications used. A total of 281,897 US dollars was paid for these billings out of the Medicaid account studied. Billings were used for statistical analyses, as they were considered the most stable indicator of cost. Motor deficits at discharge from inpatient rehabilitation (FIM motor score) showed inverse relationships to total billings (rho = -0.42, P < 0.001), subcategories of billings reflecting equipment and supplies (rho = -.26, P = 0.020), and outpatient billings (rho = -0.27, P = 0.015). Change in FIM motor scores during inpatient rehabilitation was inversely associated with billings (rho = -0.40). Change in FIM motor scores provided unique information in predicting utilization after accounting for demographic characteristics and severity of injury. CONCLUSIONS: Motor disability and improvement during inpatient rehabilitation were significant predictors of billings after traumatic brain injury. Initial severity of brain injury was not a significant factor in utilization.