Interventions to improve veterans' access to care: a systematic review of the literature.

OBJECTIVES: To conduct a systematic review to address the following key questions: (1) what interventions have been successful in improving access for veterans with reduced health care access? (2) Have interventions that have improved health care access led to improvements in process and clinical outcomes? DATA SOURCES: OVID MEDLINE, CINAHL, PsychINFO. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: English language articles published in peer-reviewed journals from 1990 to June 2010. All interventions designed to improve access to health care for US veterans that reported the impact of the intervention on perceived (e.g., satisfaction with access) or objective (e.g., travel time, wait time) access were included. APPRAISAL AND SYNTHESIS METHODS: Investigators abstracted data on study design, study quality, intervention, and impact of the intervention on access, process outcomes, and clinical outcomes. RESULTS: Nineteen articles (16 unique studies) met the inclusion criteria. While there were a small number of studies in support of any one intervention, all showed a positive impact on either perceived or objective measures of access. Implementation of Community Based Outpatient Clinics (n = 5 articles), use of Telemedicine (n = 5 articles), and Primary Care Mental Health Integration (n = 6 articles) improved access. All 16 unique studies reported process outcomes, most often satisfaction with care and utilization. Four studies reported clinical outcomes; three found no differences. LIMITATIONS: Included studies were largely of poor to fair methodological quality. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Interventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization. There was a lack of data regarding the link between access and clinical outcomes; however, the limited data suggest that increased access may not improve clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.

Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: a systematic review of the evidence.

BACKGROUND: Iraq and Afghanistan war veterans are returning from combat having sustained traumatic brain injury, mostcommonly mild traumatic brain injury (mTBI), and experiencing posttraumatic stress disorder (PTSD). Clinical guidelines for mTBI and PTSDdo not focus on the co-occurrence of these conditions (mTBI/PTSD). A synthesis of the evidence on prevalence, diagnostic accuracy, andtreatment effectiveness for mTBI/PTSD would be of use to clinicians, researchers, and policymakers. METHODS: We conducteda systematic review of studies identified through PubMed, PsycINFO, REHABDATA, Cochrane Library, pearling, and expert recommendations. Peer-reviewed English language studies published between 1980 and June, 2009 were included if they reported frequencies of traumatic braininjury and PTSD, or diagnostic accuracy or treatment effectiveness specific to mTBI/PTSD. RESULTS: Thirty-four studies metinclusion criteria. None evaluated diagnostic accuracy or treatment effectiveness. Studies varied considerably in design. Frequency ofmTBI/PTSD ranged from 0% to 89%. However, in 3 large studies evaluating Iraq and Afghanistan war veterans, frequencies ofprobable mTBI/PTSD were from 5% to 7%; among those with probable mTBI, frequencies of probable PTSD were from 33% to 39%. DISCUSSION: The wide range of mTBI/PTSD frequency levels was likely due to variation across studyparameters, including aims and assessment methods. Studies using consistent, validated methods to define and measure mTBI history andPTSD are needed.