Two Decades of Department of Veterans Affairs Traumatic Brain Injury Care and Benefits for Veterans of Post-9/11 Conflicts.

OBJECTIVE: To describe the background, methodology, and results of the congressionally mandated Department of Veterans Affairs (VA) Traumatic Brain Injury (TBI) Veterans Health Registry. SETTING: Veterans Health Administration (VHA) and Veterans Benefit Administration (VBA). PARTICIPANTS: A total of 441 639 Veterans of post-9/11 conflicts who exhibited symptoms associated with TBI and sought care or benefits from the VA between September 2001 and September 2021. Design: Retrospective analysis of VHA and VBA administrative records. MAIN MEASURES: (1) VA/Department of Defense Identity Repository to identify Veterans with a deployment to the Southwest Asia theater of operations; (2) the VA TBI Screening and Evaluation Program data; (3) Inpatient and Outpatient Encounter data; and (4) an extract of the VBA Corporate Database to identify Veterans filing benefit claims based on TBI. RESULTS: An unduplicated total of 441 639 post-9/11 Veterans were identified in the Registry via three different pathways to entry: 369 909 Veterans through a positive TBI Screen, 253 177 Veterans receiving healthcare including a TBI diagnosis, and 108 541 Veterans filing TBI disability claims. Among Veterans reporting current TBI symptoms who completed a clinical evaluation, a diagnosis of TBI was confirmed by a TBI specialist in 68.7% of the cases. The TBI severity of confirmed cases was classified as mild in 86.6% of the cases, moderate in 8.3%, and severe in 4.1%. The TBI Registry Veterans were hospitalized 66 503 times and seen 1 521 898 times as outpatients in VHA facilities with diagnoses including TBI. Among Veterans filing TBI disability claims, 67.3% were adjudicated as service-connected. CONCLUSION: The VA TBI Health Registry has identified over 440 000 Veterans of post-9/11 conflicts who presented to the VA for care or benefits with TBI symptomatology. This large number and the volume of TBI health care and benefits provided over the two decades since 9/11 demonstrate the need for the VA's strong ongoing focus on screening, evaluation, and rehabilitation of TBI. Key words:Department of Veterans Affairs, post-9/11, Registry, TBI, traumatic brain injury, VA, VBA, Veterans, Veterans Benefit Administration, Veterans Health Administration, VHA.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews.

OBJECTIVE: To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI). METHODS: Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021. ELIGIBILITY CRITERIA: Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models. DATA: Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use). SYNTHESIS: Narrative synthesis, including proportion of reviews documenting outcome benefits. RESULTS: More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease. CONCLUSIONS: Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Brain Injury Functional Outcome Measure (BI-FOM): A Single Instrument Capturing the Range of Recovery in Moderate-Severe Traumatic Brain Injury.

OBJECTIVE: To develop a measure of global functioning after moderate-severe TBI with similar measurement precision but a longer measurement range than the FIM. DESIGN: Phase 1: retrospective analysis of 5 data sets containing FIM, Disability Rating Scale, and other assessment items to identify candidate items for extending the measurement range of the FIM; Phase 2: prospective administration of 49 candidate items from phase 1, with Rasch analysis to identify a unidimensional scale with an extended range. SETTING: Six TBI Model System rehabilitation hospitals. PARTICIPANTS: Individuals (N=184) with moderate-severe injury recruited during inpatient rehabilitation or at 1-year telephone follow-up. INTERVENTIONS: Participants were administered the 49 assessment items in person or via telephone. MAIN OUTCOME MEASURES: Item response theory parameters: item monotonicity, infit/outfit statistics, and Factor 1 variance. RESULTS: After collapsing misordered rating categories and removing misfitting items, we derived the Brain Injury Functional Outcome Measure (BI-FOM), a 31-item assessment instrument with high reliability, greatly extended measurement range, and improved unidimensionality compared with the FIM. CONCLUSIONS: The BI-FOM improves global measurement of function after moderate-severe brain injury. Its high precision, relative lack of floor and ceiling effects, and feasibility for telephone follow-up, if replicated in an independent sample, are substantial advantages.

Care partner problem solving training (CP-PST) for care partners of adults with traumatic brain injury during inpatient rehabilitation: Study protocol for a multisite, randomized, single-blind clinical feasibility trial.

Traumatic brain injury (TBI) often leads to immediate and chronic functional impairments that affect care partners, or those providing physical and/or emotional support to individuals with TBI. The many challenges associated with being a care partner often lead to caregiver burden and can compromise the well-being and quality of life of care partners and individuals with TBI under their care. Equipping care partners with problem-solving skills could facilitate and sustain their transition into this supportive role. Problem-solving training (PST) has demonstrated efficacy for providing such skills to care partners of individuals with TBI after discharge from inpatient rehabilitation. We propose that PST delivered to care partners during inpatient rehabilitation of individuals with TBI will provide care partners with the skills to manage their caregiving roles across the transition from hospital to home. Herein, we describe the methodology of a current randomized controlled trial that examines the feasibility and efficacy of PST plus TBI education compared to TBI education alone to improve care partner burden, emotional distress, and adaptive coping when delivered during the inpatient rehabilitation stay of individuals with moderate-severe TBI.

Internet and Social Media Use After Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study.

OBJECTIVES: To characterize Internet and social media use among adults with moderate to severe traumatic brain injury (TBI) and to compare demographic and socioeconomic factors associated with Internet use between those with and without TBI. SETTING: Ten Traumatic Brain Injury Model Systems centers. PARTICIPANTS: Persons with moderate to severe TBI (N = 337) enrolled in the TBI Model Systems National Database and eligible for follow-up from April 1, 2014, to March 31, 2015. DESIGN: Prospective cross-sectional observational cohort study. MAIN MEASURES: Internet usage survey. RESULTS: The proportion of Internet users with TBI was high (74%) but significantly lower than those in the general population (84%). Smartphones were the most prevalent means of Internet access for persons with TBI. The majority of Internet users with TBI had a profile account on a social networking site (79%), with more than half of the sample reporting multiplatform use of 2 or more social networking sites. CONCLUSION: Despite the prevalence of Internet use among persons with TBI, technological disparities remain in comparison with the general population. The extent of social media use among persons with TBI demonstrates the potential of these platforms for social engagement and other purposes. However, further research examining the quality of online activities and identifying potential risk factors of problematic use is recommended.

Anger Self-Management Training for Chronic Moderate to Severe Traumatic Brain Injury: Results of a Randomized Controlled Trial.

OBJECTIVE: To test efficacy of 8-session, 1:1 treatment, anger self-management training (ASMT), for chronic moderate to severe traumatic brain injury (TBI). SETTING: Three US outpatient treatment facilities. PARTICIPANTS: Ninety people with TBI and elevated self-reported anger; 76 significant others (SOs) provided collateral data. DESIGN: Multicenter randomized controlled trial with 2:1 randomization to ASMT or structurally equivalent comparison treatment, personal readjustment and education (PRE). Primary outcome assessment 1 week posttreatment; 8-week follow-up. PRIMARY OUTCOME: Response to treatment defined as 1 or more standard deviation change in self-reported anger. SECONDARY OUTCOMES: SO-rated anger, emotional and behavioral status, satisfaction with life, timing of treatment response, participant and SO-rated global change, and treatment satisfaction. MAIN MEASURES: State-Trait Anger Expression Inventory-Revised Trait Anger (TA) and Anger Expression-Out (AX-O) subscales; Brief Anger-Aggression Questionnaire (BAAQ); Likert-type ratings of treatment satisfaction, global changes in anger and well-being. RESULTS: After treatment, ASMT response rate (68%) exceeded that of PRE (47%) on TA but not AX-O or BAAQ; this finding persisted at 8-week follow-up. No significant between-group differences in SO-reported response rates, emotional/behavioral status, or life satisfaction. ASMT participants were more satisfied with treatment and rated global change in anger as significantly better; SO ratings of global change in both anger and well-being were superior for ASMT. CONCLUSION: ASMT was efficacious and persistent for some aspects of problematic anger. More research is needed to determine optimal dose and essential ingredients of behavioral treatment for anger after TBI.

Impact of religious attendance on psychosocial outcomes for individuals with traumatic brain injury: A NIDILRR funded TBI Model Systems study.

OBJECTIVES: To (1) identify demographic characteristics of individuals with traumatic brain injury (TBI) who attend religious services, (2) understand the relationship between attending religious services and psychosocial outcomes and (3) examine the independent contribution of religious service attendance to psychosocial outcomes while controlling for demographic characteristics, functional status and geographic location at 1, 5 and 10-years post injury. DESIGN: Retrospective, cross-sectional cohort study using secondary data analysis of the TBI Model Systems (TBIMS) National Database (NDB). PARTICIPANTS: TBIMS NDB participants who completed 1, 5 or 10-year follow-up interview with data on religious attendance. A total of 5573 interviews were analysed. OUTCOME MEASURES: Satisfaction with Life scale (SWLS), Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-9) and Participation Assessment with Recombined Tools-Objective Social sub-scale. RESULTS: Approximately half of the sample was attending religious services at each time point. Attendance was a significant protective factor for each outcome across all three-time periods. After controlling for demographic characteristics, functional status and geographic makeup, religious attendance contributed a small but significant amount of unique variance in all models except for GAD-7 at years 1 and 10. DISCUSSION: This study highlights the benefits of religious attendance on psychosocial outcomes post-TBI. Implications for rehabilitation are discussed.

Quantifying environmental factors: a measure of physical, attitudinal, service, productivity, and policy barriers.

OBJECTIVE: To develop and test a new instrument to assess environmental barriers encountered by people with and without disabilities by using a questionnaire format. DESIGN: New instrument development. SETTING: A rehabilitation hospital and community. PARTICIPANTS: Two convenience samples: (1) 97 subjects, 50 with disabilities and 47 without disability, and (2) 409 subjects with disabilities from spinal cord injury, traumatic brain injury, multiple sclerosis, amputation, or auditory or visual impairments. In addition, a population-based sample in Colorado of 2269 people (mean age, 44 y; 57% men) with and without disabilities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Item development; factor structure; test-retest, subject-proxy and internal consistency reliability; content, construct, and discriminant validity; and subscale and abbreviated version development. RESULTS: Panels of experts on disability developed items for the Craig Hospital Inventory of Environmental Factors (CHIEF). The instrument measured the frequency and magnitude of environmental barriers reported by individuals. Five subscales were derived from factor analysis measuring (1) attitudes and support, (2) services and assistance, (3) physical and structural, (4) policy, and (5) work and school environmental barriers. The CHIEF total score had high test-retest reliability (intraclass correlation coefficient [ICC]=.93) and high internal consistency (Cronbach alpha=.93), but lower participant-proxy agreement (ICC=.62). Significant differences were found in CHIEF scores among groups of people with known differences in disability levels and disability categories. CONCLUSIONS: The CHIEF has good test-retest and internal consistency reliability with evidence of content, construct, and discriminant validity resulting from its development strategy and psychometric assessments in samples of the general population and among people with a variety of disabilities.

Population-based estimates of outcomes after hospitalization for traumatic brain injury in Colorado.

OBJECTIVE: To determine statewide, population-based outcomes of persons hospitalized with traumatic brain injury (TBI) at 1 year postinjury. DESIGN: Follow-up survey of a representative cohort. SETTING: A statewide, population-based registry and follow-up system for persons hospitalized with TBI. PARTICIPANTS: A total of 1591 adult Coloradoans with moderate and severe injury oversampled, but weighted to be representative of persons hospitalized with TBI (1996-1999) who survived their injuries and completed follow-up telephone interviews at 1 year postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Checklists of symptoms and service utilization, the FIM instrument trade mark, the Craig Handicap Assessment and Reporting Technique Short Form, a single-item quality of life (QOL) measure, and a needs assessment checklist. RESULTS: Problematic outcomes occurring at 1 year postinjury included one third or more being bothered by fatigue, feeling irritable or grouchy, having headaches, and experiencing trouble sleeping more frequently than preinjury; 37% reported needing the assistance of another person in physical and/or cognitive activities of daily living; substantial participation restrictions were noted in areas of occupation (30%) and social integration (22%); and 29% responded that their QOL was only fair or poor. Negative outcomes were reported more frequently among individuals who were more severely injured, older, or female. CONCLUSIONS: Substantial percentages of people hospitalized with TBI in a population-based sample reported a variety of problematic outcomes at 1 year postinjury.

Violence-related traumatic brain injury: a population-based study.

BACKGROUND: Most studies of traumatic brain injury (TBI) and violence are small, focus on one violent mechanism only, and are nonrepresentative. This large, population-based effort examines characteristics, circumstances of injury, treatment pathways, and outcomes of persons with TBI as a result of all types of violence, compares them with other TBI survivors, identifies a risk profile, and examines how a violent cause impacts later outcomes. METHODS: This study involved medical record abstraction and telephone survey at 1 year postinjury of a weighted sample of 2,771 Coloradans hospitalized with TBI between January 1, 1996, and June 30, 1999. RESULTS: People with violently incurred TBI are more likely to be young, male, members of minority groups, single, and premorbid alcohol abusers than other TBI survivors. At 1 year postinjury, they report less community integration and more headaches, confusion, and sensory and attentional disturbances. Predictors of these outcomes included age, gender, injury severity, and employment status. CONCLUSION: It appears that essentially the same factors that increase risk of sustaining a violent TBI negatively impact later outcomes as well.

Measuring participation across impairment groups using the Craig Handicap Assessment Reporting Technique.

OBJECTIVE: To assess the efficacy, across a range of disability groups, of the Craig Handicap Assessment and Reporting Technique (CHART), a measure of societal participation. DESIGN: Cross-sectional analysis survey methodology. A total of 1110 community-based, nonhospitalized Coloradans with spinal cord injury, traumatic brain injury, multiple sclerosis, stroke, burn, or amputation were interviewed twice, 2 wks apart, using the CHART and a single administration of the FIM. RESULTS: Across all impairment groups, the intraclass correlation for the total score and the subscales of CHART-R were high. In addition, the CHART-R discriminated among the impairment categories in a direction that parallels increasing disability. CONCLUSIONS: CHART may be an appropriate measure of handicap for a range of physical or cognitive impairments.

Evaluation of the home and community-based services brain injury Medicaid Waiver Programme in Colorado.

PRIMARY OBJECTIVES: To evaluate Colorado's Traumatic Brain Injury (TBI) Waiver programme in terms of functional, community integration and other key psychosocial outcomes. RESEARCH DESIGN: Results of telephone surveys of 66 TBI survivors who had received services through the Colorado Medicaid programme were compared with those of a matched sample not receiving such services. METHODS AND PROCEDURES: Participants were identified by Colorado's Medicaid programme and a control group was randomly selected from the population-based Colorado Traumatic Brain Injury Registry and Follow-up System. Groups were matched on Glasgow Coma Scale score at injury, age, gender,whether inpatient rehabilitation had been received and the number of years post-injury when the follow-up interview was conducted. All participants completed an extensive follow-up interview, which included CHART, the Sickness Impact Profile, the Satisfaction with Life Scale, the SF-12 and questions on symptoms and service use. MAIN OUTCOMES AND RESULTS: For four of the evaluated outcomes-relating to mental health problems (SF-12) and alcohol use-the Medicaid Waiver group had significantly fewer problems than the control group. In eight areas, the Waiver group demonstrated poorer outcomes than the control group. The Waiver group scored significantly lower on most measures of societal participation (measured by CHART), needed more help with IADLS (instrumental activities of daily living) and were less likely to be competitively employed. Additionally, Waiver recipients had significantly more case management, physical therapy and group home services and more second rehabilitation admissions than the control group. No significant differences were found for the remaining 62 outcomes that were evaluated. CONCLUSIONS: Although there were significant differences between the two groups in a few important areas, it is impossible to conclude that any outcome differences--or lack of differences---are attributable to the Waiver programme alone, since many important potential group differences could not be adequately controlled for by the design. Recommendations are offered for future research to address these limitations.

Understanding outcomes based on the post-acute hospitalization pathways followed by persons with traumatic brain injury.

PRIMARY OBJECTIVES: To identify the factors that determine the pathways of care people with traumatic brain injury (TBI) follow after acute care discharge, and to identify differences in outcome based on those pathways. RESEARCH DESIGN: Telephone survey of a statewide, population-based sample of persons surviving through acute hospitalization for TBI. METHODS AND PROCEDURES: Included were 1059 individuals who: (a) were discharged from acute care in 1996 and 1997; (b) were eligible for inclusion in the statewide, population-based TBI follow-up system, (c) had either a severe TBI or were among a 20% random sample with milder injuries, and (d) consented to participate in a 1-year post-injury follow-up survey. The survey included administration of the Functional Independence Measure (FIM), the Craig Handicap Assessment and Reporting Technique (CHART), the Alertness Behaviour Sub-scale of the Sickness Impact Profile (SIP), and the Health Status Questionnaire (HSQ-12). Medical records for all participants were abstracted for injury severity, pre-injury history (aetiologic and demographic) and discharge disposition data. Data were weighted to represent the population from which the sample was derived prior to analyses. MAIN OUTCOMES AND RESULTS: Almost 2/3 of TBI survivors in this population-based sample received no additional services following discharge from the acute care hospital. Six post-acute-hospitalization pathways were identified based on combinations of inpatient rehabilitation, community-based services and long-term care (LTC). In each category--except for the one involving a discharge directly from acute care to home--people with the most severe TBIs were disproportionately over-represented. Older people and people whose care was funded by government payers were over-represented in both care pathways involving LTC, while members of minority groups were under represented. Those who went to LTC had the poorest outcomes, but even those completing rehabilitation had relatively poor outcomes compared with those discharged directly to home. CONCLUSIONS: Of concern are the relatively large numbers of people receiving no rehabilitation and other services in all severity categories. Those in LTC--typically older and government funded people--reported the poorest outcomes. Unanswered questions remain relating to the poor perceived quality of life reported by those completing rehabilitation programmes. Further study is also needed to more fully understand the affects of such characteristics as gender, minority status, employment and funding sources on the care pathway that is followed.