Adaptation for sustainability in an implementation trial of team-based collaborative care.

Background: Sustaining healthcare interventions once they have been implemented is a pivotal public health endeavor. Achieving sustainability requires context-sensitive adaptations to evidence-based practices (EBPs) or the implementation strategies used to ensure their adoption. For replicability of adaptations beyond the specific setting in question, the underlying logic needs to be clearly described, and adaptations themselves need to be plainly documented. The goal of this project was to describe the process by which implementation facilitation was adapted to improve the uptake of clinical care practices that are consistent with the collaborative chronic care model (CCM). Method: Quantitative and qualitative data from a prior implementation trial found that CCM-consistent care practices were not fully sustained within outpatient general mental health teams that had received 1 year of implementation facilitation to support uptake. We undertook a multistep consensus process to identify adaptations to implementation facilitation based on these results, with the goal of enhancing the sustainability of CCM-based care in a subsequent trial. The logic for these adaptations, and the resulting adaptations themselves, were documented using two adaptation-oriented implementation frameworks (the iterative decision-making for evaluation of adaptations [IDEA] and the framework for reporting adaptations and modifications to evidence-based implementation strategies [FRAME-IS], respectively). Results: Three adaptations emerged from this process and were documented using the FRAME-IS: (a) increasing the scope of implementation facilitation within the medical center, (b) having the internal facilitator take a greater role in the implementation process, and (c) shortening the implementation timeframe from 12 to 8 months, while increasing the intensity of facilitation support during that time. Conclusions: EBP sustainability may require careful adaptation of EBPs or the implementation strategies used to get them into routine practice. Recently developed frameworks such as the IDEA and FRAME-IS may be used to guide decision-making and document resulting adaptations themselves. An ongoing funded study is investigating the utility of the resulting adaptations for improving healthcare.

Evidence-based treatments may not be sustained after they have been implemented in healthcare settings. To address this, treatments and implementation strategies may need to be adapted to fit the local context or the patient population. Maximizing the usefulness of such adaptations requires documenting the decision-making process. Understanding how an implementation strategy has been adapted for a given study or setting is crucial to ensuring that adaptations don't compromise fidelity to the implementation strategy while enabling its replicability in similar settings. This article uses two adaptation frameworks to describe the process by which implementation facilitation, a common implementation strategy, was adapted to help establish and sustain effective mental health clinical teams in VA medical centers. It is our hope that our description of this process may help healthcare researchers, administrators, and policymakers to describe and document adaptations to implementation strategies in their own settings.

Integrating Intimate Partner Violence Screening Programs in Primary Care: Results from a Hybrid-II Implementation-Effectiveness RCT.

INTRODUCTION: The Veterans Health Administration initiated implementation facilitation to integrate intimate partner screening programs in primary care. This study investigates implementation facilitation's impact on implementation and clinical effectiveness outcomes. STUDY DESIGN: A cluster randomized, stepped-wedge, hybrid-II implementation-effectiveness trial (January 2021-April 2022) was conducted amidst the COVID-19 pandemic. SETTING/PARTICIPANTS: Implementation facilitation was applied at 9 Veterans Health Administration facilities, staged across 2 waves. Participants were all women receiving care at participating primary care clinics 3 months before (pre-implementation facilitation n=2,272) and 9 months after initiation of implementation facilitation (implementation facilitation n=5,149). INTERVENTION: Implementation facilitation included an operations-funded external facilitator working for 6 months with a facility-funded internal facilitator from participating clinics. The pre-implementation facilitation period comprised implementation as usual in the Veterans Health Administration. MAIN OUTCOME MEASURES: Primary outcomes were changes in (1) reach of intimate partner violence (IPV) screening programs among eligible women (i.e., those seen within participating clinics during the assessment period; implementation outcome) and (2) disclosure rates among screened women (effectiveness outcome). Secondary outcomes included disclosure rates among all eligible women and post-screening psychosocial service use. Administrative data were analyzed. RESULTS: For primary outcomes, women seen during the implementation facilitation period were nearly 3 times more likely to be screened for IPV than women seen during the pre-implementation facilitation period (OR=2.70, 95% CI=2.46, 2.97). Women screened during the implementation facilitation period were not more likely to disclose IPV than those screened during the pre-implementation facilitation period (OR=1.14, 95% CI=0.86, 1.51). For secondary outcomes, owing to increased reach of screening during implementation facilitation, women seen during the implementation facilitation period were more likely to disclose IPV than those seen during the pre-implementation facilitation period (OR=2.09, 95% CI=1.52, 2.86). Women screened during implementation facilitation were more likely to use post-screening psychosocial services than those screened during pre-implementation facilitation (OR=1.29, 95% CI=1.06, 1.57). CONCLUSIONS: Findings indicate that implementation facilitation may be a promising strategy for increasing the reach of IPV screening programs in primary care, thereby increasing IPV detection and strengthening connections to support services among the patient population. TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT04106193.

Patient and provider predictors of telemental health use prior to and during the COVID-19 pandemic within the Department of Veterans Affairs.

The current study examined patient and provider differences in use of phone, video, and in-person mental health (MH) services. Participants included patients who completed ≥ 1 MH appointment within the Department of Veterans Affairs (VA) from 10/1/17-7/10/20 and providers who completed ≥ 100 VA MH appointments from 10/1/17-7/10/20. Adjusted odds ratios (aORs) are reported of patients and providers: (a) completing ≥1 video MH appointment in the pre-COVID (10/1/17-3/10/20) and COVID (3/11/20-7/10/20) periods; and (b) completing the majority of MH visits via phone, video, or in-person during COVID. The sample included 2,480,119 patients/31,971 providers in the pre-COVID period, and 1,054,670 patients/23,712 providers in the COVID period. During the pre-COVID and COVID periods, older patients had lower odds of completing ≥ 1 video visit (aORs < .65). During the COVID period, older age and low socioeconomic status predicted lower odds of having ≥ 50% of visits via video versus in-person or phone (aORs < .68); schizophrenia and MH hospitalization history predicted lower odds of having ≥ 50% of visits via video or phone versus in-person (aORs < . 64). During the pre-COVID and COVID periods, nonpsychologists (e.g., psychiatrists) had lower odds of completing video visits (aORs < . 44). Older providers had lower odds of completing ≥ 50% of visits via video during COVID (aORs <. 69). Findings demonstrate a digital divide, such that older and lower income patients, and older providers, engaged in less video care. Nonpsychologists also had lower video use. Barriers to use must be identified and strategies must be implemented to ensure equitable access to video MH services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Rapid Increase in Telemental Health Within the Department of Veterans Affairs During the COVID-19 Pandemic.

Background: The use of telemental health via videoconferencing (TMH-V) became critical during the Coronavirus disease 2019 (COVID-19) pandemic due to restriction of non-urgent in-person appointments. The current brief report demonstrates the rapid growth in TMH-V appointments in the weeks following the pandemic declaration within the Department of Veterans Affairs (VA), the largest healthcare system in the United States. Methods: COVID-19 changes in TMH-V appointments were captured during the six weeks following the World Health Organization's pandemic declaration (March 11, 2020-April 22, 2020). Pre-COVID-19 TMH-V encounters were assessed from October 1, 2017 to March 10, 2020. Results: Daily TMH-V encounters rose from 1,739 on March 11 to 11,406 on April 22 (556% growth, 222,349 total encounters). Between March 11-April 22, 114,714 patients were seen via TMH-V, and 77.5% were first-time TMH-V users. 12,342 MH providers completed a TMH-V appointment between March 11-April 22, and 34.7% were first-time TMH-V users. The percentage growth of TMH-V appointments was higher than the rise in telephone appointments (442% growth); in-person appointments dropped by 81% during this time period. Discussion and Conclusions: The speed of VA's growth in TMH-V appointments in the wake of the COVID-19 pandemic was facilitated by its pre-existing telehealth infrastructure, including earlier national efforts to increase the number of providers using TMH-V. Longstanding barriers to TMH-V implementation were lessened in the context of a pandemic, during which non-urgent in-person MH care was drastically reduced. Future work is necessary to understand the extent to which COVID-19 related changes in TMH-V use may permanently impact mental health care provision.

Novel Method to Flag Cardiac Implantable Device Infections by Integrating Text Mining With Structured Data in the Veterans Health Administration's Electronic Medical Record.

Importance: Health care-associated infections (HAIs) are preventable, harmful, and costly; however, few resources are dedicated to infection surveillance of nonsurgical procedures, particularly cardiovascular implantable electronic device (CIED) procedures. Objective: To develop a method that includes text mining of electronic clinical notes to reliably and efficiently measure HAIs for CIED procedures. Design, Setting, and Participants: In this multicenter, national cohort study using electronic medical record data for patients undergoing CIED procedures in Veterans Health Administration (VA) facilities for fiscal years (FYs) 2016 and 2017, an algorithm to flag cases with a true CIED-related infection based on structured (eg, microbiology orders, vital signs) and free text diagnostic and therapeutic data (eg, procedure notes, discharge summaries, microbiology results) was developed and validated. Procedure data were divided into development and validation data sets. Criterion validity (ie, positive predictive validity [PPV], sensitivity, and specificity) was assessed via criterion-standard manual medical record review. Exposures: CIED procedure. Main Outcomes and Measures: The concordance between medical record review and the study algorithm with respect to the presence or absence of a CIED infection. CIED infection in the algorithm included 90-day mortality, congestive heart failure and nonmetastatic tumor comorbidities, CIED or surgical site infection International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, antibiotic treatment of Staphylococci, a microbiology test of a cardiac specimen, and text documentation of infection in specific clinical notes (eg, cardiology, infectious diseases, inpatient discharge summaries). Results: The algorithm sample consisted of 19 212 CIED procedures; 15 077 patients (78.5%) were White individuals, 1487 (15.5%) were African American; 18 766 (97.7%) were men. The mean (SD) age in our sample was 71.8 (10.6) years. The infection detection threshold of predicted probability was set to greater than 0.10 and the algorithm flagged 276 of 9606 (2.9%) cases in the development data set (9606 procedures); PPV in this group was 41.4% (95% CI, 31.6%-51.8%). In the validation set (9606 procedures), at predicted probability 0.10 or more the algorithm PPV was 43.5% (95% CI, 37.1%-50.2%), and overall sensitivity and specificity were 94.4% (95% CI, 88.2%-97.9%) and 48.8% (95% CI, 42.6%-55.1%), respectively. Conclusions and Relevance: The findings of this study suggest that the method of combining structured and text data in VA electronic medical records can be used to expand infection surveillance beyond traditional boundaries to include outpatient and procedural areas.

Predictors of Employment Status in Male and Female Post-9/11 Veterans Evaluated for Traumatic Brain Injury.

OBJECTIVES: The goal of this study was to investigate predictors of employment status in male and female post-9/11 Veterans evaluated for traumatic brain injury (TBI) in the Veterans Health Administration. Prior research suggests there are gender differences in psychosocial characteristics among this cohort. METHODS: This was a cross-sectional analysis of post-9/11 Veterans who completed a TBI evaluation between July 2009 and September 2013. RESULTS: Women had lower prevalence of deployment-related TBI (65.5%) compared with men (75.3%), but the percentages of those unemployed across the TBI diagnostic categories were similar for men (38%) and women (39%). Adjusted log-binomial regression found that unemployment was significantly associated with age, education, marital status, moderate/severe TBI, suspected posttraumatic stress disorder, depression, and drug abuse/dependence, and neurobehavioral symptom severity for men, whereas for women only more severe affective and cognitive symptoms were associated with unemployment. CONCLUSIONS: Although the unemployment rate was similar across gender, there was a clearer pattern of demographic and health factors, including TBI severity, that was significantly associated with employment status in men. There may be other factors contributing to the female Veteran unemployment rate, underscoring the need to investigate unique contributors to unemployment, as well as how treatment and employment services can be expanded and tailored for post-9/11 Veterans.

External Determinants of Veterans' Utilization of VA Health Care.

OBJECTIVE: Veterans' utilization of Veterans Affairs (VA) health care is likely influenced by community factors external to the VA, including Medicaid eligibility and unemployment, although such factors are rarely considered in models predicting such utilization. We measured the sensitivity of VA utilization to changes in such community factors (hereafter, "external determinants"), including the 2014 Medicaid expansion following the Affordable Care Act. DATA SOURCES/STUDY SETTING: We merged VA health care enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices, and non-VA physician availability (2008-2014). STUDY DESIGN: For veterans aged 18-64 and ≥65, we estimated the sensitivity of annual individual VA health care utilization, measured by the cost ($) of care received, to changes in external determinants using longitudinal regression models controlling for individual fixed effects. PRINCIPAL FINDINGS: All external determinants were associated with small but significant changes in VA health care utilization. In states that expanded Medicaid in 2014, this expansion was associated with 9.1 percent ($826 million) reduction in VA utilization among those aged 18-64; sizable changes occurred in all services used (inpatient, outpatient, and prescription drugs). CONCLUSIONS: Changes in alternative insurance coverage and other external determinants may affect VA health care spending. Policy makers should consider these factors in allocating VA resources to meet local demand.

Factors associated with internal medicine physician job attitudes in the Veterans Health Administration.

BACKGROUND: US healthcare organizations increasingly use physician satisfaction and attitudes as a key performance indicator. Further, many health care organizations also have an academically oriented mission. Physician involvement in research and teaching may lead to more positive workplace attitudes, with subsequent decreases in turnover and beneficial impact on patient care. This article aimed to understand the influence of time spent on academic activities and perceived quality of care in relation to job attitudes among internal medicine physicians in the Veterans Health Administration (VHA). METHODS: A cross-sectional survey was conducted with inpatient attending physicians from 36 Veterans Affairs Medical Centers. Participants were surveyed regarding demographics, practice settings, workplace staffing, perceived quality of care, and job attitudes. Job attitudes consisted of three measures: overall job satisfaction, intent to leave the organization, and burnout. Analysis used a two-level hierarchical model to account for the nesting of physicians within medical centers. The regression models included organizational-level characteristics: inpatient bed size, urban or rural location, hospital teaching affiliation, and performance-based compensation. RESULTS: A total of 373 physicians provided useable survey responses. The majority (72%) of respondents reported some level of teaching involvement. Almost half (46%) of the sample reported some level of research involvement. Degree of research involvement was a significant predictor of favorable ratings on physician job satisfaction and intent to leave. Teaching involvement did not have a significant impact on outcomes. Perceived quality of care was the strongest predictor of physician job satisfaction and intent to leave. Perceived levels of adequate physician staffing was a significant contributor to all three job attitude measures. CONCLUSIONS: Expanding opportunities for physician involvement with research may lead to more positive work experiences, which could potentially reduce turnover and improve system performance.

Does adding clinical data to administrative data improve agreement among hospital quality measures?

BACKGROUND: Hospital performance measures based on patient mortality and readmission have indicated modest rates of agreement. We examined if combining clinical data on laboratory tests and vital signs with administrative data leads to improved agreement with each other, and with other measures of hospital performance in the nation's largest integrated health care system. METHODS: We used patient-level administrative and clinical data, and hospital-level data on quality indicators, for 2007-2010 from the Veterans Health Administration (VA). For patients admitted for acute myocardial infarction (AMI), heart failure (HF) and pneumonia we examined changes in hospital performance on 30-d mortality and 30-d readmission rates as a result of adding clinical data to administrative data. We evaluated whether this enhancement yielded improved measures of hospital quality, based on concordance with other hospital quality indicators. RESULTS: For 30-d mortality, data enhancement improved model performance, and significantly changed hospital performance profiles; for 30-d readmission, the impact was modest. Concordance between enhanced measures of both outcomes, and with other hospital quality measures - including Joint Commission process measures, VA Surgical Quality Improvement Program (VASQIP) mortality and morbidity, and case volume - remained poor. CONCLUSIONS: Adding laboratory tests and vital signs to measure hospital performance on mortality and readmission did not improve the poor rates of agreement across hospital quality indicators in the VA. INTERPRETATION: Efforts to improve risk adjustment models should continue; however, evidence of validation should precede their use as reliable measures of quality.

Building Systemwide Improvement Capability: Does an Organization's Strategy for Quality Improvement Matter?

OBJECTIVES: Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning. METHODS: Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results. RESULTS: We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success. CONCLUSIONS: This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.

Team Process Variation Across Diabetes Quality of Care Trajectories.

Conceptual frameworks in health care do not address mechanisms whereby teamwork processes affect quality of care. We seek to fill this gap by applying a framework of teamwork processes to compare different patterns of primary care performance over time. We thematically analyzed 114 primary care staff interviews across 17 primary care clinics. We purposefully selected clinics using diabetes quality of care over 3 years using four categories: consistently high, improving, worsening, and consistently low. Analyses compared participant responses within and between performance categories. Differences were observed among performance categories for action processes (monitoring progress and coordination), transition processes (goal specification and strategy formulation), and interpersonal processes (conflict management and affect management). Analyses also revealed emergent concepts related to psychological and organizational context that were reported to affect team processes. This study is a first step toward a comprehensive model of how teamwork processes might affect quality of care.

Associations Between Traumatic Brain Injury, Suspected Psychiatric Conditions, and Unemployment in Operation Enduring Freedom/Operation Iraqi Freedom Veterans.

OBJECTIVE: To examine the relations among demographic characteristics, traumatic brain injury (TBI) history, suspected psychiatric conditions, current neurobehavioral health symptoms, and employment status in Veterans evaluated for TBI in the Department of Veterans Affairs. STUDY DESIGN: Retrospective cross-sectional database review of comprehensive TBI evaluations documented between October 2007 and June 2009. PARTICIPANTS: Operation Enduring Freedom/Operation Iraqi Freedom Veterans (n = 11 683) who completed a comprehensive TBI evaluation. MAIN MEASURES: Veterans Affairs clinicians use the comprehensive TBI evaluations to obtain information about TBI-related experiences, current neurobehavioral symptoms, and to identify suspected psychiatric conditions. RESULTS: Approximately one-third of Veterans in this sample were unemployed, and of these, the majority were looking for work. After simultaneously adjusting for health and deployment-related variables, significant factors associated with unemployment included one or more suspected psychiatric conditions (eg, posttraumatic stress disorder, anxiety, depression), neurobehavioral symptom severity (ie, affective, cognitive, vestibular), former active duty status, injury etiology, age, lower education, and marital status. The associations of these factors with employment status varied by deployment-related TBI severity. CONCLUSIONS: Simultaneously addressing health-related, educational, and/or vocational needs may fill a critical gap for helping Veterans readjust to civilian life and achieve their academic and vocational potential.

How pooling fragmented healthcare encounter data affects hospital profiling.

OBJECTIVES: People receiving healthcare from multiple payers (eg, Medicare and the Veterans Health Administration [VA]) have fragmented health records. How the use of more complete data affects hospital profiling has not been examined. STUDY DESIGN: Retrospective cohort study. METHODS: We examined 30-day mortality following acute myocardial infarction at 104 VA hospitals for veterans 66 years and older from 2006 through 2010 who were also Medicare beneficiaries. Using VA-only data versus combined VA/Medicare data, we calculated 2 risk-standardized mortality rates (RSMRs): 1 based on observed mortality (O/E) and the other from CMS' Hospital Compare program, based on model-predicted mortality (P/E). We also categorized hospital outlier status based on RSMR relative to overall VA mortality: average, better than average, and worse than average. We tested whether hospitals whose patients received more of their care through Medicare would look relatively better when including those data in risk adjustment, rather than including VA data alone. RESULTS: Thirty-day mortality was 14.8%. Adding Medicare data caused both RSMR measures to significantly increase in about half the hospitals and decrease in the other half. O/E RSMR increased in 53 hospitals, on average, by 2.2%, and decreased in 51 hospitals by -2.6%. P/E RSMR increased, on average, by 1.2% in 56 hospitals, and decreased in the others by -1.3%. Outlier designation changed for 4 hospitals using O/E measure, but for no hospitals using P/E measure. CONCLUSIONS: VA hospitals vary in their patients' use of Medicare-covered care and completeness of health records based on VA data alone. Using combined VA/Medicare data provides modestly different hospital profiles compared with those using VA-alone data.

Concordance of clinician judgment of mild traumatic brain injury history with a diagnostic standard.

The concordance of Department of Veterans Affairs (VA) clinician judgment of mild traumatic brain injury (mTBI) history with American Congress of Rehabilitation Medicine (ACRM)-based criteria was examined for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans. In order to understand inconsistencies in agreement, we also examined the associations between evaluation outcomes and conceptually relevant patient characteristics, deployment-related events, current self-reported health symptoms, and suspected psychiatric conditions. The Veteran sample comprised 14,026 OIF/OEF VA patients with deployment-related mTBI history (n = 9,858) or no history of mTBI (n = 4,168) as defined by ACRM-based criteria. In the majority of cases (76.0%), clinician judgment was in agreement with the ACRM-based criteria. The most common inconsistency was between clinician judgment (no) and ACRM-based criteria (yes) for 21.3% of the patients. Injury etiology, current self-reported health symptoms, and suspected psychiatric conditions were additional factors associated with clinician diagnosis and ACRM-based criteria disagreement. Adherence to established diagnostic guidelines is essential for accurate determination of mTBI history and for understanding the extent to which mTBI symptoms resolve or persist over time in OIF/OEF Veterans.

Associations with chest illness and mortality in chronic spinal cord injury.

OBJECTIVE: Identify factors associated with chest illness and describe the relationship between chest illness and mortality in chronic spinal cord injury (SCI). DESIGN: Cross-sectional survey assessing chest illness and a prospective assessment of mortality. METHODS: Between 1994 and 2005, 430 persons with chronic SCI (mean ± SD), 52.0 ± 14.9 years old, and ≥4 years post SCI (20.5 ± 12.5 years) underwent spirometry, completed a health questionnaire, and reported any chest illness resulting in time off work, indoors, or in bed in the preceding 3 years. Deaths through 2007 were identified. Outcome measures Logistic regression assessing relationships with chest illness at baseline and Cox regression assessing the relationship between chest illness and mortality. RESULTS: Chest illness was reported by 139 persons (32.3%). Personal characteristics associated with chest illness were current smoking (odds ratio =2.15; 95% confidence interval =1.25-3.70 per each pack per day increase), chronic obstructive pulmonary disease (COPD) (3.52; 1.79-6.92), and heart disease (2.18; 1.14-4.16). Adjusting for age, subjects reporting previous chest illness had a non-significantly increased hazard ratio (HR) for mortality (1.30; 0.88-1.91). In a multivariable model, independent predictors of mortality were greater age, SCI level and completeness of injury, diabetes, a lower %-predicted forced expiratory volume in 1 second, heart disease, and smoking history. Adjusting for these covariates, the effect of a previous chest illness on mortality was attenuated (HR = 1.15; 0.77-1.73). CONCLUSION: In chronic SCI, chest illness in the preceding 3 years was not an independent risk factor for mortality and was not associated with level and completeness of SCI, but was associated with current smoking, physician-diagnosed COPD, and heart disease history.

Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience.

BACKGROUND: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). METHODS: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. RESULTS: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. CONCLUSIONS: VHA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare.

Multisensory impairment reported by veterans with and without mild traumatic brain injury history.

With the use of Veterans Health Administration and Department of Defense databases of veterans who completed a Department of Veterans Affairs comprehensive traumatic brain injury (TBI) evaluation, the objectives of this study were to (1) identify the co-occurrence of self-reported auditory, visual, and vestibular impairment, referred to as multisensory impairment (MSI), and (2) examine demographic, deployment-related, and mental health characteristics that were potentially predictive of MSI. Our sample included 13,746 veterans with either a history of deployment-related mild TBI (mTBI) (n = 9,998) or no history of TBI (n = 3,748). The percentage of MSI across the sample was 13.9%, but was 17.4% in a subsample with mTBI history that experienced both nonblast and blast injuries. The factors that were significantly predictive of reporting MSI were older age, being female, lower rank, and etiology of injury. Deployment-related mTBI history, posttraumatic stress disorder, and depression were also significantly predictive of reporting MSI, with mTBI history the most robust after adjusting for these conditions. A better comprehension of impairments incurred by deployed servicemembers is needed to fully understand the spectrum of blast and nonblast dysfunction and may allow for more targeted interventions to be developed to address these issues.

Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury: a gender comparison.

BACKGROUND: Traumatic brain injury (TBI) has substantial negative implications for the post-deployment adjustment of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF); however, most research on veterans has focused on males. This study investigated gender differences in psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF veterans with deployment-related TBI. METHODS: This population-based study examined psychiatric diagnoses and self-reported neurobehavioral symptom severity from administrative records for 12,605 United States OEF/OIF veterans evaluated as having deployment-related TBI. Men (n = 11,951) and women (n = 654) who were evaluated to have deployment-related TBI during a standardized comprehensive TBI evaluation in Department of Veterans Affairs facilities were compared on the presence of psychiatric diagnoses and severity of neurobehavioral symptoms. FINDINGS: Posttraumatic stress disorder (PTSD) was the most common psychiatric condition for both genders, although women were less likely than men to have a PTSD diagnosis. In contrast, relative to men, women were 2 times more likely to have a depression diagnosis, 1.3 times more likely to have a non-PTSD anxiety disorder, and 1.5 times more likely to have PTSD with comorbid depression. Multivariate analyses indicated that blast exposure during deployment may account for some of these differences. Additionally, women reported significantly more severe symptoms across a range of neurobehavioral domains. CONCLUSION: Although PTSD was the most common condition for both men and women, it is also critical for providers to identify and treat other conditions, especially depression and neurobehavioral symptoms, among women veterans with deployment-related TBI.

Systemic inflammation and reduced pulmonary function in chronic spinal cord injury.

OBJECTIVE: To evaluate the relationship between systemic inflammation and pulmonary function in persons with chronic spinal cord injury (SCI). DESIGN: Cross-sectional study. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Fifty-nine men with chronic SCI participating in a prior epidemiologic study. METHODS: Standardized assessment of pulmonary function and measurement of plasma C-reactive protein (CRP) and interleukin-6 (IL-6). MAIN OUTCOME MEASUREMENTS: Forced expiratory volume in 1 second (FEV(1)) and forced vital capacity (FVC). RESULTS: Persons with the highest values of IL-6 had the lowest %-predicted FEV(1) and FVC. There was a significant inverse linear trend between quartile of IL-6 and %-predicted FEV(1) (P < .001) and FVC (P < .006), unadjusted and adjusted for SCI level and completeness of injury, obstructive lung disease history, smoking, and body mass index (P = .010-.039). Although not as strong as for IL-6, there also were similar trends for %-predicted FEV(1) and FVC with CRP. CONCLUSIONS: In chronic SCI, higher levels of IL-6 and CRP were associated with a lower FEV(1) and FVC, independent of level and completeness of injury. These results suggest that the reduction of pulmonary function after SCI is related not only to neuromuscular impairment but also to factors that promote systemic inflammation.