VA Health Care
Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain Gao ID: GAO-08-276 February 8, 2008Traumatic brain injury (TBI) has emerged as a leading injury among servicemembers serving in the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) combat theaters. The widespread use of improvised explosive devices, such as roadside bombs, in these combat theaters increases the likelihood that servicemembers will be exposed to incidents that can cause a TBI. TBIs can vary from mild to severe, and in general, mild TBI can be difficult to identify. Because mild TBI can have lasting effects if not identified and treated, concerns have been raised about how the Department of Veterans Affairs (VA) identifies and treats OEF/OIF veterans with a mild TBI. In this report GAO describes VA's (1) efforts to screen OEF/OIF veterans for mild TBI, (2) steps taken so that those OEF/OIF veterans at risk for mild TBI are evaluated and treated, and (3) challenges in screening and evaluating OEF/OIF veterans for mild TBI. GAO reviewed VA's policies, interviewed VA officials and TBI experts, and reviewed nine VA medical facilities' efforts to implement TBI screening and evaluation processes.
To screen OEF/OIF veterans for mild TBI, VA implemented in its medical facilities in April 2007 a computer-based screening tool to identify OEF/OIF veterans who may have a mild TBI. VA's tool consists of questions that VA must ask all OEF/OIF veterans when they come to a VA medical facility for care. VA issued a policy requiring its medical facilities to use the tool to screen all OEF/OIF veterans who present for care in any clinic in the facility, including primary care and specialty care clinics. The policy has guidance on what types of providers may administer the tool and directs providers that a positive screening result requires a further evaluation by a specialist to determine if the veteran has mild TBI. VA's screening efforts depend on its TBI screening tool and VA recognizes the importance of determining the tool's clinical validity and reliability--that is, how effectively the tool identifies those who are and are not at risk for mild TBI and if the tool would yield consistent results if administered to the same veteran more than once. However, VA is planning to but has not yet begun to determine the tool's validity and reliability. VA's screening tool was based largely on a tool developed and validated by the Defense and Veterans Brain Injury Center (DVBIC)--a medical and educational collaboration among DOD, VA, and two civilian partners--used at selected military bases to screen returning OEF/OIF servicemembers for TBI. However, because VA's tool is a modified version of DVBIC's tool and is used to screen a slightly different population, the results of the validity study of DVBIC's tool are not directly applicable to VA's tool. To help ensure that OEF/OIF veterans identified as at risk for a mild TBI by VA's screening tool are evaluated and treated, VA developed a national protocol for their evaluation and treatment. According to VA's protocol, veterans with a positive screening result should be offered a follow-up evaluation by a specialist to determine if they have a mild TBI. The follow-up evaluation should include a history of the veteran's injury, a physical examination targeted to the veteran's symptoms, and the use of a checklist to assess the presence and severity of symptoms associated with mild TBI. VA has established training for its providers to enhance use of the protocol and help ensure veterans are evaluated and treated for mild TBI. Providers at some VA medical facilities we visited had difficulties fully following the protocol. However, the facilities had taken steps to resolve the difficulties, and VA has put in place measures to help providers follow the protocol. VA faces clinical and cultural challenges in its efforts to screen and evaluate mild TBI in OEF/OIF veterans. Clinical challenges include the lack of existing objective diagnostic tests that can definitively identify mild TBI. Also, many symptoms of mild TBI are similar to those associated with other conditions, such as post-traumatic stress disorder, making a diagnosis of mild TBI harder to reach. Some characteristics of the OEF/OIF veteran population present cultural challenges in that they may affect veterans' willingness to seek care for TBI symptoms. For example, some may believe that being labeled with a TBI could affect their ability to stay in the National Guard or Reserves.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-08-276, VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain
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United States Government Accountability Office:
GAO:
Report to Congressional Requesters:
February 2008:
VA Health Care:
Mild Traumatic Brain Injury Screening and Evaluation Implemented for
OEF/OIF Veterans, but Challenges Remain:
GAO-08-276:
GAO Highlights:
Highlights of GAO-08-276, a report to congressional requesters.
Why GAO Did This Study:
Traumatic brain injury (TBI) has emerged as a leading injury among
servicemembers serving in the Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF) combat theaters. The widespread use of
improvised explosive devices, such as roadside bombs, in these combat
theaters increases the likelihood that servicemembers will be exposed
to incidents that can cause a TBI. TBIs can vary from mild to severe,
and in general, mild TBI can be difficult to identify. Because mild TBI
can have lasting effects if not identified and treated, concerns have
been raised about how the Department of Veterans Affairs (VA)
identifies and treats OEF/OIF veterans with a mild TBI. In this report
GAO describes VA‘s (1) efforts to screen OEF/OIF veterans for mild TBI,
(2) steps taken so that those OEF/OIF veterans at risk for mild TBI are
evaluated and treated, and (3) challenges in screening and evaluating
OEF/OIF veterans for mild TBI. GAO reviewed VA‘s policies, interviewed
VA officials and TBI experts, and reviewed nine VA medical facilities‘
efforts to implement TBI screening and evaluation processes.
What GAO Found:
To screen OEF/OIF veterans for mild TBI, VA implemented in its medical
facilities in April 2007 a computer-based screening tool to identify
OEF/OIF veterans who may have a mild TBI. VA‘s tool consists of
questions that VA must ask all OEF/OIF veterans when they come to a VA
medical facility for care. VA issued a policy requiring its medical
facilities to use the tool to screen all OEF/OIF veterans who present
for care in any clinic in the facility, including primary care and
specialty care clinics. The policy has guidance on what types of
providers may administer the tool and directs providers that a positive
screening result requires a further evaluation by a specialist to
determine if the veteran has mild TBI. VA‘s screening efforts depend on
its TBI screening tool and VA recognizes the importance of determining
the tool‘s clinical validity and reliability”that is, how effectively
the tool identifies those who are and are not at risk for mild TBI and
if the tool would yield consistent results if administered to the same
veteran more than once. However, VA is planning to but has not yet
begun to determine the tool‘s validity and reliability. VA‘s screening
tool was based largely on a tool developed and validated by the Defense
and Veterans Brain Injury Center (DVBIC)”a medical and educational
collaboration among DOD, VA, and two civilian partners”used at selected
military bases to screen returning OEF/OIF servicemembers for TBI.
However, because VA‘s tool is a modified version of DVBIC‘s tool and is
used to screen a slightly different population, the results of the
validity study of DVBIC‘s tool are not directly applicable to VA‘s
tool.
To help ensure that OEF/OIF veterans identified as at risk for a mild
TBI by VA‘s screening tool are evaluated and treated, VA developed a
national protocol for their evaluation and treatment. According to VA‘s
protocol, veterans with a positive screening result should be offered a
follow-up evaluation by a specialist to determine if they have a mild
TBI. The follow-up evaluation should include a history of the veteran‘s
injury, a physical examination targeted to the veteran‘s symptoms, and
the use of a checklist to assess the presence and severity of symptoms
associated with mild TBI. VA has established training for its providers
to enhance use of the protocol and help ensure veterans are evaluated
and treated for mild TBI. Providers at some VA medical facilities we
visited had difficulties fully following the protocol. However, the
facilities had taken steps to resolve the difficulties, and VA has put
in place measures to help providers follow the protocol.
VA faces clinical and cultural challenges in its efforts to screen and
evaluate mild TBI in OEF/OIF veterans. Clinical challenges include the
lack of existing objective diagnostic tests that can definitively
identify mild TBI. Also, many symptoms of mild TBI are similar to those
associated with other conditions, such as post-traumatic stress
disorder, making a diagnosis of mild TBI harder to reach. Some
characteristics of the OEF/OIF veteran population present cultural
challenges in that they may affect veterans‘ willingness to seek care
for TBI symptoms. For example, some may believe that being labeled with
a TBI could affect their ability to stay in the National Guard or
Reserves.
What GAO Recommends:
GAO recommends that VA expeditiously evaluate the clinical validity and
reliability of its TBI screening tool. VA concurred with GAO‘s
findings, conclusions, and recommendation and discussed its plans to
evaluate its TBI screening tool. DOD declined to provide comments on
the draft report.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-276]. For more information, contact
Marjorie Kanof at (202) 512-7114 or kanofm@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
VA Has Implemented a TBI Screening Tool at Its Medical Facilities but
Has Not Determined the Clinical Validity and Reliability of the Tool:
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 Faces Clinical and Cultural Challenges in Screening and Evaluating
OEF/OIF Veterans for Mild TBI:
Conclusions:
Recommendation for Executive Action:
Agency Comments:
Appendix I: List of VA Medical Facilities, by Type of Polytrauma
Component Site:
Appendix II: Symptom Checklist Included in VA's National Traumatic
Brain Injury Evaluation and Treatment Protocol:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Table:
Table 1: Examples of Mild TBI Symptoms, by Symptom Categories:
Figures:
Figure 1: Overview of VA's TBI Screening Process:
Figure 2: Overview of VA's TBI Follow-up Evaluation Process:
Abbreviations:
ACRM: American Congress of Rehabilitation Medicine:
BTBIS: Brief Traumatic Brain Injury Screen:
CBOC: community-based outpatient clinic:
CDC: Centers for Disease Control and Prevention:
CT: computed tomography:
DOD: Department of Defense:
DVBIC: Defense and Veterans Brain Injury Center:
IED: improvised explosive device:
MRI: magnetic resonance imaging:
MTF: military treatment facility:
NIH: National Institutes of Health:
OEF: Operation Enduring Freedom:
OIF:Operation Iraqi Freedom:
PTSD: post-traumatic stress disorder:
TBI: traumatic brain injury:
VA: Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
February 8, 2008:
Congressional Requesters:
Traumatic brain injury (TBI) has emerged as a leading injury among U.S.
forces serving in military operations in Afghanistan and Iraq--known as
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),
respectively. The nature of the current conflicts--in particular the
widespread use of improvised explosive devices (IED)[Footnote 1]--
increases the likelihood that active duty servicemembers will be
exposed to incidents such as blasts that can cause a TBI, which is
defined as an injury caused by a blow or jolt to the head or a
penetrating head injury that disrupts the normal function of the
brain.[Footnote 2] According to the Defense and Veterans Brain Injury
Center (DVBIC),[Footnote 3] of the servicemembers who required medical
evacuation for battle-related injuries from the OEF/OIF combat theaters
to Walter Reed Army Medical Center from January 2003 through June 2007,
30 percent had sustained some form of TBI.[Footnote 4]
TBIs can vary greatly in terms of severity--from mild cases that might
involve a brief change in mental status, such as being dazed or
confused, to severe cases that may involve an extended period of
unconsciousness or amnesia after the injury. Servicemembers who sustain
even a mild TBI may experience short-term physical symptoms such as
headaches or dizziness, emotional symptoms such as anxiety or
irritability, cognitive deficits such as difficulty concentrating, or
sleep disturbances. Some servicemembers may experience symptoms related
to mild TBI months or even years after the injury. In general, a mild
TBI--which is commonly referred to as a concussion--can be more
difficult to identify than a severe TBI. With mild TBI, there may be no
observable head injury. In addition, in the combat theater, a mild TBI
may not be identified when it occurs at the same time as other combat
injuries that are more visible or life-threatening, such as orthopedic
injuries or open wounds. Furthermore, some of the symptoms of mild TBI-
-such as irritability and insomnia--are similar to those associated
with other conditions, such as post-traumatic stress disorder (PTSD).
Identifying mild TBI is important, as treatment can mitigate the
physical, emotional, and cognitive effects of the injury.
As the OEF and OIF military operations have continued, increasing
numbers of servicemembers from these conflicts have transitioned to
veteran status and have become eligible to receive health care from the
Department of Veterans Affairs (VA). As of October 2007, roughly
750,000 OEF/OIF servicemembers had left active duty and become eligible
for VA health care, and over one-third of these veterans--about
260,000--had accessed some type of VA health care services, which are
provided at VA medical facilities nationwide. Some of these OEF/OIF
veterans seeking care at VA medical facilities have been exposed to
events during their military service that could cause a mild TBI.
An OEF/OIF veteran's first interaction with a VA provider may occur
months or even years after exposure to an event that could have caused
a mild TBI. Some of these veterans might not seek care from VA until
several months or even years after their return from the combat theater
and their transition to veteran status. Moreover, OEF/OIF veterans who
do seek VA care soon after their return from the combat theater could
have sustained a mild TBI many months prior to their return. While
veterans who sustained a mild TBI during their military service may
have successfully been treated by Department of Defense (DOD) providers
for the condition or may have had their symptoms resolve on their own,
other OEF/OIF veterans could still be experiencing mild TBI-related
symptoms when they seek care from VA.[Footnote 5] According to VA
officials, it is important that OEF/OIF veterans who seek care from VA
are screened to determine whether they might have a mild TBI, evaluated
to confirm a diagnosis of mild TBI and have their symptoms assessed,
and treated as needed.
Because mild TBI can have lasting effects if not identified and
treated, concerns have been raised about the extent to which VA
identifies and treats OEF/OIF veterans who have sustained a mild
TBI.[Footnote 6] You asked us to identify how VA ensures that OEF/OIF
veterans who have experienced a mild TBI are identified and treated
when they seek care at VA medical facilities, as well as the obstacles
to identifying veterans with mild TBI. Specifically, in this report, we
describe (1) VA's efforts to screen OEF/OIF veterans for mild TBI, (2)
the steps that VA has taken to help ensure that OEF/OIF veterans
identified as being at risk for a mild TBI are evaluated and treated,
and (3) the challenges that VA faces in screening and evaluating OEF/
OIF veterans for mild TBI.
To describe VA's efforts to screen OEF/OIF veterans for mild TBI; the
steps VA has taken to help ensure that OEF/OIF veterans identified as
being at risk for a mild TBI are evaluated and treated; and the
challenges that VA faces in screening and evaluating OEF/OIF veterans
for mild TBI, we reviewed VA policies and procedures for the screening,
evaluation, and treatment of mild TBI in OEF/OIF veterans. The policies
and procedures we reviewed included the guidance VA developed for its
medical facilities to use to screen and evaluate OEF/OIF veterans who
may have a TBI. Some of the VA policies and procedures we reviewed
pertain to TBI generally, including mild TBI. We also interviewed VA
headquarters officials responsible for VA's efforts to screen,
evaluate, and treat OEF/OIF veterans with mild TBI. We also conducted
site visits to a total of six VA medical facilities located in Decatur,
Georgia;[Footnote 7] Augusta, Georgia; Baltimore, Maryland; Dublin,
Georgia; Richmond, Virginia; and the District of Columbia. In addition
to these site visits, we conducted phone interviews with staff from
three other VA medical facilities located in Hines, Illinois; Iron
Mountain, Michigan; and Tomah, Wisconsin. The nine facilities we
reviewed represent a judgmental sample that was selected in order to
include (1) varying geographic areas, including rural areas; (2)
facilities that had been utilized by relatively high numbers of OEF/OIF
veterans as compared to other VA medical facilities as of the end of
calendar year 2006; and (3) facilities from each of the four tiers of
facilities that comprise VA's polytrauma system of care.[Footnote 8]
The findings from our site visits and phone interviews with VA medical
facility staff cannot be generalized to other VA medical facilities.
At the six VA medical facilities we visited and for our phone
interviews with the three additional VA medical facilities, we
interviewed clinical and administrative staff to learn about their
implementation of VA's policies and procedures for mild TBI screening,
evaluation, and treatment as well as their experiences in screening,
evaluating, and treating mild TBI in OEF/OIF veterans. For each of
these facilities we reviewed documents related to mild TBI screening,
evaluation, and treatment efforts. We conducted the facility interviews
between April and July 2007. In addition, we conducted follow-up with
the nine VA medical facilities in September and October 2007. Because
VA implemented new mild TBI screening, evaluation, and treatment
processes in April 2007, our review focused on the early implementation
phase of these new processes.
In addition to reviewing VA's efforts related to screening, evaluation,
and treatment of mild TBI in OEF/OIF veterans, we also interviewed TBI
experts from DOD--including staff from the DVBIC--the Centers for
Disease Control and Prevention (CDC), and the National Institutes of
Health (NIH) about TBI screening, evaluation, and treatment issues and
reviewed relevant documents from those organizations. We also
interviewed TBI researchers and other TBI experts from academic
institutions, advocacy organizations, and private sector rehabilitation
facilities and asked them about various TBI issues. Finally, we
conducted a literature review on research related to TBI-- including
mild TBI--within civilian and military populations.
We focused our work on VA policies and procedures regarding mild TBI
screening, evaluation, and treatment and did not assess the clinical
appropriateness or effectiveness of VA's mild TBI screening and
evaluation efforts or the treatment provided to OEF/OIF veterans with
mild TBI. We performed our work from December 2006 through February
2008 in accordance with generally accepted government auditing
standards.
Results in Brief:
To screen OEF/OIF veterans for mild TBI, in April 2007, VA medical
facilities implemented 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 are required to ask OEF/OIF
veterans when the veterans come to a VA medical facility for care. VA
issued a policy requiring providers at VA medical facilities to use the
TBI screening tool to screen all OEF/OIF veterans who present
themselves for care in any clinic in the medical facility, including
the primary care clinic, dental clinic, urgent care clinic, or any
specialty clinic. The policy provides guidance on what types of
providers may administer the TBI screening tool. VA's policy also
reminds providers that a positive result from the TBI screening does
not mean that a veteran has a mild TBI and requires that veterans who
screen positive on the TBI screening tool be offered a follow-up
evaluation with a specialty provider who can determine whether the
veteran has a mild TBI. While VA's screening efforts depend on its TBI
screening tool, VA is planning to but has not yet begun to evaluate 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. When developing its screening tool, VA based the tool largely on
a DVBIC screening tool that has been used at selected military bases to
screen returning OEF/OIF servicemembers for TBI and has been shown to
be clinically valid, according to DVBIC. However, because VA's TBI
screening tool is a modified version of DVBIC's screening tool and is
being used to screen a slightly different population, the results of
the validity study of DVBIC's screening tool are not directly
applicable to VA's screening tool. In order to avoid delaying the start
of VA's TBI screening efforts, VA officials began implementing TBI
screening for OEF/OIF veterans before evaluating the screening tool's
validity and reliability. However, until such an evaluation takes
place, VA providers will continue to use the screening tool without
knowing how effective the tool is in identifying which OEF/OIF veterans
are and are not at risk for a mild TBI.
To help ensure that OEF/OIF veterans identified as at risk for a mild
TBI by VA's computerized screening tool are evaluated and treated, VA
developed a national protocol for their evaluation and treatment.
According to VA's evaluation and treatment protocol, veterans should be
informed when they screen positive, offered a follow-up evaluation with
a specialist to determine if they have a mild TBI, and contacted by
facility staff to schedule the follow-up evaluation. The protocol also
specifies that the follow-up evaluation should be completed by a
provider from a specialty department and that the evaluation should
include a complete history of the veteran's injury and current
symptoms, a physical examination targeted to the veteran's symptoms,
and the use of a checklist to assess the presence and severity of
symptoms associated with mild TBI.[Footnote 9] The protocol also
provides guidance on developing an individualized treatment plan and
information on referring veterans whose symptoms do not resolve for
further VA care. VA has established training for its providers to help
ensure veterans are evaluated and treated for mild TBI. Although VA has
implemented the protocol nationwide, we found that some medical
facilities had difficulty fully following some of the protocol
requirements. One of the nine facilities we reviewed experienced
difficulties implementing the electronic consultation request used to
communicate to the designated specialty department the need for the
veteran to have a follow-up evaluation and took corrective action to
address the problem. At two facilities we reviewed, providers were not
using the symptom checklist to evaluate a veteran at the time of our
visit in July 2007, though the providers were using the symptom
checklist several months later. VA has put in place measures to help
ensure that all providers follow the protocol. For example, VA has
implemented two performance measures designed to track whether facility
staff contacted veterans who screened positive on the TBI screening
tool to schedule the follow-up evaluation and whether the evaluation
was completed. VA also implemented in November 2007 a computer-based
template intended to help ensure providers follow the protocol when
conducting a follow-up evaluation.
VA faces a number of clinical and cultural challenges in its efforts to
screen and evaluate mild TBI in OEF/OIF veterans. One clinical
challenge facing VA as well as other health care providers is the lack
of any objective diagnostic tests--such as magnetic resonance imaging
(MRI) or laboratory tests--that can definitively and reliably identify
mild TBI. Another clinical challenge is the fact that many symptoms of
mild TBI, such as insomnia and irritability, are similar to the
symptoms associated with other conditions--such as PTSD--or are
commonly found in the general population, making a definitive diagnosis
of mild TBI more difficult to reach. An additional clinical challenge
is that OEF/OIF veterans with mild TBI might not realize that they have
an injury and should seek care. This can occur for several reasons--for
example, symptoms of mild TBI that are subtle and easy to overlook and
the fact that those with mild TBI may not have an obvious physical
injury. Several characteristics of the OEF/OIF veteran population
present cultural challenges to VA's screening and evaluation efforts in
that they may affect OEF/OIF veterans' willingness to report TBI-
related symptoms or veterans' ability to seek care for these symptoms.
For example, officials at several VA medical facilities we reviewed
told us that OEF/OIF veterans may not want to risk being labeled with a
condition that could be perceived as a mental illness or that they
believe could compromise their ability to remain in the National Guard
or Reserves. Facility officials also reported that OEF/OIF veterans--
who tend to be younger than other VA patient groups--may not schedule
or keep appointments for VA care in a timely manner due to priorities
or constraints such as full time jobs, school, and childcare needs.
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. 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, and discussed its plans to evaluate its TBI screening
tool. 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 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.
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.[Footnote 10] TBI has been
a frequent diagnosis among OEF/OIF servicemembers medically evacuated
to Walter Reed Army Medical Center or the National Naval Medical
Center.[Footnote 11] 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).[Footnote 12] 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.[Footnote 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.
Table 1: Examples of Mild TBI Symptoms, by Symptom Categories:
Physical:
* Headache;
* Nausea;
* Vomiting;
* Balance problems;
* Dizziness;
* Visual problems (e.g., blurred vision or eyes that tire easily);
* Fatigue;
* Sensitivity to light;
* Sensitivity to noise;
* Numbness/tingling;
* Dazed or stunned;
* Ringing in the ears.
Cognitive:
* Feeling mentally "foggy";
* Feeling slowed down;
* Difficulty concentrating;
* Difficulty remembering;
* Difficulty making decisions;
* Forgetful of recent information or conversations;
* Confused about recent events;
* Answers questions slowly;
* Repeats questions.
Emotional:
* Irritability;
* Sadness;
* More emotional;
* Mood changes;
* Nervousness.
Sleep-related:
* Drowsiness;
* Sleeping less than usual;
* Sleeping more than usual;
* Trouble falling asleep.
Source: GAO summary of CDC information.
[End of table]
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.[Footnote 14] 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.[Footnote 15] 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.[Footnote 16] 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.[Footnote 17] 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.[Footnote 18] 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.[Footnote 19]
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.[Footnote 20]
* 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.[Footnote 21],[Footnote 22] 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.[Footnote 23],[Footnote 24]
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.[Footnote 25] 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.
Figure 1: Overview of VA's TBI Screening Process:
[See PDF for image]
This figure is an illustration of the Overview of VA's TBI Screening
Process. The following data is depicted:
Veteran presents to VA medical facility and is asked a series of TBI
screening questions:
1. Does the veteran have a separation date after 9/11/01?
Yes: VA TBI Screening Tool activates;
No: Screen not needed; end of screening process.
2. Did the veteran serve in OEF or OIF?
Yes: Go to question 3.
No: Screen not needed; end of screening process.
3. Does the veteran have a prior diagnosis of TBI?
Yes: Go to question 4.
No: Ask TBI screening questions:
3a. Does the veteran give at least one positive answer in each section
of the TBI screening questions below?
Section 1: During any of your OEF/OIF deployment(s) did you experience
any of the following events?(check all that apply):
Blast or Explosion;
Vehicular accident/crash (including aircraft);
Fragment wound or bullet wound above shoulders;
Fall.
Section 2: Did you have any of these symptoms immediately afterwards?
(check all that apply):
Losing consciousness/’knocked out“;
Being dazed, confused or ’seeing stars“;
Not remembering the event;
Concussion;
Head injury.
Section 3: Did any of the following problems begin or get worse
afterwards? (check all that apply):
Memory problems or lapses;
Balance problems or dizziness;
Sensitivity to bright light;
Irritability;
Headaches;
Sleep problems.
Section 4: In the past week, have you had any of the symptoms from
section 3? (check all that apply):
Memory problems or lapses;
Balance problems or dizziness;
Sensitivity to bright light;
Irritability;
Headaches;
Sleep problems.
No positive answers: Screen negative; End of screening process.
Positive answers: Screen positive; Continue to step 4 of screening
process.
4. After discussion with provider, veteran agrees to further evaluation
or assistance?
Yes: Consult request should be sent to specialty department. Move on to
VA's follow-up evaluation and treatment. (See fig. 2)
No: Refusal should be documented. Pursue follow-up at future visits.
Source: GAO analysis of VA TBI Screening Policy (data); Art Explosion
(graphics).
[End of figure]
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[Footnote 26]
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.[Footnote 27]
VA based its screening tool largely on a TBI screening tool developed
and used by the DVBIC--the Brief Traumatic Brain Injury Screen
(BTBIS).[Footnote 28] 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.[Footnote 29] When
developing its screening tool, VA made some changes to the questions
contained in the BTBIS.[Footnote 30] 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,[Footnote 31] 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.[Footnote 32] 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.[Footnote 33] 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.[Footnote 34] 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.
Figure 2: Overview of VA's TBI Follow-up Evaluation Process:
[See PDF for image]
This figure is an illustration of the Overview of VA's TBI Follow-up
Evaluation Process. The following data is depicted:
Consult received by specialty department. Outreach to veteran begins
for VA‘s follow-up evaluation and treatment:
1. Specialty department makes initial contact with OEF/OIF veteran to
schedule an appointment?
Yes: Go to number 2.
No: Two additional calls should be made and one certified letter should
be sent to the veteran. If no response, these efforts should be
documented. End of evaluation process.
2. An appointment for follow-up evaluation is made with veteran.
Yes: Go to number 3.
No: If veteran refuses to set up an appointment, these efforts should
be documented. End of evaluation process.
3. An evaluation is conducted by specialty provider to determine if
veteran has mild TBI.
If symptoms are found, go to number 4.
If no symptoms are found: If no symptoms are found, the evaluation
should be documented. End of evaluation process.
4. A treatment plan is developed for the veteran‘s symptoms.
If symptoms persist: The veteran should be referred to a higher level
of VA care for more intensive evaluation and treatment.
What happens during the follow-up evaluation?
According to VA, during the follow-up evaluation the specialty provider
should:
* Obtain a complete history of the veteran‘s injury and current
symptoms;
* Conduct a physical exam targeted to the veteran‘s symptoms;
* Use a specially designed checklist to assess the presence and
severity of symptoms that may be related to TBI.
Source: GAO analysis of VA TBI Evaluation and Treatment Protocol
(data); Art Explosion (graphics).
[End of figure]
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.[Footnote 35] 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.[Footnote 36]
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.[Footnote 37] 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 [hyperlink, 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.
Signed by:
Marjorie Kanof:
Managing Director, Health Care:
List of Requesters:
The Honorable Daniel K. Akaka:
Chairman:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Michael H. Michaud:
Chairman:
Subcommittee on Health:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Wayne Allard:
United States Senate:
The Honorable Christopher S. Bond:
United States Senate:
The Honorable Barbara Boxer:
United States Senate:
The Honorable Tom Harkin:
United States Senate:
The Honorable Joseph I. Lieberman:
United States Senate:
The Honorable Claire McCaskill:
United States Senate:
The Honorable Patty Murray:
United States Senate:
The Honorable Barack Obama:
United States Senate:
The Honorable Ken Salazar:
United States Senate:
The Honorable Bernard Sanders:
United States Senate:
The Honorable Peter Welch:
House of Representatives:
[End of section]
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.[Footnote 38]
Minneapolis, MN;
Palo Alto, CA;
Richmond, VA;
Tampa, FL.
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.
Augusta, GA;
Boston, MA;
Bronx, NY;
Cleveland, OH;
Dallas, TX;
Denver, CO;
Hines, IL;
Houston, TX;
Indianapolis, IN;
Lexington, KY;
Minneapolis, MN;
Palo Alto, CA;
Philadelphia, PA;
Richmond, VA;
Seattle, WA;
St. Louis, MO;
Syracuse, NY;
Tampa, FL;
Tucson, AZ;
Washington, DC;
West Los Angeles, CA.
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.
Albany, NY;
Albuquerque, NM;
Alexandria, LA;
Altoona, PA;
Ann Arbor, MI;
Atlanta, GA;
Baltimore, MD;
Bath, NY;
Bay Pines, FL;
Birmingham, AL;
Black Hills, SD;
Boise, ID;
Brooklyn, NY;
Buffalo, NY;
Butler, PA;
Canandaigua, NY;
Castle Point, NY;
Charleston, SC;
Chicago, IL;
Cincinnati, OH;
Coatesville, PA;
Columbia, MO;
Danville, IL;
Dayton, OH;
Detroit, MI;
East Orange, NJ;
Erie, PA;
Gainesville, FL;
Grand Junction, CO;
Hampton, VA;
Huntington, WV;
Iowa City, IA;
Jackson, MS;
Kansas City, MO;
Knoxville, IA;
Lebanon, PA;
Little Rock, AR;
Long Beach, CA;
Loma Linda, CA;
Louisville, KY;
Lyons, NJ;
Madison, WI;
Martinsburg, WV;
Memphis, TN;
Miami, FL;
Milwaukee, WI;
Montrose, NY;
Mountain Home, TN;
Muskogee, OK;
Nashville, TN;
New York, NY;
North Chicago, IL;
Northport, NY;
Pittsburgh, PA;
Portland, OR;
Sacramento, CA;
Salisbury, NC;
Salt Lake City, UT;
San Antonio, TX;
San Diego, CA;
Sioux Falls, SD;
St. Albans, NY;
Temple, TX;
Togus, ME;
Tomah, WI;
Tuscaloosa, AL;
West Haven, CT;
West Palm, FL;
Wilkes-Barre, PA;
Wilmington, DE;
White River, VT.
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.
Amarillo, TX;
American Lake, WA;
Anchorage, AK;
Asheville, NC;
Battle Creek, MI;
Beckley, WV;
Bedford, MA;
Big Spring, TX;
Biloxi, MS;
Cheyenne, WY;
Chillicothe, OH;
Clarksburg, WV;
Columbia, MO;
Columbus, OH;
Des Moines, IA;
Dublin, GA;
Durham, NC;
El Paso, TX;
Fargo, ND;
Fayetteville, AR;
Fayetteville, NC;
Fort Harrison, MT;
Fresno, CA;
Grand Island, NE;
Honolulu, HI;
Iron Mountain, MI;
Kerrville, TX;
Las Vegas, NV;
Lincoln, NE;
Manchester, NH;
Manila, PI;
Marion, IL;
Marion, IN;
New Orleans, LA;
Northampton, MA;
Oklahoma City, OK;
Omaha, NE;
Orlando, FL;
Phoenix, AZ;
Poplar Bluff, MO;
Prescott, AZ;
Providence, RI;
Reno, NV;
Roseburg, OR;
Saginaw, MI;
Salem, VA;
San Francisco, CA;
Sepulveda, CA;
Sheridan, WY;
Shreveport, LA;
Spokane, WA;
St. Cloud, MN;
Topeka, KS;
Tuskegee, AL;
Viera, FL;
Waco, TX;
Walla Walla, WA;
Wichita, KS;
White City, OR.
Source: GAO summary of VA information.
[End of section]
Appendix II: Symptom Checklist Included in VA's National Traumatic
Brain Injury Evaluation and Treatment Protocol:
Neurobehavioral Symptom Inventory:
Please rate the following symptoms with regard to how much they have
disturbed you since your injury.
0 = None- Rarely if ever present; not a problem at all.
1 = Mild- Occasionally present, but it does not disrupt activities; I
can usually continue what I'm doing; doesn't really concern me.
2 = Moderate- Often present, occasionally disrupts my activities; I can
usually continue what I'm doing with some effort; I feel somewhat
concerned.
3 = Severe- Frequently present and disrupts activities; I can only do
things that are fairly simple or take little effort; I feel like I need
help.
4 = Very Severe- Almost always present and I have been unable to
perform at work, school or home due to this problem; I probably cannot
function without help.
1. Feeling dizzy:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
2. Loss of balance:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
3. Poor coordination, clumsy:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
4. Headaches:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
5. Nausea:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
6. Vision problems, blurring, trouble seeing:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
7. Sensitivity to light:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
8. Hearing difficulty:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
9. Sensitivity to noise:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
10. Numbness or tingling on parts of my body:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
11. Change in taste and/or smell:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
12. Loss of appetite or increase appetite:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
13. Poor concentration, can't pay attention, easily distracted:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
14. Forgetfulness, can't remember things:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
15. Difficulty making decisions:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
16. Slowed thinking, difficulty getting organized, can't finish things:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
17. Fatigue, loss of energy, getting tired easily:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
18. Difficulty falling or staying asleep:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
19. Feeling anxious or tense:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
20. Feeling depressed or sad:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
21. Irritability, easily annoyed:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
22. Poor frustration tolerance, feeling easily overwhelmed by things:
None (0):
Mild (1):
Moderate (2):
Severe (3):
Very Severe (4):
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
January 31, 2008:
Ms. Marjorie E. Kanof:
Managing Director, Health Care:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Kanof:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA Health Care: Mild
Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF
Veterans but Challenges Remain (GAO-08-276), agrees with GAO's
conclusions, and concurs with GAO's recommendations.
The Department of Veterans Affairs concurs with GAO's findings and the
recommendation to expedite the evaluation of the clinical validity and
reliability of VA's traumatic brain injury (TBI) screening tool. I
agree that mild TBI should be screened, evaluated and treated to
mitigate physical, emotional, and cognitive effects of the injury.
The enclosure specifically addresses GAO's recommendation and provides
comments to the draft report. VA appreciates the opportunity to comment
on your draft report.
Sincerely yours,
Signed by:
James B. Peake, M.D.
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report:
VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation
Implemented for OEF/OIF Veterans but Challenges Remain (GAO-08-276):
To establish whether the use of VA's TBI screening tool is effective in
identifying OEF/OIF veterans at risk for mild TBI, GAO recommends that
the Secretary of Veterans Affairs take the following action:
* Direct the Under Secretary for Health to expeditiously evaluate the
clinical validity and reliability of VA's TBI screening tool.
Concur - As GAO reports, VA began implementing TBI screening for
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
veterans before conducting a study on the clinical validity and
reliability of the TBI screening tool to avoid delaying the start of
TBI screening efforts. The screening tool is appropriate for
identifying veterans who require a full evaluation for mild traumatic
brain injury (MTBI). MTBI is considered a signature injury of the
OEF/OIF conflict, often called an invisible wound, and as such, VA is
committed to identifying and treating veterans with all levels of a
TBI. Because no validated screening tool existed for MTBI, both DoD and
VA developed new ways of screening for MTBI based on best available
evidence. When VA was directed to improve rates of screening OEF/OIF
veterans for mild TBI, the Polytrauma Quality Enhancement Research
Initiative (QUERI) conducted a literature review and determined that no
screening tool existed except for the DoD model. Any other tools that
did exist were designed for use immediately at time of injury, and none
existed that would assess months after time of injury. Further, no
tools existed for assessing combat-related injuries; e.g., blast. In
December 2006, VA established a task force to develop a MTBI screening
procedure. By April 2007, the task force completed developing a MTBI
screening instrument and evaluation protocol. An automated MTBI
clinical Reminder was established in the clinical patient record
system, policy was established (VHA Directive 2007-013), and national
training was completed for over 50,000 VA practitioners. VA implemented
the national clinical reminder for screening on April 14, 2007. All
OEF/OIF veterans who enter the VA system of care are screened for
possible MTBI.
VA's Office of Research and Development is finalizing a validation
study for the VA MTBI screening tool. VA will fast-track this
validation study with preliminary results expected by the end 2008. The
protocol will be made available to the VA health system within 12
months of study initiation. Additional important questions, such as
estimates of the health needs of veterans with TBI and outcomes over a
planned 2 year follow-up period, will be addressed during the entire
study duration, estimated at approximately 4 years. Finally, the
Veterans Health Administration (VHA) Office of Research and Development
(ORD) is actively soliciting proposals to develop, evaluate, and
validate new, more accurate methods of diagnosing TBI, with a
particular focus on situations that involve co-occurring conditions
such as post traumatic stress disorder, substance use disorders, and
physical trauma.
There is no "gold standard" for the diagnosis of TBI, and in
particular, mild TBI. The goal of this protocol is both to assess the
present screening tool, and to develop a better one. The goal of such
an instrument is to reliably predict the long-term outcomes and care
needs of TBI patients and thus provide clinically targeted
interventions earlier in the care process. Such predictions require
long-term follow-up of patients. This is particularly true for mild
TBI, where clinical problems often appear 18-months or later post
injury. The initial assessment of the current instrument, as compared
with an in-depth neuropsychological assessment (criterion validity)
will be available after the first year. Determining the predictive
validity of the instrument and any alternative measures will take the
full 4 years because of the clinical course of this condition. VHA will
issue the service directed research (SDR) in early February with
proposals due in late March. We expect funding to begin in May. It is
likely to take 6 months to obtain institutional review board (IRB)
approval from the many sites this protocol will require. We anticipate
data collection to begin in November 2008 with phase one results
available in December 2009. Second phase result will be available 3
years later.
VA's strategy to carefully evaluate and validate its screening program
for TBI is reinforced by recently published research from DoD:
"Screening for mild TBI months after injury [which is the case with the
VA screening] is likely to result in the referral of a large number of
persons for evaluation and treatment of nonspecific brain injuries,
with potential unintended iatrogenic consequences. Evaluation of the
screening programs for TBI is needed to ensure that the risks do not
outweigh the benefits and that screening is conducted within an
effective structure of care" (see New England Journal of Medicine,
January 31, 2008, article entitled "Mild Traumatic Brain Injury in U.S.
Soldiers Returning from Iraq"). Results of this research further
advocate that screening for TBI should be "conducted within an
effective structure of care," which is consistent with VA's deployment
of its screening tool within the TBI/polytrauma system of care.
Although the DoD research concludes that persistence of "post-
concussive symptoms" is related to emotional-behavioral components,
this may be the case with most symptom-based disorders and not unique
to MTBI. VA and DoD health care systems uniquely treat patients at
different phases of their life and career, and more time and research
may be needed to ensure consensus in the medical community about the
diagnosis of TBI and the implications for recovery.
Page 34 of the report (now on page 31) notes that VA lacks any
objective diagnostic test, such as laboratory tests or neuroimaging
tests like magnetic resonance imaging (MRI) and computed tomography
(CT) scans that definitively and reliably identify mild TB; However, it
should also be noted that this limitation is not unique to VA, as there
is no universally used diagnostic tool currently available anywhere.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marjorie Kanof, (202) 512-7114 or kanofm@gao.gov:
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.
[End of section]
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.
Footnotes:
[1] An IED is a bomb designed to cause death or injury using explosives
alone or in combination with chemicals or other materials. IEDs take a
variety of shapes and sizes and have been employed in a number of
different ways. For example, in Iraq, many IEDs have been hidden and
disguised along traffic routes and then remotely detonated.
[2] See Centers for Disease Control and Prevention, [hyperlink,
http://www.cdc.gov/ncipc/tbi/TBI.htm] (accessed Nov. 20, 2007).
[3] DVBIC is a multisite center that serves active duty servicemembers,
their dependents, and veterans with TBI through medical care, clinical
research initiatives, and educational programs. It is a collaboration
between the Department of Defense (DOD), the Department of Veterans
Affairs (VA), and two civilian partners, and is funded through DOD. In
November 2007, DOD announced that the DVBIC had been integrated into
DOD's new Defense Center of Excellence for Psychological Health and
Traumatic Brain Injury, which began initial operations on November 30,
2007, and is expected to be fully functional by October 2009. The
center will be developing a national collaborative network to advance
and disseminate psychological health and TBI knowledge, enhance
clinical and management approaches, and facilitate services for those
dealing with psychological health issues or TBI, or both, according to
DOD.
[4] Defense and Veterans Brain Injury Center, "OIF/OEF Fact Sheet"
(Washington, D.C., June 2007).
[5] DOD is planning to begin routinely screening OEF/OIF servicemembers
for possible TBI immediately upon their return from the combat theater
as well as 3 to 6 months thereafter, as part of the required post-
deployment health assessment process. See 10 U.S.C. § 1074f. DOD also
plans to screen all servicemembers annually for possible TBI that may
or may not be related to combat experience. The National Defense
Authorization Act for Fiscal Year 2007 required GAO to study DOD's
implementation of new requirements under 10 U.S.C. § 1074f that
prescribed enhanced mental health screening, referral, and services for
members of the Armed Forces. Pub. L. No. 110-364, § 738(e), 120 Stat.
2083, 2304 (2006). GAO's work in response to that mandate will include
a review of DOD's implementation of TBI screening as part of the
routine pre-and post-deployment health assessments of OEF/OIF
servicemembers.
[6] Following a series of Washington Post articles in February 2007
that disclosed deficiencies in the provision of outpatient services at
Walter Reed Army Medical Center and raised broader concerns about the
care of returning servicemembers and veterans, three review groups were
tasked with investigating the reported problems and making
recommendations. Among the common areas of concern identified by the
three review groups was the need to better understand and diagnose TBI.
See GAO, DOD and VA: Preliminary Observations on Efforts to Improve
Health Care and Disability Evaluations for Returning Servicemembers,
GAO-07-1256T (Washington, D.C.: Sept. 26, 2007).
[7] This VA medical facility is referred to as the Atlanta VA medical
facility.
[8] VA has classified its medical facilities into a four-tiered
polytrauma system of care that helps address the medical needs of
returning OEF/OIF veterans, in particular those who have suffered
polytraumatic injuries--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. Each tier represents a different level of
available specialty services. For a list of the VA medical facilities
and which tier they are assigned to, see app. I.
[9] See app. II for VA's symptom checklist.
[10] DOD and VA officials have stated that it is unclear at this time
whether mild TBI due to a blast differs from nonblast mild TBI.
[11] Servicemembers who sustain serious injuries in the OEF or OIF
conflict areas are usually brought to Landstuhl Regional Medical Center
in Germany for treatment. From there, they are usually transported to
military treatment facilities located in the United States, with most
admitted to Walter Reed Army Medical Center or the National Naval
Medical Center, both of which are in the Washington, D.C., area. Once
servicemembers are medically stabilized, DOD can elect to send those
with TBI or other complex trauma, such as missing limbs, to VA medical
facilities for medical and rehabilitative care. While many
servicemembers who receive such rehabilitative services return to
active duty after they are treated, others who are more seriously
injured are likely to be discharged from their military obligations and
return to civilian life with disabilities.
[12] The mission of the American Congress of Rehabilitation Medicine is
to enhance the lives of persons living with disabilities through a
multidisciplinary approach to rehabilitation and to promote
rehabilitation research and its application in clinical practice. For
details about ACRM's mild TBI definition, developed by its Mild
Traumatic Brain Injury Committee, see Thomas Kay et al., "Definition of
Mild Traumatic Brain Injury," Journal of Head Trauma Rehabilitation,
vol. 8, no. 3 (1993), pp. 86-87.
[13] According to CDC, the Glasgow Coma Scale is a widely-used 15-point
scoring system for assessing coma and impaired consciousness. Higher
scores indicate a less severe injury while lower scores indicate a more
severe injury.
[14] For more information on the symptoms and effects of mild TBI, see
CDC's "Heads Up: Brain Injury in Your Practice" tool kit for
physicians, which was updated and revised in June 2007 and includes a
booklet with information on the diagnosis and management of mild TBI.
See also CDC's "Report to Congress on Mild Traumatic Brain Injury in
the United States: Steps to Prevent a Serious Public Health Problem"
(Atlanta, Ga., September 2003). Both publications are available at
[hyperlink, http://www.cdc.gov/ncipc/tbi/TBI_Publications.htm]
(accessed Sept. 28, 2007).
[15] See National Defense Authorization Act for Fiscal Year 2008, Pub.
L. No. 110-181, § 1707 (to be codified at 38 U.S.C. § 1710(e)(3)(C)).
To be eligible, veterans must have served in combat during a period of
war after the Persian Gulf War or against a hostile force during a
period of hostilities after November 11, 1998. See 38 U.S.C. §
1710(e)(1)(D); VHA Directive 2005-020, Determining Combat Veteran
Eligibility (June 2, 2005). "Hostilities" is defined as an armed
conflict in which the servicemembers are subjected to danger comparable
to the danger encountered in combat with enemy armed forces during a
period of war, as determined by the Secretary of VA. See 38 U.S.C. §
1712A(a)(2)(B). Eligibility under 38 U.S.C. § 1710(e)(1)(D) does not
extend, however, to veterans whose disabilities are found to have
resulted from a cause other than the service described in the statute.
[16] See 38 U.S.C. §§ 1705, 1710; 38 C.F.R. § 17.36 (2007).
[17] DOD provides health care to its beneficiaries through TRICARE--a
regionally structured program that uses civilian contractors to
maintain provider networks to complement health care services provided
at MTFs.
[18] VA delegates decision making regarding financing and service
delivery for health care services to its 21 health care networks,
including most budget and management responsibilities concerning
medical facility operations.
[19] Vet Centers offer counseling services to all OEF/OIF combat
veterans with no cost to the veteran.
[20] VA plans to begin construction on a fifth polytrauma
rehabilitation center in San Antonio, Texas, in 2008.
[21] VA issued a policy on April 13, 2007, that outlined key
requirements related to the TBI screening tool, such as which veterans
should be screened for TBI and in which clinical settings. See VHA
Directive 2007-013, Screening and Evaluation of Possible Traumatic
Brain Injury in Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) Veterans (Washington, D.C.: Apr. 13, 2007). VA policy
states that screening, evaluation, and the initial treatment for
patients with both traumatic spinal cord injury and TBI are to be
handled by VA Spinal Cord Injury team members, who have the expertise
needed to provide the required evaluations and care for veterans who
have a traumatic spinal cord injury and TBI. VA's policy also states
that VA medical facilities are not required to screen OEF/OIF veterans
who are seen solely for examinations related to disability claims. VA's
policy does not require veterans who are receiving counseling only at
Vet Centers to be screened for TBI.
[22] While active duty servicemembers may receive care at VA medical
facilities under VA and DOD agreements, VA medical facilities are not
required to screen active duty OEF/OIF servicemembers for mild TBI.
Seven of the nine medical facilities we reviewed had opted to screen
active duty OEF/OIF servicemembers for TBI. Facilities reported that if
an active duty servicemember screens positive for TBI at their
facility, the provider administering the TBI screening tool refers the
servicemember for further TBI evaluation within his or her VA facility
or at an MTF.
[23] All VA medical facilities have electronic medical record systems.
The development of VA's electronic medical record began in the mid-
1990s when VA integrated a set of clinical applications that work
together to provide clinicians with comprehensive medical information
about the veterans they treat. Electronic medical records allow
clinical information to be readily accessible to health care providers
at the point of care because the veteran's medical record is always
available in VA's computer system.
[24] Clinical reminders are alerts in veterans' electronic medical
records that remind providers to address specific health issues. VA
uses a number of clinical reminders to alert providers that a veteran
needs to be screened for conditions such as PTSD, substance abuse, and
TBI.
[25] The TBI screening tool automatically activates in the electronic
medical record of veterans whose date of separation from military duty
or active duty status occurred after September 11, 2001. VA's policy
does not require VA providers to rescreen OEF/OIF veterans for TBI once
they have been screened using the TBI screening tool. However, if OEF/
OIF veterans, such as those who are members of the National Guard or
Reserves, deploy again to the OEF or OIF theater of operations, the TBI
screening tool should automatically reactivate in the veteran's
electronic VA medical record on the veteran's next visit to a VA
facility, even if the TBI screening tool has previously been completed.
[26] DOD uses multiple health assessments to determine servicemembers'
physical and mental health status at different points during the
deployment cycle. VA providers commonly participate in DOD's post-
deployment health reassessment efforts, which occur 90 to 180 days
after return from deployment and are intended to focus on physical or
mental health conditions that emerge over time after deployment. See
GAO, 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.: Jan. 25,
2008).
[27] The reliability of a screening tool refers to whether the tool
yields results that are reproducible. For example, reliability reflects
whether the screening results are the same when a person is screened
more than once by the same screener, as well as whether the screening
results are the same when a person is screened by different screeners.
[28] VA's TBI screening tool was developed by a VA interdisciplinary
task force created in December 2006 to address the need to screen OEF/
OIF veterans for TBI as they are released from active duty and enter
VA's health care system.
[29] According to DVBIC, BTBIS was validated in a small, initial study
conducted with active duty servicemembers who served in Iraq or
Afghanistan between January 2004 and January 2005. The BTBIS is
available at [hyperlink, http://www.dvbic.org]. See also Karen A.
Schwab, et al., "The Brief Traumatic Brain Injury Screen (BTBIS):
Investigating the validity of a self-report instrument for detecting
traumatic brain injury (TBI) in troops returning from deployment in
Afghanistan and Iraq," Neurology, vol. 66, no. 5, supp. 2 (2006), p.
A235, and Karen A. Schwab, et al., "Screening for Traumatic Brain
Injury in Troops Returning From Deployment in Afghanistan and Iraq:
Initial Investigation of the Usefulness of a Short Screening Tool for
Traumatic Brain Injury," Journal of Head Trauma Rehabilitation, vol.
22, no. 6 (2007), pp. 377-389.
[30] The changes VA made included, for example, some changes in the
examples and wording of the events and symptoms a veteran could have
experienced while deployed.
[31] For example, one key difference between the OEF/OIF active duty
population and the OEF/OIF veteran population is the potential time
that may have elapsed since possible exposure to a TBI-causing event.
In general, OEF/OIF active duty servicemembers will have experienced
such events more recently than OEF/OIF veterans.
[32] In addition to a study of the TBI screening tool's validity and
reliability, VA also plans to conduct a study of the effect of its TBI
screening effort by studying topics including veterans' use of health
care services following TBI screening.
[33] VA's protocol was issued to VA facilities in April 2007, along
with the computer-based TBI screening tool.
[34] The follow-up evaluation can be completed by a variety of
specialty providers. According to the protocol, the follow-up
evaluation should be completed by a specialty provider from a VA
Component II Polytrauma Network Site; a Component III Polytrauma
Support Clinic Team; or, when not available at the medical facility, a
specialist with the appropriate background and skills, such as a
neurologist. In addition, according to a VA official, a medical
facility can refer a veteran to a non-VA provider for the follow-up
evaluation for mild TBI. Medical facilities may refer to non-VA
providers when those providers have the expertise required and when
there would be a significant burden to the veteran to travel. VA
recommends that, when possible, community providers with expertise come
to the VA to provide the follow-up evaluation on a contract or part-
time basis.
[35] The lack of objective diagnostic tests to identify mild TBI is not
a challenge that is unique to VA.
[36] Researchers are studying whether there are diagnostic laboratory
tests that could be used to identify mild TBI, according to an NIH
official.
[37] See Charles W. Hoge, et al., "Mild Traumatic Brain Injury in U.S.
Soldiers Returning from Iraq," New England Journal of Medicine, vol.
358, no. 5 (2008), pp. 453-463.
[38] VA plans to begin construction on a fifth polytrauma
rehabilitation center in San Antonio, Texas, in 2008.
[End of section]
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