VA Health Care:

Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain

GAO-08-276: Published: Feb 8, 2008. Publicly Released: Feb 8, 2008.

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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.

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.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendation for Executive Action

    Recommendation: To establish whether the use of VA's TBI screening tool is effective in identifying OEF/OIF veterans at risk for mild TBI, the Secretary of Veterans Affairs should direct the Under Secretary for Health to expeditiously evaluate the clinical validity and reliability of VA's TBI screening tool.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA has evaluated the clinical validity and reliability of VA's TBI screening tool through conducting seven investigations related to evaluating Traumatic Brain Injury (TBI) screening instruments. Four of these studies had been completed as of May 2012, with the remaining three studies expected to be completed by the end of 2012. Studies included (1) Validation of Brief Objective Neurobehavioral Detectors of Mild TBI, (2) Characteristics of the TBI Clinical Reminder Screening Process, (3) Evaluation of VA's TBI Clinical Reminder and Secondary Level Evaluation, (4) Evaluation of TBI Screening Processes and Healthcare Utilization, (5) TBI Evaluation Instruments and Processes for Clinical Follow-up, (6) TBI Screening Instruments and Processes for Clinical Follow-Up, and (7) Existing Practice Patterns for Screening Mild TBI in Operation Enduring Freedom and Operation Iraqi Freedom Veterans.

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