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2023 HSR&D/QUERI National Conference Abstract

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1036 — Increased Risk for Adverse Outcomes among Post-9/11 Veterans who Screen Positive for TBI and do not Receive a Follow-up Comprehensive TBI Evaluation

Lead/Presenter: Terri Pogoda,  COIN - Bedford/Boston
All Authors: Pogoda TK (Center for Healthcare Organization and Implementation Research, Boston), Amuan, ME (Epidemiology, Salt Lake City) Carlson, KF (Center to Improve Veteran Involvement in Care, Portland) Adams, RS (Mental Illness Research, Education and Clinical Center, Denver) Dismuke-Greer, CE (Health Economics Research Center, Palo Alto) Pugh, MJ (Epidemiology, Salt Lake City)

Objectives:
In 2007, the Veterans Health Administration (VHA) implemented a screening for mild traumatic brain injury (mTBI) among Post-9/11 Veterans seeking VA healthcare. Veterans who screen positive are offered a referral to a comprehensive TBI evaluation (CTBIE) where mTBI history is confirmed (yes/no), and then connected to interdisciplinary care as needed. However, not all Veterans accept or complete the referral. Those who screen positive but do not receive a CTBIE may be at increased risk for adverse outcomes since mTBI among Post-9/11 Veterans frequently co-occurs with a range of physical, mental, and psychosocial conditions that can be identified at the CTBIE. Without medical record documentation among Veterans who experienced mTBI, Veterans may not receive appropriate treatment for conditions associated with mTBI history. This study’s objective was to examine whether Veterans who screened positive for mTBI, but did not complete a CTBIE, are at higher risk for adverse outcomes within 3 years post-TBI screen compared to Veterans who screened negative for TBI.

Methods:
This retrospective longitudinal study included data from the Department of Veterans Affairs (VA), Department of Defense (DoD), and National Death Index. DoD data ranged from Fiscal Years [FYs]2000-2019 and VHA data ranged from FYs2002-2019. Post-9/11 Veterans who were screened for mTBI during FY2008-2016 and accessed VA care at least once annually during a 3-year follow-up period post-TBI screen were identified. Adverse outcomes of interest were incident diagnoses for: substance use disorder (SUD), alcohol use disorder (AUD), opioid use disorder (OUD), overdose, and homelessness. To examine associations between screening/CTBIE determinations and adverse outcomes, multivariate Cox proportional hazard models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI).

Results:
The final cohort of 281,342 Veterans were classified into the following 4 groups: (1) Clinician-confirmed mTBI at CTBIE (screened+/CTBIE+) (n = 21,670), (2) No clinician-confirmed mTBI at CTBIE (screened+/CTBIE-) (n = 6,619), (3) Screened positive, no completion of CTBIE (Screened+/no CTBIE follow-up [or other documented mTBI]) (n = 10,163), and 4) Screened negative (n = 246,352). Compared to Veterans who screened negative for TBI, Veterans who screened positive for TBI but never completed a CTBIE were at increased risk for incident SUD (HR = 1.32, 95% CI = 1.19-1.46), AUD (HR = 1.24, 95% CI = 1.11-1.38), OUD (HR = 1.64, 95% CI = 1.30-2.07), overdose (HR = 1.32, 95% CI = 1.07-1.64), and homelessness (HR = 1.38, 95% CI = 1.23-1.56) within 3-years following their TBI screening, after controlling for demographic, military, and regional covariates.

Implications:
Veterans who screen positive for TBI but do not receive a CTBIE are at increased risk for incident AUD, SUD, OUD, overdose, and homelessness relative to Veterans who screen negative for TBI. This potentially represents missed opportunities for access to interdisciplinary care to identify and address mTBI history and/or other conditions that can diminish health and quality of life.

Impacts:
To fulfill the purpose of the mTBI screening program, education about the importance of the CTBIE for providers and Veterans, and targeted outreach to Veterans who are difficult to contact, should be implemented to document and address healthcare needs to minimize the risk of adverse outcomes.