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Summary The Veterans Benefits Administration (VBA) provides disability compensation to veterans with a service-connected injury. Disability compensation is âa tax-free monetary benefit paid to veterans with disabilities that are the result of a disease or injury incurred or aggravated during active military service.â To receive disability compensation from the Department of Veterans Affairs (VA), a veteran must submit a claim or have a claim submitted on his or her behalf. A disability percentage is then assigned in a process summarized below: 1. The veteran or veterans service organization acting as the veteranâs proxy submits a claim to VBA. 2. VBA receives the claim. If all necessary information is provided, the claim will be processed. In most cases, the medical information submitted is not âadequate for rating purposes,â and VBA orders a compensation and pension (C&P) exam from a C&P examiner, who can be a Veterans Health Administration (VHA) clinician or a VBA-contracted clinician. 3. The C&P examiner notes the diagnosis and evaluates the degree of impairment, functional limitation, and disability. The examiner records information using a Disability Benefits Questionnaire (DBQ). 4. DBQ results are submitted to VBA via the compensation and pension record interchange. At VBA, a veterans service representative may determine that there is enough evidence to make a rating or request more information. If there is enough evidence, a ratings veteransâ service representative makes a disability rating decision by comparing DBQ results and other evidence to criteria in the Veterans Affairs Schedule for Rating Disabilities (VASRD). 5. The veteran begins receiving disability benefits. 6. The veteran may appeal to have his case reviewed by the Board on Veterans Appeals if he does not agree with the rating decision. The appeals process re-reviews the case. A committee was formed in response to Public Law 114-315 passed on December 16, 2016, which required that the VA contract with the National Academies to provide an independent review of the process by which the VA assesses impairments resulting from traumatic brain injury (TBI) for purposes of awarding disability compensation. The committeeâs statement of task is described in the next section. 1
2 TRAUMATIC BRAIN INJURY IN VETERANS STATEMENT OF TASK The committee will review the process by which impairments that result from TBI are assessed for purposes of awarding disability compensation. The specific tasks are noted in Box S-1. BOX S-1 Statement of Task The National Academies of Sciences, Engineering, and Medicine will convene a committee to make: (A) A determination of the adequacy of the tools and protocols used by the Department of Veterans Affairs to provide examinations; and (B) A determination of which credentials are necessary for health care specialists and providers to perform such portions of such examinations that relate to an assessment of all disabling effects. Additionally, the committee shall include in its final report: (1) Findings with respect to the comprehensive review noted in (A) and (B) above; and (2) Recommendations for legislative or administrative action for improving the adjudication of veteransâ claims seeking entitlement to compensation for all impairments arising from a traumatic brain injury APPROACH TO THE TASK A committee of experts in emergency medicine, neurology, neurosurgery, psychiatry, psychology, physical medicine and rehabilitation, and epidemiology and biostatistics was convened to address the statement of task. Given the task, the committee found it necessary to review the scientific literature on TBI, gain an understanding of each step of the adjudication process for residuals of TBI1 (from submission of claims through appeals), and learn what measures the VA has already taken to ensure the quality of its process. In this publication the committee provides recommendations to the VA related to the health care specialists who diagnose TBI, the adequacy of the tools used by the VA to provide clinical examinations and disability ratings for TBI residuals (the DBQ and the VASRD), and the overall adjudication process. 1 Residuals of TBI include three main areas of dysfunction that might result from sustaining a TBI. These might have profound effects on functioning, including cognitive, emotional/behavioral, and physical. âResidualâ is a term used by the VA in its VASRD (Veterans Affairs Schedule for Rating Disabilities) and DBQ (Disability Benefits Questionnaire), but the scientific community uses the term âsequelaâ to indicate outcomes resulting from a TBI.
SUMMARY 3 HEALTH CARE PROFESSIONALS TRAINED TO DIAGNOSE TRAUMATIC BRAIN INJURY The committee reviewed the scientific literature on the natural history of TBI and how it is diagnosed in military personnel, veterans, and civilians in order to comment on the credentials and training necessary for health care specialists to diagnose TBI. Given the complexities in diagnosing TBI and the time that might have elapsed since the original injury, the diagnostician needs to have experience with TBI and be trained in and familiar with the state of the science for making a determination of brain injury and its severity. In addition, there is enough ongoing research and new theoretical views on the trajectory of recovery after TBI that new developments are likely forthcoming that would assist providers who have training and experience with TBI to accurately diagnose TBI. Currently the VA requires one of four specialists to diagnose TBI: a neurologist, neurosurgeon, physiatrist, or psychiatrist. The committee found that in addition to those four specialties, there are many specialties and subspecialties involved in making the diagnosis of a brain injury, particularly if the diagnosis occurs months to years following the injury. Clinical psychology and clinical neuropsychology, for example, are disciplines where specialized training in assessment of TBI consequences is common and documentable. Even if the sole determination is not made by one of those professionals, it is difficult to see how adequate information about cognitive consequences of TBI could be collected without a formal assessment. Given todayâs increased awareness of TBI, more medical specialties now include training in TBI within their curriculum and have continued updates concerning the current state of the science. Additionally, there are at least 18 Accreditation Council for Graduate Medical Education (ACGME) accredited brain injury programs to train physicians of many specialties to assist in the diagnosis, treatment, and rehabilitation of individuals diagnosed with brain injury. Thus, the VA should allow health care professionals, including non-physicians, with additional training and experience in brain injury, to make the TBI diagnoses. The committee believes that it is the training and experience, not necessarily the medical specialty that renders a health care specialist capable of an accurate diagnosis. The committee recommends that the Department of Veterans Affairs allow health care professionals who have specific traumatic brain injury (TBI) training and experience, in addition to the current required specialists, to make a TBI diagnosis. Furthermore, the committee recommends pertinent and ongoing clinical training that is up to date with the state of current knowledge regarding TBI. THE DISABILITY BENEFITS QUESTIONNAIRE AND THE VA SCHEDULE FOR RATING DISABILITIES FOR RESIDUALS OF TRAUMATIC BRAIN INJURY As previously noted, after the claim is filed with VBA, if the VBA employee determines additional medical evidence is needed, a C&P examination is completed by a VHA clinician or a VBA-contracted clinician to provide medical information to VBA to help determine the presence and degree of medical impairment incurred by the veteran. The C&P exam should note the diagnosis and the medical nature of the condition and record all requested measurements and test results in a DBQ. As its name suggests, a DBQ is a questionnaire and therefore provides limited information that is relevant only to making the rating. The DBQs do not document all C&P
4 TRAUMATIC BRAIN INJURY IN VETERANS examination findings. They provide medical information that is directly relevant to the VASRD, a federal regulation that lists criteria that provide the majority of the medical evidence that VBA rating specialists need as they process the claim. There are more than 70 DBQs for various medical conditions, including one for the residuals of TBI. The criteria in the DBQ for the residuals of TBI mirror those in the section of the VASRD used for rating the residuals of TBI, as the DBQ was developed to aid the non-clinician VBA rating specialist in determining the disability rating. The committee reviewed the criteria in the DBQ and VASRD in response to the VAâs request for them to determine the adequacy of the tools used in providing examinations. The DBQ and the VASRD provide a list of common residuals of TBI that are used to rate the level of disability associated with TBI. For the most part, the identified residuals accurately reflect problems that are most likely to disrupt quality of life following TBI. However, some of the characteristics of the criteria used to rate severity of disability (e.g., the frequency at which the problem is observed) do not fully capture the residualâs potential impact. Furthermore, they fail to take into account some basic medical knowledge concerning how residuals of TBI might manifest and affect disability. The committee recommends that the Department of Veterans Affairs convene experts from both Veterans Health Administration and Veterans Benefits Administration, including clinicians who diagnose and assess residuals of traumatic brain injury, to regularly update the Veterans Affairs Schedule for Rating Disabilities and the Disability Benefits Questionnaires for residuals of TBI to better reflect the current state of medical knowledge. In the committeeâs review of the residuals of TBI DBQ, it found that there are important residuals that were not included. In particular, three important residuals of TBI are not adequately covered by any of the existing DBQs: insomnia, vestibular dysfunction, and near- vision dysfunction (near point accommodative and convergence insufficiency). Isolated questions related to insomnia and sleep disruption can be found on four DBQs (mental disorders, chronic fatigue syndrome, PTSD, and sleep apnea), but no single DBQ combines them all in a way that captures the full extent of disability associated with post-TBI sleep disruption. Sleep disruption occurs commonly after TBI, contributing to fatigue, cognitive dysfunction, and disrupted mood. Isolated questions and physical exam elements related to vestibular dysfunction can be found on two DBQs (cranial nerves diseases and ear conditions), but no single DBQ combines them in a way that captures the full extent of disability associated with post-TBI vestibular dysfunction. This dysfunction is typically a mix of both peripheral (ear and vestibulocochlear nerves) and central (vestibulo-spinal and vestibulo-ocular) vestibular structure disruption. Vestibular dysfunction occurs commonly after TBI, producing symptoms related to (1) altered postural stability (imbalance and abnormal gait); (2) altered oculomotor function (reduced dynamic visual acuity, dizziness with head movement, dizziness with movement of objects in visual field); and (3) reduced concentration or âfogginessâ when in motion. Vestibular dysfunction may also contribute to altered mood, particularly anxiety. Although the eye conditions DBQ provides questions related to diplopia, no existing DBQ includes questions or physical exam elements intended to capture the full extent of disability associated with near-point accommodative and convergence insufficiency. These near vision problems occur commonly after TBI, and can result in not only diplopia but also blurred
SUMMARY 5 vision, headache, nausea, and an inability to maintain focus while reading and doing other close- range visual activities. The committee recommends that the Department of Veterans Affairs add insomnia, vestibular dysfunction, and near-vision dysfunction to the Disability Benefits Questionnaires for residuals of traumatic brain injury. QUALITY OF THE ADJUDICATION PROCESS In the committeeâs discussions with VBA officials, VBA placed great emphasis on the consistency of the rating process, rather than on the outcome of the disability determinations. Consistency of process was presented as an end in and of itself, rather than as a way of ensuring the reliability and validity of the assessments, i.e., the characteristics of the process needed to ensure that the veteran had been given an accurate disability rating. VBA has taken great pains to train its raters so that they might accurately and reliably rate a disability; however, the emphasis on consistency of process does not actually ensure the reliability or the validity of the rating. Furthermore, and just as important, a lack of consistency in process does not necessarily mean there is a lack of reliability or validity. It is plausible that those factors are related to assessment performance, but it is not guaranteed to be true. The committee discussed several major domains of quality and how they are related to the adjudication process for veteran disability claims, including reliability and validity. A process with high reliability is one in which repeated evaluations of the same service member would result in the same disability rating. An adjudication process with high validity would be one in which the disability rating reflects the true degree of service-connected disability. A high-quality adjudication process would ideally excel in both of these quality domains, while also being transparent, timely, and credible and minimizing burden to the veteran. To ensure and maintain high quality, systems need to measure both process and outcome quality, incorporate feedback, correct themselves, and measure outcomes after such a correction. The committeeâs review of the VAâs quality assurance measures found that the VAâs quality measures focus on consistency in the disability rating step of the process. One example of a VA quality measure that focuses on consistency of process but with unclear effect on reliability or validity is the measurement of the fraction of diagnoses of TBI that are made by a physician board-certified in one of four specialties: neurology, neurosurgery, physical medicine and rehabilitation, or psychiatry. While the committee appreciates that an understanding of the pathophysiology of TBI and of the proximal and distal signs and symptoms associated with this diagnosis is necessary for an accurate diagnosis, there need not be an inordinate amount of emphasis placed on the specialty of the examiner or on adherence to this policy if there is no evidence that this will lead to more accurate evaluations of disability. The transparency of the adjudication process is another key quality characteristic. Transparency should be considered from the points of view of both the individual veteran and the system. Transparency from the point of view of the individual veteran would include, for example, access to the details of his or her individual application (e.g., the results of the examination as documented on the DBQ, details regarding additional materials that have been requested by VBA). Transparency from a system-wide point of view would include easy access to and widespread distribution of data on the system performance, including performance with respect to both process quality measures (e.g., timeliness of and access to VHA examinations,
6 TRAUMATIC BRAIN INJURY IN VETERANS percent of examinations conducted by contracted examiners) and outcome quality measures (e.g., the consistency of outcomes across geographic regions, the accuracy of disability determinations evaluated using standardized patients, the inter-rater reliability of determinations as assessed through independent examinations and ratings of random cases). The committee found that transparency was inadequately appreciated as a goal by both VHA and VBA personnel. The committee recommends that Veterans Health Administration (VHA) and Veterans Benefits Administration take specific actions to increase transparency at both individual and system-wide levels, including but not limited to providing full access to veterans of the details of their examinations and ratings and providing public access to detailed system-wide data, with separation by geographic location and examination type (e.g., VHA versus contracting examiner), on the outcomes of evaluations and outcome quality. Careful consideration should be given to the methods that the VA uses to evaluate the processes of diagnosis and disability assessment, including not only the disability rating step, but also the diagnosis of TBI, the determination of service connection, and the detection and characterization of the sequelae of TBI (e.g., as documented in the DBQ). The overall goal of the evaluation is to ensure that the approaches taken by the examiner result in an evaluation that accurately capture the effects of TBI on disability in veterans. The committee recommends that the Department of Veterans Affairs institute processes and programs to measure the reliability and validity of the adjudication process, identify opportunities for improvement in the quality of outcomes, and implement modifications of the adjudication process as needed to optimize the quality of both the adjudication process and the reliability and validity of the outcomes. Four specific recommendations for the initial steps to be taken are (1) instituting a program of standard patients to directly measure the reliability and validity of the examination and rating processes for such patients; (2) the use of experienced, second-level reviewers to conduct fully independent evaluations to evaluate the criterion validity of actual veteransâ evaluations; (3) creating a system by which veterans may rate the quality of their own evaluations; and (4) the systematic and transparent collection and comparison of disability outcome data across geographic regions. The implementation of these final two recommendations will represent a fundamental enhancement in the methods used by the VA to ensure the quality of disability evaluations for TBI. Shifting from a focus on the consistency of the process (e.g., for the rating step in disability determination) and on practitioner qualifications to a focus on the accuracy of the outcome of the evaluation is intended and expected to identify steps or components in the disability evaluation process that warrant improvement. In fact, the identification of such opportunities for improvement will be a key indicator of the success and positive impact of these recommendations in improving the system, rather than a criticism of the current system or the personnel who work within it. Furthermore, by adopting an explicit learning structure in which the reliability and validity of disability determinations are directly assessed, the VA will be able
SUMMARY 7 to devote its resources to those modifications and enhancements of the disability evaluation system that will have the greatest impact in improving the service provided to injured veterans.