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5 Summary and Recommendations The Department of Veterans Affairs (VA) requested a comprehensive review of the examinations conducted by the VA of individuals who submit claims to the VA secretary for compensation for traumatic brain injury (TBI). The process is a complex one, which has been detailed in the previous chapters. Veterans who submit claims for TBI-related sequelae first have to demonstrate that they had sustained a TBI. Once the diagnosis of TBI has been proven, then the veteran may seek compensation for sequelae (i.e., residuals) of TBI. The administrations within the VA that are involved in this process are the Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA); each administration has distinct requirements and responsibilities for the health of the veteran and compensation decisions. The specific statement of task is provided in Box 5-1 below. BOX 5-1 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. 97
98 TRAUMATIC BRAIN INJURY IN VETERANS DIAGNOSING TBI Damage to the brain caused by trauma is referred to as TBI. TBI may be blunt, non- penetrating, penetrating, or due to blast. According to the Centers for Disease Control and Prevention, mild TBI (mTBI) (often referred to as a concussion) manifests initially as a brief change in mental status or unconsciousness, whereas severe TBI results in an extended period of unconsciousness or amnesia. The first step in the compensation process for residuals of TBI is to be able to prove the diagnosis of a TBI. TBI severity is typically defined at the time of initial injury; the Glasgow Coma Scale (GCS) has been the gold standard of neurologic assessment of trauma patients since its development. Other TBI severity-classification systems rely on single indicators, such as a loss of consciousness or the duration of posttraumatic amnesia. The predictive value of those measures has been demonstrated, but each may be influenced by factors unrelated or indirectly related to the severity of TBI (e.g., intoxication). Ultimately, the severity of injury as it is defined initially does not necessarily predict the trajectory or natural history of TBI, as individuals diagnosed with mTBI can experience ongoing impairment. In the absence of clear biomarkers, self-report based on a validated screening method is currently considered the gold standard for obtaining a comprehensive lifetime history of exposure to TBI. Reliance on medical records is often insufficient because many injuries are not treated, including, occasionally, even more severe injuries. Screening instruments vary in the extent to which their psychometrics have been established, with single-item screens tending to be the least reliable and to be unlikely to capture all TBIs. Many mTBIs incurred during deployment are not evaluated at the time of injury and must be evaluated retrospectively, typically with the Brief Traumatic Brain Injury Screen, a four-item measure that is typically completed upon return from deployment as part of a comprehensive health screening. A positive screen is followed by a more comprehensive evaluation, the VA Comprehensive TBI Evaluation. The current method of TBI diagnosis after initial injury relies on a report of certain symptoms at the time of injury from the person who was injured or from a witness. However, not all individuals who have sustained a TBI are identified at the time of initial injury (e.g., in the case of complex polytrauma); for instance, other injuries might appear to be more severe so that the head injury is not assessed, or, in the case of mTBI, the individual might not present for medical care. Furthermore, there are no current tests to help make, and perhaps document, the diagnosis more than 24 hours after injury, although new tests have been approved by the Food and Drug Administration for use early after injury. Thus, when considering the diagnosis of TBI in the clinical setting, it is important to understand the role that patient and family self-report have in providing evidence of injury. While prospective evaluation is often able to document an initial injury, prior injuries are typically undocumented or elicited via informal methods. Furthermore, TBI is often confused with a variety of other conditions, including aging, depression, and emotional problems such as posttraumatic stress disorder (PTSD). Even when medical records are available, a large percentage of prior injuries often do not receive recognition or medical attention. Therefore, patient self-report of previous head trauma is often used in both clinical practice and research as a screening method to identify TBI. TBI has been associated with behavioral outcomes such as depression, anxiety, aggression, and impulse control and overlaps with the symptoms of PTSD. Thus, a TBI evaluation might be incomplete unless the diagnostician is familiar with the symptoms of PTSD
SUMMARY AND RECOMMENDATIONS 99 and other common comorbidities. PTSD and other psychiatric conditions are often diagnosed concurrent with or following a brain injury. PTSD and TBI share some pathophysiologic characteristics, and both are associated with cognitive impairment and sleep disruption. It is important to recognize that mental health symptoms might have causes other than TBI, among which are pain, the use of medications, alcohol or drug use or intoxication, and PTSD, which can be present either in isolation or in addition to a brain injury and, as noted, can confound or complicate the diagnosis. Given the complexities in diagnosing TBI and the time that might have elapsed since the original injury, a diagnostician needs to have experience with TBI and to 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 more accurately diagnose TBI. Currently the VA requires one of four medical specialties to diagnose TBI: neurology, neurosurgery, physiatry, and psychiatry. 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. Universities and medical schools offer special training in brain injury to train physicians and other health care professionals with an interest in the field to assist in the diagnosis, treatment, and rehabilitation of individuals diagnosed with brain injury. Thus, the VA should consider allowing other health care professionals with experience and pertinent ongoing training in brain injury to make TBI diagnoses. The committee believes that it is the training and experience and not necessarily the specialty that renders a health care professional 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 ADJUDICATION PROCESS The VA requested that the committee review the adjudication process by which residuals of TBI are assessed for awarding disability compensation. Thus the committee examined the adequacy of the tools and protocols used by the VA in providing examinations to veterans and reviewed the credentials and training of the providers who perform such examinations. The adjudication process for VA disability compensation involves several stakeholders, including the veteran, VBA, VHA, and staff offices that work with veterans on appeals. As a first step, the veteran or the veteran service organization representative submits a claim to VBA. If all necessary information is provided, VBA will process the claim, but the residuals of TBI must be assessed to enable VBA to determine a disability rating. In most cases, VBA orders a compensation and pension (C&P) exam. A VHA physician or VBA clinician contractor evaluates the degree of impairment, functional limitation, and disability resulting from the residuals of TBI. The C&P examiner records information using the Disability Benefits Questionnaire (DBQ) for residuals of TBI, which is then submitted to VBA. A rating veterans service representative makes a percentage disability rating decision by
100 TRAUMATIC BRAIN INJURY IN VETERANS comparing DBQ results and other evidence to criteria in the VA Schedule for Rating (VASRD), and an effective start date is assigned. The veteran may file an appeal to have the case reviewed if he or she does not agree with the rating decision. The DBQ guides the documentation of C&P exams by providing a structure for the standardized reporting of results. The VA developed the DBQs to mirror the VASRD, which consists of the criteria encoded in federal regulation for assigning disability ratings, in order to simplify decision making for raters in determining a disability rating. Although the DBQ is completed by a clinician, the disability rating is made by a non-clinician VBA contractor. The clinician essentially plays no role in applying the diagnosis and medical information to the VASRD. The DBQ and the VASRD provide a list of common sequelae (i.e., residuals) of TBI that are used to rate the level of disability associated with TBI. For the most part, the identified residuals accurately reflect the problems that are most likely to disrupt an individualâs quality of life following TBI. However, some of the characteristics of the sequelae used to rate severity of disability (e.g., the frequency at which the problem is observed) do not fully capture the sequelaâs 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 (VA) convene experts from both the Veterans Health Administration and the Veterans Benefits Administration, including clinicians who diagnose and assess residuals of traumatic brain injury (TBI), to regularly update the VA Schedule for Rating Disabilities and disability benefits questionnaire for residuals of TBI to better reflect the current state of medical knowledge. In the committeeâs review of the residuals of the 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 altered postural stability (imbalance and abnormal gait), altered oculomotor function (reduced dynamic visual acuity, dizziness with head movement, dizziness with movement of objects in visual field), and 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 provides questions or physical exam elements intended to capture the full extent of disability associated with near-point accommodative and convergence insufficiency. These near-
SUMMARY AND RECOMMENDATIONS 101 vision problems occur commonly after TBI and can result in not only diplopia but also blurred 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 questionnaire for residuals of traumatic brain injury. With regard to the clinicians who conduct C&P exams, the committee learned that there are differences in training and access to medical records between VHA clinicians and VBA- contracting clinicians. That is notable, given the recent increase in the percentage of C&P evaluations performed by contractors for TBI claims (from 26 percent in 2016 to 58 percent in 2017 and 71 percent to date in 2018). VBA contractors often do not have the same access to VHA medical records as VHA clinicians. While VHA clinicians have access to the veteranâs full medical record, contractors have access only to the information that VBA (or VHA) provides to them. VHA clinicians and VBA contractors do not receive the same training. Hiring standards are different for VHA clinicians and VBA contractors. Contractors might not have the military cultural competence that VHA clinicians do. Furthermore, contracting clinicians might not have the same additional expertise available to them as VA clinicians, which could affect sections on the DBQ that might require a referral to a clinician with different expertise from the examining physician. The committee recommends that the Department of Veterans Affairs provide Veterans Benefits Administration contractors with the same training and access to medical records as Veterans Health Administration clinicians in order to ensure equitable disability determinations for all veterans. ADEQUACY OF THE ADJUDICATION PROCESS The committee was tasked with evaluating the âadequacyâ or quality of the adjudication process for impairments resulting from TBI. Thus, the committee examined desirable characteristics of quality indicators that would be beneficial for the VA to monitor and to use to drive improvements in the adjudication process. The committee notes that although VBA has systems in place to review the consistency of its process, it does not appear to measure reliability or validity. Thus, the committee discussed several major domains of quality and how they are related to the adjudication process for veteran disability claims. 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 (reliability and validity) 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.
102 TRAUMATIC BRAIN INJURY IN VETERANS In the committeeâs review of the VAâs quality assurance measures, it found that the VAâs quality measures focus on consistency in the disability rating step of the process. As described in Chapter 3, VBA has implemented measures to ensure the consistency of the rating process. One example of a VA quality measure that focuses on the consistency of the 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 who is board certified in one of four specialties: neurology, neurosurgery, physical medicine and rehabilitation, or psychiatry. As noted in Chapter 2, 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, 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 the Veterans Health Administration (VHA) and Veterans Benefits Administration (VBA) 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 VBA contracting physician), 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 the 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 captures 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.
SUMMARY AND RECOMMENDATIONS 103 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 the 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 those recommendations in improving the system, rather than a criticism of the current system or the personnel who work within it.