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Whiteneck G, Williams W, Almeida E, Bidelspach D, Culpepper W, Picon LM, Eagye CB, Dr Mellick D. Two Decades of Department of Veterans Affairs Traumatic Brain Injury Care and Benefits for Veterans of Post-9/11 Conflicts. J Head Trauma Rehabil 2024:00001199-990000000-00143. [PMID: 38652670 DOI: 10.1097/htr.0000000000000952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To describe the background, methodology, and results of the congressionally mandated Department of Veterans Affairs (VA) Traumatic Brain Injury (TBI) Veterans Health Registry. SETTING Veterans Health Administration (VHA) and Veterans Benefit Administration (VBA). PARTICIPANTS A total of 441 639 Veterans of post-9/11 conflicts who exhibited symptoms associated with TBI and sought care or benefits from the VA between September 2001 and September 2021. Design: Retrospective analysis of VHA and VBA administrative records. MAIN MEASURES (1) VA/Department of Defense Identity Repository to identify Veterans with a deployment to the Southwest Asia theater of operations; (2) the VA TBI Screening and Evaluation Program data; (3) Inpatient and Outpatient Encounter data; and (4) an extract of the VBA Corporate Database to identify Veterans filing benefit claims based on TBI. RESULTS An unduplicated total of 441 639 post-9/11 Veterans were identified in the Registry via three different pathways to entry: 369 909 Veterans through a positive TBI Screen, 253 177 Veterans receiving healthcare including a TBI diagnosis, and 108 541 Veterans filing TBI disability claims. Among Veterans reporting current TBI symptoms who completed a clinical evaluation, a diagnosis of TBI was confirmed by a TBI specialist in 68.7% of the cases. The TBI severity of confirmed cases was classified as mild in 86.6% of the cases, moderate in 8.3%, and severe in 4.1%. The TBI Registry Veterans were hospitalized 66 503 times and seen 1 521 898 times as outpatients in VHA facilities with diagnoses including TBI. Among Veterans filing TBI disability claims, 67.3% were adjudicated as service-connected. CONCLUSION The VA TBI Health Registry has identified over 440 000 Veterans of post-9/11 conflicts who presented to the VA for care or benefits with TBI symptomatology. This large number and the volume of TBI health care and benefits provided over the two decades since 9/11 demonstrate the need for the VA's strong ongoing focus on screening, evaluation, and rehabilitation of TBI. Key words:Department of Veterans Affairs, post-9/11, Registry, TBI, traumatic brain injury, VA, VBA, Veterans, Veterans Benefit Administration, Veterans Health Administration, VHA.
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Affiliation(s)
- Gale Whiteneck
- Author Affiliations: Research Department, Craig Hospital (Dr Whiteneck, Mr Williams, Ms Almeida, Ms Eagye, and Dr Mellick), Englewood, Colorado; Rehabilitation and Prosthetic Services (Mr Bidelspach and Ms Picon); and Epidemiology Program, Health Outcomes of Military Exposures (Dr Culpepper), Veterans Health Administration, Washington, District of Columbia
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Meyer EJ, Correa ET, Monuteaux MC, Mannix R, Hatoun J, Vernacchio L, Lyons TW. Patterns and Predictors of Health Care Utilization After Pediatric Concussion: A Retrospective Cohort Study. Acad Pediatr 2024; 24:51-58. [PMID: 37148968 DOI: 10.1016/j.acap.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To characterize types, duration, and intensity of health care utilization following pediatric concussion and to identify risk factors for increased post-concussion utilization. METHODS A retrospective cohort study of children 5 to 17 years old diagnosed with acute concussion at a quaternary center pediatric emergency department or network of associated primary care clinics. Index concussion visits were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We analyzed patterns of health care visits 6 months before and after the index visit using interrupted time-series analyses. The primary outcome was prolonged concussion-related utilization, defined as having ≥1 follow-up visits with a concussion diagnosis more than 28 days after the index visit. We used logistic regressions to identify predictors of prolonged concussion-related utilization. RESULTS Eight hundred nineteen index visits (median [interquartile range] age, 14 [11-16] years; 395 [48.2%] female) were included. There was a spike in utilization during the first 28 days after the index visit compared to the pre-injury period. Premorbid headache/migraine disorder (adjusted odds ratio (aOR) 2.05, 95% confidence interval [CI] 1.09-3.89) and top quartile pre-injury utilization (aOR 1.90, 95% CI 1.02-3.52) predicted prolonged concussion-related utilization. Premorbid depression/anxiety (aOR 1.55, 95% CI 1.31-1.83) and top quartile pre-injury utilization (aOR 2.29, 95% CI 1.95-2.69) predicted increased utilization intensity. CONCLUSIONS Health care utilization is increased during the first 28 days after pediatric concussion. Children with premorbid headache/migraine disorders, premorbid depression/anxiety, and high baseline utilization are more likely to have increased post-injury health care utilization. This study will inform patient-centered treatment but may be limited by incomplete capture of post-injury utilization and generalizability.
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Affiliation(s)
- Erin J Meyer
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass.
| | - Emily Trudell Correa
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass
| | - Michael C Monuteaux
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
| | - Rebekah Mannix
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
| | - Jonathan Hatoun
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass; Department of Pediatrics (J Hatoun and L Vernacchio), Boston Children's Hospital and Harvard Medical School, Mass
| | - Louis Vernacchio
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass; Department of Pediatrics (J Hatoun and L Vernacchio), Boston Children's Hospital and Harvard Medical School, Mass
| | - Todd W Lyons
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
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Kinney AR, Yan XD, Schneider AL, Rickles E, King SE, O'Donnell F, Forster JE, Brenner LA. Unmet Need for Outpatient Occupational Therapy Services Among Veterans With Mild Traumatic Brain Injury in the Veterans Health Administration: The Role of Facility Characteristics. Arch Phys Med Rehabil 2023; 104:1802-1811. [PMID: 37116557 DOI: 10.1016/j.apmr.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE To investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics. DESIGN In a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics. SETTING Outpatient setting in the VHA. PARTICIPANTS 8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684). INTERVENTIONS None. MAIN OUTCOME MEASURE(S) OT utilization was measured within a year of M2PI administration using VHA administrative data. RESULTS Many Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans' OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904). CONCLUSIONS Participation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities.
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Affiliation(s)
- Adam R Kinney
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO.
| | - Xiang-Dong Yan
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Alexandra L Schneider
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Emma Rickles
- University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
| | - Samuel E King
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Frederica O'Donnell
- Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, DC
| | - Jeri E Forster
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
| | - Lisa A Brenner
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Aurora, CO
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Hoover P, Adirim-Lanza A, Adams RS, Dismuke-Greer CE, French LM, Caban J. Changes in Outpatient Healthcare Utilization and Costs Following Mild Traumatic Brain Injury Among Service Members in the Military Health System by Preexisting Behavioral Health Condition Status. J Head Trauma Rehabil 2023; 38:368-379. [PMID: 36854098 DOI: 10.1097/htr.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To evaluate changes in healthcare utilization and cost following an index mild traumatic brain injury (mTBI) diagnosis among service members (SMs). We hypothesized that differences in utilization and cost will be observed by preexisting behavioral health (BH) diagnosis status. SETTING Direct care outpatient healthcare facilities within the Military Health System. PARTICIPANTS A total of 21 984 active-duty SMs diagnosed with an index mTBI diagnosis between 2017 and 2018. DESIGN This retrospective study analyzed changes in healthcare utilization and cost in military treatment facilities among SMs with an index mTBI diagnosis. Encounter records 1 year before and after mTBI were assessed; preexisting BH conditions were identified in the year before mTBI. MAIN MEASURES Ordinary least squares regressions evaluated difference in the average change of total outpatient encounters and costs among SMs with and with no preexisting BH conditions (eg, posttraumatic stress disorder, adjustment disorder). Additional regressions explored changes in utilization and cost within clinic types (eg, mental health, physical rehabilitation). RESULTS There was a 39.5% increase in overall healthcare utilization during the following year, representing a 34.8% increase in total expenditures. Those with preexisting BH conditions exhibited smaller changes in overall utilization (β, -4.9; [95% confidence interval (CI), -6.1 to -3.8]) and cost (β, $-1873; [95% CI, $-2722 to $-1024]), compared with those with no BH condition. The greatest differences were observed in primary care clinics, in which those with prior BH conditions exhibited an average decreased change of 3.2 encounters (95% CI, -3.5 to -3) and reduced cost of $544 (95% CI, $-599 to $-490) compared with those with no prior BH conditions. CONCLUSION Despite being higher utilizers of healthcare services both pre- and post-mTBI diagnosis, those with preexisting BH conditions exhibited smaller changes in overall cost and utilization. This highlights the importance of considering prior utilization and cost when evaluating the impact of mTBI and other injury events on the Military Health System.
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Affiliation(s)
- Peter Hoover
- National Intrepid Center of Excellence (NICoE), Walter Reed National Military Medical Center, Bethesda, Maryland (Messrs Hoover and Adirim-Lanza and Drs French and Caban); Division of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts (Dr Adams); VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, Colorado (Dr Adams); Health Economics Resource Center (HERC), VA Palo Alto Healthcare System, Palo Alto, California (Dr Dismuke-Greer); and Uniformed Services University of the Health Sciences, Bethesda, Maryland (Dr French)
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Miles SR, Sayer NA, Belanger HG, Venkatachalam HH, Kozel FA, Toyinbo PA, McCart JA, Luther SL. Comparing Outcomes of the Veterans Health Administration's Traumatic Brain Injury and Mental Health Screening Programs: Types and Frequency of Specialty Services Used. J Neurotrauma 2023; 40:102-111. [PMID: 35898115 DOI: 10.1089/neu.2022.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The Veterans Health Administration (VHA) screens veterans who deployed in support of the wars in Afghanistan and Iraq for traumatic brain injury (TBI) and mental health (MH) disorders. Chronic symptoms after mild TBI overlap with MH symptoms, for which there are already established screens within the VHA. It is unclear whether the TBI screen facilitates treatment for appropriate specialty care over and beyond the MH screens. Our primary objective was to determine whether TBI screening is associated with different types (MH, Physical Medicine & Rehabilitation [PM&R], and Neurology) and frequency of specialty services compared with the MH screens. A retrospective cohort design examined veterans receiving VHA care who were screened for both TBI and MH disorders between Fiscal Year (FY) 2007 and FY 2018 (N = 241,136). We calculated service utilization counts in MH, PM&R, and Neurology in the six months after the screens. Zero-inflated negative binomial regression models of encounters (counts) were fit separately by specialty care type and for a total count of specialty services. We found that screening positive for TBI resulted in 2.38 times more specialty service encounters than screening negative for TBI. Compared with screening positive for MH only, screening positive for both MH and TBI resulted in 1.78 times more specialty service encounters and 1.33 times more MH encounters. The TBI screen appears to increase use of MH, PM&R, and Neurology services for veterans with post-deployment health concerns, even in those also identified as having a possible MH disorder.
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Affiliation(s)
- Shannon R Miles
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Hospital, Tampa, Florida, USA.,Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Departments of Medicine and Psychiatry, University of Minnesota, Minneapolis, USA
| | - Heather G Belanger
- Department of Psychology, University of South Florida, Tampa, Florida, USA.,United States Special Operations Command, St. Michael's Inc.,Research and Development Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA
| | - Hari H Venkatachalam
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA
| | - Frank Andrew Kozel
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Florida State University, Tallahassee, Florida, USA
| | - Peter A Toyinbo
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA.,College of Public Health, University of South Florida, Tampa, Florida, USA
| | - James A McCart
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA.,College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Stephen L Luther
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA.,College of Public Health, University of South Florida, Tampa, Florida, USA
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Belanger HG, Toyinbo P, Barrett B, King E, Sayer NA. Concussion coach for postconcussive symptoms: A randomized, controlled trial of a smartphone application with Afghanistan and Iraq war Veterans. Clin Neuropsychol 2022; 36:2093-2119. [PMID: 34184976 DOI: 10.1080/13854046.2021.1936188] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective: Investigate the effectiveness of Concussion Coach, an interactive smartphone application, as a treatment for residual neurobehavioral symptoms and distress in Veterans with a history of mild traumatic brain injury (mild TBI). Methods: Veterans with mild TBI were randomized to Concussion Coach (n = 238) or Treatment-as-Usual (TAU) (n = 241) in a 3-month randomized controlled trial. Primary outcome measures included postconcussive symptom (PCS) severity as measured by the Neurobehavioral Symptom Inventory (NSI), and psychological distress as measured by the Brief Symptom Inventory-18 (BSI-18). Measures of self-efficacy, social support, and comfort with technology were administered as potential moderators and mediators. An intention-to-treat (ITT) analysis was performed (N = 461: Concussion Coach = 231 and TAU = 230) using Bayesian Network (BN)modeling. Results: The probability of decreased PCS severity was significantly greater for those assigned to Concussion Coach, .35 [.32,.37], than for TAU, .29 (.27, .32), with an odds ratio (OR) of 1.29. Also, Concussion Coach showed a significantly greater probability of increased self-efficacy (.36 [.32, .39]) than did TAU (.28 [.25, .30], OR = 1.42). In turn, self-efficacy (increased vs. decreased) showed a significantly greater probability of decreased PCS severity (.51 [.47, .54] vs. .27 [.24, .30], OR = 2.71) and decreased psychological distress (.53 [.49, .56] vs. .32 [.29, .35], OR = 2.35), suggesting that self-efficacy may have mediated Concussion Coach effects. Conclusions: Concussion Coach is effective at reducing PCS severity and psychological distress. Increased self-efficacy/perception of self-management of symptoms may be key to successful treatment of residual symptoms in those with history of concussion.
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Affiliation(s)
- Heather G Belanger
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL, USA.,United States Special Operations Command (USSOCOM), Tampa, FL, USA.,Department of Psychology and Psychiatry & Behavioral Neurosciences, University of South Florida, Tampa, FL, USA.,St Michael's Inc, Tampa, FL, USA
| | - Peter Toyinbo
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - Blake Barrett
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL, USA
| | | | - Nina A Sayer
- Minneapolis VA Health Care System, Minneapolis, MN, USA.,Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System and Departments of Medicine and Psychiatry, University of Minnesota, Minneapolis, MN, USA
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Clark JMR, Mahmood Z, Jak AJ, Huckans M, O'Neil ME, Roost MS, Williams RM, Turner AP, Pagulayan KF, Storzbach D, Twamley EW. Neuropsychological Performance and Functional Capacity Following Mild Traumatic Brain Injury in Veterans. J Head Trauma Rehabil 2022; 37:E488-E495. [PMID: 36345556 DOI: 10.1097/htr.0000000000000748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship between neuropsychological functioning and performance-based functional capacity in veterans with a history of mild traumatic brain injury (mTBI), as well as the moderating effects of age and psychiatric symptoms on this relationship. SETTING Three Veterans Affairs medical centers. PARTICIPANTS One hundred nineteen Iraq/Afghanistan veterans with a history of mTBI and self-reported cognitive difficulties. DESIGN Cross-sectional, secondary data analysis of baseline measures in a randomized controlled trial. MAIN MEASURES The main outcome measure, functional capacity, was assessed using the objective and performance-based University of California San Diego Performance-based Skills Assessment-Brief. A global deficit score (GDS) was created as a composite score for performance on a battery of neuropsychological measures assessing domains of attention, processing speed, executive functioning, and verbal memory performance. Posttraumatic stress disorder (PTSD) symptom severity was assessed using the PTSD Checklist-Military Version, and depressive symptom severity was assessed using the Beck Depression Inventory, Second Edition. RESULTS Bivariate analyses indicated that worse neuropsychological performance (ie, higher GDS) and greater PTSD symptom severity were associated with worse communication abilities and worse overall functional capacity. Multiple linear regressions demonstrated that GDS and PTSD symptom severity explained 9% of the variance in communication and 10% of the variance in overall functional capacity; however, GDS emerged as the only significant predictor in both regressions. Age, PTSD, and depressive symptom severity did not moderate the relationship between GDS and overall functional capacity. Performance in the verbal learning and memory domain emerged as the strongest neuropsychological predictor of communication and overall functional capacity. CONCLUSIONS Worse neuropsychological functioning was moderately associated with worse performance-based functional capacity, even when accounting for PTSD symptom severity. Verbal learning and memory was the primary neuropsychological domain driving the relationship with functional capacity; improvement in verbal learning and memory may translate into improved functional capacity.
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Affiliation(s)
- Jillian M R Clark
- Center of Excellence for Stress and Mental Health (Drs Clark, Jak, and Twamley), Mental Health Service (Drs Clark and Jak), and Research Service (Ms Mahmood and Dr Twamley), VA San Diego Healthcare System, San Diego, California; Department of Psychiatry, University of California San Diego, La Jolla (Drs Jak and Twamley); SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California (Ms Mahmood); VA Portland Health Care System, Portland, Oregon (Drs Huckans, O'Neil, Roost, and Storzbach); Department of Psychiatry, Oregon Health & Science University, Portland (Drs Huckans, O'Neil, Roost); VA Puget Sound Health Care System, Seattle, Washington (Drs Williams, Turner, and Pagulayan); Departments of Rehabilitation Medicine (Drs Williams and Turner) and Psychiatry and Behavioral Sciences (Dr Pagulayan), University of Washington School of Medicine, Seattle
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Eliacin J, Fortney SK, Rattray NA, Kean J. Patients' and caregivers' perspectives on healthcare navigation in Central Indiana, USA after brain injury. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:988-997. [PMID: 33471969 DOI: 10.1111/hsc.13275] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 06/12/2023]
Abstract
Little research has documented the experiences of patients with traumatic brain injury (TBI) and their caregivers in navigating health systems for TBI care. In this qualitative study, we conducted semi-structured interviews with 62 participants (34 patients with moderate or severe TBI and 28 caregivers) from Central Indiana. Data were collected from January to September 2016 and analysed using a constructivist grounded theory approach. Participants discussed three significant challenges about navigating health services for TBI care: lack of support for care navigation, financial barriers, and communication barriers. Participants described how navigating outpatient healthcare services for TBI remains complex and emphasised the need for ongoing care navigation support throughout the care continuum. They detailed the long-term financial burden of TBI including high treatment costs, limited insurance coverage, and the emotional toll that financial stress has on their ability to navigate healthcare services for ongoing TBI-related needs. They also discussed how ineffective patient-provider communication and lack of reliable, timely and comprehensive health information about TBI limited their engagement in and navigation of TBI health services. Findings suggest that persons with TBI and their caregivers need ongoing support to manage the long-term impacts of TBI. Efforts to provide care coordination and navigation to patients with TBI and their families are urgently needed to facilitate greater access to care, effective healthcare navigation and improved health outcomes.
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Affiliation(s)
- Johanne Eliacin
- Richard L. Roudebush Department of Veterans Affairs Medical Center, Center for Health Information and Communication, Health Services Research and Development, Indianapolis, IN, USA
- Departments of Psychology, Indiana University Purdue University at Indianapolis, Indianapolis, IN, USA
- Regenstrief Institute, Inc. Indianapolis, IN, USA
- Act Center of Indiana, Indianapolis, IN, USA
| | - Sarah K Fortney
- Departments of Psychology, Indiana University Purdue University at Indianapolis, Indianapolis, IN, USA
| | - Nicholas A Rattray
- Richard L. Roudebush Department of Veterans Affairs Medical Center, Center for Health Information and Communication, Health Services Research and Development, Indianapolis, IN, USA
- Department of Anthropology, Indiana University Purdue University at Indianapolis, Indianapolis, IN, USA
| | - Jacob Kean
- Informatics, Decision-Enhancement and Analytic Sciences Center, Health Services Research and Development, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Population Health Sciences and Department of Communication Sciences and Disorders, University of Utah School of Medicine, Salt Lake City, UT, USA
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Mac Donald CL, Barber J, Johnson A, Patterson J, Temkin N. Global Disability Trajectories Over the First Decade Following Combat Concussion. J Head Trauma Rehabil 2022; 37:63-70. [PMID: 35258037 PMCID: PMC8908784 DOI: 10.1097/htr.0000000000000738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine global disability trajectories in US military with and without traumatic brain injury (TBI) over the first decade following deployment to identify risk profiles for better intervention stratification, hopefully reducing long-term cost. SETTING Patients and participants were enrolled in combat or directly following medical evacuation at the time of injury and followed up every 6 months for 10 years. PARTICIPANTS There are 4 main groups (n = 475), 2 primary and 2 exploratory: (1) combat-deployed controls without a history of blast exposure "non-blast- control" (n = 143), (2) concussive blast TBI "'blast-TBI" (n = 236) (primary), (3) combat-deployed controls with a history of blast exposure "blast-control" (n = 54), and (4) patients sustaining a combat concussion not from blast "non-blast-TBI" (n = 42) (exploratory). DESIGN Prospective, observational, longitudinal study. MAIN MEASURES Combat concussion, blast exposure, and subsequent head injury exposure over the first decade post-deployment. Global disability measured by the Glasgow Outcome Scale Extended (GOSE). RESULTS Latent class growth analysis identified 4 main trajectories of global outcome, with service members sustaining combat concussion 37 to 49 times more likely to be in the worse disability trajectories than non-blast-controls (blast-TBI: odds ratio [OR] = 49.33; CI, 19.77-123.11; P < .001; non-blast-TBI: OR = 37.50; CI, 10.01-140.50; P < .001). Even blast-exposed-controls were 5 times more likely to be in these worse disability categories compared with non-blast-controls (OR = 5.00; CI, 1.59-15.99; P = .007). Adjustment for demographic factors and subsequent head injury exposure did not substantially alter these odds ratios. CONCLUSIONS Very high odds of poor long-term outcome trajectory were identified for those who sustained a concussion in combat, were younger at the time of injury, had lower education, and enlisted in the Army above the risk of deployment alone. These findings help identify a risk profile that could be used to target early intervention and screen for poor long-term outcome to aid in reducing the high public health cost and enhance the long-term quality of life for these service members following deployment.
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Affiliation(s)
- Christine L Mac Donald
- University of Washington School of Medicine, Seattle (Drs Donald and Temkin, Mr Barber, and Ms Patterson); and Washington University, Saint Louis, Missouri (Ms Johnson)
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Raikwar SP, Thangavel R, Ahmed ME, Selvakumar GP, Kempuraj D, Wu K, Khan O, Bazley K, Bussinger B, Kukulka K, Zaheer S, Iyer SS, Govindarajan R, Burton C, James D, Zaheer A. Real-Time Noninvasive Bioluminescence, Ultrasound and Photoacoustic Imaging in NFκB-RE-Luc Transgenic Mice Reveal Glia Maturation Factor-Mediated Immediate and Sustained Spatio-Temporal Activation of NFκB Signaling Post-Traumatic Brain Injury in a Gender-Specific Manner. Cell Mol Neurobiol 2021; 41:1687-1706. [PMID: 32785863 PMCID: PMC8188847 DOI: 10.1007/s10571-020-00937-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022]
Abstract
Neurotrauma especially traumatic brain injury (TBI) is the leading cause of death and disability worldwide. To improve upon the early diagnosis and develop precision-targeted therapies for TBI, it is critical to understand the underlying molecular mechanisms and signaling pathways. The transcription factor, nuclear factor kappa B (NFκB), which is ubiquitously expressed, plays a crucial role in the normal cell survival, proliferation, differentiation, function, as well as in disease states like neuroinflammation and neurodegeneration. Here, we hypothesized that real-time noninvasive bioluminescence molecular imaging allows rapid and precise monitoring of TBI-induced immediate and rapid spatio-temporal activation of NFκB signaling pathway in response to Glia maturation factor (GMF) upregulation which in turn leads to neuroinflammation and neurodegeneration post-TBI. To test and validate our hypothesis and to gain novel mechanistic insights, we subjected NFκB-RE-Luc transgenic male and female mice to TBI and performed real-time noninvasive bioluminescence imaging (BLI) as well as photoacoustic and ultrasound imaging (PAI). Our BLI data revealed that TBI leads to an immediate and sustained activation of NFκB signaling. Further, our BLI data suggest that especially in male NFκB-RE-Luc transgenic mice subjected to TBI, in addition to brain, there is widespread activation of NFκB signaling in multiple organs. However, in the case of the female NFκB-RE-Luc transgenic mice, TBI induces a very specific and localized activation of NFκB signaling in the brain. Further, our microRNA data suggest that TBI induces significant upregulation of mir-9-5p, mir-21a-5p, mir-34a-5p, mir-16-3p, as well as mir-155-5p within 24 h and these microRNAs can be successfully used as TBI-specific biomarkers. To the best of our knowledge, this is one of the first and unique study of its kind to report immediate and sustained activation of NFκB signaling post-TBI in a gender-specific manner by utilizing real-time non-invasive BLI and PAI in NFκB-RE-Luc transgenic mice. Our study will prove immensely beneficial to gain novel mechanistic insights underlying TBI, unravel novel therapeutic targets, as well as enable us to monitor in real-time the response to innovative TBI-specific precision-targeted gene and stem cell-based precision medicine.
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Affiliation(s)
- Sudhanshu P Raikwar
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA.
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA.
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA.
| | - Ramasamy Thangavel
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA
| | - Mohammad Ejaz Ahmed
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA
| | - Govindhasamy Pushpavathi Selvakumar
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA
| | - Duraisamy Kempuraj
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA
| | - Kristopher Wu
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Osaid Khan
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Kieran Bazley
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Bret Bussinger
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Klaudia Kukulka
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Smita Zaheer
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Shankar S Iyer
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA
| | - Raghav Govindarajan
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA
| | | | | | - Asgar Zaheer
- Department of Neurology, School of Medicine, University of Missouri, Columbia, MO, USA.
- Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO, USA.
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA.
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11
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Cogan AM, Pape TLB, Yeaw J, DeKoven M, Anupindi R, Jordan N. Health Care Resource Utilization and Costs for Adults With Mild Traumatic Brain Injury With Chronic Vestibular Impairment. Arch Phys Med Rehabil 2021; 103:90-97.e8. [PMID: 34634230 DOI: 10.1016/j.apmr.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/25/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To quantify the economic burden of all-cause health care resource utilization (HCRU) among adults with and without chronic vestibular impairment (CVI) after a mild traumatic brain injury (mTBI). DESIGN Retrospective matched cohort study. SETTING IQVIA Integrated Data Warehouse. PARTICIPANTS People with mTBI+CVI (n=20,441) matched on baseline age, sex, year of mTBI event, and Charlson Comorbidity Index (CCI) score to people with mTBI only (n=20,441) (N=40,882). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All-cause health HCRU and costs at 12 and 24 months post mTBI diagnosis. RESULTS People with mTBI+CVI had significantly higher all-cause HCRU and costs at both time points than those with mTBI only. Multivariable regression analysis showed that, when controlling for baseline variables, costs of care were 1.5 times higher for mTBI+CVI than mTBI only. CONCLUSIONS People who developed CVI after mTBI had greater overall HCRU and costs for up to 2 years after the injury event compared with people who did not develop CVI after controlling for age, sex, region, and CCI score. Further research on access to follow-up services and effectiveness of interventions to address CVI is warranted.
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Affiliation(s)
- Alison M Cogan
- Washington DC VA Medical Center, Physical Medicine and Rehabilitation Service, Washington, DC.
| | - Theresa L Bender Pape
- Department of Veterans Affairs, Center for Innovation in Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Neil Jordan
- Department of Veterans Affairs, Center for Innovation in Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Behavioral Sciences and Preventive Medicine, Chicago, Illinois
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12
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Koenig S, Morcos G, Gopinath R, Wang K, Henn F, Leong NL. Is MRI Overutilized for Evaluation of Knee Pain in Veterans? J Knee Surg 2021; 36:305-309. [PMID: 34474493 PMCID: PMC9925228 DOI: 10.1055/s-0041-1733880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
MRI is an essential diagnostic imaging modality for many knee conditions; however, it is not indicated in the setting of advanced knee arthritis. Inappropriate MRI imaging adds to health care costs and may delay definitive management for many patients. The primary purpose of this study was to ascertain the frequency of inappropriate MRI scans performed at one Veterans' Administration Medical Center (VAMC). We performed a retrospective chart review of all knee MRIs ordered over a 6-month period. Inappropriate MRI was defined as MRI performed prior to radiographs (XRs), or in the presence of XRs demonstrating severe osteoarthritis, without leading to a nonarthroplasty procedure of the knee. Of the 304 cases reviewed, 36.8% (112) of the MRIs were deemed inappropriate, 33 were ordered by orthopedists, and 79 were ordered by other health care providers. Of the 33 ordered by orthopedists, 25 were ordered by retired/nonsurgical orthopedists. Obtaining an MRI delayed care by an average of 29.2 days. Of the 252 cases that had XR prior to MRI, none included all four views in the standard knee XR series and only four had weightbearing images. Over a third of knee MRIs performed at this VAMC were inappropriate and delayed care. Additionally, no XRs in our study contained all the necessary views to properly assess knee arthritis. These concerning findings signify a potential opportunity for education in diagnostic strategies, to better patient care and resource utilization in the VAMC.
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Affiliation(s)
- Scott Koenig
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - George Morcos
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - Rohan Gopinath
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - Kenneth Wang
- Department of Radiology, Veterans Affairs Commission, Baltimore, Maryland
| | - Frank Henn
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland
| | - Natalie L. Leong
- University of Maryland School of Medicine, Orthopaedics, Baltimore, Maryland,Address for correspondence Natalie L. Leong, MD 10 N. Greene Street, Baltimore, MD 21201
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13
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Dalton MK, Jarman MP, Manful A, Koehlmoos TP, Cooper Z, Weissman JS, Schoenfeld AJ. Long-Term Healthcare Expenditures Following Combat-Related Traumatic Brain Injury. Mil Med 2021; 187:513-517. [PMID: 34173828 DOI: 10.1093/milmed/usab248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is one of the most common injuries resulting from U.S. Military engagements since 2001. Long-term consequences in terms of healthcare utilization are unknown. We sought to evaluate healthcare expenditures among U.S. military service members with TBI, as compared to a matched cohort of uninjured individuals. METHODS We identified service members who were treated for an isolated combat-related TBI between 2007 and 2011. Controls consisted of hospitalized active duty service members, without any history of combat-related injury, matched by age, biologic sex, year of hospitalization, and duration of follow-up. Median total healthcare expenditures over the entire surveillance period represented our primary outcome. Expenditures in the first year (365 days) following injury (hospitalization for controls) and for subsequent years (366th day to last healthcare encounter) were considered secondarily. Negative binomial regression was used to identify the adjusted influence of TBI. RESULTS The TBI cohort consisted of 634 individuals, and there were 1,268 controls. Healthcare expenditures among those with moderate/severe TBI (median $154,335; interquartile range [IQR] $88,088-$360,977) were significantly higher as compared to individuals with mild TBI (median $113,951; IQR $66,663-$210,014) and controls (median $43,077; IQR $24,403-$83,590; P < .001). Most expenditures were incurred during the first year following injury. CONCLUSION This investigation represents the first continuous observation of healthcare utilization among individuals with combat-related TBI. Our findings speak to continued consumption of health care well beyond the immediate postinjury period, resulting in total expenditures approximately six to seven times higher than those of service members hospitalized for noncombat-related reasons.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adoma Manful
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Champagne AA, Coverdale NS, Ross A, Murray C, Vallee I, Cook DJ. Characterizing changes in network connectivity following chronic head trauma in special forces military personnel: a combined resting-fMRI and DTI study. Brain Inj 2021; 35:760-768. [PMID: 33792439 DOI: 10.1080/02699052.2021.1906951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Soldiers are exposed to significant repetitive head trauma, which may disrupt functional and structural brain connectivity patterns. PURPOSE/HYPOTHESIS Integrate resting-state functional MRI (rs-fMRI) and diffusion tensor imaging (DTI) to characterize changes in connectivity biomarkers within Canadian Special Operations Forces (CANSOF), hypothesizing that alterations in architectural organization of cortical hubs may follow chronic repetitive head trauma. METHODS Fifteen CANSOFs with a history of chronic exposure to sub-concussive head trauma and concussive injuries (1.9 ± 2.0 concussions (range: [0-6])), as well as an equal age-matched cohort of controls (CTLs) were recruited. BOLD-based rs-fMRI was combined with DTI to reconstruct functional and structural networks using independent component analyses and probabilistic tractography. Connectivity markers were computed based on the distance between functional seeds to assess for possible differences in injury susceptibility of short- and long-range connections. RESULTS/DISCUSSION Significant hyper- and hypo-connectivity differences in cortical connections were observed suggesting that chronic head trauma may predispose soldiers to changes in the functional organization of brain networks. Significant structural alterations in axonal fibers directly connecting disrupted functional nodes were specific to hyper-connected long-range connections, suggesting a potential relationship between axonal injury and increases in neural recruitment following repetitive head trauma from high-exposure military duties.
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Affiliation(s)
- Allen A Champagne
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,School of Medicine, Queen's University, Kingston, ON, Canada
| | - Nicole S Coverdale
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | | | | | - Isabelle Vallee
- Canadian Special Operations Forces Command, Ottawa, ON, Canada
| | - Douglas J Cook
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Surgery, Queen's University, Kingston, ON, Canada
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Eliacin J, Yang Z, Kean J, Dixon BE. Characterizing health care utilization following hospitalization for a traumatic brain injury: a retrospective cohort study. Brain Inj 2021; 35:119-129. [PMID: 33356602 DOI: 10.1080/02699052.2020.1861650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/31/2020] [Accepted: 12/05/2020] [Indexed: 10/22/2022]
Abstract
Objective: The purpose of this study was to characterize health services utilization among individuals hospitalized with a traumatic brain injury (TBI) 1-year post-injury.Methods: Using a retrospective cohort design, adult patients (n = 32, 042) hospitalized with a traumatic brain injury between 2005 and 2014 were selected from a statewide traumatic brain injury registry. Data on health services utilization for 1-year post-injury were extracted from electronic medical and administrative records. Descriptive statistics and logistic regression were used to characterize the cohort and a subgroup of superutilizers of health services.Results: One year after traumatic brain injury, 56% of participants used emergency department services, 80% received inpatient services, and 93% utilized outpatient health services. Superutilizers had ≥3 emergency department visits, ≥3 inpatient admissions, or ≥26 outpatient visits 1-year post-injury. Twenty-six percent of participants were superutilizers of emergency department services, 30% of inpatient services, and 26% of outpatient services. Superutilizers contributed to 81% of emergency department visits, 70% of inpatient visits, and 60% of outpatient visits. Factors associated with being a superutilizer included sex, race, residence, and insurance type.Conclusions: Several patient characteristics and demographic factors influenced patients' healthcare utilization post-TBI. Findings provide opportunities for developing targeted interventions to improve patients' health and traumatic brain injury-related healthcare delivery.
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Affiliation(s)
- Johanne Eliacin
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, USA
- Department of Psychology, Indiana University-Purdue University - Indianapolis, Indianapolis, USA
- Health Services Research, Regenstrief Institute, Inc., Indianapolis, USA
| | - Ziyi Yang
- Department of Biostatistics, Indiana University-Purdue University - Indianapolis, Indianapolis, USA
| | - Jacob Kean
- Informatics, Decision-Enhancement and Analytic Sciences Center, Health Services Research and Development, VA Salt Lake City Health Care System, Salt Lake City, USA
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, USA
- Department of Communication Sciences and Disorders, University of Utah School of Medicine, Salt Lake City, USA
| | - Brian E Dixon
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, USA
- Department of Epidemiology, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, USA
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, USA
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16
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Healthcare Utilization Following Traumatic Brain Injury in a Large National Sample. J Head Trauma Rehabil 2020; 36:E147-E154. [PMID: 33201034 DOI: 10.1097/htr.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of traumatic brain injury (TBI) on healthcare utilization (HCU) over a 1-year period in a large national sample of individuals diagnosed with TBI across multiple care settings. SETTING Commercial insurance enrollees. PARTICIPANTS Individuals with and without TBI, 2008-2014. DESIGN Retrospective cohort. MAIN MEASURES We compared the change in the 12-month sum of inpatient, outpatient, emergency department (ED), and prescription HCU from pre-TBI to post-TBI to the same change among a non-TBI control group. Most rehabilitation visits were not included. We stratified models by age ≥65 and included the month of TBI in subanalysis. RESULTS There were 207 354 individuals in the TBI cohort and 414 708 individuals in the non-TBI cohort. Excluding the month of TBI diagnosis, TBI resulted in a slight increase in outpatient visits (rate ratio [RtR] = 1.05; 95% confidence interval [CI], 1.04-1.06) but decrease in inpatient HCU (RtR = 0.86; 95% CI, 0.84-0.88). Including the month of TBI in the models resulted in increased inpatient (RtR = 1.55; 95% CI, 1.52-1.58) and ED HCU (RtR = 1.37; 95% CI, 1.34-1.40). CONCLUSION In this population of individuals who maintained insurance coverage following TBI, results suggest that TBI may have a limited impact on nonrehabilitation HCU at the population level.
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Vanier C, Pandey T, Parikh S, Rodriguez A, Knoblauch T, Peralta J, Hertzler A, Ma L, Nam R, Musallam S, Taylor H, Vickery T, Zhang Y, Ranzenberger L, Nguyen A, Kapostasy M, Asturias A, Fazzini E, Snyder T. Interval-censored survival analysis of mild traumatic brain injury with outcome based neuroimaging clinical applications. JOURNAL OF CONCUSSION 2020. [DOI: 10.1177/2059700220947194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objective The purpose of this study was to assess the relationship between MRI findings and clinical presentation and outcomes in patients following mild traumatic brain injury (mTBI). We hypothesize that imaging findings other than hemorrhages and contusions may be used to predict symptom presentation and longevity following mTBI. Methods Patients (n = 250) diagnosed with mTBI and in litigation for brain injury underwent 3T magnetic resonance imaging (MRI). A retrospective chart review was performed to assess symptom presentation and improvement/resolution. To account for variable times of clinical presentation, nonuniform follow-up, and uncertainty in the dates of symptom resolution, a right censored, interval censored statistical analysis was performed. Incidence and resolution of headache, balance, cognitive deficit, fatigue, anxiety, depression, and emotional lability were compared among patients. Image findings analyzed included white matter hyperintensities (WMH), Diffusion Tensor Imaging (DTI) fractional anisotropy (FA) values, MR perfusion, auditory functional MRI (fMRI) activation, hippocampal atrophy (HA) and hippocampal asymmetry as defined by NeuroQuant ® volumetric software. Results Patients who reported LOC were significantly more likely to present with balance problems (p < 0.001), cognitive deficits (p = 0.010), fatigue (p = 0.025), depression (p = 0.002), and emotional lability (p = 0.002). Patients with LOC also demonstrated significantly slower recovery of cognitive function than those who did not lose consciousness (p = 0.044). Patients over the age of 40 had significantly higher odds of presenting with balance problems (p = 0.006). Additionally, these older patients were slower to recover cognitive function (p = 0.001) and less likely to experience improvement of headaches (p = 0.007). Abnormal MRI did not correlate significantly with symptom presentation, but was a strong indicator of symptom progression, with slower recovery of balance (p = 0.009) and cognitive deficits (p < 0.001). Conclusion This analysis demonstrates the utility of clinical data analysis using interval-censored survival statistical technique in head trauma patients. Strong statistical associations between neuroimaging findings and aggregate clinical outcomes were identified in patients with mTBI.
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Affiliation(s)
- Cheryl Vanier
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Trisha Pandey
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Shaunaq Parikh
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
- IMGEN LLC., Las Vegas, NV, USA
- Department of Family Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, USA
| | | | | | - John Peralta
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Amanda Hertzler
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Leon Ma
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Ruslan Nam
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Sami Musallam
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Hallie Taylor
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Taylor Vickery
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Yolanda Zhang
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Logan Ranzenberger
- Department of Radiology, Michigan State University, East Lansing, MI, USA
- Department of Radiology, McClaren Health Care, Flint, MI, USA
| | - Andrew Nguyen
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Mike Kapostasy
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
- IMGEN LLC., Las Vegas, NV, USA
| | - Alex Asturias
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Enrico Fazzini
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
| | - Travis Snyder
- Department of Research, Touro University Nevada, Las Vegas, NV, USA
- IMGEN LLC., Las Vegas, NV, USA
- SimonMed Imaging, Las Vegas, NV, USA
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Prevalence and Severity of Psychiatric Disorders and Suicidal Behavior in Service Members and Veterans With and Without Traumatic Brain Injury: Systematic Review. J Head Trauma Rehabil 2020; 35:1-13. [DOI: 10.1097/htr.0000000000000478] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Legg M, Foster M, Parekh S, Nielsen M, Jones R, Kendall E, Fleming J, Geraghty T. Trajectories of Rehabilitation across Complex Environments (TRaCE): design and baseline characteristics for a prospective cohort study on spinal cord injury and acquired brain injury. BMC Health Serv Res 2019; 19:700. [PMID: 31615532 PMCID: PMC6794776 DOI: 10.1186/s12913-019-4564-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 09/26/2019] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Trajectories of Rehabilitation across Complex Environments (TRaCE), a consented prospective cohort study, addresses a critical need to better understand access to the healthcare system after acute treatment and specialist inpatient rehabilitation for acquired disability. It is expected that this study will produce new knowledge on access to healthcare through the linkage of administrative, survey, and spatial datasets on the one cohort. This paper outlines the study design and baseline characteristics of the cohort. METHODS The TRaCE cohort is comprised of 165 inpatients who are currently being followed up for 12 months after discharge from specialist rehabilitation for acquired brain injury (ABI) and spinal cord injury (SCI). This project combines a data linkage framework on health service use with a prospective survey on psychosocial wellbeing, geographical information systems to examine spatial accessibility to services, and qualitative interviews with a sub-cohort on experiences of service access. CONCLUSION Ultimately, TRaCE will have strong translational impact on strategies for more targeted interventions to improve the healthcare system and support individuals with acquired disabilities in the long-term.
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Affiliation(s)
- Melissa Legg
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University and the Division of Rehabilitation, Metro South Health Hospital and Health Service, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland 4102 Australia
| | - Michele Foster
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University and the Division of Rehabilitation, Metro South Health Hospital and Health Service, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland 4102 Australia
| | - Sanjoti Parekh
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University and the Division of Rehabilitation, Metro South Health Hospital and Health Service, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland 4102 Australia
| | - Mandy Nielsen
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University and the Division of Rehabilitation, Metro South Health Hospital and Health Service, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland 4102 Australia
| | - Rachel Jones
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University and the Division of Rehabilitation, Metro South Health Hospital and Health Service, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland 4102 Australia
| | - Elizabeth Kendall
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University and the Division of Rehabilitation, Metro South Health Hospital and Health Service, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland 4102 Australia
| | - Jennifer Fleming
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
| | - Timothy Geraghty
- The Hopkins Centre: Research for Rehabilitation and Resilience, Menzies Health Institute Queensland, Griffith University and the Division of Rehabilitation, Metro South Health Hospital and Health Service, 199 Ipswich Road, Woolloongabba, Brisbane, Queensland 4102 Australia
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Novakovic-Agopian T, Kornblith E, Abrams G, McQuaid JR, Posecion L, Burciaga J, D'Esposito M, Chen AJW. Long-term effects of executive function training among veterans with chronic TBI. Brain Inj 2019; 33:1513-1521. [PMID: 31423838 DOI: 10.1080/02699052.2019.1645357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective: To investigate long-term effects of GOALS executive function training in Veterans with chronic TBI. In a recently completed study Veterans with chronic TBI showed improvement immediately post-GOALS but not control training on measures of executive function, functional task performance, and emotion regulation. We now examine the long-term maintenance of post-GOALS training changes in the same sample. Setting: San Francisco VA Health Care System (SFVAHCS), and VA Northern California Health-Care System (VANCHS) in Martinez. Participants and Design: 24 Veterans with chronic TBI were assessed at baseline, post-GOALS training, and long-term follow-up 6+ months following completion of training with a structured telephone interview, neuropsychological and complex functional performance measures, and self-report measures of daily and emotional functioning. Results: Participants reported an increased likelihood of involvement in competitive employment/volunteering at follow-up (61%) compared to baseline (26%; χ2 = 5.66, p < .01, ѱ = .35). Repeated measures MANOVAS indicated improvement on attention/executive function (F = 13.85, p < .01, partial η2 = .42), complex functional task performance (GPS Total: F = 9.12, p < .01, partial η2 = .38) and daily functioning (MPAI Total: F = 3.23, p < .05, partial η2 = .21), and reduction in overall mood disturbance (POMS Total: F = 3.42, p < .05, partial η2 = .22) at follow-up relative to baseline. Discussion: Training in attention regulation applied to participant-defined goals is associated with meaningful long-term improvement in cognitive skills, emotion regulation, and daily functioning in Veterans with chronic TBI.
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Affiliation(s)
- Tatjana Novakovic-Agopian
- Mental Health Service, San Francisco VA Health Care System , San Francisco , California , USA.,Department of Psychiatry, University of California , San Francisco , California , USA.,Neurology Service, Veteran's Administration Northern California Health Care System , Martinez , California , USA
| | - Erica Kornblith
- Mental Health Service, San Francisco VA Health Care System , San Francisco , California , USA
| | - Gary Abrams
- Neurology Service, San Francisco VA Health Care System , San Francisco , California , USA.,Department of Neurology, University of California , San Francisco , California , USA
| | - John R McQuaid
- Mental Health Service, San Francisco VA Health Care System , San Francisco , California , USA.,Department of Psychiatry, University of California , San Francisco , California , USA
| | - Lainie Posecion
- Mental Health Service, San Francisco VA Health Care System , San Francisco , California , USA
| | - Joaquin Burciaga
- Mental Health Service, San Francisco VA Health Care System , San Francisco , California , USA
| | - Mark D'Esposito
- Neurology Service, Veteran's Administration Northern California Health Care System , Martinez , California , USA.,Helen Wills Neuroscience Institute, University of California , Berkeley , USA
| | - Anthony J W Chen
- Neurology Service, Veteran's Administration Northern California Health Care System , Martinez , California , USA.,Neurology Service, San Francisco VA Health Care System , San Francisco , California , USA.,Helen Wills Neuroscience Institute, University of California , Berkeley , USA
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21
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Royes LFF, Gomez-Pinilla F. Making sense of gut feelings in the traumatic brain injury pathogenesis. Neurosci Biobehav Rev 2019; 102:345-361. [PMID: 31102601 DOI: 10.1016/j.neubiorev.2019.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is a devastating condition which often initiates a sequel of neurological disorders that can last throughout lifespan. From metabolic perspective, TBI also compromises systemic physiology including the function of body organs with subsequent malfunctions in metabolism. The emerging panorama is that the effects of TBI on the periphery strike back on the brain and exacerbate the overall TBI pathogenesis. An increasing number of clinical reports are alarming to show that metabolic dysfunction is associated with incidence of long-term neurological and psychiatric disorders. The autonomic nervous system, associated hypothalamic-pituitary axis, and the immune system are at the center of the interface between brain and body and are central to the regulation of overall homeostasis and disease. We review the strong association between mechanisms that regulate cell metabolism and inflammation which has important clinical implications for the communication between body and brain. We also discuss the integrative actions of lifestyle interventions such as diet and exercise on promoting brain and body health and cognition after TBI.
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Affiliation(s)
- Luiz Fernando Freire Royes
- Exercise Biochemistry Laboratory, Center of Physical Education and Sports, Federal University of Santa Maria - UFSM, Santa Maria, RS, Brazil
| | - Fernando Gomez-Pinilla
- Departments of Neurosurgery, and Integrative and Biology and Physiology, UCLA Brain Injury Research Center, University of California, Los Angeles, USA.
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22
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Powell MR, Brown AW, Klunk D, Geske JR, Krishnan K, Green C, Bergquist TF. Injury Severity and Depressive Symptoms in a Post-acute Brain Injury Rehabilitation Sample. J Clin Psychol Med Settings 2019; 26:470-482. [PMID: 30690670 DOI: 10.1007/s10880-019-09602-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study explored the relationship between injury severity and depressive symptoms for treatment-seeking individuals with traumatic brain injury (TBI). The Mayo Classification System was used to classify TBI severity in 72 participants who completed the Patient Health Questionnaire at admission and at dismissal from rehabilitation. Patients with mild TBI reported more depressive symptoms than those with moderate or severe TBI at admission and at dismissal. Although injury severity groups differed by gender composition, gender had no effect on severity of depressive symptoms. All participants reported fewer depressive symptoms at dismissal from rehabilitation, including lower endorsement of dysphoria by discharge. Participants with mild TBI, however, continued to report depressive symptoms of a mild severity at dismissal, with residual problems with anhedonia. These findings underscore the benefit of interdisciplinary post-acute rehabilitation services for persons with TBI of any severity, including those with mild injury.
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Affiliation(s)
- Matthew R Powell
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. .,Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Allen W Brown
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Danielle Klunk
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jennifer R Geske
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Kamini Krishnan
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Cleveland Clinic, Cleveland, OH, USA
| | - Cassie Green
- Kirk Neurobehavioral Health, Louisville, CO, USA
| | - Thomas F Bergquist
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Physical Medicine and Rehabilitation, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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23
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Kerr WT, Janio EA, Braesch CT, Le JM, Hori JM, Patel AB, Gallardo NL, Bauirjan J, Chau AM, Hwang ES, Davis EC, Buchard A, Torres-Barba D, D'Ambrosio S, Al Banna M, Cho AY, Engel J, Cohen MS, Stern JM. An objective score to identify psychogenic seizures based on age of onset and history. Epilepsy Behav 2018; 80:75-83. [PMID: 29414562 PMCID: PMC5845850 DOI: 10.1016/j.yebeh.2017.11.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Psychogenic nonepileptic seizure (PNES) is a common diagnosis after evaluation of medication resistant or atypical seizures with video-electroencephalographic monitoring (VEM), but usually follows a long delay after the development of seizures, during which patients are treated for epilepsy. Therefore, more readily available diagnostic tools are needed for earlier identification of patients at risk for PNES. A tool based on patient-reported psychosocial history would be especially beneficial because it could be implemented in the outpatient clinic. METHODS Based on the data from 1375 patients with VEM-confirmed diagnoses, we used logistic regression to compare the frequency of specific patient-reported historical events, demographic information, age of onset, and delay from first seizure until VEM in five mutually exclusive groups of patients: epileptic seizures (ES), PNES, physiologic nonepileptic seizure-like events (PSLE), mixed PNES plus ES, and inconclusive monitoring. To determine the diagnostic utility of this information to differentiate PNES only from ES only, we used multivariate piecewise-linear logistic regression trained using retrospective data from chart review and validated based on data from 246 prospective standardized interviews. RESULTS The prospective area under the curve of our weighted multivariate piecewise-linear by-sex score was 73%, with the threshold that maximized overall retrospective accuracy resulting in a prospective sensitivity of 74% (95% CI: 70-79%) and prospective specificity of 71% (95% CI: 64-82%). The linear model and piecewise linear without an interaction term for sex had very similar performance statistics. In the multivariate piecewise-linear sex-split predictive model, the significant factors positively associated with ES were history of febrile seizures, current employment or active student status, history of traumatic brain injury (TBI), and longer delay from first seizure until VEM. The significant factors associated with PNES were female sex, older age of onset, mild TBI, and significant stressful events with sexual abuse, in particular, increasing the likelihood of PNES. Delays longer than 20years, age of onset after 31years for men, and age of onset after 40years for women had no additional effect on the likelihood of PNES. DISCUSSION Our promising results suggest that an objective score has the potential to serve as an early outpatient screening tool to identify patients with greater likelihood of PNES when considered in combination with other factors. In addition, our analysis suggests that sexual abuse, more than other psychological stressors including physical abuse, is more associated with PNES. There was a trend of increasing frequency of PNES for women during childbearing years and plateauing outside those years that was not observed in men.
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Affiliation(s)
- Wesley T Kerr
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States; Department of Internal Medicine, Eisenhower Medical Center, Rancho Mirage, CA, United States.
| | - Emily A Janio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Chelsea T Braesch
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Justine M Le
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Jessica M Hori
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Akash B Patel
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Norma L Gallardo
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Janar Bauirjan
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Andrea M Chau
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Eric S Hwang
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Emily C Davis
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Albert Buchard
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - David Torres-Barba
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Shannon D'Ambrosio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Mona Al Banna
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Andrew Y Cho
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Jerome Engel
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States; Departments of Neurology and Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Brain Research Institute, University of California Los Angeles, Los Angeles, CA, United States
| | - Mark S Cohen
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States; Departments of Neurology and Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Departments of Radiology, Psychology, Biomedical Physics, and Bioengineering, University of California Los Angeles, Los Angeles, CA, United States; California NanoSystems Institute, University of California Los Angeles, Los Angeles, CA, United States
| | - John M Stern
- Departments of Neurology and Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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