Traumatic brain injury, posttraumatic stress disorder, and pain diagnoses in OIF/OEF/OND Veterans
By Campbell, Emily Hagel | |
Proquest LLC |
Abstract-To identify the prevalence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain in Veterans from Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND), Veterans who received any inpatient or outpatient care from
Key words: military healthcare, military Veterans, Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn, pain, posttraumatic stress disorder, PTSD, TBI, traumatic brain injury.
Abbreviations: FY = fiscal year, ICD-9-CM = International Classification of Diseases-9th Revision-Clinical Modification, NPCD = National Patient Care Database, OEF = Operation Enduring Freedom, OIF = Operation Iraqi Freedom, OND = Operation New Dawn, PTBRI = Polytrauma Blast-Related Injury, PTSD = posttraumatic stress disorder, QUERI = Quality Enhancement Research Initiative, SM = servicemember, TBI = traumatic brain injury, VA =
INTRODUCTION
Traumatic brain injury (TBI) has been termed the "signature injury" of the wars in
Prior studies have identified TBI, PTSD, and pain to be the major comorbid elements most frequently seen in those previously deployed to
A 2009 national sample of all OIF/OEF Veterans who received VA care during that year revealed that 6.7 percent had been diagnosed with TBI [7]. In this TBI group, 89 percent had a concomitant mental health disorder, with the most frequent diagnosis being PTSD (73%); 70 percent had a concomitant pain disorder; and 54 percent had both PTSD and pain (the polytrauma triad). These data are of great importance in providing a "snapshot" of polytrauma nationally. However, they reflect only 1 year of the VA's experience, and a broader, multiyear evaluation is needed to better understand the phenomenon. Other investigators have looked at longer time spans, but these studies have focused on relatively small, local cohorts [3--4]. The present study represents the first examination of a large, national sample over a multiyear time frame. To this end, the
METHODS
The study population consisted of all Veterans who received any inpatient or outpatient care from
Descriptive statistics were used to report the mean incidence of the diagnoses of TBI, PTSD, and pain (head, neck, or back), both in isolation and in combination. Percentages were computed. All analyses were performed using SAS version 9.2 (
RESULTS
For FY2009--11, 613,391 unique OIF/OEF/OND Veterans accessed VHA inpatient or outpatient services at least once. Table 2 describes demographic characteristics. Overall, the Veterans were 31.9 Ā± 9.6 yr old (mean Ā± standard deviation). Of the Veterans, 51.8 percent had at least one of the three polytrauma diagnoses (TBI, PTSD, or pain) during the triennium.
While the incidence of a TBI diagnosis in any one year's data was slightly less than 7 percent, when data from 3 years were pooled, 9.6 percent or 58,885 unique OIF/OEF/OND Veterans were diagnosed with TBI in at least one of those years. This apparent disparity between individual and cumulative years relates to the fact that 1 year of data measures any diagnosis assigned during that FY, while the cumulative prevalence takes into account all visits over the 3-year period. Similarly, when pooling all 3 years, 29.3 percent or 179,723 Veterans were diagnosed with PTSD and 40.2 percent or 246,883 Veterans were diagnosed with head, neck, or back pain. The incidence of the full polytrauma triad expression of TBI, PTSD, and pain was diagnosed in 6.0 percent (36,800) of all Veterans. These increases reflect the variability of the services provided to each OIF/OEF/OND Veteran during any given year and the accompanying diagnoses for those services. The presence of these diagnoses could not be associated with the etiology or timing of the causative event(s) or combat-relatedness. Of note, only 0.8 percent of all 613,391 OIF/OEF/OND Veterans received a diagnosis of isolated TBI (i.e., unaccompanied by either pain or PTSD). Other combinations of these diagnoses may be found in Table 3 and Figures 1 and 2.
Since many Veterans access care on an ongoing basis, oftentimes over multiple FYs, the total number of OIF/ OEF/OND Veterans receiving care for these 3 years was higher (n = 613,391) than the number of unique Veterans who accessed care over any of the 3 years of the analyses (FY2009 = 327,388, FY2010 = 398,453, and FY2011 = 471,383). The number of Veterans accessing services increased by 122 percent from FY2009 to FY2010 and 118 percent from FY2010 to FY2011, with the total increase over the triennium being 144 percent. The relative proportions of Veterans with the polytrauma triad did not change meaningfully across any or all of the years.
DISCUSSION
This nationwide, multiyear investigation is notable in three aspects. First, the data are strikingly consistent from year to year in all diagnostic categories and dyad and triad combinations. Second, the prevalence of TBI is lower than previously reported, in particular for the diagnosis of isolated TBI (Figure 2). Third, among those Veterans with clinician-diagnosed TBI, we find that mental health, particularly PTSD, and pain-related comorbidity is the norm. Both the individual year and pooled 3-year prevalence of all diagnoses are considerably smaller than estimates that have been reported in either self-report survey or single-center (TBI) studies [4,12]. Of note, the survey work was based on self-report of the Veteran's or SM's recollection of the injury and related symptoms as measured by in-person written or telephone surveys and were not exclusive to VA-enrolled Veterans [13--15]. This carries an inherent risk of false positives and false negatives, as well as sampling differences [16]. The gold standard for TBI diagnosis is a clinical interview and evaluation with a specialist (as opposed to self-report surveys, imaging, or laboratory testing) because of the difficulty obtaining accurate information on TBI history through brief self-report measures and no defined physiologic or biologic marker [7]. Self-report measures may overestimate the rate of TBI compared with clinical assessment, just as they have been found to overestimate the rate of PTSD relative to gold standard interviews [17-- 18]. On the other hand, clinical assessment is also subject to error, and in fact, these medical diagnoses may be underreported in VA records [18--19]. Those individuals who have had an OIF/OEF/OND deployment-related TBI, but who had no acute or persistent sequelae, should still be recorded as having a diagnosis of TBI but on rare occasions may not receive a referral for specialty TBI care, or more typically, even if referred, patients may elect to not follow up with the specialist. The VA is currently reporting that about 95 percent of these Veterans are successfully screened and that about 75 percent of those who screen positive undergo comprehensive evaluation [20]. While it is most likely that the diagnosis of TBI is appropriately entered into the NPCD system for those individuals with persistent symptoms who are referred and/or seen by the specialty programs for care, it is unclear whether those individuals who have sustained a TBI but have had complete resolution of symptoms are consistently recorded for this exposure in the system. In sum, while our findings describe the proportion of OIF/OEF/OND Veteran VA users with TBI diagnosis in the VA FY2009-- 11 administrative data, they may not describe the actual incidence of TBI or the impairment or disability related to TBI in the population of all OIF/OEF/OND Veterans.
The findings presented in this report should be taken in context with potential limitations. First, we did not examine the universe of possible TBI-related comorbidities but rather focused on mental health and select painrelated problems in order to better characterize the prevalence of the polytrauma triad in VA users with TBI. Indeed, the difficulties inherent to postdeployment syndrome extend beyond the polytrauma triad to include these other conditions [21]. Second, the findings are based on administrative data, which may be limited by errors in documentation of the patient characteristics, diagnoses, or procedures. Details on the severity of the TBI are difficult to reliably obtain from the administrative record, so while the majority of Veterans with a diagnosis of TBI are likely to have mild TBI, we were not able to report results separately based on the severity of the injury. Additionally, we did not have available information on diagnoses of OIF/OEF/OND Veterans who did not use VA services. As one would expect across the 3 years of this study, the overall assessment and care of OIF/OEF/OND Veterans with TBI, PTSD, and/or pain have experienced an ongoing process of service enhancements under the guidance of the VHA's Polytrauma System of Care. These improvements in service have included educational initiatives, clinical training, and translational research that have informed both specialty and primary care clinicians. While these developments are likely to have improved the overall awareness and diagnostic precision for the entire polytrauma triad, this may not be as easily reflected in the data analyzed. While changes in combat injury patterns may have been present and increased the incidence of the TBI-pain dyad, it is also feasible that the increased emphasis on pain awareness and education had an effect. Of note, while this investigation used more than 50 ICD-9-CM codes for pain diagnoses, numerous other pain codes were not included. In contrast, the longstanding and pervasive emphasis in the VA system regarding PTSD and other mental health disorders [20,22--23] appears to have already sensitized VA providers to the diagnosis of PTSD in patients with TBI.
The challenges of using ICD-9-CM codes to characterize prevalence of various health conditions across large healthcare systems are formidable and may have contributed to inaccuracies in this investigation. As Lorence has noted, imprecise coding has become more of a factor because physicians are asked to make coding decisions directly into electronic records and may code differently than coding specialists [24]. Lorence also noted considerable regional variations in coding practices that have important implications for national studies and need to be considered carefully [24]. Others have noted problems with coding of injury causation [25], as well as issues involved with inconsistent PTSD diagnosis and coding [26]. The present study did not attempt to control for TBI causation or time of injury. This limitation may add "noise" to the results, and future investigations are needed to address this effectively. While standardized training and certification programs are currently in place for medical coding, the accuracy of coding would be further enhanced by formalizing diagnostic criteria. This could be accomplished using normative, standardized instruments with proven reliability, such as the ClinicianAdministered PTSD Scale [27] or the Visual Analog Scale for Pain [28]. Others have more bluntly stated that "Relying on medical records staff to code cases using [ICD-9-CM] numbers without providing some direction as to an appropriate code is a major part of the problem" and called for an overarching primary TBI diagnosis with more detailed coding added if warranted [29]. The possibility that the VA's emphasis on educating providers about TBI may have resulted in heightened use of TBI codes, even though the bulk of symptoms could be accounted for with a mental health diagnosis, has also been raised [30]. The difficulty in coding is also magnified because TBI, most particularly mild TBI, is a historical diagnosis not even requiring the presence of current symptoms.
CONCLUSIONS
This investigation represents the first multiyear, systemwide analysis of TBI, mental health, and pain-related comorbidities and triad diagnostic trends from the VHA. The findings support that large and increasing numbers of Veterans from the OIF/OEF/OND wars accessed the VHA for healthcare over a 3-year period. Of those Veterans, approximately 10 percent were diagnosed with TBI, 30 percent with PTSD, and 40 percent with pain, and approximately 6 percent had all three diagnoses or the polytrauma triad. Among those with a TBI diagnosis, the majority had a clinician-diagnosed mental health disorder and approximately half of those with TBI had both PTSD and pain. Overall, while the absolute number of OIF/OEF/OND Veterans increased by over 40 percent between FY2009 and FY2011, the relative proportion of Veterans diagnosed with TBI and the high rate of comorbid PTSD and pain in this population remained relatively stable.
ACKNOWLEDGMENTS
Author Contributions:
Study concept and design:
Acquisition of data:
Analysis and interpretation of data:
Drafting of manuscript:
Critical revision of manuscript for important intellectual content:
Statistical analysis:
Obtained funding:
Administrative, technical, or material support:
Study supervision:
Financial Disclosures: The authors have declared that no competing interests exist.
Funding/Support: This material was based on work supported by the
Institutional Review: The institutional review board of the
Disclaimer: The views expressed herein do not necessarily represent the views of the VA or the
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