Community Care Utilization among Post-9/11 Veterans with Traumatic Brain Injury

背景：据估计，20%或更多的9/11后退伍军人至少经历过一次 军事相关的创伤性脑损伤（TBI）;大多数被归类为轻度（mTBI）。所有级别的TBI 严重程度，包括mTBI，可导致慢性身体，认知和情绪症状，对许多人来说， 干扰日常运作。它还与创伤后应激障碍等共病诊断有关 障碍、抑郁、疼痛、痴呆和自杀意念。因此，早期发现和协调治疗 对于预防有TBI病史的退伍军人的慢性功能障碍、残疾和早期死亡至关重要。 VA多发性创伤/创伤性脑损伤护理系统（PSC）通过一个区域综合结构，通过以下方式履行这一职能： 监督和提供筛选，评估，教育，并为那些需要循证治疗 TBI相关护理PSC将在未来几十年内照顾这一庞大的患者群体。 自2014年通过《退伍军人选择法》和最近通过的《退伍军人事务部使命法》以来，退伍军人事务部 将大量医疗保健外包给非VA提供者（“社区护理”）。社区护理 可能会改善退伍军人获得护理的机会;然而，医疗保健系统和提供者的双重使用可能会导致 由于护理分散，结果不佳。初步研究表明， 与TBI诊断的退伍军人，相对于那些没有TBI，正在接受VA社区护理服务， 这可能导致接受不推荐用于TBI患者的治疗。 意义/影响：这项研究将为制定和实施战略提供信息，以加强 使用VA社区护理服务的TBI退伍军人接受的护理。这项工作将查明 随着VA社区护理服务的不断扩大，及时提供循证TBI护理 根据新的使命法案。我们的研究结果将有助于确保TBI退伍军人得到护理， 协调、跨学科和以证据为基础，促进他们的最佳健康和功能。 创新：该项目将开发有关社区护理利用和成果的新知识， 接受TBI护理的退伍军人，一个高优先级，临床复杂的患者群体。这将是第一个，我们的 知识，以衡量患者报告的健康和功能结果之间的退伍军人谁接受 社区护理。此外，我们将链接到多个VA和国防部（DoD）数据库， 客观地解释那些使用和不使用社区护理的人之间的特征差异。 具体目标：我们的目标是：（1）描述VA社区护理的利用率（比率和类型;依赖 （2）估计退伍军人对社区的依赖之间的关联 护理及其健康和功能结果;（3）了解退伍军人的需要，看法， 社区护理的经验。 方法：这个为期4年的混合方法项目将把识别9/11后退伍军人TBI的数据与 识别VA医疗保健使用的管理数据，包括社区护理。对于目标1，我们将研究 社区护理使用模式（率和类型;依赖）随着时间的推移和退伍军人 社会人口统计学、军事史、TBI严重程度、医疗复杂性和PSC使用史。对于目标2， 我们将对1,800名TBI退伍军人进行分层随机抽样调查，以估计他们之间的关联。 依赖社区护理及其健康和功能结果，同时考虑到潜在的 混杂因素和偏倚来源。对于目标3，我们将采访100名退伍军人，以检查与他们的 获得、满意、信任以及社区护理的实际和感知质量。 实施/后续步骤：这项工作可以确定退伍军人的亚组，他们的医疗保健需求不是 以及面临不良结果风险的人。成果将为战略提供信息，以确保持续提供 在整个范围内协调，高质量的护理，其中TBI退伍军人正在接受VA护理。

Background: Estimates suggest that 20% or more of Post-9/11 Veterans have experienced at least one military-related traumatic brain injury (TBI); the majority are categorized as mild (mTBI). TBI of all levels of severity, including mTBI, can lead to chronic physical, cognitive, and emotional symptoms that, for many, interfere with daily functioning. It is also associated with comorbid diagnoses such as posttraumatic stress disorder, depression, pain, dementia, and suicidal ideation. As such, early detection and coordinated treatment are critical for preventing chronic dysfunction, disability, and early mortality among Veterans with TBI history. The VA Polytrauma/TBI System of Care (PSC), through a regional, integrated structure, serves this function by overseeing and providing screening, evaluation, education, and evidence-based treatment for those in need of TBI-related care. The PSC will care for this substantial patient population for decades to come. Since the 2014 passage of the Veterans Choice Act and, more recently, the VA MISSION Act, the VA has been outsourcing larger amounts of healthcare to non-VA providers (“Community Care”). VA Community Care may improve Veterans’ access to care; however, dual use of healthcare systems and providers can lead to poor outcomes due to fragmentation of care. Preliminary work has suggested that higher proportions of Veterans with TBI diagnoses, relative to those without TBI, are receiving VA Community Care services, and that this may be leading to the receipt of therapies that are not recommended for patients with TBI. Significance/Impact: This study will inform the development and implementation of strategies to enhance the care received by Veterans with TBI who use VA Community Care services. This work will identify gaps in the provision of evidence-based TBI care in a timely manner, as VA Community Care services continue to expand under the new MISSION Act. Our results will help ensure that Veterans with TBI receive care that is coordinated, interdisciplinary, and evidence-based, and that promotes their optimal health and functioning. Innovation: This project will develop new knowledge about Community Care utilization and outcomes among Veterans receiving care for TBI, a high-priority, clinically-complex patient population. It will be the first, to our knowledge, to measure patient-reported health and functional outcomes among Veterans who receive Community Care. Additionally, we will link to multiple VA and Department of Defense (DoD) databases to objectively account for differences in characteristics between those who do and do not use Community Care. Specific Aims: Our aims are to: (1) Describe utilization of VA Community Care (rates and types of; reliance on) among Post-9/11 Veterans with TBI; (2) Estimate associations between Veterans’ reliance on Community Care and their health and functional outcomes; and (3) Understand Veterans’ need for, perceptions of, and experiences with VA Community Care. Methodology: This 4-year, mixed-methods project will link data identifying Post-9/11 Veterans with TBI to administrative data identifying VA healthcare use including Community Care. For Aim 1, we will examine patterns of Community Care use (rates and types of; reliance on) over time and by Veterans’ sociodemographics, military history, TBI severity, medical complexity, and PSC utilization history. For Aim 2, we will survey a stratified, random sample of 1,800 Veterans with TBI to estimate associations between their reliance on Community Care and their health and functional outcomes, while accounting for potential confounders and sources of bias. For Aim 3, we will interview 100 Veterans to examine factors related to their access to, satisfaction with, trust of, and actual and perceived quality of Community Care. Implementation/Next Steps: This work may identify subgroups of Veterans whose healthcare needs are not being met and who are at risk of poor outcomes. Results will inform strategies to ensure continued delivery of coordinated, high-quality care across the entire spectrum in which Veterans with TBI are receiving VA care.