Access to Treatment of TBI-Related Vestibular Disorders_A Systemwide Investigation

背景头晕是初级保健中最常见的症状之一， 轻度创伤性脑损伤（mTBI）伴头痛[1-3]。眩晕和眩晕是 [14]《孝经》云：“孝者，孝也。前庭康复是最重要的， 成功治疗mTBI患者的模式。意义/影响。这个项目的挑战 地址是将这些知识从专业设施翻译到社区一级， mTBI的退伍军人居住。拟议的研究项目解决了HSR&D研究的优先主题 包括使用医疗保健信息学来改善获得护理的机会， 提供服务和护理管理，促进最佳恢复、康复和重返社会 对于TBI。这项研究计划的长期目标是改善医疗保健的可及性和质量 治疗外伤性脑损伤相关的前庭疾病创新短期目标是检查 报告头晕的退伍军人使用VA服务（国家级数据），并确定 提供的治疗是有效的（地方一级数据）。具体目标。目的是：（1）确定，使用 国家数据，报告头晕症状的OEF/OIF患者对VA服务的利用，（2） 使用当地部署后康复和评估计划（PREP）数据确定预测因素 前庭功能障碍的严重程度和影响前庭功能障碍的因素 康复，和（3）增加可靠地测量前庭功能有效性的能力。 mTBI患者的康复。方法论Aim 1采用回顾性大数据设计 和国家创伤性脑损伤综合二级考试资料。频率 不同类型的转介建议和跟进探访将以表格形式列出。Logistic 回归分析将用于识别与以下因素相关的退伍军人、临床医生和系统级因素： 患者接受转诊的可能性和对转诊的跟进。Aim 2将使用 回顾性设计和当地（坦帕PREP）数据，对 与前庭康复相关的变化幅度。姿势稳定、平衡、自我感知 头晕障碍、脑震荡后症状和凝视稳定结果指标将被 使用多元线性回归进行评估。解释的差异百分比将计算为 所有模型并进行比较，以确定哪个前庭康复结果变量似乎是最好的 由一组患者、临床医生和系统级预测器解释。目标3将使用目标2数据进行评估 心理测量学特性和对所选前庭改变的反应性或临床敏感性 TBI相关前庭功能障碍人群的功能测量。如果这个项目的目的是 实现，将确定以下内容：（1a）与TBI相关前庭的退伍军人的数量 转诊接受治疗的功能障碍以及谁对转诊进行了随访以及（1b）条件/因素 使转诊/治疗处于风险之中/最大化;（2）治疗建议， 实现临床有意义改善的概率;和（3）一组评价指标， 相应的管理、评分和解释指南，可供临床医生使用， 评估临床上有意义的改善前庭康复。后续步骤/实施。 这项研究的结果将与目前HSR&D研究的结果相结合， TBI相关的视力损害，以传播多学科（PT，OT，听力学， 验光、理疗、视力专家和听力学）治疗方法。执行 指导方针将由共同研究者和专家小组成员提供帮助， 和我们的计划办公室合作伙伴。

Background. Dizziness is one of the most common symptoms in primary care and the most frequent comorbidity of mild traumatic brain injury (mTBI) followed by headache [1-3]. Vertigo and dizziness are predictors of headache persistence [4]. Vestibular rehabilitation is one of the most important and successful treatment modalities for patients with mTBI. Significance/Impact. The challenge this project addresses is translation of this knowledge from the specialized facility to the community level where most Veterans with mTBI reside. The proposed research project addresses HSR&D Research Priority Topics including the use of healthcare informatics to improve access to care and the examination of models of service delivery and care management that promote optimal recovery, rehabilitation, and reintegration for TBI. The long-term goal of this program of research is to improve access to and quality of health care for Veterans with TBI-related vestibular disorders. Innovation. The short-term goals are to examine utilization of VA services by Veterans who report dizziness (national level data) and to determine if the treatment provided is effective (local level data). Specific Aims. The Aims are to: (1) Determine, using national data, the utilization of VA services by OEF/OIF patients who report dizziness symptoms, (2) Determine, using local Post-Deployment Rehabilitation & Evaluation Program (PREP) data, predictors of severity of vestibular dysfunction and factors that influence the effectiveness of vestibular rehabilitation, and (3) Increase the capacity to reliably measure the effectiveness of vestibular rehabilitation for individuals with mTBI. Methodology. Aim 1 uses a retrospective, big data design and national Comprehensive Traumatic Brain Injury Level II Examination data. Frequencies of the different types of referral recommendations made and follow up visits will be tabulated. Logistic regression analysis will be used to identify Veteran, clinician, and system-level factors associated with patient likelihood of receiving a referral and following up with the referral. Aim 2 will use a retrospective design and local (Tampa PREP) data to conduct an uncontrolled exploration of the magnitude of change associated with vestibular rehabilitation. Postural stability, balance, self-perceived dizziness handicap, post-concussive symptoms, and gaze stabilization outcome measures will be evaluated using multiple linear regression. The percentage of variance explained will be calculated for all models and compared to identify which vestibular rehabilitation outcome variable appears to be best explained by a set of patient, clinician, and system level predictors. Aim 3 will use Aim 2 data to evaluate the psychometric properties and responsiveness or clinical sensitivity to change of selected vestibular function measures for the TBI-related vestibular dysfunction population. If the aims of this project are achieved, the following will be identified: (1a) the number of Veterans with TBI-related vestibular dysfunction referred for treatment and who followed up with the referral and (1b) the conditions/factors that put referral/treatment at risk/maximize; (2) treatment recommendations that confer a high/low probability of achieving clinically meaningful improvement; and (3) a set of evaluation measures with corresponding administration, scoring, and interpretation guidelines that can be used by clinicians to assess clinically meaningful improvement in vestibular rehabilitation. Next Steps/Implementation. Findings from this study will be combined with findings from a current HSR&D study that investigates TBI-related vision impairment to disseminate guidelines for a multidisciplinary (PT, OT, audiology, optometry, physiatry, vision specialist, and audiology) treatment approach. Implementation of guidelines will be facilitated by co-investigators and Expert Panel members who sit in in key policy positions and by our Program Office Partner.