A RAND study, the first to examine care received by a census of active-duty service members diagnosed with mild traumatic brain injury in the Military Health System, assessed the number and characteristics of these patients (including deployment history and history of traumatic brain injury), their care settings, the treatments they received, co-occurring conditions, the duration of treatment, and the risk factors for requiring long-term care.

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Understanding Treatment of Mild Traumatic Brain Injury in the Military Health System

by Carrie M. Farmer, Heather Krull, Thomas W. Concannon, Molly M. Simmons, Francesca Pillemer, Teague Ruder, Andrew M. Parker, Maulik P. Purohit, Liisa Hiatt, Benjamin Saul Batorsky, et al.

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Research Questions

  1. How many active-duty nondeployed service members received a diagnosis of mTBI in 2012?
  2. What are the demographic and military characteristics of service members diagnosed with mTBI?
  3. In what clinical settings do service members with mTBI receive care?
  4. What kind of therapies and treatments do service members with mTBI receive in the six months following diagnosis?
  5. What co-occurring conditions and symptoms are common among service members with mTBI?
  6. For how long do service members with mTBI receive treatment?
  7. Which service members require persistent care?

Traumatic brain injury (TBI) is considered a signature injury of modern warfare, though TBIs can also result from training accidents, falls, sports, and motor vehicle accidents. Among service members diagnosed with a TBI, the majority of cases are mild TBIs (mTBIs), also known as concussions. Many of these service members receive care through the Military Health System, but the amount, type, and quality of care they receive has been largely unknown. A RAND study, the first to examine the mTBI care of a census of patients in the Military Health System, assessed the number and characteristics (including deployment history and history of TBI) of nondeployed, active-duty service members who received an mTBI diagnosis in 2012, the locations of their diagnoses and next health care visits, the types of care they received in the six months following their mTBI diagnosis, co-occurring conditions, and the duration of their treatment. While the majority of service members with mTBI recover quickly, the study further examined a subset of service members with mTBI who received care for longer than three months following their diagnosis. Diagnosing and treating mTBI can be especially challenging because of variations in symptoms and other factors. The research revealed inconsistencies in the diagnostic coding, as well as areas for improvement in coordinating care across providers and care settings. The results and recommendations provide a foundation to guide future clinical studies to improve the quality of care and subsequent outcomes for service members diagnosed with mTBI.

Key Findings

Understanding the Characteristics of Service Members with mTBI and Their Patterns of Treatment Can Inform the Delivery of High-Quality Care

  • Service members who received treatment for a new mTBI diagnosis in 2012 tended to be young and junior enlisted.
  • Most service members appeared to recover quickly following their mTBI diagnosis, but a minority had complex and persistent care needs.
  • Most service members with a new mTBI diagnosis were diagnosed in an emergency department and had their next health care visit in a primary care setting.
  • Many service members with a new mTBI diagnosis also received treatment for co-occurring behavioral health conditions, pain, and sleep disorders.
  • Service members with a new mTBI diagnosis received a variety of assessments and treatments, such as CT scans, physical therapy, and pain medication, in the six months following the mTBI diagnosis, but there were differences by whether the service member had experienced a prior TBI.

Variations in Diagnostic Coding and Other Data Limitations Pose Challenges to Identifying Service Members with mTBI and Profiling Their Care

  • Health care providers face confusing diagnostic coding guidelines and use inconsistent coding practices when diagnosing and treating TBI.

Variations in Diagnostic Coding and Other Data Limitations Pose Challenges to Identifying Service Members with mTBI and Profiling Their Care

  • Available data track the characteristics of service members and their care, but there is a critical need for data on clinical outcomes, patient satisfaction, and other factors that would provide a more complete picture of an episode of mTBI care and more specific guidance for improving the quality of care for service members with mTBI.

Recommendations

  • Identify opportunities to coordinate care. Service members diagnosed with mTBI receive treatment in a variety of clinical settings — not just in military facilities. It is important for the Military Health System to understand the challenges and develop strategies for care coordination and to identify best practices.
  • Assess the quality of care for service members with mTBI. Future research should extend these analyses, examining not only the type of care provided but also its quality. Given the variability in symptom presentation and recovery, the Military Health System should develop clearer standards of care for mTBI.
  • Reconsider current TBI coding guidance. DoD TBI coding guidance requires that providers record a TBI diagnosis only at the first visit, with subsequent visits coded with relevant symptom diagnostic codes. As a result, it is not possible to use administrative data to observe treatment for mTBI over time. DoD should consider whether the advantages of the current coding guidance outweigh the disadvantages for understanding the nature of care provided to service members with all types of TBIs.
  • Improve data quality to increase capacity for research. Improving connections between administrative claims and other clinical data (e.g., chart data, pharmacy data) would facilitate a wide range of research.
  • Conduct further research on the conditions and care of service members with mTBI. This study was designed to establish a foundation for hypothesis-directed clinical studies. Future analyses should focus on care patterns and their predictors, variations in diagnoses and care, and the cohort with persistent mTBI-related problems.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methods

  • Chapter Three

    How Many Service Members Receive Treatment for mTBI?

  • Chapter Four

    What Are the Characteristics of Nondeployed Active-Duty Service Members Who Receive Treatment for an mTBI Through the MHS?

  • Chapter Five

    Where Do Nondeployed Active-Duty Service Members with mTBI Receive Care?

  • Chapter Six

    What Are the Duration and Patterns of Health Care in the Six Months After an mTBI Diagnosis?

  • Chapter Seven

    What Types of Care Do Nondeployed Active-Duty Service Members with mTBI Receive in the Six Months After Their mTBI Diagnosis?

  • Chapter Eight

    Who Receives Persistent Care Following mTBI Diagnosis?

  • Chapter Nine

    Findings and Recommendations

  • Appendix A

    Using ICD-9 Codes to Identify mTBI

  • Appendix B

    Comparison and Variation Using the Project and Other ICD-9 Definitions

  • Appendix C

    ICD-9 to ICD-10 Considerations

  • Appendix D

    Variable Definitions

  • Appendix E

    Additional Analyses

Research conducted by

This research was sponsored by the Defense and Veterans Brain Injury Center in the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

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