Background:People with traumatic brain injury (TBI) morbidity (impaired cognition and behavioral regulation) and polytrauma comorbidity (depression, posttraumatic stress disorder [PTSD], chronic pain, and sleep disorders) experience health care inequities. Among Veterans and Service Members (V/SMs), TBI morbidity or polytrauma comorbidity may impact access and meaningful engagement in the high-quality health care needed to reduce poor health care outcomes. The National Academy of Science, Engineering, and Medicine Report on Accelerating Progress in TBI highlights a dearth of implementation science research in TBI that may help overcome health care access challenges. Implementation science uses a mixed methods approach to understand, implement, and examine outcomes associated with using evidence-based care in practice. Objective:The I-HEAL (Improving Health Care Access and Engagement for Veterans and Service Members with TBI Morbidity) protocol includes 4 synergistic projects with the goal of addressing key knowledge gaps that will improve access and engagement in high-quality, evidence-based health care services for V/SMs with TBI morbidity. Collectively, the 4 projects propose to: (1) adapt existing interventions to promote access and engagement in health care; (2) engage stakeholder communities to maximize uptake and translation; (3) promote research translation that informs policy and practice through knowledge translation products and deliverables targeting key partners (clinicians, V/SMs, caregivers, policymakers, and researchers); (4) facilitate research and implementation to enhance access to high-quality health care for V/SMs with TBI-related morbidity; and (5) foster the development of early/mid-career researchers in advancing implementation science research on access to care for V/SMs with TBI. Methods:Project 1 will involve the development of a nudge intervention (electronic health care reminder) for providers to engage health care proxies when interacting with cognitive disability at risk for poor health care engagement. Project 2 will involve the development of a provider toolkit of adaptations of guideline-endorsed behavioral health interventions for common polytrauma comorbidities to meet the needs of cognitively impaired individuals. Project 3 will involve the adaptation and dissemination of evidence-based team interventions for managing maladaptive behaviors after TBI. Project 4 will involve evaluation and recommendations for policy for virtual health modalities among persons with TBI and polytrauma comorbidity. Results:I-HEAL has been funded as an implementation science Focused Program Award by Congressionally Directed Medical Research Programs, and start-up activities began in October 2023. All 4 projects are currently underway with funding through September 2027. Project 1 has enrolled 48 participants, and project 3 has enrolled 34 participants through September 2025. Conclusions:TBI is associated with increased health care utilization, comorbid health conditions, and premature mortality. This study has proposed to utilize strategies from the implementation science field to help overcome barriers to physical and psychological health care in order to reduce health care disparities associated with TBI disability.

Research Objectives To identify health care provider practices for identification of persons with TBI-related cognitive impairments who might benefit from care partner inclusion in appointments, and identify strategies for inclusion. Design Eight focus groups Setting Virtual (i.e., Teams) Participants Providers worked in civilian (n=14) and VA (Veterans Affairs) (n=15) settings. Participants’ average age was 43, and they were mostly women (17% men) and White (Asian 10%, Hispanic 7%, Black 7%). Working in-patient and out-patient, the participating neuropsychologists or rehabilitation psychologists (33%), occupational, recreational, or physical therapists (33%), and other providers (33%) had treated TBI survivors for about 12 years. Interventions N/A Main Outcome Measures A focus group guide developed with input from a seven-person engagement group of Veterans with TBI and care partners included prompts like, “How would you recognize someone with a cognitive challenge affecting their ability to participate in appointments? What obstacles arise in care partner inclusion?” Reflexive thematic analysis involved priori and emergent codes from Access to Care theory, Consolidated Framework for Implementation Research (CFIR), and the data themselves. Results Practices for identifying whether a patient with TBI had cognitive challenges necessitating care partner inclusion revolved around three themes. 1) Signs, before or during appointment, including informal and formal bedside evaluation or seen in the electronic health record (EHR). 2) Care team communication, for sharing identifications through standing formal practices internally, with similar structures and ad hoc processes used externally. 3) The EHR, the default place to record identifications, though its trustworthiness and operability were an identified challenge, particularly in VA contexts. For inclusion strategies, 1) care partner and patient education across topics and methods formed a bedrock to maximize appointment success. Upon this, 2) providers managed social dynamics through structured meetings and communication to set up the partnership for long-term support. Then, 3) providers evaluated care partners, including for interfering behaviors, capacity, or relationship attributes. Finally, 4) strategies to address challenges ranged from treatment plan alignment across parties, avoiding infantilization, and balancing provision of support with fostering independence. Conclusions Findings show a multistep, dynamic process used to identify and include care partners. With civilian and VA nuances, CFIR contextual determinants at the Access domains of Appropriateness and Ability to Engage inform design of a VA EHR flag to cue providers that a patient with TBI would benefit from care partner inclusion, along with strategies to optimize inclusion.

La Crosse virus is a rare infection in humans that can cause encephalopathy and neuroinvasive disease following infection. While pediatric outcomes have been studied, long-term neuropsychological and functional outcomes in adults remain undocumented. This case report compares existing literature with the extended clinical course of a 19-year-old, young adult male Marine recruit who contracted LACV. The Marine presented with lethargy, altered mental status, and abnormal neuroimaging. After improvements in alertness and command following, he was transferred from acute care to an inpatient neurorehabilitation unit. Disability was measured with the Functional Independence Measure (FIM). Cognitive impairment was documented with neuropsychological assessments. After rehabilitation discharge, he was readmitted approximately 4.75 years postinfection for a respite stay and re-evaluated. FIM scores at admission to the neurorehabilitation facility reflected nearly total dependence. He emerged from a confusional state by 3.5 months postinfection but with severe and nearly global cognitive impairment. By 4.75 years, he showed improved independence in self-care and mobility. Neuropsychological gains were observed in the domains of memory, attention, and executive functioning. Persistent deficits in processing speed and motor dexterity remained. This case highlights the potential for significant long-term functional and cognitive recovery following severe La Crosse encephalitis with global impairment acutely. Periodic neuropsychological re-evaluation may be warranted after infection to inform updated rehabilitation goals and maximize functional independence.

INTRODUCTION:Over 514,000 active duty Service Members (SMs) have sustained traumatic brain injuries (TBIs) since 2000, with mild TBI (mTBI) emerging as the signature injury of recent wars. Although many recover fully, some experience chronic mTBI with persistent symptoms such as headaches, memory issues, post-traumatic stress disorder (PTSD), chronic pain, depression, and cognitive impairment. The 2021 Department of Veterans Affairs (VA)/Department of Defense (DOD) clinical practice guidelines (CPGs) recommend symptom-focused treatment, addressing comorbid conditions, and supporting reintegration. Congress mandated specialized centers to provide comprehensive care, research, and rehabilitation for combat-injured Veterans and SMs (V/SMs) leading to the development of Intensive Evaluation and Treatment Programs (IETPs) at 5 VA Polytrauma Rehabilitation Centers offering interdisciplinary, individualized inpatient care. The IETPs integrate rehabilitation and specialty services for V/SMs with chronic mTBI and associated health issues. OBJECTIVE:The study aimed to describe the IETPs and the participants it serves with chronic, multiple mTBI and comorbidities. METHODS:Participants were V/SMs enrolled in the VA TBI Model Systems study and admitted to 1 of the 5 IETPs between 2009 and 2023. Inclusion criteria included TBI diagnosis, age ≥16, and consent for study participation. Data included demographics, military service characteristics, TBI history, and comorbidities. Injury data represented the index TBI qualifying participants for the study, although many had multiple TBIs. Measures included Functional Independence Measure, Disability Rating Scale, PTSD Checklist, and Neurobehavioral Symptom Inventory, among others. RESULTS:There have been 821 IETP participants from the program start through 2023. Participants averaged 35.3 years at admission, were predominantly White, non-Hispanic, married men, and included active duty SMs, many from Special Operations Forces (74.2%). DISCUSSION AND CONCLUSIONS:Our findings show the prevalence of participants with comorbidities at IETP admission. The 2021 VA/DOD CPGs caution against over-involvement of specialty care for mTBI but acknowledge that patients with persistent symptoms and comorbidities may benefit from specialized programs like IETPs. Chronic pain, sleep apnea, musculoskeletal issues, and hypertension were common among IETP participants, highlighting the need for intensive inpatient care to address dynamic and interactive symptoms. IETPs provide integrated treatment, removing external demands and offering opportunities for medication trials, interventions, and evidence-based therapies.

People with traumatic brain injury (TBI)-related morbidity (impaired cognition, behavioral regulation) and polytrauma comorbidity (depression, posttraumatic stress disorder (PTSD), chronic pain, sleep disorders) experience healthcare inequities leading to poor health outcomes. Our work has highlighted that Veterans and Service Members (V/SMs) with TBI have high rates of rehospitalization, unique healthcare needs, and distinct causes of early mortality (self-inflicted deaths and preventable injuries). Any TBI morbidity or polytrauma comorbidity may impact access and meaningful engagement in the high-quality healthcare needed to reduce poor healthcare outcomes. The National Academy of Science, Engineering, and Medicine Report on Accelerating Progress in TBI recognizes and calls for action to improve healthcare access for persons with TBI and highlights a dearth of implementation science research in TBI that may help overcome healthcare access challenges. Implementation science uses a mixed methods approach to understand, implement, and examine outcomes associated with using evidence-based care in practice. It also uses evidence-based practice for adaptations or innovations in how care is delivered (to retain technical quality, fidelity) across healthcare systems (e.g., Veterans Affairs, Department Of Defense, civilian settings) and populations (e.g., disabled vs healthy cohorts) to achieve healthcare equity. The I-HEAL protocol includes four synergistic projects with the goal to address key knowledge gaps that will improve access and engagement in high-quality, evidence-based healthcare services for V/SM with TBI morbidity. Specific foci include the following: Project 1) development of a nudge intervention (electronic healthcare reminder) for providers to engage healthcare proxies when interacting with cognitive disability at risk for poor healthcare engagement; Project 2) development of a provider toolkit of adaptations of guideline-endorsed behavioral health interventions for common polytrauma comorbidities (sleep, PTSD, depression, chronic pain) to meet the needs of cognitively impaired individuals; Project 3) adaptation and dissemination of evidence-based team interventions for managing maladaptive behaviors after TBI; and Project 4) evaluation and recommendations for policy for virtual health modalities for persons with TBI and polytrauma comorbidity. Collectively the four projects propose to accomplish the following overarching objectives: 1) adapt existing interventions to promote access and engagement in healthcare; 2) engage stakeholder communities to maximize uptake and translation; 3) promote research translation that informs policy and practice through knowledge translation products and deliverables targeting key partners (clinicians, Veterans, Service Members, caregivers, policymakers, and other researchers); 4) facilitate research and implementation to enhance access to high-quality healthcare for V/SM with TBI-related morbidity; and 5) foster development of early/mid-career researchers in advancing implementation science research on access to care for V/SM with TBI. TBI is associated with increased healthcare utilization, comorbid health conditions, and premature mortality. This study proposed to utilize strategies from the implementation science field to help overcome barriers to physical and psychological healthcare to reduce healthcare disparities associated with TBI disability.

To examine the association between environmental barriers and unmet rehabilitation needs during chronic recovery from traumatic brain injury (TBI) in persons discharged from inpatient rehabilitation. Five Veterans Affairs Polytrauma Rehabilitation Centers. Cohort study of Veterans Affairs TBI Model Systems study participants who completed a 10 or 15 year follow up (N = 474). Craig Hospital Inventory of Environmental Factors, Short Form (CHIEF-SF); TBI Rehabilitation Needs Survey (RNS). RNS scores ranged from 0 to 42 with an average score of 6.9 (SD = 7.7). The most frequent unmet needs endorsed included the need to improve memory, solve problems, and control physical symptoms. In the adjusted model, unmet rehabilitation needs (RNS total) was associated with overall environmental barriers (CHIEF-SF Total Score) and three of five CHIEF-SF subscales: Policy barriers, Attitudes/Support barriers, and Services/Assistance barriers. Results from this study suggest that rehabilitation needs persist for at least a decade after TBI and occur in areas that may be modifiable with intervention. Health care providers shoulder consider periodic screening for unmet needs and consider potential treatments to address them as medically indicated Also, results support the growing recognition of TBI as a dynamic and lifelong condition necessitating a chronic disease management model. Despite significant investment in healthcare infrastructure for Veterans and Service Members, knowledge gaps remain regarding understanding and addressing their long-term rehabilitation needs, as well as and how environmental barriers impact the ability to address those needs. Unmet needs among women and minority groups; as well as evaluation of systems interventions to ameliorate environmental barriers they face are important foci of future research.

Objective: Vestibular dysfunction is common following mild-to-moderate traumatic brain injury (TBI) and impacts quality of life. However, little is known regarding the persistence and stability of vestibular symptoms over time and their effects on cognition. This study examined self-reported vestibular symptoms 1 to 2 years following mild-to-moderate TBI in a Military/Veteran cohort. We further evaluated the association of vestibular symptoms with 5-year post-TBI cognitive outcomes. Method: Military service members and Veterans enrolled in the VA TBI Model Systems (TBIMS) completed follow-up interviews at 1-, 2-, and 5-years post-TBI, with valid symptom and performance validity. Study 1 examined vestibular symptom change from 1 to 2 years with the Neurobehavioral Symptom Inventory (N = 76). Study 2 examined the association between year 2 vestibular symptoms and year 5 cognitive performance on Brief Test of Adult Cognition by Telephone (BTACT), controlling for demographics, posttraumatic amnesia duration, and mood symptoms (N = 67). Results: Vestibular symptoms were stable between 1- and 2-year follow-up (88% with no reliable change, 63% with disruptive vestibular symptoms at both time points). Year 2 vestibular symptoms did not predict year 5 BTACT Verbal Memory or Executive Function composites after controlling for covariates. Older age and greater depression symptoms predicted worse executive function. Conclusions: Although vestibular symptoms did not predict cognitive performance, we describe chronic disruptive vestibular symptoms and mood effects on executive functioning for years following mild-to-moderate TBI. Despite study limitations, large effect size differences between TBI-severity groups warrants further exploration to potentially mitigate influence of persistent vestibular symptoms on health outcomes.

ObjectivesTo summarize patient perspectives after participating in a behavioral intervention designed to improve adherence to positive airway pressure therapy in Veterans with traumatic brain injury (TBI) and obstructive sleep apnea. The four-module adherence intervention was based on Motivational Interviewing and Cognitive Behavior Therapy principles and was adapted for persons with cognitive impairments.MethodsPost-intervention semi-structured interviews were conducted with 13 patients with moderate-to-severe TBI. This qualitative study used a pragmatic and deductive approach with the Health Belief Model as the overarching framework. Two qualitative researchers coded and analyzed data with saturation reached after six interviews.ResultsThe sample mean age was 51.4 years (SD = 10.8), who were on average 9.4 years post-TBI (SD = 10.1) and 6.8 years (SD = 5.1) post-OSA diagnosis. Patient feedback was organized into four themes that aligned with the Health Belief Model and two themes pertaining to logistics.ConclusionsParticipation in this adherence intervention was associated with increased awareness of OSA severity, its impact on them, and treatment benefits. Future research should examine the effectiveness of the intervention in real world clinical settings and obtain consumer input from treating clinicians to optimize the program and patient health and functioning.

Objective: Obstructive sleep apnea (OSA) has been associated with structural and functional brain changes and cognitive impairment in sleep clinic samples. Persons with traumatic brain injury (TBI) are at increased risk of OSA compared to community samples, and many experience chronic cognitive disability. However, the impact of OSA on cognitive outcome after TBI is unknown. The purpose of this study was to examine the relationship between polysomnographic sleep parameters on neuropsychological performance 2 years following TBI. We hypothesized that oxygen desaturation, sleep fragmentation, and sleep depth would predict neuropsychological performance. Method: Participants (N = 123) were persons with moderate-to-severe TBI who underwent Type 1 Polysomnography during acute neurorehabilitation. At 2 years post-TBI, participants completed telephone-based neuropsychological testing (the Brief Test of Adult Cognition by Telephone). General linear models were fit to investigate the relationship between sleep parameters and neuropsychological performance, controlling for demographics and posttraumatic amnesia. Results: When controlling for demographics, injury characteristics, and other sleep parameters, greater percent of Stage 1 sleep time predicted poorer cognitive performance (Overall BTACT composite, p = 0.0078, ηp2 = 6.6%; Verbal Memory composite, p = 0.0407, ηp2 = 3.9%; Executive Function composite, p = 0.0215, ηp2 = 4.9%). Oxygen desaturation, cortical arousals, Stage 3 sleep, and the obstructive apnea-hypopnea index were not significantly associated with cognitive outcome. Conclusions: Reduced sleep depth was associated with cognitive outcome in persons with TBI; these findings require replication. Future research should examine whether improving sleep (e.g. increasing deep sleep) during acute recovery can improve cognitive recovery following TBI.

Despite high obstructive sleep apnea (OSA) prevalence (68%) during a time of critical neural repair following hospitalized traumatic brain injury (TBI), OSA screening and diagnosis is uncommon in TBI healthcare settings. Unrecognized OSA is problematic given its association with increased morbidity and early mortality. A recent multicenter comparativeness effectiveness trial (NCT 03033901) identified the best screening and diagnostic approach for use during inpatient rehabilitation following TBI. To support access to OSA management for a disabled population that experiences healthcare disparity, the study team leveraged stakeholder engagement to identify determinants (factors that facilitate or hinder) clinical translation of findings (OSA screening, diagnosis). Stakeholders involved in the trial (n = 37) comprising individuals with lived experience of TBI; providers (rehabilitation, sleep medicine), researchers, industry representatives, healthcare administrators and policy professionals were asked to identify key considerations for translating findings into real-world practice. At trial conclusion, respondents were asked to answer, “What are the key things we need to consider to move the study results into real-world practice?” via a graffiti wall technique. Rapid content analysis was used to generate themes and validated by a third rater with TBI and OSA expertise. Responses resulted in the identification of seven determinants to OSA screening and diagnostic tool implementation during inpatient rehabilitation. Thematic analysis revealed the following needs: 1) Improve societal understanding of the importance of sleep, 2) Increase motivation/understanding of the need for OSA identification and treatment, 3) Research to identify the impact of OSA on TBI outcomes; 4) Understanding the cost to implementation of OSA management in inpatient settings, 5) Improve reimbursement for OSA management during inpatient rehabilitation, 6) Address logistical considerations of implementing screening, diagnosis, and treatment during hospitalization, and 7) Develop/adapt interventions to improve positive airway pressure compliance in a disabled population (hospitalized TBI) at risk for healthcare disparity. This study identified determinants of clinical translation of screening and diagnostic tools for OSA in TBI from multiple stakeholder perspectives. These findings will inform future patient-, provider-, system-, and policy-level interventions to reduce healthcare disparity in TBI by improving access to high-quality OSA care. PCORI: CER-1511-33005; CDMRP: HT9425-23-1-0621

OBJECTIVES:To summarize patient perspectives after participating in a behavioral intervention designed to improve adherence to positive airway pressure therapy in Veterans with traumatic brain injury (TBI) and obstructive sleep apnea. The four-module adherence intervention was based on Motivational Interviewing and Cognitive Behavior Therapy principles and was adapted for persons with cognitive impairments. METHODS:Post-intervention semi-structured interviews were conducted with 13 patients with moderate-to-severe TBI. This qualitative study used a pragmatic and deductive approach with the Health Belief Model as the overarching framework. Two qualitative researchers coded and analyzed data with saturation reached after six interviews. RESULTS:The sample mean age was 51.4 years (SD = 10.8), who were on average 9.4 years post-TBI (SD = 10.1) and 6.8 years (SD = 5.1) post-OSA diagnosis. Patient feedback was organized into four themes that aligned with the Health Belief Model and two themes pertaining to logistics. CONCLUSIONS:Participation in this adherence intervention was associated with increased awareness of OSA severity, its impact on them, and treatment benefits. Future research should examine the effectiveness of the intervention in real world clinical settings and obtain consumer input from treating clinicians to optimize the program and patient health and functioning.

Abstract Introduction Obstructive Sleep Apnea (OSA) is prevalent in neurorehabilitation admissions in patients with traumatic brain injury (TBI). OSA is independently associated with hospital readmission within 30 days of discharge in the general population. Prior studies showed rates of rehospitalizations in TBI patients are estimated at 28%. The most common rehospitalization causes are infection, neurologic issues, neurosurgical procedures, injury, psychiatric, and orthopedic. While older age, history of seizure, and greater physical and mental health comorbidities have been associated with rehospitalization following TBI, early objective measures of OSA have not been examined. Methods This is a retrospective analysis of TBI Model Systems (TBIMS) participants enrolled in a multicenter comparative effectiveness trial followed over the first two years post-discharge (n=175). Participants received level I polysomnography (PSG) during inpatient neurorehabilitation. Differences in PSG indices were examined by rehospitalization rates to determine associations. Mean age of 43.4 (SD 17.6), mostly of white ethnicity (74%). Multiple regression was used to examine rates of hospitalizations across PSG indices controlling for age. Results 102 patients (58%) had no hospitalization in the first 2 years of follow-up while 73 (42%) had at least 1 hospitalization (28 had 1 hospitalization, 45 had >1 hospitalization). While the apnea hypopnea index between the re-hospitalized (15.7) vs non-re-hospitalized (14.8) was not significantly different, the mean O2 nadir was 84.8% and 86.9%, respectively (r2=-2.49, p < 0.02, CI: -4.53, -0.45). Conclusion This is the first study looking at rehospitalization in patients with TBI and OSA, showing that re-hospitalized patients were more likely to have a worse O2 nadir warranting further exploration of PSG indices and the role of sleep apnea in rehospitalization following neurorehabilitation discharge after TBI. Support (if any) The research reported in this abstract was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award. The TBI Model Systems is a funded collaboration between the Department of Veterans Affairs and the Department of Health and Human Services: National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR).

Research ObjectivesTo identify Department of Defense-specific facilitators and barriers to delivering healthcare services post military traumatic brain injury and highlight recommendations to improve systems of care.DesignA qualitative descriptive study design will be used.SettingAdministrators and policymakers from the Department of Defense.ParticipantsKey informant stakeholder interviews with high-level policy and administrative staff from within the DoD. Participants had specialized knowledge due to their unique positions and responsibilities. One-hour Interviews were conducted either virtually or in-person.InterventionsN/A.Main Outcome MeasuresFacilitators and barriers to delivering healthcare services post military traumatic brain injury.ResultsThe DoD administrators focused on a cultural shift in TBI care since the implementation of the Warfighter Brain Health Initiative to improve brain health, including the long-term outcomes of service members post-TBI. Specifically, this shift from a deployment and injury-based model of care to a long-term model of care that includes monitoring through baseline and intermittent assessments includes both organizational improvements (e.g., education and training to improve screening practices), as well as patient-specific improvements (e.g., promotion of health literacy and beliefs about TBI). Administrators also identified a lack of funding and personnel as key challenges to implementation, as well as collaborative challenges among the VA and DoD due to siloed funding and leadership turnover within these organizations.ConclusionsEarly implementation of the Warfighter Brain Health Policy to improve brain health, including the long-term outcomes of Service Members and Veterans with TBI, has created a cultural shift in how TBI is perceived, prevented, identified, and monitored from the healthcare system viewpoint. Early implementation efforts highlight the need for strengthening of partnerships between DoD and VA and continued education and training at both the organizational and patient (health belief) levels.Author(s) DisclosuresThe views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@health.mil. UNCLASSIFIED.

Objective: To examine, among persons discharged from inpatient rehabilitation for traumatic brain injury (TBI), the degree to which pre-TBI factors were associated with post-TBI hospitalization for psychiatric reasons. The authors hypothesized that pre-TBI psychiatric hospitalization and other pre-TBI mental health treatment would predict post-TBI psychiatric hospitalization following rehabilitation discharge, up to 5 years post-TBI. Setting: Five Veterans Affairs Polytrauma Rehabilitation Centers. Participants: Participants with nonmissing rehospitalization status and reason, who were followed at 1 year (N = 1006), 2 years (N = 985), and 5 years (N = 772) post-TBI. Design: A secondary analysis of the Veterans Affairs TBI Model Systems, a multicenter, longitudinal study of veterans and active-duty service members with a history of mild, moderate, or severe TBI previously admitted to comprehensive inpatient medical rehabilitation. This study examined participants cross-sectionally at 3 follow-up timepoints. Main Measures: Psychiatric Rehospitalization was classified according to Healthcare Cost and Utilization Project multilevel Clinical Classifications diagnosis terminology (Category 5). Results: Rates of post-TBI psychiatric hospitalization at years 1, 2, and 5 were 4.3%, 4.7%, and 4.1%, respectively. While bivariate comparisons identified pre-TBI psychiatric hospitalization and pre-TBI mental health treatment as factors associated with psychiatric rehospitalization after TBI across all postinjury timepoints, these factors were statistically nonsignificant when examined in a multivariate model across all timepoints. In the multivariable analysis, pre-TBI psychiatric hospitalization was significantly associated with increased odds of post-TBI psychiatric hospitalization only at 1-year post-TBI (adjusted odds ratio = 2.65; 95% confidence interval, 1.07-6.55, P = .04). Posttraumatic amnesia duration was unrelated to psychiatric rehospitalization. Conclusions: Study findings suggest the limited utility of age, education, and pre-TBI substance use and mental health utilization in predicting post-TBI psychiatric hospitalization. Temporally closer social and behavior factors, particularly those that are potentially modifiable, should be considered in future research.

Abstract Introduction Obstructive sleep apnea (OSA) is associated with structural and functional brain changes and reduced cognition. Persons with traumatic brain injury (TBI) show disproportionately higher risk of OSA compared to community samples. Moderate-to-severe TBI often results in disabling cognitive sequelae, although the impact of OSA on cognitive outcome after TBI is poorly understood. The purpose of this study was to examine the degree to which OSA features predict cognitive performance during early TBI recovery. We hypothesized that greater obstructions, oxygen saturation, and cortical arousals would predict poorer cognition. Methods This was a secondary analysis of participants co-enrolled in the TBI Model Systems (TBIMS) and Comparison of Sleep Apnea Screening and Diagnostic Tools (CSAS) studies. Participants underwent attended PSG while admitted for neurorehabilitation following moderate-to-severe TBI. Telephone follow-up interviews were conducted 2 years ± 3 months from injury date and included the Brief Test of Adult Cognition by Telephone (BTACT). Spearman correlations were calculated between PSG metrics and BTACT performance. Results Of 184 participants co-enrolled in the CSAS and TBIMS studies, 123 had valid BTACT data and compromised the analytical sample. There was a negative correlation between the total Apnea-Hypopnea Index (AHI) and the BTACT Executive Function composite (ρ=-0.189, p=0.040), working memory (ρ=-0.199, p=0.029), and reasoning (ρ=-0.192, p=0.035). Cortical arousals was negatively correlated with reasoning (ρ=0.211, p=0.021). Correlations between PSG metrics of oxygen desaturation (nadir, desaturation index, percent sleep time below 90% peripheral oxygen saturation) and BTACT performance were statistically nonsignificant. Conclusion This study provides evidence that PSG metrics of OSA are associated with decreased cognitive performance during early recovery from moderate-to-severe TBI. Future studies should examine the degree to which OSA treatment can ameliorate cognitive deficits following TBI. Support (if any) PCORI (CER-1511-33005), NIDILRR (90DPTB0007, 90DP0084, 90DPTB0013, 90DPTB0008, 90DPT80004, 90DPTB0001, 90DPTB0024), and DHA Contract HT0014-22-C-0016 (For information, contact dha.TBICOEinfo@health.mil. UNCLASSIFIED). Defined as U.S. Government work under Title 17 U.S.C.§101. Supported with resources and use of facilities at the James A Haley Veterans’ Hospital. Views presented are of the authors and do not necessarily represent official policy or position of any U.S. government agency.

Few studies have examined long-term mortality following traumatic brain injury (TBI) in a military population. This is a secondary analysis of a prospective, longitudinal study that examines long-term mortality (up to 10 years) post-TBI, including analyses of life expectancy, causes of death, and risk factors for death in service members and veterans (SM/V) who survived the acute TBI and inpatient rehabilitation. Among 922 participants in the study, the mortality rate was 8.3% following discharge from inpatient rehabilitation. The mean age of death was 54.5 years, with death occurring on average 3.2 years after injury, and with an average 7-year life expectancy reduction. SM/V with TBI were nearly four times more likely to die compared with the U.S. general population. Leading causes of death were external causes of injury, circulatory disease, and respiratory disorders. Also notable were deaths due to late effects of TBI itself and suicide. Falls were a significant mechanism of injury for those who died. Those who died were also more likely to be older at injury, unemployed, non-active duty status, not currently married, and had longer post-traumatic amnesia, longer rehabilitation stays, worse independence and disability scores at rehabilitation discharge, and a history of mental health issues before injury. These findings indicate that higher disability and less social supportive infrastructure are associated with higher mortality. Our investigation into the vulnerabilities underlying premature mortality and into the major causes of death may help target future prevention, surveillance, and monitoring interventions.

This study evaluates the use of the crosswalk between the PTSD Checklist-Civilian (PCL-C) and PTSD Checklist for DSM-5 (PCL-5) designed by Moshier et al. (2019) in a sample of service members and veterans (SM/V; N = 298) who had sustained a traumatic brain injury (TBI) and were receiving inpatient rehabilitation. The PCL-C and PCL-5 were completed at the same time. Predicted PCL-5 scores for the sample were obtained according to the crosswalk developed by Moshier et al. We used three measures of agreement: intraclass correlation coefficient (ICC), mean difference between predicted and observed scores, and Cohen's κ to determine the performance of the crosswalk in this sample. Subgroups relevant to those who have sustained a TBI, such as TBI severity, were also examined. There was strong agreement between the predicted and observed PCL-5 scores (ICC = .95). The overall mean difference between predicted and observed PCL-5 scores was 0.07 and not statistically significant (SD = 8.29, p = .89). Significant mean differences between predicted and observed PCL-5 scores calculated between subgroups were seen in Black participants (MD = -4.09, SD = 8.41, p = .01) and those in the Year 5 follow-up group (MD = 1.77, SD = 7.14, p = .03). Cohen's κ across subgroups had a mean of κ = 0.76 (.57-1.0), suggesting that there was moderate to almost perfect diagnostic agreement. Our results suggest the crosswalk created by Moshier et al. can be applied to SM/V who have suffered a TBI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Research ObjectivesMost studies of rehospitalization following traumatic brain injury (TBI) examine all-cause, with scant research on hospitalization for psychiatric reasons. This is despite research showing that psychiatric disorders are common following TBI, with rates of psychiatric hospitalization ranging from 5-10% during the chronic recovery phase. In this study, persons with and without psychiatric hospitalization within the first 5 years of TBI were compared on demographic and injury-related characteristics.DesignSecondary analysis of the TBI Model Systems longitudinal multicenter study. Follow up interviews occurred at 1-, 2-, and/or 5-years post-TBI.SettingFive Veterans Affairs Polytrauma Rehabilitation Centers.ParticipantsIn this observational study, Veterans who completed a 1 year (N=1006), 2-year (N=985), or 5-year (N=772) post-TBI follow up. Lost to follow up rate was 7.8-14.5% depending on follow up year. Retention rate at each year was 79%, 77%, and 72%, respectively.InterventionsN/A.Main Outcome MeasuresPsychiatric rehospitalization.ResultsPer univariable analyses, predictors of psychiatric rehospitalization at 1-, 2-, and 5-year follow-up were pre-TBI psychiatric hospitalization (OR=4.48, p<.01; OR=4.49, p<.01; OR=3.74, p<.01) and pre-TBI mental health treatment (OR=2.20, p=.01;OR=2.46, p<.01; OR=2.97, p<.01). At years 1 and 2 follow up only, pre-TBI suicide attempts predicted psychiatric rehospitalization (OR=3.68, p<.01; OR=2.61, p=.01), while active duty status (versus veteran) at time of TBI were less likely to be psychiatrically rehospitalized. Duration of posttraumatic amnesia did not predict psychiatric rehospitalization at 1, 2, or 5-years post-TBI.ConclusionsAnalysis revealed that pre-TBI psychiatric hospitalization and mental health treatment predicted post-TBI psychiatric rehospitalization consistently during the first 5 years post-TBI. Follow up multivariable analysis is needed to better account for shared variance and shed light on unique predictors.Author(s) DisclosuresThe authors declare no conflicts of interest. The views expressed are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. This work was prepared under Contract HT0014-22-C-0016 with DHA Contracting Office (CO-NCR) HT0014 and, therefore, is defined as U.S. Government work under Title 17 U.S.C.§101.

Objective:To characterize reasons for rehospitalization of Veterans and Service Members with mild, moderate, and severe traumatic brain injury (TBI) who received inpatient rehabilitation at a Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC) up to 10 years postinjury. TBI is a chronic condition, and a subset of TBI survivors experience rehospitalization after discharge from inpatient rehabilitation. Extant literature focuses primarily on persons with moderate-to-severe TBI and utilizes broad categories when determining readmission reasons. The present study aimed to delineate with greater specificity the reasons for rehospitalization up to 10 years postinjury across the TBI severity spectrum.Participants and Methods:Participants were drawn from the VA TBI Model Systems multicenter longitudinal study for a cross-sectional analysis. Eligibility criteria included TBI diagnosis per case definition; age > 16 years at TBI; admitted for inpatient rehabilitation at one of the five VA PRCs; and informed consent by the participant or legally authorized representative. At follow up interviews 1, 2, 5, and 10 years post-TBI, participants were asked whether they were rehospitalized within the past year (up to five admissions). Rehospitalizations were classified according to the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project classification (18 categories). In the present analyses, TBI severity was classified by duration of posttraumatic amnesia (PTA; 0-1 days=mild, 2+ days=moderate-severe). Statistical analyses were conducted in SPSS.Results:Participants (N=1101; n=338 0-1 days PTA, n=513 2+ days PTA, n=250 no PTA data) ranged in age from 17 years to 91 years at the time of interview. Participants across all follow up timepoints reported 317 rehospitalizations in the past year. 19.45% of Year 1 participants, 24.37% of Year 2 participants, 16.19% of Year 5 participants, and 16.25% of Year 10 participants reported 1+ rehospitalizations in the past year. When controlling for age, participants with at least 2 days of PTA were more likely to be rehospitalized at least once compared to those with 0-1 days of PTA at Year 2 (OR=4.05, p<0.001) and Year 5 (OR=2.39, p=0.03) post-TBI. The three most common reasons for rehospitalization across all timepoints were injury and poisoning (17.3%), mental illness (16.7%), and diseases of the nervous system and sense organs (9.1%). Mental illness was the modal reason for rehospitalization at Years 2, 5, and 10, frequently due to substance- or alcohol-related disorders and suicide/intentional self-inflicted injury.Conclusions:Compared to prior research, rates of rehospitalization were lower in this sample across follow-up time points. The inclusion of mild TBI in this analysis may partially explain the discrepancy. Importantly, two of the top three rehospitalization reasons are potentially preventable, and strategies to reduce risk of re-injury and minimize escalation of psychiatric distress should therefore be explored. Psychoeducation, supervision, and mental health support during the transition from hospital to community should be considered in order mitigate preventable causes of rehospitalization among long-term TBI survivors.