Blasts due to IEDs and other explosive devices have been one of the  leading causes of injury for those serving in OEF and OIF—and in  particular have been a leading cause of TBI. Mild  TBI can also be present in servicemembers whose injuries do not result in  medical evacuation out of the combat theater. (See table 1 for examples of symptoms associated with mild TBI  as categorized by CDC.) According to literature on  mild TBI in the civilian population, the duration of mild TBI symptoms can  vary. VA Has Implemented a TBI Screening Tool at Its Medical Facilities but Has Not Determined the Clinical Validity and Reliability of the Tool

In April 2007, VA implemented in its medical facilities a computer-based  screening tool to identify OEF/OIF veterans who may have a mild TBI. VA’s screening tool consists of a series of questions that VA providers  must ask OEF/OIF veterans when the veterans come to a VA medical  facility for care. While VA’s screening efforts depend on  its TBI screening tool, VA has not determined the clinical validity and  reliability of the screening tool—that is, respectively, how effective the  tool is in identifying those who are and are not at risk for mild TBI and  whether the screening tool would yield consistent results if administered  to the same veteran more than once. VA requires its  medical facilities to use the TBI screening tool to screen every OEF/OIF  veteran who presents for care at any clinic in the medical facility,  including primary care, dental, and urgent care clinics, CBOCs, or  specialty clinics, such as cardiology or orthopedic clinics. Although VA’s TBI Screening Efforts Depend on the Screening Tool, VA Has Not Determined the Tool’s Clinical Validity and Reliability

The key component of VA’s efforts to screen OEF/OIF veterans for mild  TBI is VA’s requirement that VA medical facilities administer the TBI  screening tool to these veterans when they seek care at VA facilities. VA based its screening tool largely on a TBI screening tool developed and  used by the DVBIC—the Brief Traumatic Brain Injury Screen (BTBIS). The BTBIS has been used at select military bases to screen returning  OEF/OIF servicemembers for TBI and has been shown to be clinically  valid, according to the DVBIC. First, because VA’s TBI screening tool is a  modified version of the BTBIS and is being used to screen a slightly  different population, the results from DVBIC’s validity study of the BTBIS  would not be directly applicable to VA’s screening tool. Also, because veterans who screen positive  are to receive a follow-up evaluation by a specialty provider to determine  whether they actually have a mild TBI, false positives affect specialty  providers’ workload and may affect their capacity to see other veterans. VA Has Implemented a Protocol to Help Ensure Evaluation and Treatment of OEF/OIF Veterans Who Screen Positive for Possible TBI; However, Some Medical Facilities Had Difficulties Fully Following the Protocol

VA has implemented a national protocol to help ensure that OEF/OIF  veterans who screen positive on its TBI screening tool are evaluated by a  specialty provider and receive treatment, if necessary, for mild TBI. VA has  established training for its providers to enhance providers’ use of the  protocol and thereby help ensure veterans are evaluated and treated for  mild TBI. VA medical facilities have taken steps to resolve these  difficulties, and VA has put in place measures to help ensure that all VA  providers follow the protocol. According to the  protocol, providers conducting the follow-up evaluations should obtain a  complete history of the veteran’s injury and current symptoms, conduct a  physical examination targeted to the veteran’s symptoms, and use a  symptom checklist to assess the presence and severity of various  symptoms associated with mild TBI. 2.) VA Faces Clinical and Cultural Challenges in Screening and Evaluating OEF/OIF Veterans for Mild TBI

VA faces a number of clinical and cultural challenges in its efforts to  screen and evaluate OEF/OIF veterans for mild TBI. The lack of objective  diagnostic tests that can identify mild TBI, and the fact that many  symptoms of mild TBI are similar to those of other conditions, such as  PTSD, represent clinical challenges to VA’s screening and evaluation  efforts. Characteristics of Military Culture and of OEF/OIF Veterans Create Cultural Challenges to VA’s Mild TBI Screening and Evaluation Efforts

Several characteristics of the OEF/OIF veteran population create cultural  challenges to VA’s effort to screen OEF/OIF veterans for mild TBI and  evaluate those who screen positive. VA recognizes the importance of  evaluating the screening tool’s validity and reliability—and is planning to  do so. However, VA has not yet begun its evaluation.
Why GAO Did This Study

Traumatic brain injury (TBI) has emerged as a leading injury among servicemembers serving in the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) combat theaters. The widespread use of improvised explosive devices, such as roadside bombs, in these combat theaters increases the likelihood that servicemembers will be exposed to incidents that can cause a TBI. TBIs can vary from mild to severe, and in general, mild TBI can be difficult to identify. Because mild TBI can have lasting effects if not identified and treated, concerns have been raised about how the Department of Veterans Affairs (VA) identifies and treats OEF/OIF veterans with a mild TBI. In this report GAO describes VA's (1) efforts to screen OEF/OIF veterans for mild TBI, (2) steps taken so that those OEF/OIF veterans at risk for mild TBI are evaluated and treated, and (3) challenges in screening and evaluating OEF/OIF veterans for mild TBI. GAO reviewed VA's policies, interviewed VA officials and TBI experts, and reviewed nine VA medical facilities' efforts to implement TBI screening and evaluation processes.

What GAO Found

To screen OEF/OIF veterans for mild TBI, VA implemented in its medical facilities in April 2007 a computer-based screening tool to identify OEF/OIF veterans who may have a mild TBI. VA's tool consists of questions that VA must ask all OEF/OIF veterans when they come to a VA medical facility for care. VA issued a policy requiring its medical facilities to use the tool to screen all OEF/OIF veterans who present for care in any clinic in the facility, including primary care and specialty care clinics. The policy has guidance on what types of providers may administer the tool and directs providers that a positive screening result requires a further evaluation by a specialist to determine if the veteran has mild TBI. VA's screening efforts depend on its TBI screening tool and VA recognizes the importance of determining the tool's clinical validity and reliability--that is, how effectively the tool identifies those who are and are not at risk for mild TBI and if the tool would yield consistent results if administered to the same veteran more than once. However, VA is planning to but has not yet begun to determine the tool's validity and reliability. VA's screening tool was based largely on a tool developed and validated by the Defense and Veterans Brain Injury Center (DVBIC)--a medical and educational collaboration among DOD, VA, and two civilian partners--used at selected military bases to screen returning OEF/OIF servicemembers for TBI. However, because VA's tool is a modified version of DVBIC's tool and is used to screen a slightly different population, the results of the validity study of DVBIC's tool are not directly applicable to VA's tool. To help ensure that OEF/OIF veterans identified as at risk for a mild TBI by VA's screening tool are evaluated and treated, VA developed a national protocol for their evaluation and treatment. According to VA's protocol, veterans with a positive screening result should be offered a follow-up evaluation by a specialist to determine if they have a mild TBI. The follow-up evaluation should include a history of the veteran's injury, a physical examination targeted to the veteran's symptoms, and the use of a checklist to assess the presence and severity of symptoms associated with mild TBI. VA has established training for its providers to enhance use of the protocol and help ensure veterans are evaluated and treated for mild TBI. Providers at some VA medical facilities we visited had difficulties fully following the protocol. However, the facilities had taken steps to resolve the difficulties, and VA has put in place measures to help providers follow the protocol. VA faces clinical and cultural challenges in its efforts to screen and evaluate mild TBI in OEF/OIF veterans. Clinical challenges include the lack of existing objective diagnostic tests that can definitively identify mild TBI. Also, many symptoms of mild TBI are similar to those associated with other conditions, such as post-traumatic stress disorder, making a diagnosis of mild TBI harder to reach. Some characteristics of the OEF/OIF veteran population present cultural challenges in that they may affect veterans' willingness to seek care for TBI symptoms. For example, some may believe that being labeled with a TBI could affect their ability to stay in the National Guard or Reserves.