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Gaps in Access to Cognitive Rehabilitation Referrals Among Veterans With Mild Traumatic Brain Injury
Adam R Kinney1, Molly E Penzenik1, Jeri E Forster1
1Department of Veterans Affairs, Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO.
Objective:
To examine whether cognitive symptoms, an indicator of need, were associated with the likelihood that veterans with mild traumatic brain injury (mTBI) received a cognitive rehabilitation referral in the Veterans Health Administration (VHA). We also examined whether nonclinical factors modified the relationship between cognitive symptoms and receipt of a referral.
Design:
Retrospective cohort study of VHA medical record data. Modified Poisson regression was used to model the likelihood of receiving a cognitive rehabilitation referral based on cognitive symptom severity and nonclinical predisposing (eg, race/ethnicity) and enabling (eg, drive time) factors. Discipline-specific models were specified to explain a referral to occupational therapy; speech-language pathology services, and neuropsychology. Statistical interactions determined whether nonclinical factors modified the relationship between cognitive symptoms and receipt of a referral.
Setting:
VHA.
Participants:
Veterans with a mTBI (n=77,001), determined using the Comprehensive Traumatic Brain Injury (TBI) Evaluation database.
Interventions:
Not applicable.
Main Outcome Measures:
Cognitive rehabilitation referrals (no/yes), identified using a validated algorithm.
Results:
Only 26% received a cognitive rehabilitation referral, with speech-language pathology services being the most common discipline (19%), followed by neuropsychology (6%) and occupational therapy (3%). Veterans with more severe cognitive symptoms were more likely to receive a referral, and this relationship was stable in discipline-specific models. However, many veterans without a referral reported severe cognitive challenges, indicating unmet need. Moreover, nonclinical factors-including Hispanic ethnicity, employment status, rurality, drive time, neighborhood disadvantage, and VHA enrollment priority group (eg, requiring a copayment)-modified the relationship between cognitive symptom severity and receipt of a referral.
Conclusions:
These results suggest that although cognitive rehabilitation services tend to be allocated to those in need, significant gaps in access exist. Findings lay the foundation for developing strategies that expand access to beneficial cognitive rehabilitation among veterans with mTBI, reducing their cognitive symptoms and enhancing their daily function.
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