VA's process for determining TBI in veterans seeking disability compensation examined in new report

The U.S. Department of Veterans Affairs (VA) should expand the requirement in its disability compensation process regarding who can diagnose traumatic brain injury (TBI) to include any health care professional with pertinent and ongoing brain injury training and experience, says a new congressionally mandated report from the National Academies of Sciences, Engineering, and Medicine. Currently, one of four specialties must diagnose TBI—a neurologist, neurosurgeon, physiatrist, or psychiatrist—but Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans says that it is the training and experience, not necessarily the medical specialty, that renders a health care provider capable of an accurate diagnosis.

TBI results from an external force that leads to temporary or permanent impairment of cognitive, physical, or psychosocial function. It is a form of acquired brain injury that may be open (penetrating) or closed (non-penetrating) and can be categorized as mild, moderate, or severe. TBIs have been an increasing cause of injury and disability in the military since the conflicts in Iraq and Afghanistan began. The military incurred an estimated 384,000 incidents of TBI between 2000 and 2018, the report says.

Veterans with an injury related to their service can seek disability compensation from the Veterans Benefits Administration (VBA). The compensation is a tax-free monetary benefit paid to veterans with disabilities that are the result of a disease or injury incurred or aggravated during active military service. The amount of compensation is determined in a six-step process that begins with the veteran (or a proxy) filing a claim, the report says. It typically requires an examination by an approved clinician who diagnoses and evaluates the degree of impairment, functional limitation, and disability.

Diagnosing TBI

Because of increased awareness of TBI, more medical specialties now include TBI training within their curriculum and receive continued updates concerning the current state of the science. There are at least 18 brain injury programs accredited by the Accreditation Council for Graduate Medical Education to train physicians of many specialties to assist in the diagnosis, treatment, and rehabilitation of individuals with brain injury. Looking at the credentials and training necessary for health care specialists to diagnose TBI, the committee that conducted the study recommended that the VA allow health care professionals who have specific TBI training and experience, in addition to the current approved specialists, to make TBI diagnoses. Furthermore, the committee recommended pertinent and ongoing clinical training that is up-to-date with the state of current knowledge regarding TBI.

Quality of the Adjudication Process

The report also looks at several aspects of quality, such as reliability, validity, and transparency, and how they relate to the adjudication process for veterans' disability claims. The committee recommended that the VA take specific actions to increase transparency at both individual and systemwide levels, such as providing veterans full access to the details of their examinations and providing public access to detailed systemwide data, separated by geographic location and examination type, on the outcomes of evaluations and outcome quality. In addition, the committee recommended that the VA institute processes and programs to measure the reliability and validity of the adjudication process, identify opportunities for improvement in the quality of outcomes, and implement modifications as needed.

Tools Used to Provide Clinical Examinations and Disability Ratings

The claims process usually requires an examination that provides information to help determine the presence and degree of medical impairment. This exam records the diagnosis and the medical nature of the condition along with all requested measurements and test results using a tool called the Disability Benefits Questionnaire (DBQ). After the DBQ results are submitted, a veterans service representative may determine that there is enough evidence to make a rating, or request more information. If there is enough evidence, the disability rating is determined by comparing the DBQ results and other evidence with criteria in the Veterans Affairs Schedule for Rating Disabilities (VASRD). The committee reviewed the criteria in the DBQ and VASRD and found that, for the most part, they accurately reflect problems most likely to disrupt quality of life following TBI. However, some of the characteristics of the criteria used to rate severity of disability do not fully capture the potential side effects, such as insomnia, vestibular dysfunction, and near vision dysfunction. The VA should convene experts from both VBA and the Veterans Health Administration (VHA), including clinicians who diagnose and assess residual effects of TBI, to regularly update the VASRD and DBQ to better reflect the current state of medical knowledge, the report says.

"Our scientific understanding of TBI has increased dramatically in recent years, and that understanding needs to be incorporated into the VA's disability determination process," said Dan Blazer, J.P. Gibbons Professor of Psychiatry emeritus, Duke University Medical Center, and chair of the committee that conducted the study. "The implementation of our report's recommendations will represent a fundamental enhancement in the methods used by the VA to ensure the quality of its evaluations for TBI. Shifting from a focus on the consistency of the process to a focus on the reliability and validity of the evaluations' outcomes will identify areas for improvement. Making those modifications will have the greatest impact on improving the outcomes for veterans."