Rates and Predictors of Completed Cognitive Rehabilitation Referrals Among Veterans With Traumatic Brain Injury.

Abstract

Objective: Among Veterans with traumatic brain injury (TBI) who received a cognitive rehabilitation referral, we sought to describe rates of referral completion (ie, Veteran attends the initial encounter). Second, we examined nonclinical factors associated with referral completion.

Setting: Veterans Health Administration (VHA).

Participants: Veterans with 1) clinician-confirmed TBI determined using the Comprehensive TBI Evaluation database and 2) a cognitive rehabilitation referral, determined using a validated algorithm (n = 19,923 mild TBI [mTBI]; n = 3797 moderate-severe TBI).

Design: Retrospective cohort study of VHA medical record data. Modified Poisson regression was used to model the likelihood of completing a cognitive rehabilitation referral based on nonclinical predisposing (eg, age) and enabling (eg, homelessness) factors. All analyses were stratified by TBI severity (mTBI vs. moderate-severe TBI).

Main measures: Completed cognitive rehabilitation referrals (no/yes), identified in the VHA electronic medical record. Cognitive rehabilitation referrals are documented as "complete" when the Veteran attends an initial encounter with the provider who receives the referral.

Results: The proportion of Veterans who completed their cognitive rehabilitation referral was similar across severities, with 69% of Veterans with mTBI and 68% of Veterans with moderate-severe TBI completing the referral. Veterans with mTBI who were older, married, and those who identified as students/homemakers/volunteers or unemployed and not looking (vs. employed) were more likely to complete the referral. Among Veterans with moderate-severe TBI, history of homelessness was associated with a reduced likelihood of completing a cognitive rehabilitation referral.

Conclusions: While most Veterans with TBI initiate cognitive rehabilitation after receipt of a referral, a notable portion do not, suggesting missed opportunities for beneficial services in this population. Furthermore, patient factors such as age, marital status, employment status, and history of homelessness were associated with referral completion. Findings lay the foundation for system-level strategies that facilitate engagement with cognitive rehabilitation among Veterans with TBI.