Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans

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The Veterans Benefits Administration (VBA) provides disability compensation to veterans with a service-connected injury, and to receive disability compensation from the Department of Veterans Affairs (VA), a veteran must submit a claim or have a claim submitted on his or her behalf. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans reviews the process by which the VA assesses impairments resulting from traumatic brain injury for purposes of awarding disability compensation. This report also provides recommendations for legislative or administrative action for improving the adjudication of veterans' claims seeking entitlement to compensation for all impairments arising from a traumatic brain injury.

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210 pages · 8.5 x 11 · paperback
ISBN Paperback: 0-309-48686-6
ISBN Ebook: 0-309-48687-4
DOI: https://doi.org/10.17226/25317

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National Academies of Sciences, Engineering, and Medicine. 2019. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington, DC: The National Academies Press.

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Jeffrey J. Bazarian

Dr. Jeff Bazarian, M.D., M.P.H., is a tenured professor of Emergency Medicine at the University of Rochester with an active research program in sport concussion. Dr. Bazarian and his research team have enrolled over 2000 collegiate athletes in studies evaluating a variety of blood and imaging-based brain biomarkers. In 2010, he joined the University of Rochester Sport Concussion Clinic, providing concussion care to area high school and collegiate athletes. Dr. Bazarian has served on several TBI-related task forces and panels for the Centers for Disease Control and Prevention, the National Institutes of Health, the National Science Foundation, and the Institure of Medicine. He currently serves on the HMD Committee on Health Care Utilizations and Adults with Disabilities.

Jennifer Bogner

Jennifer Bogner, Ph.D., ABPP, FACRM, is a Professor, Vice-Chair of Research and Academic Affairs, and Director of the Division of Rehabilitation Psychology in the OSU Department of Physical Medicine and Rehabilitation. She holds the Bert C. Wiley, MD Endowed Chair in Physical Medicine and Rehabilitation. She also serves as Associate Editor for the Journal of Head Trauma Rehabilitation, as the Secretary for the American Congress of Rehabilitation Medicine (ACRM), and as the Chair of the Brain Injury Interdisciplinary Special Interest Group of ACRM. She is the Project Director (PI) of the Ohio Regional Traumatic Brain Injury (TBI) Model System and the Co-Project Director of the Ohio Regional Spinal Cord Injury Model System. She is also the PI of a PCORI-funded project, “Comparative Effectiveness of Rehabilitation Interventions for Traumatic Brain Injury”, and site PI for two additional PCORI-funded projects. She has published over 70 articles in peer-reviewed journals, focusing primarily on modifiable factors influencing long-term outcomes after TBI. She also served on the HMD Committee on Health Care Utilizations and Adults with Disabilities.

John D. Corrigan

John D. Corrigan, PhD, is a Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University in Columbus Ohio, USA, and Director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation. He is Editor-in-Chief of the Journal of Head Trauma Rehabilitation. Dr. Corrigan has led the Ohio Regional Traumatic Brain Injury Model System since 1997 and chaired the Executive Committee of the TBI Model Systems Project Directors from 2007-2017. He is the Director of the Ohio Brain Injury Program, which is the designated lead agency in the state of Ohio for TBI policy and planning. Dr. Corrigan is a member of the Board of Directors of the Brain Injury Association of America and the Neurological & Behavioral Health Subcommittee of the U.S. Department of Defense, Defense Health Board. He has received many awards for his service and research in brain injury rehabilitation, including the Brain Injury Association of America’s William Fields Caveness Award, the 2007 Robert L. Moody Prize and the Gold Key Award from the American Congress of Rehabilitation Medicine.

Dr. Corrigan has published more than 140 articles in peer-reviewed journals and authored multiple book chapters. He has attracted almost $30 million in research and demonstration grants from state, federal and private funding sources. He is a frequent invited speaker at national and international conferences.

Charles C. Engel

Charles Engel, M.D., M.P.H., is a senior physician policy researcher at the RAND Corporation. Also a psychiatrist and clinical epidemiologist, his research has focused on health system strategies for improving quality of care and outcomes related to chronic mental and physical health conditions. His work has often focused on the health effects of war, terrorism, and disasters. Engel has authored or coauthored more than 130 scholarly articles, including in the New England Journal of Medicine, JAMA, and the American Journal of Psychiatry. He has published more than 200 scholarly abstracts and delivered more than 200 invited presentations in eleven countries. His work covers mental health in primary care, post-war syndromes and symptoms (e.g., Gulf War syndrome) and PTSD as well as research methods relating to pragmatic randomized trial design, health knowledge readiness and impact assessment, clinical practice guideline development, program evaluation, and implementation science. Funding for Engel's research has come from the National Institutes of Health, Centers for Disease Control, Department of Veterans Affairs, Department of Defense and other agencies. Before RAND, Engel was associate chair for research for the Uniformed Services University Department of Psychiatry. Engel served on the Board of Directors of the International Society for Traumatic Stress Studies and is a recipient of the Porter Award from the Association of Military Surgeons of the U.S. for contributions to psychiatry in the military.

Matthew E. Fink

Matthew E. Fink, M.D., is currently the Louis and Gertrude Feil Professor and Chairman of the Department of Neurology at Weill Cornell Medical College, and Neurologist-in-Chief at New York Presbyterian Hospital / Weill Cornell Medical Center. In addition, he is Chief of the Division of Stroke and Critical Care Neurology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and Vice Chairman of the Medical Board.

Dr. Fink was a founding member and chairman of the Critical Care Section of the American Academy of Neurology, and the Research Section for Neurocritical Care of the World Federation of Neurology. He is board-certified in internal medicine, neurology, critical care medicine, vascular neurology, and neurocritical care. He has been elected as a Fellow of the American Neurological Association, the American Academy of Neurology, and the Stroke Council of the American Heart Association.

Throughout his career, Dr. Fink has been involved in the education and training of students, residents and fellows in the field of stroke and critical care neurology, as well as an active participant in clinical research within this field. He is a leader in this new specialty, has lectured widely, and has published many research and clinical articles in the field of stroke and critical care. In addition, he currently serves as editor of the monthly publication, NEUROLOGY ALERT, and is a Past-President of the New York State Neurological Society.

Annette Fitzpatrick

Annette Fitzpatrick, Ph.D., is an Epidemiologist and Research Professor in the Departments Family Medicine, Epidemiology, and Global Health and a former Associate Dean in the School of Public Health at the University of Washington (UW), Seattle. Her primary interests are in the fields of chronic disease and healthy aging focusing on hypertension, diabetes, heart disease, stroke, and dementia in US and global settings. She was the first Program Director of the multi-site Cardiovascular Health Study (CHS) in 1990 and is an active investigator in the Multi-Ethnic Study of Atherosclerosis (MESA) leading the Cognition Working Group. She has been Principal or Co-investigator in over 30 NIH or CDC-funded studies involving research methodology, cardiovascular risk factors, disease surveillance, and cognitive function in collaborative studies across the US and globally in Vietnam, Nepal, Cambodia, Chile, and Peru. She has published 170 articles to date in peer-reviewed journals and she mentors PhD, MS, MPH and post-doctoral students in the UW School of Public Health and School of Medicine. Dr. Fitzpatrick currently serves on the HMD Committee on Health Care Utilizations and Adults with Disabilities.

Jessica M. Gill

Jessica Gill, Ph.D., R.N., FAAN, obtained a post-doctoral fellowship at the National Institute of Nursing Research (NINR) to better understand the biological mechanisms of PTSD and depression, finding central and peripheral alterations in the in-vivo functioning of both immune and endocrine systems. This line of research also led her to become a Clinical Investigator in the Center for Neuroscience and Regenerative Medicine (CNRM). She also is involved in leading national biomarker studies in athletes, military personnel and civilians. In these positions, she advises in the design and implementation of biomarker studies to ultimately improve the care of individuals with concussions and TBIs.

Currently, Jessica Gill is developing a novel line of research in an effort to reveal the mechanisms underlying differential responses to combat trauma and traumatic brain injury (TBI). This line of inquiry employs a cutting-edge type of biomarker harvesting technology using a nanoparticle capture platform in a prospective sample of patients immediately following a trauma. Findings from her research will identify the clinical and biological risks that predict post-traumatic stress disorder (PTSD) onset and neurological compromise following a traumatic injury.

In her research, Dr. Gill combines biological methods—including proteomics and epigenetics—with neuronal imaging to follow a unique sample of patients during their immediate recoveries and for years afterwards to better understand the risk and resiliency factors related to clinical outcomes. Dr. Gill plans to use this knowledge to improve methods for identifying patients at high risk for psychological and neurological impairments following a traumatic injury, and ultimately develop preventive interventions that are personalized to meet the needs of each patient—mitigating these risks and preserving health.

Jeanne M. Hoffman

Jeanne M. Hoffman, Ph.D., is a Professor in the Department of Rehabilitation Medicine at the University of Washington School of Medicine and is a clinical psychologist who provides direct patient care on the inpatient rehabilitation unit and outpatient clinic at the University of Washington Medical Center. She is active in research examining interventions to improve symptoms and quality of life for individuals with TBI. She has been an investigator with the University of Washington TBI Model System since 2001 and the Project Director since 2015. During that time she has been involved with multiple trials and observational studies. She is the Chair of the National TBIMS Research Committee. She is also the PI of a recently completed Department of Defense (DoD) funded study to compare telephone-delivered cognitive behavioral therapy to education for Veterans with TBI and chronic pain. In addition, she is co-PI of a large pragmatic 6-site trial funded by the Patient Centered Outcome Research Institute (PCORI) to compare two approaches to transition from inpatient rehabilitation after moderate to severe TBI and is the site PI on another PCORI trial to study sleep apnea early after moderate to severe TBI.

Heather Krull

Heather Krull, Ph.D., is a senior economist at the RAND Corporation. Her research spans military recruiting, retention, and health policy topics. She has led a number of studies related to the joint Department of Defense/Department of Veterans Affairs disability evaluation system. Other work includes assessments of how traumatic brain injury and mental health are treated in the military health system, options for maintaining clinical proficiency for future deployments among military providers, developing competencies for providers who rehabilitate service members and veterans who have experienced amputation, and examining readiness patterns among those who transfer from the active component to the reserve component. Krull also led an assessment of the current and projected health care needs of patients served by Veterans Affairs, a requirement of the Veterans Access, Choice, and Accountability Act of 2014. She earned her B.A. in economics and mathematics from St. Norbert College and her Ph.D. in economics from the University of North Carolina-Chapel Hill.

Roger J. Lewis

Roger Lewis, M.D., Ph.D., is a Professor at the David Geffen School of Medicine at UCLA and Chair of the Department of Emergency Medicine at Harbor-UCLA Medical Center. Dr. Lewis’s expertise centers on adaptive and Bayesian clinical trials, including platform trials; translational, clinical, health services and outcomes research; interim data analysis; data monitoring committees; and informed consent in emergency research studies.

Dr. Lewis has served as a grant reviewer for the Agency for Healthcare Research and Quality (AHRQ), the Canadian Institutes of Health Research (CIHR), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute of France, the National Institutes of Health (NIH), the Patient Centered Outcomes Research Institute (PCORI) and foundations. He has also served as a member of the Medicare Evidence Development & Coverage Advisory Committee of the Centers for Medicare & Medicaid Services and as the chair of data and safety monitoring boards (DSMB) for both federally-funded and industry-sponsored clinical trials, including international trials. He is a member of the US FDA Blood Products Advisory Committee. Dr. Lewis is a research methodology reviewer for JAMA and an editor of the JAMA series entitled “JAMA Guides to Statistics and Methods.” He has served as a content reviewer for many other peer reviewed journals. He has authored or coauthored over 240 original research publications, reviews, editorials, and chapters.

In 2009, Dr. Lewis was elected to membership in the National Academy of Medicine. He is a Past President of the Society for Academic Emergency Medicine (SAEM), currently a member of the Board of Directors for the Society for Clinical Trials, and the Senior Medical Scientist at Berry Consultants, LLC, a group that specializes in adaptive clinical trials.

Geoffrey T. Manley

Geoffrey T. Manley, M.D., Ph.D., is the Chief of Neurosurgery at Zuckerberg San Francisco General Hospital and Vice-Chair and Professor of Neurosurgery at the University of California, San Francisco (UCSF). He is a trauma neurosurgeon with clinical interests in brain injury, spinal cord injury and neurocritical critical care. His translational research interests span from the laboratory to the bedside.

Dr. Manley is an internationally recognized expert in neurotrauma. He has published over 250 manuscripts that reflect a wide range of research interests from molecular aspects of brain injury to the clinical care of head trauma patients. He has helped to define new molecular mechanisms of injury to the nervous system that may lead to new treatments for these devastating injuries. He is also considered a leader in the rapidly growing field of precision medicine and clinical informatics for neurocritical care. His many honors include the General Motors Trauma Research Award and the Trauma Research Award from the American College of Surgeons. He has served as a Consultant for the Prehospital Guidelines Committee for the World Health Organization and on numerous research and policy committees for the National Institutes of Health and the Department of Defense.

Judith G. McKenzie

Judith G. McKenzie, M.D., M.P.H., is a Professor, Division Chief, and Residency Program Director in the Division of Occupational and Environmental Medicine, Department of Emergency Medicine at the University of Pennsylvania’s Perelman School of Medicine. Dr. McKenzie’s clinical work centers on disability management, injury care, and environmental exposures. Her research focuses on outcomes in occupational and environmental medicine, especially in the areas of blood borne pathogen exposures, the cost of work-related disability, and graduate medical education. She currently serves on three HMD committees: the Committee of Medical Experts to Assist Social Security on Disability Issues, the Committee on Health Care Utilizations and Adults with Disabilities, and the Committee on Functional Assessment for Adults with Disabilities.

George W. Rutherford

George Rutherford, M.D., A.M., is the Salvatore Pablo Lucia Professor of Epidemiology, Preventive Medicine, Pediatrics and History and Head of the Division of Infectious Disease Epidemiology and Vice Chair of the Department of Epidemiology and Biostatistics at the University of California, San Francisco (UCSF) School of Medicine. He is also Adjunct Professor of Epidemiology and Health Administration at the School of Public Health at UC Berkeley (UCB), and Director of the Joint UCSF-UCB Residency Program in Public Health and General Preventive Medicine. He also directs the Global Strategic Information Group within UCSF's Institute for Global Health Sciences. He is Principal Investigator of a group of cooperative agreements with CDC to support its Center for Global Health and works on projects in Brazil, Cameroon, Côte d’Ivoire, Croatia, the Dominican Republic, the Eastern Caribbean, Ghana, Haiti, Iran, Kenya, Mozambique, Namibia, South Africa, Tanzania, Uganda, Ukraine, Vietnam, and Zambia and Zimbabwe.

He is board certified in pediatrics and general preventive medicine and public health. He has worked primarily in public health, with an emphasis on the epidemiology and control of communicable diseases, both domestically and internationally. He has held a number of positions in public health agencies, including serving as State Health Officer and State Epidemiologist for California, Director of the AIDS Office for the San Francisco Department of Public Health, Director of Immunizations for the New York City Department of Health and an EIS Officer at CDC.

Dr. Rutherford serves as an advisor to the World Health Organization and the United Nations Joint Programme on HIV and AIDS, is the past Chair of the American Academy of Pediatrics Section on Epidemiology and was the first Chair of the Department of Veterans Affairs Research Advisory Council. He served on the Institute of Medicine's Board on the Health of Select Populations and participated in several Academies’ committees, including chairing committees on traumatic brain injury in Iraq and the readjustment needs of military personnel and reservists returning from Iraq and Afghanistan and their families.

Jennifer M. Zumsteg

Jennifer M. Zumsteg, M.D., is a Physical Medicine & Rehabilitation physician in the Department of Rehabilitation Medicine at the University of Washington. She is board certified in PM&R and Brain injury Medicine and holder of the Rehabilitation Medicine Residency Director Endowed Professorship.

Dr. Zumsteg serves patients after neurological and traumatic injuries by working with the interdisciplinary rehabilitation team to address acute and chronic medical and rehabilitation needs. Her clinical work includes inpatient rehabilitation and outpatient clinic based at Harborview Medical Center, the regional level 1 trauma center and a stroke center. She strives to deliver patient-centered rehabilitation care that keeps in mind the best medical treatments possible, patient preference and quality of life, by treating the whole person.

Dr. Zumsteg serves as the PM&R Residency Program Director and the Brain Injury Fellowship Program Director. She is an investigator with the University of Washington TBI Model System.

Dan G. Blazer, II

Dan Blazer, M.D., M.P.H., Ph.D., is a J.P. Gibbons Professor of Psychiatry Emeritus and Professor of Community and Family Medicine at Duke University and also serves as Adjunct Professor in the Department of Epidemiology, School of Public Health, University of North Carolina. Following nine years in academic administration (two as Chair of the Department of Psychiatry and seven as Dean of Medical Education at Duke University School of Medicine) Dr. Blazer returned to teaching, research and practice in July of 1999. From September 1, 2002 until August 30, 2003 he was a fellow at the Center for Advanced Studies of the Behavioral Sciences at Stanford University. He is the author or editor of 39 books, author or co-author of over 220 published abstracts and over 480 peer-reviewed articles. He is also the author or co-author of over 180 book chapters. Many of the book chapters and scientific articles are on the topics of late life depression, epidemiology, consultation liaison psychiatry, the interface between religion and psychiatry, and the epidemiology of substance use disorders.

Dr. Blazer has been the principal investigator on many projects funded by federal grants, state grants and grants funded by private foundations. Most of these research projects have focused on the prevalence of physical and mental illness in the elderly such as the Epidemiologic Catchment Area Project and the Established Populations for Epidemiologic Studies of the Elderly. He has served as the Principal Investigator of the Duke University EPESE, the Piedmont Health Survey of the Elderly and the MacArthur Field Studies of Successful Aging. He also was the original principal investigator (PI) of the Duke Clinical Research Center for the Study of Depression in Late Life and has been funded as PI for a number of training grants as well as the Data and Statistical Coordinating Center for the Clinical Trials Network of the National Institute of Drug Abuse.

Dr. Blazer is an elected member of the National Academy of Medicine from which he received the Walsh McDermott Award for Distinguished Lifetime Service to the Academy. He currently serves on the Committee on Health Care Utilizations and Adults with Disabilities. Dr. Blazer has served on over twenty HMD committees.

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Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans

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