Factors Influencing Access to Cognitive Rehabilitation Referrals Among Veterans With Moderate-Severe Traumatic Brain Injury.

OBJECTIVE

Examine whether self-reported cognitive symptoms, an indicator of need, were associated with the likelihood that Veterans with moderate-severe traumatic brain injury (msTBI) received a cognitive rehabilitation referral. We also explored whether non-clinical factors modified the relationship between cognitive symptoms and receipt of a referral.

SETTING

Veterans Health Administration (VHA).

PARTICIPANTS

Veterans with msTBI, determined using Comprehensive Traumatic Brain Injury Evaluation data from 2013-2023 ( n = 10 790).

DESIGN

Cross-sectional study of VHA medical record data. Modified Poisson regression modelled the likelihood of cognitive rehabilitation referral based on cognitive symptom severity and non-clinical predisposing (eg, race/ethnicity) and enabling (eg, drive time) factors. Models were specified to explain referral to occupational therapy (OT), speech-language pathology (SLP), and neuropsychology. Statistical interactions determined whether non-clinical factors modified the relationship between cognitive symptoms and referral.

MAIN MEASURES: Cognitive rehabilitation referrals, identified using a validated algorithm detecting key phrases in unstructured consult data. Self-reported cognitive symptom severity measuring using the Neurobehavioral Symptom Inventory.

RESULTS

Only 35% received a cognitive rehabilitation referral, with SLP services being the most common discipline (25%). Veterans with more severe self-reported cognitive symptoms were more likely to receive a referral (relative risk [RR], 1.06; 99% confidence interval [CI], 1.05-1.08), and this relationship was stable in discipline-specific models. However, many Veterans without a referral reported disabling cognitive challenges, indicating unmet need. Non-clinical factors-including drive time (RR, 0.86; 95% CI, 0.77-0.97) and rurality (RR, 0.92; 95% CI, 0.85-0.99)-were associated with receipt of a referral, though these relationships varied across discipline-specific models. Interactions did not provide support for non-clinical factors modifying the relationship between cognitive symptoms and receipt of a referral.

CONCLUSIONS

While cognitive rehabilitation services tend to be allocated to those in need, results revealed gaps in access. Findings can guide development of strategies expanding access to cognitive rehabilitation among Veterans with msTBI, enhancing clinical outcomes.