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Identification of brain injuries in deployed environment surged after enactment of DoD policies

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SILVER SPRING, Md. — Between 2006 and 2013, policies developed and implemented by the Department of Defense to encourage reporting of theater sustained brain injuries more than doubled the number of identified traumatic brain injuries (TBIs) in the U.S. military, according to a new study by researchers at the Defense and Veterans Brain Injury Center (DVBIC). This study is the first comprehensive analysis of the role of Defense Department and service-specific policies on identification of deployment-related TBI.

The results, reported in today’s issue of the American Journal of Public Health, point to a number of Army Messages (ALARACTs) and Department of Defense Instructions that effectively curbed underreporting and underdiagnoses of theater-sustained concussions. 

“More than 2.6 million service members were deployed to Afghanistan and Iraq, where TBI, primarily caused by blast, was underreported and underdiagnosed” said lead author Yll Agimi, a contract health data scientist at DVBIC. “Even in the challenging theater environment, Department of Defense and service-specific efforts showed considerable success in tackling this longstanding problem.”

The Defense Department was criticized for not doing enough to identify brain injuries among deployed service members. “The Defense Department responded by enacting specific requirements that led to a significant increase in the identification and treatment of service members with combat sustained TBIs that may have been missed otherwise,” said Donald Marion, a contract senior neurosurgeon with DVBIC and co-author of the study.  

Agimi and colleagues compared the number of TBIs before and after introduction of new policies aimed at screening for and identifying deployment-related TBIs. Two Army policies were especially impactful. ALARACT 143/2006, which alerted Army commanders to concussions and to medically evaluate soldiers if they showed “red flags,” was associated with a nearly three-fold increase in identified TBIs. ALARACT 160/2007, which required TBI awareness training for all pre-deployment service members, was associated with another one-fold increase in the rate of reported TBIs. Among airmen, introduction of TBI screening questions on the Post Deployment Health Assessment was associated with a 78 percent increase in reported TBIs. The 2010 Defense Department’s Directive Type Memorandum (DTM 09-033), mandating medical evaluation of those within 50 meters of a blast, was associated with an 80 percent increase in identified TBIs among soldiers, a 51 percent increase among sailors, and a 124 percent increase among Marines. These findings held even after the researchers accounted for other factors that could influence higher TBI rates, ranging from higher combat intensity and improved medical technologies in theater to better TBI documentation across the Military Health System.

Importantly, the study found that development of new TBI identification and treatment policies may not have the intended impact unless there is adequate and effective DoD-wide communication of the policy. “A key finding of this study is the importance of disseminating a new policy to all service members,” said Katherine Helmick, DVBIC acting director, also a co-author on the study. “These policies worked because the Defense Department and the services got the word out about them. However, more work remains to be done. It is very important that these findings spur further study to determine the best approach to ensure all service members with brain injuries are identified and treated.”

Ultimately, the identification of more TBIs should lead to better outcomes. “Early detection of brain injury affords the opportunity for the earliest treatment, which promotes best outcomes,” said Helmick. “And we have a commitment to our service members to get them treated in the best way possible and to those whom they defend to ensure a medically ready force.”

The study, entitled “Role of Department of Defense policies on traumatic brain injury identification and reporting among deployed US service members (2001-2016)”appears in the March 22 issue of the American Journal of Public Health. The Defense and Veterans Brain Injury Center, a center of excellence with the Defense Health Agency, supported this work.

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