Research Career Scientist (RCS) Award Renewal

Va Salt Lake City Healthcare System, Salt Lake City UT

Investigators

Abstract

My VA Career Scientist Award afforded an opportunity to develop health services informatics studies focused on computational phenotyping in Veterans with complex comorbidity related to brain health (e.g, TBI, epilepsy, dementia) and begin a body of caregiver research examining the impact of caregiving for Veterans with complex comorbidity. It also allowed me the opportunity to share scholarly findings in excellent journals, to mentor 27 members of the next generation of VA, academic and Department of Defense (DOD) researchers in the past three years, and to provide leadership and service to VA-DoD research partners and colleagues. With the onset and duration of the Post-9/11 conflicts, I translated my early research on quality of care for older Veterans to understanding complex comorbidity in Post-9/11 era Veterans to identify high-impact problems that can be informed using health services research. To address VA priorities, I focused my research on traumatic brain injury (TBI) and TBI sequelae/comorbidity (including epilepsy), and issues related to caregivers of Veterans with complex comorbidity. I am VA's primary expert in using diverse DoD and VA data to develop comorbidity phenotypes (patterns of comorbidity) to guide VA policy and clinical care. My work in TBI phenotyping was described by the Cohen Brain Trauma Blueprint as the first step in identifying the right treatment for the right patient at the right time. Using longitudinal VA health system data we found, for the first time, three Polytrauma (TBI, mental health and pain) phenotypes (stable, decline, and improvement) that are meaningfully associated with adverse outcomes (e.g., homelessness, suicidality, overdose). Our finding that those in the improvement phenotype were less likely to have mental health diagnoses in DoD led us to develop the Long-term Impact of Military Relevant Brain Injury Consortium (LIMBIC) Phenotype study that is currently using DoD and VA data to develop longitudinal phenotypes in DoD data, which are then linked to VA outcomes (for those with VA care); and to help understand differences between those who do and do not receive VA care and the treatment trajectories associated with better outcomes. My work in epilepsy has focused on quality measure development/assessment and phenotyping post- traumatic epilepsy (PTE) and related outcomes. My early work developing the first epilepsy quality measures provided the foundation for American Academy of Neurology quality measures and an impetus for health services research in epilepsy. We continue to use these measures to assess quality of care within the VA in collaboration with the VA Epilepsy Centers of Excellence (ECOE). Concern among ECOE clinicians for post- traumatic epilepsy (PTE) in Post-9/11 Veterans led to the development of my program of research on post- traumatic epilepsy with an emphasis on Veterans with mild TBI (mTBI). We found that Veterans with mTBI documented in VA/DoD care have elevated risk for epilepsy, but it is higher among those with a lifetime history of moderate or severe TBI. We also found that those with PTE are more likely than other Veterans to have treatment-resistant epilepsy, and significantly lower quality of life and health status. My collaboration with Veterans, Service Members, and caregivers led to a focus on the health impact of caregiving for patients with complex comorbidity and culminated in my leading the Data and Policy Core of the VA HSR&D funded Elizabeth Dole Center of Excellence (CoE) for Veteran and Caregiver Research. Data from an early national survey revealed phenotypes of caregiver distress associated with suicidal ideation/ attempt since becoming a caregiver that were also associated with a “loss of self” in the caregiver role. Within the Dole CoE we are further expanding this exploration to unmet needs in caregivers and Veterans who are at high risk of institutionalization that can inform VA programs and policies for the caregiver support program. These studies are addressing VA's Strategic plan to identify/define Veterans with complex care needs, identify treatment patterns/outcomes, and identify gaps for future programs/policies to meet those needs.