Publicly Released: March 30, 2023
The objective of this evaluation was to determine the extent to which the Defense Health Agency and Military Service medical departments implemented policies and procedures and provided oversight to ensure that Service members who experienced a traumatic brain injury (TBI) were identified and screened to determine their appropriate level of care. In addition, we determined the extent to which the U.S. Central Command (USCENTCOM) Service Components screened, identified, and documented signs and symptoms of TBIs.
As highlighted in the DoD OIG November 2021 report on traumatic brain injuries in the USCENTCOM area of responsibility, TBIs are one of the invisible wounds of war and one of the signature injuries of troops wounded in Afghanistan and Iraq. From 2000 to 2022, approximately 458,894 Service members were diagnosed with a TBI during training or in combat. Due to the high rate of TBIs, the National Defense Authorization Act for FY 2020 required the DoD to study the effectiveness of the use of routine neuroimaging in diagnosis, treatment, and prevention of brain injury due to blast pressure exposure during combat and training. In a 2020 letter to the DoD Acting Inspector General, the Congressional Brain Injury Task Force emphasized the importance of accurate and transparent reporting of traumatic brain injuries.
The DoD did not consistently implement policies and procedures to determine the care needed for Service members with TBIs. Specifically:
- Military Health System (MHS) providers did not consistently identify and assess patients with TBIs;
- the DoD did not implement consistent processes for the management of TBI care; and
- the DoD did not implement consistent processes for the disposition of care, including return to duty status for patients diagnosed with a TBI.
We recommend that the Director of the Defense Health Agency review and update Defense Health Agency Procedural Instruction 6 490.04. At a minimum, the review and update should:
- establish the timeline associated with 72-hour followup,
- change the 72-hour followup from a recommendation to a requirement, and
- review the applicability and clinical use in its entirety of the Military Acute Concussion Evaluation, Version 2 (MACE 2) tool in Military Treatment Facilities.
We recommend that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Assistant Secretary of Defense (Health Affairs), Director of the Defense Health Agency, Service Surgeons General, and Joint Staff Surgeon, establish an oversight plan for the management of TBI care within the MHS. At a minimum, the oversight plan should:
- include the completion and tracking of required screening tools, including MACE 2;
- include the completion and tracking of the Progressive Return to Activity protocol;
- include the completion and tracking of any required followup processes for Service members diagnosed with a TBI; and
- develop a revised methodology to verify that MHS providers consistently code all Service members diagnosed with a TBI.
We recommend that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Assistant Secretary of Defense (Health Affairs), Director of the Defense Health Agency, Service Surgeons General, and Joint Staff Surgeon, establish a Traumatic Brain Injury Program of Record for traumatic brain injury care within the Military Health System that:
- establishes baseline resource requirements and guidance for personnel, equipment, and staffing and budget modeling; and
- standardizes programming, concept of operations, business practices, staffing, and referral standards.
We recommend that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Assistant Secretary of Defense (Health Affairs), Director of the Defense Health Agency, Service Surgeons General, and Joint Staff Surgeon, establish a process by which MHS providers can access, create, and update Service members’ profiles, regardless of their Service Component.
Management Comments and Our Response
The Under Secretary for Personnel and Readiness and the Director of the Defense Health Agency did not respond to the recommendations in the report. Therefore, the recommendations are unresolved. We request they provide comments within 30 days of final report issuance. Please see the Recommendations Table on the next page.
This report is a result of Project No. D2022-DEV000-0020.000.