Systematic Review of the Military Career Impact of Mental Health Evaluation and Treatment.

INTRODUCTION: Military leaders are concerned that active duty members' fear of career impact deters mental health (MH) treatment-seeking. To coalesce research on the actual and perceived consequences of MH treatment on service members' careers, this systematic review of literature on the U.S. Military since 2000 has been investigating the following three research questions: (1) is the manner in which U.S. active duty military members seek MH treatment associated with career-affecting recommendations from providers? (2) Does MH treatment-seeking in U.S. active duty military members impact military careers, compared with not seeking treatment? (3) Do U.S. active duty military members perceive that seeking MH treatment is associated with negative career impacts? MATERIALS AND METHODS: A search of academic databases for keywords "military 'career impact' 'mental health'" resulted in 653 studies, and an additional 51 additional studies were identified through other sources; 61 full-text articles were assessed for eligibility. A supplemental search in Medline, PsycInfo, and Google Scholar replacing "career impact" with "stigma" was also conducted; 54 articles (comprising 61 studies) met the inclusion criteria. RESULTS: As stipulated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies were summarized on the population studied (U.S. Military Service[s]), sample used, intervention type, comparison group employed, outcome variables, and findings. Self-referred, compared with command-directed, service members appear to be less likely to face career-affecting provider recommendations in non-deployed and deployed settings although the data for the latter are not consistent. Of the two studies that tested if MH treatment actually negatively impacts military careers, results showed that those who sought treatment were more likely to be discharged although the casual nature of this relationship cannot be inferred from their design. Last, over one-third of all non-deployed service members, and over half of those who screened positive for psychiatric problems, believe that seeking MH treatments will harm their careers. CONCLUSIONS: Despite considerable efforts to destigmatize MH treatment-seeking, a substantial proportion of service members believe that seeking help will negatively impact their careers. On one hand, these perceptions are somewhat backed by reality, as seeking MH treatment is associated with a higher likelihood of being involuntarily discharged. On the other hand, correlational designs cannot establish causality. Variables that increase both treatment-seeking and discharge could include (1) adverse childhood experiences; (2) elevated psychological problems (including both [a] the often-screened depression, anxiety, and posttraumatic stress problems and [b] problems that can interfere with military service: personality disorders, psychotic disorders, and bipolar disorder, among others); (3) a history of aggressive or behavioral problems; and (4) alcohol use and abuse. In addition, most referrals are self-directed and do not result in any career-affecting provider recommendations. In conclusion, the essential question of this research area-"Does seeking MH treatment, compared with not seeking treatment, cause career harm?"-has not been addressed scientifically. At a minimum, longitudinal studies before treatment initiation are required, with multiple data collection waves comprising symptom measurement, treatment, and other services obtained, and a content-valid measure of career impact.

Epilepsy quality performance in a national sample of neurologists and primary care providers: Characterizing trends in acute and chronic care management.

INTRODUCTION: Epilepsy-specific quality indicators and performance measures have been published and revised multiple times. The application of epilepsy-specific quality measures has been demonstrated in a few healthcare systems. However, there is no information to date on changes in epilepsy performance measures over time, and across settings, in a national sample. The Department of Veterans Affairs (VA) healthcare system provides an opportunity to study the changes in epilepsy-specific performance over time, in acute versus chronic epilepsy care, as well as in primary versus specialty care. METHODS: Chart extractions of newly diagnosed epilepsy and chronic care of Veterans with epilepsy within the VA system were performed. Veterans with ICD-9-CM diagnosis 345.XX and 780.39 from 2007-2014 were identified. Epilepsy-specific performance measures based on the Quality Indicators in Epilepsy Treatment (QUIET) VA measurement were ascertained for each Veteran with epilepsy. Difference in care across time (2009, 2012, and 2014), source of epilepsy care (primary care only, neurology only, and shared care between neurology and primary care) was analyzed. Differences in proportion of care measures across variables were compared using chi-square statistics. RESULTS: Chart reviews of 2386 Veterans with epilepsy included 297 women (11.2%), 281 (10.5%) receiving acute care and 2105 (89.5%) receiving chronic care. Across all years 203 (72.5%) had electroencephalograph ordered/performed, 225 (80.4%) had neuroimaging ordered/performed, 106 (37.9%) were instructed about driving precautions, 71 (25.4%) were educated about safety and injury prevention, and 251 (89.6%) had anti-seizure medication monotherapy initiated. The proportion of people with new-onset seizures educated about diagnosis and type of seizure increased over time 30 (34.9%) in 2008, 42 (43.8%) in 2012, and 52 (53.1%). Of the 2105 Veterans receiving chronic care 864 (41.1%) encounters documented compliance of anti-seizure medication, 361 (17.15%) encounters addressed driving restrictions, 1345 (63.9%) encounters documented general education and counseling, 250 (11.9%) of encounters documented safety and injury prevention, 488 (23.2%) of encounters documented medication side effects, and 463 (22.0%) of encounters documented discussion of treatment options. With chronic epilepsy care, documentation of quality measures did not change with time. Veterans who were co-managed by primary care and neurology had a higher proportion of driving instruction and safety instructions compared to neurology or primary care alone. DISCUSSION: In general, the epilepsy performance measures were high (>70% of new-onset epilepsy) for documentation diagnostic procedures (such as EEG and neuroimaging) and low across key educational and counseling measures (<50%). Despite the emphasis on the importance of psychosocial education and holistic management in the academic literature, through advocacy work, and during professional meetings, there was not a significant improvement in education and counseling over time. Some aspects of psychosocial education were performed better among primary care providers compared to neurologists. However, more attention and work need to be dedicated on implementing and documenting education and counseling people with epilepsy in the clinical setting.

Measuring coordination of epilepsy care: A mixed methods evaluation of social network analysis versus relational coordination.

OBJECTIVES: Coordination of multidisciplinary care is critical to address the complex needs of people with neurological disorders; however, quality improvement and research tools to measure coordination of neurological care are not well-developed. This study explored and compared the value of social network analysis (SNA) and relational coordination (RC) in measuring coordination of care in a neurology setting. The Department of Veterans Affairs Healthcare System (VA) established an Epilepsy Centers of Excellence (ECOE) hub and spoke model of care, which provides a setting to measure coordination of care across networks of providers. METHODS: In a parallel mixed methods approach, we compared coordination of care of VA providers who formally engage the ECOE system to VA providers outside the ECOE system using SNA and RC. Coordination of care scores were compiled from provider teams across 66 VA facilities, and key informant interviews of 80 epilepsy care team members were conducted concurrently to describe the quality of epilepsy care coordinating in the VA healthcare system. RESULTS: On average, members of healthcare teams affiliated with the ECOE program rated quality of communication and respect higher than non-ECOE physicians. Connectivity between neurologist and primary care providers as well as between neurologists and mental health providers were higher within ECOE hub facilities compared to spoke referring facilities. Key informant interviews reported the important role of formal and informal programming, social support and social capital, and social influence on epilepsy care networks. CONCLUSION: For quality improvement and research purposes, SNA and RC can be used to measure coordination of neurological care; RC provides a detailed assessment of the quality of communication within and across healthcare teams but is difficult to administer and analyze; SNA provides large scale coordination of care maps and metrics to compare across large healthcare systems. The two measures provide complimentary coordination of care data at a local as well as population level. Interviews describe the mechanisms of developing and sustaining health professional networks that are not captured in either SNA or RC measures.

Guidelines and Quality Standards for Adults with Epilepsy.

Guidelines and quality measures for epilepsy care have the potential to improve the quality of epilepsy care. Quality measures are increasingly used for pay-for-performance. This article describes different guidelines and quality measures that have been used to identify best practices, types of best practices for use in clinical care developed using each of these approaches, and information on how to interpret the recommendations in specific guidelines and quality measures described elsewhere in this issue.

The prevalence of epilepsy and association with traumatic brain injury in veterans of the Afghanistan and Iraq wars.

OBJECTIVE: To examine the association of epilepsy with traumatic brain injury (TBI) in Afghanistan and Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) Veterans. DESIGN: Cross-sectional observational study. PARTICIPANTS: A total 256 284 OEF/OIF Veterans who received inpatient and outpatient care in the Veterans Health Administration in fiscal years 2009-2010. MAIN OUTCOME MEASURES: We used algorithms developed for use with International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify epilepsy, TBI (penetrating TBI [pTBI]/other TBI), and other risk factors for epilepsy (eg, stroke). TBI and other risk factors were identified prior to the index date (first date of seizure or October 1, 2009) for primary analyses. RESULTS: Epilepsy prevalence was 10.6 per 1000 (N = 2719) in fiscal year 2010; age-adjusted prevalence was 6.1. Of 37 718 individuals with a diagnosis of TBI, 29 297 Veterans had a diagnosis of TBI prior to the index date. Statistically significant associations were found between epilepsy and prior TBI diagnosis (pTBI: adjusted odds ratio = 18.77 [95% confidence interval, 9.21-38.23]; other TBI: adjusted odds ratio = 1.64 [1.43-1.89]). CONCLUSIONS: Among OEF/OIF Veterans, epilepsy was associated with previous TBI diagnosis, with pTBI having the strongest association. Because war-related epilepsy in Vietnam War Veterans with TBI continued 35 years postwar, a detailed, prospective study is needed to understand the relationship between epilepsy and TBI severity in OEF/OIF Veterans.

Providers' perspectives on treating psychogenic nonepileptic seizures: frustration and hope.

Recent diagnostic and treatment advances in psychogenic nonepileptic seizures (PNES) have the potential to improve care for patients, but little is known about the current state of PNES care delivery in the Veterans Health Administration (VA). We conducted semistructured interviews with 74 health-care clinicians and workers in the VA, eliciting provider perceptions of PNES care. Data were analyzed according to principles of Grounded Theory. The results revealed variation in care and two emergent domain themes of frustration and hope. Frustration was manifest in subthemes including Complexity, Patient Acceptance, Uncertainty About Treatment, Need for Evidence-based Treatment, and Failure of Cross-Disciplinary Collaboration between neurologists and mental health providers. Hope encompassed subthemes of Positive Attitudes, Developing Cross-Disciplinary Treatment, and Specific PNES Care. Increased resources for diagnosing, treating, and researching PNES have improved awareness of the disorder. More research is needed to understand patients' and caregivers' perceptions of PNES care.

Implementation of the Epilepsy Center of Excellence to improve access to and quality of care--protocol for a mixed methods study.

BACKGROUND: To address the growing problem of epilepsy among aging Veterans and younger Veterans who have experienced a traumatic brain injury (TBI), the Veterans Health Administration (VA) has implemented 16 Epilepsy Centers of Excellence (ECOE) to assure increased access to high quality of care for Veterans with epilepsy. Each ECOE consists of a network of regional hubs to which spoke facilities refer Veterans for subspecialty treatment. The ECOEs are expected to improve access to and quality of epilepsy care through patient care, consultation and education. This study aims to: evaluate the effectiveness of the ECOE structure by describing changes in the quality of and access to care for epilepsy before and after the ECOE initiative using QUality Indicators in Epilepsy Treatment (QUIET Indicators); describe associations between changes in the structure and processes of care and Relational Coordination (RC), a model of task-oriented communication that has been shown to play a role in implementation science; and determine if variations in care are related to levels of RC. METHODS: This four-year comparative case study uses a mixed-methods approach. We will use VA inpatient, outpatient, pharmacy, and chart abstraction data to identify changes in the quality of and access to epilepsy care in the VA between Fiscal Year 2008 and Fiscal Year 2014. Qualitative and survey methods will be used to identify changes in the structure and processes of epilepsy care and RC over the course of the study. We will then link data from the first two objectives to determine the extent to which quality of and access to epilepsy care is associated with RC using multivariable models. DISCUSSION: This innovative study has the potential to improve understanding of hub-and-spoke model effectiveness, VA epilepsy care, and models of epilepsy specialty care more globally. Moreover, it contributes to implementation science by advancing understanding of the role of RC in the context of a major transformation in the structure of care delivery in a national integrated healthcare system.