Gaps in Access to Cognitive Rehabilitation Referrals Among Veterans with Mild Traumatic Brain Injury

Adam R Kinney; Molly E Penzenik; Jeri E Forster; Frederica O'Donnell; Nazanin H Bahraini

doi:10.1016/j.apmr.2025.11.023

Gaps in Access to Cognitive Rehabilitation Referrals Among Veterans with Mild Traumatic Brain Injury

Arch Phys Med Rehabil. 2025 Dec 10:S0003-9993(25)01073-1. doi: 10.1016/j.apmr.2025.11.023. Online ahead of print.

Authors

Adam R Kinney¹, Molly E Penzenik², Jeri E Forster², Frederica O'Donnell³, Nazanin H Bahraini⁴

Affiliations

¹ Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO. Electronic address: Adam.Kinney@va.gov.
² Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO.
³ Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, DC.
⁴ Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, CO; University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation and Psychiatry, Aurora, CO.

PMID: 41386575
DOI: 10.1016/j.apmr.2025.11.023

Abstract

Objective: To examine whether cognitive symptoms, an indicator of need, was associated with the likelihood that Veterans with mild traumatic brain injury (mTBI) received a cognitive rehabilitation referral in the Veterans Health Administration (VHA). We also examined whether non-clinical factors modified the relationship between cognitive symptoms and receipt of a referral.

Design: Retrospective cohort study of VHA medical record data. Modified Poisson regression was used to model the likelihood of receiving a cognitive rehabilitation referral based on cognitive symptom severity and non-clinical predisposing (e.g., race/ethnicity) and enabling (e.g., drive time) factors. Discipline-specific models were specified to explain a referral to occupational therapy (OT); speech-language pathology (SLP) services, and neuropsychology. Statistical interactions determined whether non-clinical factors modified the relationship between cognitive symptoms and receipt of a referral.

Setting: VHA.

Participants: Veterans with a mTBI, determined using the Comprehensive Traumatic Brain Injury (TBI) Evaluation database (n=77,001).

Interventions: N/A.

Main outcome measure: Cognitive rehabilitation referrals (no/yes), identified using a validated algorithm.

Results: Only 26% received a cognitive rehabilitation referral, with SLP services being the most common discipline (19%), followed by neuropsychology (6%) and OT (3%). Veterans with more severe cognitive symptoms were more likely to receive a referral, and this relationship was stable in discipline-specific models. However, many Veterans without a referral reported severe cognitive challenges, indicating unmet need. Moreover, non-clinical factors-including Hispanic ethnicity, employment status, rurality, drive time, neighborhood disadvantage, and VHA enrollment priority group (e.g., requiring a co-pay)-modified the relationship between cognitive symptom severity and receipt of a referral.

Conclusions: These results suggest that while cognitive rehabilitation services tend to be allocated to those in need, significant gaps in access exist. Findings lay the foundation for developing strategies that expand access to beneficial cognitive rehabilitation among Veterans with mTBI, reducing their cognitive symptoms and enhancing their daily function.

Keywords: Brain Injuries, Traumatic; Cognitive Dysfunction; Cognitive Training; Guideline Adherence; Health Care Quality, Access, and Evaluation.