Dr. Jessica L Ryan

Introduction Over 514,000 active duty Service Members (SMs) have sustained traumatic brain injuries (TBIs) since 2000, with mild TBI (mTBI) emerging as the signature injury of recent wars. Although many recover fully, some experience chronic mTBI with persistent symptoms such as headaches, memory issues, post-traumatic stress disorder (PTSD), chronic pain, depression, and cognitive impairment. The 2021 Department of Veterans Affairs (VA)/Department of Defense (DOD) clinical practice guidelines (CPGs) recommend symptom-focused treatment, addressing comorbid conditions, and supporting reintegration. Congress mandated specialized centers to provide comprehensive care, research, and rehabilitation for combat-injured Veterans and SMs (V/SMs) leading to the development of Intensive Evaluation and Treatment Programs (IETPs) at 5 VA Polytrauma Rehabilitation Centers offering interdisciplinary, individualized inpatient care. The IETPs integrate rehabilitation and specialty services for V/SMs with chronic mTBI and associated health issues. Objective The study aimed to describe the IETPs and the participants it serves with chronic, multiple mTBI and comorbidities. Methods Participants were V/SMs enrolled in the VA TBI Model Systems study and admitted to 1 of the 5 IETPs between 2009 and 2023. Inclusion criteria included TBI diagnosis, age ≥16, and consent for study participation. Data included demographics, military service characteristics, TBI history, and comorbidities. Injury data represented the index TBI qualifying participants for the study, although many had multiple TBIs. Measures included Functional Independence Measure, Disability Rating Scale, PTSD Checklist, and Neurobehavioral Symptom Inventory, among others. Results There have been 821 IETP participants from the program start through 2023. Participants averaged 35.3 years at admission, were predominantly White, non-Hispanic, married men, and included active duty SMs, many from Special Operations Forces (74.2%). Discussion and Conclusions Our findings show the prevalence of participants with comorbidities at IETP admission. The 2021 VA/DOD CPGs caution against over-involvement of specialty care for mTBI but acknowledge that patients with persistent symptoms and comorbidities may benefit from specialized programs like IETPs. Chronic pain, sleep apnea, musculoskeletal issues, and hypertension were common among IETP participants, highlighting the need for intensive inpatient care to address dynamic and interactive symptoms. IETPs provide integrated treatment, removing external demands and offering opportunities for medication trials, interventions, and evidence-based therapies.

•TBI disability is a barrier to receiving nonpharmacologic chronic pain treatment.•Patient lack of trust in non-pharmacologic evidence-based interventions is a barrier to accessing treatment.•Access barriers to evidence-based chronic pain treatments were more prevalent in civilian versus Veterans Affairs healthcare settings.
To examine determinants to evidence-based, non-pharmacologic treatments for chronic pain among persons with traumatic brain injury (TBI) utilizing an access-to-care lens. Chronic conditions such as TBI commonly co-occur with chronic pain which contributes to long-term health outcomes. Despite guideline endorsement of evidence-based non-pharmacologic treatments (NP-EBT) for long-term chronic pain management, persons with TBI report low rates of utilization.
Convenience sample of respondents to an online survey directed to rehabilitation professionals.
Civilian and VA-based centers with TBI providers.
145 US-based providers (63% civilian; 34% VA, 3% DOD).
NA
10-item survey examining barriers to non-pharmacologic evidence-based therapies informed by the robust Levesque access to care framework which includes supply and demand characteristics. Six of the items described patient and community abilities to access care and four focused on healthcare system or infrastructure critical in access. Based on their professional experience, participants were asked to separately rate the frequency of the ten barriers for each of the three specific guideline endorsed interventions for chronic pain: behavioral health therapies, comprehensive chronic pain programs, and substance use disorder treatment.
Across all three interventions, morbidity associated with TBI (i.e., cognitive, physical disabilities), patient lack of understanding, trust, or beliefs about efficacy of intervention, and lack of qualified providers who can deliver the intervention were the most frequently endorsed barriers to delivering NP-EBTs for chronic pain. Subgroup analyses found higher frequency of barriers in civilian vs VA settings particularly related to patient ability to afford [58-70% difference] and insurance coverage [54-61%] of interventions.
Findings have implication for policy and practice to address healthcare inequities that persons with TBI-related disability experience in accessing high-quality, evidence-based treatments.
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Introduction: This study directly compared the relative effectiveness of Strategic Memory Advanced Reasoning Training (SMART), which focuses on metacognitive strategies, to a traditional cognitive rehabilitation (CR) program previously developed and validated for the Study of Cognitive Rehabilitation Effectiveness study (SCORE), in treating warfighters with a history of mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PCS).
Methods: A total of 148 active-duty service members (SMs) were recruited for this randomized controlled trial (RCT). Participants were randomly assigned to either the SMART (n = 80) or SCORE (n = 68) intervention arms. Outcome measures were administered at the start (T1) and end of treatment (T2), and at 3 months post-treatment (T3). Only participants with data from all timepoints and adequate performance validity (SMART: n = 51; SCORE: n = 43) were used in analyses. The primary outcome measure was the Global Deficit Scale (GDS), a composite of seven different objective measures of cognitive performance. Secondarily, participants
completed the Neurobehavioral Symptom Inventory (NSI) and Key Behaviors Change Inventory (KBCI) self-report measures of post concussive symptoms (PCS). Lastly, a cost effectiveness analysis (CEA) was performed directly comparing the relative efficiencies of the two CR interventions.
Results: Mixed Analysis of Variance (ANOVA) showed a significant decrease in GDS scores from T1 to T3 (p < 0.001, ηp2 = 0.217), irrespective of intervention type (p = 0.986, ηp2 = 0.000). The greatest improvement occurred between T1 (SMART: M = 0.70, SD = 0.79; SCORE: M = 0.70, SD = 0.72) and T2 (SMART:M = 0.29, SD = 0.58; SCORE: M = 0.29, SD = 0.40), with scores plateauing at T3
(SMART: M = 0.28, SD = 0.52; SCORE: M = 0.29, SD = 0.57). Similarly, there was a significant decrease in NSI scores over the same period (p < 0.001, ηp2 = 0.138), regardless of intervention type (p = 0.412, ηp2 = 0.010). Additionally, treatment improved patient perceived functionality (KBCI) from T1 to T2 and these gains remained stable at T3 (p < 0.001, ηp2 = 0.377). CEA revealed SMART represented a 60% reduction in cost compared to SCORE.
Discussion: This study demonstrates that SMART is an effective strategy for reducing cognitive deficits and PCS in SMs with a history of mTBI, producing comparable outcomes to a traditional CR program in less time and with improved cost efficiencies.

Purpose: Pollution affects both health and climate change. There is no published research on the use of four environmental pollution exposure codes new to ICD-10-CM. The purpose of this research is to provide a baseline use of the four codes in Florida, the most frequent related principal diagnoses, demographics of patients exposed to environmental pollution, total charges, and associations of total charges that are related to environmental pollution.
Principal Results: There were 341 patients in Florida who visited an ED due to environmental pollution exposure from 2016 to 2019 and 159 patients in Florida who were hospitalized. The total charges for all patients with a documented exposure to environmental pollution were $1,379,217 for ED patients and $9,933,752 for inpatients. The independent variables that were statistically significant in the ED regression model of total charges were other insurance (-0.361 parameter estimate, 0.017 p-value, -30.3% decrease to charges); and for-profit ownership (0.376 parameter estimate, 0.0005 p-value, 45.7% increase to charges). For the inpatient regression model, the independent variables that were statistically significant were Medicare (0.317 parameter estimate, 0.027 p-value, 37.3% increase to charges); LOS (0.091 parameter estimate, <0.0001 p-value, 9.5% increase to charges); exposure to other pollution (0.407 parameter estimate, 0.002 p-value, 50.3% increase to charges); and for-profit hospital ownership (0.292 parameter estimate, 0.012 p-value, 33.9% increase to charges).
Major Conclusions: Patients exposed to air pollution frequently were diagnosed with asthma or other chronic obstructive pulmonary disease. Patients with water pollution exposure frequently had open wounds or infections stemming from open wounds. For both ED and inpatient visits, $11,312,969 was charged to patients over the four year period. Due to the challenges of documenting it clinically, the true charges of healthcare due to environmental pollution are probably much higher. Education may be needed for pollution codes to be understood and used more frequently by clinicians and coders.

Introduction: Ownership may influence trauma center (TC) location. For-profit (FP) TCs require a favorable payor mix to thrive, whereas not-for-profit (NFP) centers may rely on government funding, grants, and patient volume. We hypothesized that the demographics of trauma patients would be different for NFP and FP TCs due to ownership type. We also hypothesized that these demographic differences might be associated with outcomes such as length of stay, reported complications, and mortality.
Methods: We used the Florida Agency for Health Care Administration (AHCA) 2016-2017 inpatient dataset to examine differences in outcomes by trauma center ownership type. Negative binomial and logistical regression was used to compare trauma ownership, length of stay (LOS), reported complications, and mortality of severely injured nonelderly adult trauma patients.
Results: Our study analyzed risk factors and outcomes for 10,700 trauma alert patients. Patients treated at FP TCs were less likely to be Black (OR 0.70, 95% CI: 0.62-0.78), to be uninsured (OR 0.40, 95% CI 0.36-0.45), have Medicare (OR 0.53, 95% CI 0.43-0.66), or Medicaid (OR 0.57, 95% CI 0.50-0.65) (all P < 0.001). Patients treated at FP centers were less likely to have comorbidities (OR 0.89, 95% CI 0.82-0.96) and were associated with a longer LOS (0.10, 95% 0.05-0.15, P < 0.001) in nonelderly adult trauma patients. FP TCs were associated with fewer reported complications (OR 0.83, 95% CI 0.74-0.94) and were associated with a higher likelihood of mortality in nonelderly adults (OR 1.70, 95% CI 1.35-2.12, P < 0.001).
Conclusions: Among this cohort of severe International Classification of Diseases-based injury severity score (ICISS) patients, complications were less likely, but LOS and mortality were increased among FP TC patients. FP centers cared for fewer patients who were Black, uninsured, or who were Medicare/Medicaid/noncommercial insurance.

Public acceptance of the HPV vaccine has not matched that of other common adolescent vaccines, and HPV vaccination rates remain below the Healthy People 2020 target of 80% compliance. The purpose of this study was to evaluate the capacity of nine pediatric clinics in a Federally Qualified Health Center organization to implement a systems-based intervention targeting office staff and providers using EHRs and a statewide immunization information system to increase HPV vaccination rates in girls and boys, ages 11 to 16 over a 16-month period. System changes included automated HPV prompts to staff, postcard reminders to parents when youths turned 11 or 12 years old, and monthly assessment of provider vaccination rates. During the intervention, 8960 patients (11–16 yo) were followed, with 48.8% girls (n=4370) and 51.2% boys (n=4590). For this study period, 80.5% of total patients received the first dose of the HPV vaccine and 47% received the second dose. For the first dose, 55.5% of 11 year old girls and 54.3% of 11 year old boys were vaccinated. For ages 12 to 16, first dose
vaccination rates ranged from the lowest rate of 84.5% for 14 yo girls up to the highest rate of 90.5% for 13 yo boys. Logistic regression showed age was highly significantly associated with first dose completion (OR 1.565, 95% CI 1.501, 1.631) while males did not have a significant association with first dose completion compared to females. The intervention increased overall counts of first and second HPV vaccination rates.

Background: For-profit (FP) trauma centers (TCs) charge more for trauma care than not-for-profit (NFP) centers. We sought to determine charges, length of stay (LOS), and complications associations with TC ownership status (FP, NFP, and government) for three diagnoses among patients with overall low injury severity.
Methods: Adult patients treated at TCs with an International Classification of Diseases-based injury severity score (ICISS) survival probability ≥ 0.85 were identified. Only those who with a principal diagnosis of femur, tibial or rib fractures were included.
Results: Total charges were significantly higher at FP centers than NFP and lower at government centers (89.6% and -12.8%, respectively). FP TCs had a 12.5% longer LOS and government TCs had a 20.4% longer LOS than NFP TCs.
Conclusion: Patients presenting to FP TCs with mild/moderate femur, tibial, or rib fractures experienced higher charges and increased LOS compared with government or NFP centers. There was no difference in overall complication rates.

Background: Illicit drug use increases visits to the hospital. Research is limited on the costs of these healthcare
visits by illicit drug.
Methods: Florida’s Agency for Health Care Administration’s emergency department and inpatient datasets from
2016 to 2018 were analyzed. Adults who used an illicit drug were included in the study population resulting in 709,
658 observations. Cost-to-charge ratios were used to estimate healthcare costs. Linear regression analyzed
associations of illicit drugs with total healthcare cost.
Results: Total healthcare costs are estimated at $6.4 billion over the 3 year period. Medicare paid for the most
patient care ($2.16 billion) with Medicaid and commercial insurance each estimated at $1.36 billion. Cocaine (9.25%)
and multiple drug use (6.12%) increased the costs of an ED visit compared to a patient with cannabis SUD. Opiods
(23.40%) and inhalants use (16.30%) increased the costs of inpatient compared to cannabis SUD.
Conclusion: Healthcare costs are high of patients with illicit drug SUD and poisoning, over half of which are paid
for with tax payer dollars and to an unknown degree hospital write-offs. Injuries and illness of patients using
cocaine and multiple drugs are associated with more expensive ED patient care and opioids and inhalants are
associated with more expensive inpatient care.