Hearing Addresses Neurology CoE Challenges

On January 8, 2020, Iran fired 15 ballistic missiles at the Al-Asad Airbase, where Alan Johnson, an Army Lieutenant Colonel and Aeromedical Physician Assistant, was deployed.

“I have no memory of the first 3 missile impacts because the third missile impact knocked me unconscious,” Johnson said in a statement to a House Committee on Veterans’ Affairs subcommittee on Health in a March 5 hearing. “I woke up just in time to experience missiles 4, 5, and 6.”

March is Brain Injury Awareness month, highlighting how nearly 1 in 4 veterans has screened positive for probable traumatic brain injury (TBI). Veterans with TBI also have a higher risk of suicide: in 2023, the suicide rate for veterans with a recent TBI diagnosis was > 94% higher than for veterans without a TBI diagnosis.

“For many veterans, TBI is not a single episode of care; it is a chronic neurological condition requiring coordinated, longitudinal management,” Glenn D. Graham, MD, PhD, president of the Association of VA Neurology Service (AVANS) and former executive director of the US Department of Veterans Affairs (VA) Neurology Clinical Programs said in a statement. “TBI is neurologically complex and often intertwined with other conditions … Accurate diagnosis and effective treatment require subspecialty expertise in areas such as epilepsy, headache medicine, and neurodegenerative disease. The Centers of Excellence (CoE) ensure that this expertise is available across our national system.”

An estimated 25% of service members who have been hospitalized with TBI will develop long-term disability. Studies show direct links between TBI and the development of neurological disorders. Lt. Col. Johnson, for instance, has been diagnosed with posttraumatic stress disorder, cranial nerve damage, double vision, chronic insomnia, ringing in the ears, neck pain, balance problems, difficulty in word finding, and depression. After 37 years in emergency medicine, Johnson said, he had to “bench” himself due to the sequelae: “I can’t do what I love to do anymore.”

However, many service members may not be diagnosed correctly. Blast-related brain injuries may be delayed, subtle, and easily missed in combat environments. In research Johnson coauthored, > 20% of troops were diagnosed with mild TBIs 4 weeks after the attack. Moreover, he said, soldiers being screened may underreport their symptoms in order to return to duty.

Timely diagnosis is key, but so is consistent follow-up. Ranking Member Rep. Julia Brownley (D-CA) said, “TBI is not an illness that goes away with medicine … It is a long-term chronic condition for which many veterans need ongoing integrated and well-coordinated care.”

The Veterans Health Administration (VHA) has 5 polytrauma rehabilitation centers, 23 polytrauma network sites, numerous polytrauma support clinics, and > 110 TBI teams. Rachel McArdle, deputy executive director of rehabilitation and prosthetic services at VHA, told the subcommittee that since 2007, VHA has screened 1.8 million veterans for TBI. Every veteran, she said, receives an individualized plan addressing physical, cognitive, and emotional needs, often integrated with mental health services and patient-centered care approaches.

Graham and others expressed concern that despite their importance, the CoEs faced daunting challenges.

“Budgets have generally increased in recent years, but often unpredictably,” Graham noted. “Due to the recent focus on downsizing VHA staffing, a number of key positions are currently vacant due to clinical and administrative staff reassignment, resignation to accept positions outside VHA, or opting for early or standard retirement.”

In a statement, Natalia S. Rost, MD, MPH, President of the American Academy of Neurology, urged Congress to continue to provide funds for Neurology CoEs: “We look forward to continuing to work with Congress to secure robust, sustained funding to ensure our nation’s veterans receive the highest quality of neurologic care for years to come.”

Joel Scholten, MD, VA Executive Director of Physical Medicine and Rehabilitation, told the panel that the VA Office of Research and Development allocated $50 million for fiscal year 2025 research projects on TBI. Some are aimed at developing better biomarkers not only for TBI but also co-occurring mental health diagnoses. “As we work to better understand and better identify biomarkers not only for TBI but also looking at those associated or affiliated risk factors that can enhance suicide risk, we'll better be able to care for veterans.”

“I’m confident that the VA has all the data, legal authority, and funding it needs to effectively treat TBI,” Rep. Mariannette Miller-Meeks (R-IA), subcommittee chair, added. “Here's where I’ve seen the VA needs improvement: Consistent quality in patient care and data.”

Still, Graham argued that staffing reductions may be straining VHA’s ability to continue its mission. Anxiety about job security, increased vacancies, inadequate space in overcrowded VA medical centers due to the return to office mandate, and the loss of psychological safety and a positive workplace culture threatened the quality of neurology care at VHA.

“The VHA has long promoted the path to becoming a high reliability organization, with an obsessive attention to accuracy and avoidance of clinical errors, in a climate of psychological safety that encourages reporting of mistakes and ‘near misses’ in a concerted effort to prevent patient harm,” he argued. “Unfortunately, these principles appear to be in abeyance at present.”