Exploring Early Mild Traumatic Brain Injury Healthcare Access for Adults Seeking Care in Civilian Healthcare Systems

Abstract

University of Washington Abstract Exploring Early Mild Traumatic Brain Injury Healthcare Access for Adults Seeking Care in Civilian Healthcare Systems Orli Miryam Shulein Chair of the Supervisory Committee: Jeanne M. Hoffman Department of Rehabilitation Medicine The overall purpose of this three-paper dissertation is to explore early healthcare access for adults with mild traumatic brain injury (TBI) seeking care in civilian healthcare systems. Particular emphasis is placed on those seeking care for cognitive difficulties given that they are linked to poor outcomes such as incomplete recovery (Eagle et al., 2023; Theadom et al., 2018) and reduced quality of life (Eagle et al., 2023; Merritt et al., 2022; Voormolen et al., 2019; Yousefzadeh-Chabok et al., 2021), and may impede healthcare access by complicating adherence to treatment recommendations (Hamilton et al., 2026; Nelson et al., 2025).The first paper, titled “Referral Practices for Uncomplicated Mild Traumatic Brain Injury-Related Cognitive Concerns: A Health Services Study,” was a retrospective data analysis of electronic medical records from an academic medical system in the Pacific Northwest from 2022 and 2023. Although clinical practice guidelines recommend referral to mild TBI specialists for uncomplicated mild TBI symptoms persisting beyond one month, real-world referral practices are less understood. This study examined the pattern and timing of initial referrals to mild TBI specialty providers, including those treating cognitive symptoms, across the first year post-diagnosis in 780 patients. Data were analyzed using proportions, confidence intervals, and bivariate tests. Observed rates of first referrals to any specialty provider by 1, 3, and 12 months post uncomplicated mild TBI diagnosis were 12%, 17%, and 24%, respectively; rates of first referrals to cognitive providers were 2%, 4%, and 5% at the same time points. Several symptom- and demographic-related peri-diagnostic risk factors (i.e. headaches, anxiety, sleep problems, cognitive problems, dizziness, female sex, age over 40) were associated with increased likelihood of referral to mild TBI specialty and cognitive providers by 3 months. These findings indicate that that a small proportion of individuals were referred during the early intervention window—by 3 months—and that research is needed to understand the factors driving this pattern. The second paper, titled “Early Medical Care Following a Diagnosis of Mild TBI: The Perspectives of Individuals with Persistent Symptoms” was a qualitative study examining the barriers and facilitators of accessing early mild TBI healthcare, and their impact on recovery, from the perspective of 13 individuals with persistent symptoms. A content analysis was used to identify barriers and facilitators in relation to 1) providers’ engagement in healthcare encounters, 2) healthcare system navigation, and 3) patient factors that impacted healthcare encounters. The conclusions were that patients with persistent symptoms perceive a myriad of provider-, system-, and patient-specific factors that shape their recovery experience positively and negatively as they attempt to access early mild TBI care. The third paper, titled “Mild Traumatic Brain Injury: Could Early Self-Management Be the Key to Improving Care of Cognitive Symptoms Before They Become Persistent?” was a commentary paper. It began with a literature review examining systemic and patient factors that act as barriers to accessing early mild TBI care and ended with a proposition to research the integration of self-management interventions into initial healthcare encounters. The paper posited that training patients on self-management skills at the onset of their injury may be a viable way to help them overcome personal and systemic barriers to accessing care. It suggested that mobile health apps may be an accessible and viable way to do so. Overall, this dissertation highlights different gaps in accessing early mild TBI care that originate within healthcare systems, providers, and patients. It also highlights facilitators to accessing care and proposes interventions to improve access to treatment for post-injury symptoms; most notably cognitive concerns. Given the complexity of this issue, the dissertation emphasizes that future research 1) focuses on transferability of findings to communities with similar healthcare systems and populations, 2) integrates a multi-stakeholder perspective when formulating research questions, and 3) involves a multidisciplinary team of researchers.