slargestcentralizedhealthsystem, caring for nearly 500,000 indi- vidualswithPTSD,theVHAisuniquely positioned to examine variation in itsprescribing practices.One specific area of concern re-lated to practice variation is thequality of care delivered by VHAcommunity-based outpatient clinics(5). The goal with the establishmentof these clinics is to offer accessnearer to the veteran
s home, andover 800 clinics were in operation asof 2010. The challenge is to ensurehigh-quality care equivalent to thatprovided by Veterans Affairs (VA)medical centers, despite differencesin the breadth of services availableand many other important resources.One particular concern has beenmental health monitoring and a per-ceived lack of access to mental healthspecialists (6).Access to high-quality care atcommunity-based outpatient clinicsis particularly important for rural veterans, who account for approxi-mately 41% of VHA enrollees (7). Animportant driving force behind clinicexpansion has been the increasingnumber of veterans serving in com-bat roles who came from and arereturning to rural areas (7). Ruralresidence has been associated withproblems accessing health care, worsehealth status, and higher prevalenceof chronic diseases (8
12). Differ-ences in physician practice patternsbetween rural and urban settings havebeen observed, although much of this work has been done outside the VHA(13
16). Although there do not ap-pear to be important disparities inaccess to prescription medications(17), some studies suggest that ruralresidents may be at increased risk for certain types of inappropriate pre-scribing practices (18,19). Ensuringaccess for rural veterans has beena focal point for the VHA, but thepotential impact on prescribing qual-ity has neither been sufficiently stud-ied nor well characterized among veterans with PTSD.To address these important issues,this study included two primary objectives related to benzodiazepineprescribing variation among veterans with PTSD. Our first objective was tocharacterize the variation in prescribingfrequency across multiple levels of aggregation, including census region, Veterans Integrated Service Network (VISN), and individual medical center. We hypothesized that clinically signif-icant variation in benzodiazepine pre-scribing would be observed at all levelsbut that the extent of variation woulddecrease over time. Our second objec-tive was to evaluate differences inbenzodiazepine prescribing frequency between rural and urban residents andbetween community-based outpatientclinicsand medicalcenters.Wehypoth-esized that benzodiazepine prescribing would be more common among ruralresidents and for patients receivingcare at community-based clinics.
National administrative VHA data were obtained for the 11-year periodspanning fiscal years (FYs) 1999through 2009 (October 1, 1998, toSeptember 30, 2009). Prescriptiondrug records were obtained from the VHA Pharmacy Benefits Manage-ment Services. Inpatient dischargeand outpatient encounter data sets were obtained from the Austin In-formation Technology Center. Thisstudy was approved by the University of Iowa Institutional Review Boardand the Iowa City VHA Research andDevelopment Committee.
Eligible veterans for this study in-cluded all VHA enrollees in FY 1999through FY 2009 who had an in-patient or outpatient encounter withan
code of 309.81. Veterans wereconsideredtohavePTSDduringa given year if they had at least oneencounter coded for PTSD as either a primary or secondary diagnosis. ThisPTSD case definition has been usedin several prior studies examiningpsychiatric medication use among veterans with PTSD (20
22). Theestimated rate of false-positive casesresulting from administrative miscod-ing is infrequent (
4%) with thismethodology (23,24). As previously reported, the number of veteranstreated for PTSD in the VHA in-creased nearly threefold during thestudy time frame, from 170,685 in FY1999 to 498,081 in FY 2009 (22). InFY 2009, 7.5% of veterans with PTSD were women, and the mean
SD age was 53.8
Benzodiazepine use was defined asany outpatient prescription fill for thefollowing medications: alprazolam,chlordiazepoxide, clonazepam, clor-azepate, diazepam, estazolam, fluraze-pam,halazepam,lorazepam,oxazepam,prazepam, quazepam, temazepam, andtriazolam. This definition did not in-clude any requirement for a minimumquantity, days
supply, or specific dos-age form. A majority (94%) of veterans with any benzodiazepine use received
supply, and approximately two-thirds received more than 90 daysofcontinuousbenzodiazepinetreatment(22).
Site of care
The primary site of PTSD care wasassigned on the basis of the station where the veteran had the mostPTSD-coded encounters during a given fiscal year. Each site of care was classified as a community-basedoutpatient clinic or medical center and aggregated at multiple organiza-tional levels for different analyses.Each community-based outpatientclinic in the VHA is assigned to a parent medical center, and medicalcenters are assigned to a VISN. Wefurther grouped VISNs into regionsbased on overlapping boundaries with U.S. census regions (Northeast,South, Midwest, and West). Stations were considered a medical center according to the classification usedby the 2009
VHA Facility Qualityand Safety Report
(25). Medicalcenters and community-based out-patient clinics are predominantly located in urban areas (86% and58%, respectively).
Rural or urban residence
Rural or urban residence was de-termined by using the Rural-UrbanCommuting Areas (RUCA) system, which was mapped with the zip codeof the veteran
s residence (26). Be-ginning with the RUCA four-category classification system (urban, largerural towns, small rural towns, andisolated rural towns), we further collapsed all nonurban categories
January 2013 Vol. 64 No. 1