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Inappropriate Treatments for PTSD

Inappropriate Treatments for PTSD

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Despite guideline recommendations against their use, benzodiazepines are among the most commonly prescribed psychotropic medications administered to veterans with post-traumatic stress disorder (PTSD), according to this cross-sectional analysis of electronic pharmacy data from the Veterans Health Administration. About two-thirds of the veterans received prescriptions for selective serotonin-norepinephrine reuptake inhibitors, another one-quarter received second-generation antipsychotics, and about one-third were prescribed benzodiazepines. The authors note that most of these prescriptions were written by mental health care providers.
Despite guideline recommendations against their use, benzodiazepines are among the most commonly prescribed psychotropic medications administered to veterans with post-traumatic stress disorder (PTSD), according to this cross-sectional analysis of electronic pharmacy data from the Veterans Health Administration. About two-thirds of the veterans received prescriptions for selective serotonin-norepinephrine reuptake inhibitors, another one-quarter received second-generation antipsychotics, and about one-third were prescribed benzodiazepines. The authors note that most of these prescriptions were written by mental health care providers.

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Published by: Children Of Vietnam Veterans Health Alliance on Feb 12, 2013
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06/10/2014

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BenzodiazepinePrescribingVariationandClinicalUncertaintyinTreatingPosttraumaticStressDisorder 
Brian C. Lund, Pharm.D., M.S. Thad E. Abrams, M.D., M.S.Nancy C. Bernardy, Ph.D.Bruce Alexander, Pharm.D.Matthew J. Friedman, M.D., Ph.D.
Objective:
 Despite guideline recommendations against their use, ben-zodiazepines are among the most commonly prescribed psychotropicmedications among veterans with posttraumatic stress disorder (PTSD)in the Veterans Health Administration (VHA). This observation suggeststhe potential for significant clinical uncertainty concerning the role of benzodiazepines in PTSD, which was examined by characterizing pre-scribing variation in the VHA across multiple levels of geographic aggre-gation and over time.
 Methods:
 Veterans with PTSD were identified fromnational VHA administrative data in fiscal years 1999 through 2009. Ben-zodiazepine prescribing frequencies were aggregated across 137 medicalcenters, 21 networks, and four U.S. regions, and the extent of variation wascharacterized at each level. Prescribing variation was also examined by comparing benzodiazepine use between rural and urban veterans and be-tweenveteransreceivingcareatcommunity-basedoutpatientclinicsversusmedical centers.
 Results:
 Benzodiazepine prescribing variation decreasedover time, particularly at the network and regional levels. Facility-levelvariation (medical centers) also declined, but substantial variation persistedthrough 2009 (range 14.7%
56.8%). At the national level, rural veterans were more likely to receive benzodiazepines in 1999 (odds ratio=1.24; 95%confidenceinterval=1.22
1.27),andthisassociationpersistedthrough2009.However,regionalsubanalysesrevealedthatrural-versus-urbandifferences were observed only in the Midwest and South. Benzodiazepine prescribing was similar between community-based outpatient clinics and medical cen-ters.
Conclusions:
 VariabilityinbenzodiazepineprescribingacrosstheVHA reflects uncertainty regarding the adoption of guideline recommendations. Although variation has decreased in recent years, targeted interventionsamong facilities with high rates of prescribing may be an efficient strategy topromoteguideline-concordantcare.(
 PsychiatricServices
64:21
27,2013;doi: 10.1176/appi.ps.201100544)
P
osttraumatic stress disorder (PTSD) has affected the livesof hundreds of thousands of U.S. veterans and continues to afflictthousands of veterans returning fromcombat. Fortunately, several interna-tionally recognized, evidenced-basedclinicalpracticeguidelinesareavailableto aid clinicians in caring for veterans with PTSD (1
3). Among the morecontroversial positions expressed inthese guidelines isthat benzodiazepineuseisinappropriateinthemanagementof PTSD. Despite this recommenda-tion, benzodiazepines are among themost common medications prescribedin this population. In 2009, 30.6% of  veterans with PTSD who sought carethrough the Veterans Health Adminis-tration (VHA) received a benzodiaze-pine, which was a higher proportionthan those who received second-generation antipsychotics (24.3%),trazodone (23.0%), nonbenzodiaze-pine hypnotics (12.8%), and prazosin(9.1%) (4). Benzodiazepine prescrib-ing was second only to selective se-rotonin reuptake inhibitors (52.5%),the only therapeutic class containingmedications with U.S. Food and DrugAdministration approval for PTSD.These findings suggest considerableuncertainty across VHA prescribersconcerning the implementation of guideline recommendations againstbenzodiazepine use. One commonstrategy to examine clinical uncer-tainty is to study practice variation,typically across geographic regionsor health service catchment areas.
Dr. Lund is affiliated with the Center for Comprehensive Access and Delivery Research andEvaluation and the Veterans Rural Health Resource Center 
 – 
Central Region, Iowa CityVeterans Affairs (VA) Health Care System, Mailstop 152, 601 Hwy. 6 W., Iowa City, IA52246 (e-mail: brian.lund@va.gov ). Dr. Abrams is with the Center for Comprehensive Accessand Delivery Research and Evaluation, Iowa City VA Health Care System, and theDepartment of Internal Medicine, University of Iowa, Iowa City. Dr. Bernardy and Dr.Friedman are with the National Center for PTSD, White River Junction VA Medical Center,White River Junction, Vermont, and with the Department of Psychiatry, Geisel School of Medicine at Dartmouth University, Hanover, New Hampshire. Dr. Alexander is with theDepartment of Pharmacy Services, Iowa City VA Health Care System, Iowa City.
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Asthenation
slargestcentralizedhealthsystem, caring for nearly 500,000 indi- vidualswithPTSD,theVHAisuniquelpositioned 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 primarobjectives 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.
Methods
 Data sources
National administrative VHA dat 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.
 Patients
Eligible veterans for this study in-cluded all VHA enrollees in FY 1999through FY 2009 who had an in-patient or outpatient encounter withan
 ICD-9
 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
6
SD age was 53.8
6
14.6 years.
 Benzodiazepine use
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
$
30 days
 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 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 predominantllocated 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 furthecollapsed all nonurban categories
22
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(large, small, and isolated rural towns)into one rural category.
 Analyses
Benzodiazepine frequencies werereported at three hierarchical levels:medicalcenter(N=137),VISN(N=21),and region (N=4). Variation in pre-scribing frequency was described atthe medical center and VISN levels by using range and interquartile range.Inferential statistics were not used tomake comparisons across these levelsbecause our data included the entirepopulation of veterans receiving care within the VHA. However, we dis-cussed the clinical significance of theobserved frequencies and variability.Comparisons in benzodiazepine pre-scribing frequencies by rural and urbanresidencewereexpressedasoddsratios(ORs) with 95% confidence intervals(CIs). Statistical comparisons betweencommunity-basedoutpatientclinicsandmedical centers used a chi square test.All statistical analyses were conducted with SAS version 9.2.
Results
 Region, network,and medical center 
Benzodiazepine prescribing frequen-cies among veterans with PTSD,stratified by geographic region, areshown in Table 1. Substantial varia-tion was observed early in the study period and ranged from 31.1% in theNortheast to 43.3% in the South inFY1999. Benzodiazepine use declinedover the study period in all regions butdeclined most notably in the South.The range in regional prescribingfrequencies decreased from 12.2% inFY 1999 to 4.0% in FY 2009.Decreased variation was also ob-served at the VISN level and acrossmedical centers (Table 2). Variation atthe network level declined by justover 50% from FY 1999 to FY 2009
a findingsupportedbythereductioninthe interquartile range. Relative to thenetwork level, the magnitude of vari-ation was greater at the medical center level (FY 1999 minimum 14.0% tomaximum of 75.9%), although varia-tion declined at the facility level over time (from 14.9% in FY 1999 to 9.1%in FY 2009). Whereas the national trend towarddeclining benzodiazepine use wasclear,severalVISNs(N=3)andmedicalfacilities (N=33) experienced increasesin benzodiazepine prescribing. At thenetwork level, two VISNs had abso-lute frequency increases
 ,
1%, butone VISN had an increase of 5.9%.Increases at the medical center levelranged from .3% to 19.2% and tendedto occur among medical centers withlow initial rates, which likely reflectedregression to the mean.
 Rural residence
Nationally, 26.9% of veterans withPTSD resided in rural areas in FY2009, and this frequency varied by region: Northeast, 20.1%; West,21.9%; South, 28.8%; Midwest,36.0%. Benzodiazepine prescribingfrequencies for rural and urban veterans with PTSD can be com-pared by national region in Table 3.At the national level, rural veterans were more likely than their urbancounterparts to receive benzodi-azepines (40.4% versus 35.2%) inFY 1999 (OR=1.24). By FY 2009,prescribing frequencies decreasedfor both rural (33.2%) and urban(29.4%) veterans, but the magnitude
Table 1
Benzodiazepine prescribing frequency for Veterans Health Administrationpatients with PTSD, by geographic region in fiscal years 1999
2009
Geographic region
b
Fiscal year National Northeast West Midwest South Range1999 36.5 31.1 32.7 35.1 43.3 12.22001 35.2 29.1 33.5 35.4 40.1 11.02003 33.7 27.7 33.2 34.2 37.1 9.42005 32.0 27.0 32.0 32.8 34.2 7.22007 31.9 28.1 31.6 32.7 33.3 5.22009 30.4 27.9 29.7 31.9 31.2 4.0
 Values are in percentages. PTSD, posttraumatic stress disorder 
b
Assignment of Veterans Integrated Service Networks (VISNs) by U.S. census geographic region:Northeast, VISNs 1
5; Midwest, VISNs 10
12, 15, and 23; South, VISNs 6
9, 16, and 17; and West, VISNs 18
22
Table 2 
Benzodiazepine prescribing frequency, by care facility, fiscal years 1999
2009
Fiscal year Characteristic 1999 2001 2003 2005 2007 2009 Veterans Integrated ServiceNetworksMedian 35.3 34.9 31.5 30.6 30.6 29.1Interquartile range 10.8 11.2 10.3 6.6 7.1 5.325th percentile 30.5 29.5 28.8 28.6 28.7 27.975th percentile 41.3 40.7 39.1 35.2 35.8 33.2Range 29.1 22.5 18.5 16.7 15.9 16.8Minimum 23.2 24.4 23.1 22.7 24.3 21.8Maximum 52.3 46.9 41.6 39.4 40.1 38.6Medical centersMedian 36.9 34.5 33.7 32.0 31.4 30.3Interquartile range 14.9 12.3 13.2 10.5 9.7 9.125th percentile 28.5 28.6 27.3 27.1 27.6 25.875th percentile 43.5 41.9 40.5 37.6 37.3 34.9Range 61.9 54.0 54.3 57.8 54.1 42.1Minimum 14.0 12.6 13.5 14.6 15.6 14.7Maximum 75.9 66.6 67.8 72.4 69.6 56.8
 Values are in percentages.
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