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Rates of Non-evidenced Based Treatment for Rural Veterans with Post Traumatic Stress Disorder
Abrams T. Rates of Non-evidenced Based Treatment for Rural Veterans with Post Traumatic Stress Disorder. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 5; Phoenix, AZ.
Post Traumatic Stress Disorder (PTSD) is one of the signature wounds afflicting returning veterans from Iraq and Afghanistan. Although recent efforts from VA have focused on improving guideline based prescribing, non-evidenced based benzodiazepines (BZD) remain the third most commonly prescribed class of medications among veterans with PTSD. Evidence generating these estimates has relied heavily on the use of administrative data. Yet, multiple coding algorithms exist and there is little agreement on an optimal algorithm for identifying PTSD. Thus, we sought to examine the variation in benzodiazepine use by three common PTSD coding algorithms.
A cross-sectional study design was used to identify all veterans with a visit for PTSD (n = 498,081) in fiscal year 2009 using three PTSD coding algorithm methods: 1) one or two outpatient visits, 2) three or more outpatient visits, or 3) at least one inpatient visit. BZD use was identified using electronic pharmacy data and defined by receipt of at least one prescription fill for 90 days. Unadjusted analyses used chi square to compare demographics (e.g. age, sex, period of service, residence, and location of PTSD diagnosis) multivariate logistic regression models adjusted BZD use for demographics.
Average age was 53.8 (SD 14.6) and 93% were male; overall, BZD fills were identified in 30.6% of veterans. Variations in BZD fills were substantial by coding algorithm. For method 1, 20% of veterans with PTSD had a BZD fill; for method 2, 34% of veterans had a BZD fill; and for method three, 44% of veterans identified with PTSD by one or more inpatient codes had a BZD fill. Multivariate logistic regression models indicated that veterans with an inpatient PTSD code had an odds ratio of 1.92 (95% CI, 1.83 - 2.10) for BZD fill relative to veterans with one or two outpatient codes. Odds for the receipt for a BZD correlated with increasing use of outpatient visits for PTSD.
BZD use remains high among veterans identified with PTSD and the identification such veterans using administrative data strongly depends on the coding algorithm employed with an observed prevalence of varying from 44% to 20%.
As BZD have received a Class D guideline recommendation (e.g. no benefit with significant chance for harm) efforts to reduce the use of BZD among veterans with PTSD remain a priority in the VA. This study suggests that those efforts should perhaps be focused first on veterans receiving care from the inpatient setting.