Benzodiazepine Prescribing for Veterans with PTSD Remains Common and Varied across the VA Healthcare System
BACKGROUND:
Despite guideline recommendations against their use, benzodiazepines are among the most commonly prescribed psychotropic medications among Veterans with PTSD in the VA healthcare system. Benzodiazepine prescribing was second only to selective-serotonin reuptake inhibitors, the only therapeutic class containing medications with FDA approval for PTSD. These findings suggest considerable uncertainty across VA prescribers concerning the implementation of guideline recommendations against benzodiazepine use. One common strategy to examine clinical uncertainty is to study practice variation. Therefore, this study examined variation in benzodiazepine prescribing frequency across the VA healthcare system (by VAMC, VISN, and region), and evaluated differences in prescribing frequency among rural vs. urban residents, and between community-based outpatient clinics (CBOCs) relative to medical centers. Using VA data from FY99 through FY09, investigators identified Veterans with a diagnosis of PTSD, as well as benzodiazepine prescriptions and sites of care (e.g., rural vs. urban, CBOC vs. VAMC). The number of Veterans treated for PTSD in the VA healthcare system increased nearly 3-fold during the study time frame — from 170,685 in FY99 to 498,081 in FY09.
FINDINGS:
- Benzodiazepine prescribing among Veterans with PTSD remains common despite guideline recommendations against their use, and the level of practice variation was extensive.
- While prescribing variation at the regional, network and facility levels declined over the study period, facility-level benzodiazepine prescribing variation remains high at 15% to 57%.
- Rural veterans with PTSD received equivalent, if not higher, quality of care (as reflected by benzodiazepine prescribing frequency) from community-based outpatient clinics compared to medical centers.
- The authors suggest that the wide variation in prescribing practices reflects uncertainty among providers regarding best practices, and is ultimately due to the limited number of effective PTSD treatments supported by a strong evidence base.
LIMITATIONS:
- Veterans with PTSD were identified using administrative data, which are susceptible to sensitivity and specificity problems.
- Investigators did not know the clinical indication for which the benzodiazepines were prescribed.
AUTHOR/FUNDING INFORMATION:
This study was funded through VA/HSR&D's Quality Enhancement Research Initiative (QUERI; RRP 11-001). Drs. Lund and Abrams also were supported by HSR&D Career Development Awards, and are part of HSR&D's Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, IA.
Lund B, Abrams T, Bernardy N, Alexander B, and Friedman M. Benzodiazepine Prescribing Variation and Clinical Uncertainty in Treating Posttraumatic Stress Disorder. Psychiatric Services January 2013;64(1):21-27.
