Benzodiazepine Prescribing Variation

and Clinical Uncertainty in Treating

Posttraumatic Stress Disorder
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 psychotropic
medications among veterans with posttraumatic stress disorder (PTSD)
in the Veterans Health Administration (VHA). This observation suggests
the 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 from
national VHA administrative data in fiscal years 1999 through 2009. Ben-
zodiazepine prescribing frequencies were aggregated across 137 medical
centers, 21 networks, and four U.S. regions, and the extent of variation was
characterized at each level. Prescribing variation was also examined by
comparing benzodiazepine use between rural and urban veterans and be-
tween veterans receiving care at community-based outpatient clinics versus
medical centers. Results: Benzodiazepine prescribing variation decreased
over time, particularly at the network and regional levels. Facility-level
variation (medical centers) also declined, but substantial variation persisted
through 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%
confidence interval=1.221.27), and this association persisted through 2009.
However, regional subanalyses revealed that rural-versus-urban differences
were observed only in the Midwest and South. Benzodiazepine prescribing
was similar between community-based outpatient clinics and medical cen-
ters. Conclusions: Variability in benzodiazepine prescribing across the VHA
reflects uncertainty regarding the adoption of guideline recommendations.
Although variation has decreased in recent years, targeted interventions
among facilities with high rates of prescribing may be an efficient strategy
to promote guideline-concordant care. (Psychiatric Services 64:2127, 2013;
doi: 10.1176/appi.ps.201100544)
P
osttraumatic stress disorder
(PTSD) has affected the lives
of hundreds of thousands of
U.S. veterans and continues to afflict
thousands of veterans returning from
combat. Fortunately, several interna-
tionally recognized, evidenced-based
clinical practice guidelines are available
to aid clinicians in caring for veterans
with PTSD (13). Among the more
controversial positions expressed in
these guidelines is that benzodiazepine
use is inappropriate in the management
of PTSD. Despite this recommenda-
tion, benzodiazepines are among the
most common medications prescribed
in this population. In 2009, 30.6% of
veterans with PTSD who sought care
through the Veterans Health Adminis-
tration (VHA) received a benzodiaze-
pine, which was a higher proportion
than 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 containing
medications with U.S. Food and Drug
Administration approval for PTSD.
These findings suggest considerable
uncertainty across VHA prescribers
concerning the implementation of
guideline recommendations against
benzodiazepine use. One common
strategy to examine clinical uncer-
tainty is to study practice variation,
typically across geographic regions
or health service catchment areas.
Dr. Lund is affiliated with the Center for Comprehensive Access and Delivery Research and
Evaluation and the Veterans Rural Health Resource CenterCentral Region, Iowa City
Veterans Affairs (VA) Health Care System, Mailstop 152, 601 Hwy. 6 W., Iowa City, IA
52246 (e-mail: brian.lund@va.gov). Dr. Abrams is with the Center for Comprehensive Access
and Delivery Research and Evaluation, Iowa City VA Health Care System, and the
Department 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 the
Department of Pharmacy Services, Iowa City VA Health Care System, Iowa City.
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1 21
As the nations largest centralized health
system, caring for nearly 500,000 indi-
viduals with PTSD, the VHAis uniquely
positioned to examine variation in its
prescribing practices.
One specific area of concern re-
lated to practice variation is the
quality of care delivered by VHA
community-based outpatient clinics
(5). The goal with the establishment
of these clinics is to offer access
nearer to the veterans home, and
over 800 clinics were in operation as
of 2010. The challenge is to ensure
high-quality care equivalent to that
provided by Veterans Affairs (VA)
medical centers, despite differences
in the breadth of services available
and many other important resources.
One particular concern has been
mental health monitoring and a per-
ceived lack of access to mental health
specialists (6).
Access to high-quality care at
community-based outpatient clinics
is particularly important for rural
veterans, who account for approxi-
mately 41% of VHA enrollees (7). An
important driving force behind clinic
expansion has been the increasing
number of veterans serving in com-
bat roles who came from and are
returning to rural areas (7). Rural
residence has been associated with
problems accessing health care, worse
health status, and higher prevalence
of chronic diseases (812). Differ-
ences in physician practice patterns
between rural and urban settings have
been observed, although much of this
work has been done outside the VHA
(1316). Although there do not ap-
pear to be important disparities in
access to prescription medications
(17), some studies suggest that rural
residents may be at increased risk for
certain types of inappropriate pre-
scribing practices (18,19). Ensuring
access for rural veterans has been
a focal point for the VHA, but the
potential 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 benzodiazepine
prescribing variation among veterans
with PTSD. Our first objective was to
characterize the variation in prescribing
frequency 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 levels
but that the extent of variation would
decrease over time. Our second objec-
tive was to evaluate differences in
benzodiazepine prescribing frequency
between rural and urban residents and
between community-based outpatient
clinics and medical centers. We hypoth-
esized that benzodiazepine prescribing
would be more common among rural
residents and for patients receiving
care at community-based clinics.
Methods
Data sources
National administrative VHA data
were obtained for the 11-year period
spanning fiscal years (FYs) 1999
through 2009 (October 1, 1998, to
September 30, 2009). Prescription
drug records were obtained from the
VHA Pharmacy Benefits Manage-
ment Services. Inpatient discharge
and outpatient encounter data sets
were obtained from the Austin In-
formation Technology Center. This
study was approved by the University
of Iowa Institutional Review Board
and the Iowa City VHA Research and
Development Committee.
Patients
Eligible veterans for this study in-
cluded all VHA enrollees in FY 1999
through FY 2009 who had an in-
patient or outpatient encounter with
an ICD-9 code of 309.81. Veterans
were considered to have PTSDduring
a given year if they had at least one
encounter coded for PTSD as either
a primary or secondary diagnosis. This
PTSD case definition has been used
in several prior studies examining
psychiatric medication use among
veterans with PTSD (2022). The
estimated rate of false-positive cases
resulting from administrative miscod-
ing is infrequent (,4%) with this
methodology (23,24). As previously
reported, the number of veterans
treated for PTSD in the VHA in-
creased nearly threefold during the
study time frame, from 170,685 in FY
1999 to 498,081 in FY 2009 (22). In
FY 2009, 7.5% of veterans with PTSD
were women, and the mean6SD age
was 53.8614.6 years.
Benzodiazepine use
Benzodiazepine use was defined as
any outpatient prescription fill for the
following medications: alprazolam,
chlordiazepoxide, clonazepam, clor-
azepate, diazepam, estazolam, fluraze-
pam, halazepam, lorazepam, oxazepam,
prazepam, quazepam, temazepam, and
triazolam. This definition did not in-
clude any requirement for a minimum
quantity, 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 days
of continuous benzodiazepine treatment
(22).
Site of care
The primary site of PTSD care was
assigned on the basis of the station
where the veteran had the most
PTSD-coded encounters during a
given fiscal year. Each site of care
was classified as a community-based
outpatient clinic or medical center
and aggregated at multiple organiza-
tional levels for different analyses.
Each community-based outpatient
clinic in the VHA is assigned to a
parent medical center, and medical
centers are assigned to a VISN. We
further grouped VISNs into regions
based on overlapping boundaries
with U.S. census regions (Northeast,
South, Midwest, and West). Stations
were considered a medical center
according to the classification used
by the 2009 VHA Facility Quality
and Safety Report (25). Medical
centers and community-based out-
patient clinics are predominantly
located in urban areas (86% and
58%, respectively).
Rural or urban residence
Rural or urban residence was de-
termined by using the Rural-Urban
Commuting Areas (RUCA) system,
which was mapped with the zip code
of the veterans residence (26). Be-
ginning with the RUCA four-category
classification system (urban, large
rural towns, small rural towns, and
isolated rural towns), we further
collapsed all nonurban categories
22 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1
(large, small, and isolated rural towns)
into one rural category.
Analyses
Benzodiazepine frequencies were
reported at three hierarchical levels:
medical center (N=137), VISN(N=21),
and region (N=4). Variation in pre-
scribing frequency was described at
the medical center and VISN levels by
using range and interquartile range.
Inferential statistics were not used to
make comparisons across these levels
because our data included the entire
population of veterans receiving care
within the VHA. However, we dis-
cussed the clinical significance of the
observed frequencies and variability.
Comparisons in benzodiazepine pre-
scribing frequencies by rural and urban
residence were expressed as odds ratios
(ORs) with 95% confidence intervals
(CIs). Statistical comparisons between
community-based outpatient clinics and
medical 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, are
shown in Table 1. Substantial varia-
tion was observed early in the study
period and ranged from 31.1% in the
Northeast to 43.3% in the South in
FY 1999. Benzodiazepine use declined
over the study period in all regions but
declined most notably in the South.
The range in regional prescribing
frequencies decreased from 12.2% in
FY 1999 to 4.0% in FY 2009.
Decreased variation was also ob-
served at the VISN level and across
medical centers (Table 2). Variation at
the network level declined by just
over 50% from FY 1999 to FY 2009
a finding supported by the reduction in
the interquartile range. Relative to the
network level, the magnitude of vari-
ation was greater at the medical center
level (FY 1999 minimum 14.0% to
maximum 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 toward
declining benzodiazepine use was
clear, several VISNs (N=3) and medical
facilities (N=33) experienced increases
in benzodiazepine prescribing. At the
network level, two VISNs had abso-
lute frequency increases ,1%, but
one VISN had an increase of 5.9%.
Increases at the medical center level
ranged from .3% to 19.2% and tended
to occur among medical centers with
low initial rates, which likely reflected
regression to the mean.
Rural residence
Nationally, 26.9% of veterans with
PTSD resided in rural areas in FY
2009, and this frequency varied by
region: Northeast, 20.1%; West,
21.9%; South, 28.8%; Midwest,
36.0%. Benzodiazepine prescribing
frequencies 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 urban
counterparts to receive benzodi-
azepines (40.4% versus 35.2%) in
FY 1999 (OR=1.24). By FY 2009,
prescribing frequencies decreased
for both rural (33.2%) and urban
(29.4%) veterans, but the magnitude
Table 1
Benzodiazepine prescribing frequency for Veterans Health Administration
patients with PTSD, by geographic region in fiscal years 19992009
a
Geographic region
b
Fiscal year National Northeast West Midwest South Range
1999 36.5 31.1 32.7 35.1 43.3 12.2
2001 35.2 29.1 33.5 35.4 40.1 11.0
2003 33.7 27.7 33.2 34.2 37.1 9.4
2005 32.0 27.0 32.0 32.8 34.2 7.2
2007 31.9 28.1 31.6 32.7 33.3 5.2
2009 30.4 27.9 29.7 31.9 31.2 4.0
a
Values are in percentages. PTSD, posttraumatic stress disorder
b
Assignment of Veterans Integrated Service Networks (VISNs) by U.S. census geographic region:
Northeast, VISNs 15; Midwest, VISNs 1012, 15, and 23; South, VISNs 69, 16, and 17; and
West, VISNs 1822
Table 2
Benzodiazepine prescribing frequency, by care facility, fiscal years 19992009
a
Fiscal year
Characteristic 1999 2001 2003 2005 2007 2009
Veterans Integrated Service
Networks
Median 35.3 34.9 31.5 30.6 30.6 29.1
Interquartile range 10.8 11.2 10.3 6.6 7.1 5.3
25th percentile 30.5 29.5 28.8 28.6 28.7 27.9
75th percentile 41.3 40.7 39.1 35.2 35.8 33.2
Range 29.1 22.5 18.5 16.7 15.9 16.8
Minimum 23.2 24.4 23.1 22.7 24.3 21.8
Maximum 52.3 46.9 41.6 39.4 40.1 38.6
Medical centers
Median 36.9 34.5 33.7 32.0 31.4 30.3
Interquartile range 14.9 12.3 13.2 10.5 9.7 9.1
25th percentile 28.5 28.6 27.3 27.1 27.6 25.8
75th percentile 43.5 41.9 40.5 37.6 37.3 34.9
Range 61.9 54.0 54.3 57.8 54.1 42.1
Minimum 14.0 12.6 13.5 14.6 15.6 14.7
Maximum 75.9 66.6 67.8 72.4 69.6 56.8
a
Values are in percentages.
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1 23
of the rural-urban difference re-
mained consistent (OR=1.19).
However, aggregate national find-
ings were not representative of rural-
urban differences across individual
geographic regions. Rural-urban dif-
ferences in benzodiazepine prescrib-
ing in the Northeast and West regions
were statistically significant in some
years, but the relationship was in-
consistent and effect sizes were small.
In contrast, rural-urban differences
were substantial in the Midwest and
South. In FY1999, the benzodiazepine
frequency for rural veterans in the
Midwest was 40.2%, compared with
32.4% for urban veterans (OR=1.41,
CI=1.341.48). Benzodiazepine pre-
scribing declined substantially by FY
2009 for both rural (35.6%) and urban
(29.8%) Midwest veterans, but the
rural-urban difference persisted (OR=
1.30, CI=1.271.34). A similar pattern
was seen in the South, where benzo-
diazepine prescribing frequencies de-
creased among both groups from FY
1999 to FY 2009 (rural, from 46.5%
to 34.0%; urban, from 41.9% to
29.8%), although rural-urban differ-
ences remained consistent.
Community-based
outpatient clinics
Rates of care at community-based
outpatient clinics increased during
the study period, particularly among
veterans in rural areas. In FY 1999,
31.7% of rural veterans had the
majority of their PTSD encounters at
a community-based outpatient clinic,
which increased to 50.9% in FY 2009.
Community-based outpatient clinic
use also increased for urban veterans,
with PTSD encounters ranging from
35.0% in FY 1999 to 45.3% in FY
2009. Benzodiazepine prescribing
frequencies at community-based out-
patient clinics and medical centers
are shown in Table 4. Among all
veterans with PTSD, benzodiazepine
prescribing frequencies were gener-
ally similar for patients receiving care
at community-based outpatient clinics
and medical centers across all years
during the study period. However,
stratification by rural and urban resi-
dence revealed some differences.
Benzodiazepine prescribing frequen-
cies were generally similar between
community-based outpatient clinics
and medical centers for urban veter-
ans. In contrast, significant differences
between care at community-based
outpatient clinics and medical centers
were apparent for rural veterans
beginning in FY 2003, where benzo-
diazepine prescribing frequencies
were lower for veterans treated at
community-based outpatient clinics.
Discussion
This study examined variation in
benzodiazepine prescribing over an
11-year period using several aggrega-
tion approaches, based on both geo-
graphic and health systemboundaries.
Our primary finding was that the level
of practice variation was extensive,
with benzodiazepine prescribing fre-
quencies ranging from 14.0% to
75.9% across VA medical centers in
FY 1999. This finding suggests the
existence of clinically relevant uncer-
tainty among VHA prescribers con-
cerning the role of benzodiazepines
for veterans with PTSD. Building on
prior work demonstrating a general
declining trend in the absolute
frequency of benzodiazepine pre-
scribing (22), this study documented
important decreases in variation over
the same period. This observation was
consistent across multiple levels of
aggregation, including medical cen-
ter, VISN, and regional levels. We
further observed that benzodiazepine
prescribing was elevated among rural
veterans at a national level but that
this association appeared to be limited
to the South and Midwest regions of
the United States. Finally, benzodi-
azepine prescribing at community-
based outpatient clinics was similar to
that at medical centers for veterans
with PTSD overall and was somewhat
lower for the veterans who were rural
residents.
The driving forces behind declining
variation in benzodiazepine prescrib-
ing are unclear. Potential regional
influences present in FY 1999 (range
31.1%43.3%) were essentially elimi-
nated by FY 2009 (range 27.9%
31.9%), drivenprincipally by a decrease
of 12.1 percentage points in prescrib-
ing in the South. VISN-level differ-
ences were also substantially reduced,
froman interquartile range of 10.8%to
5.3%. In FY 2009, the 25th and 75th
percentiles were 27.9% and 33.2%,
respectively, suggesting minimal influ-
ence of VISN-level policies or organi-
zational characteristics on current rates
Table 3
Regional differences in benzodiazepine prescribing among rural and urban residents treated in fiscal years 19992009
by the Veterans Health Administration
a
Geographic region
National Northeast West Midwest South
Fiscal year OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
1999 1.24 1.221.27 1.06 .991.12 1.07 1.021.13 1.41 1.341.48 1.21 1.161.25
2001 1.22 1.191.24 1.09 1.031.15 1.04 .991.09 1.36 1.301.43 1.19 1.151.23
2003 1.19 1.171.22 .99 .941.04 1.10 1.061.14 1.31 1.261.37 1.19 1.151.22
2005 1.17 1.151.19 1.05 1.011.10 1.02 .991.06 1.26 1.211.31 1.19 1.161.22
2007 1.19 1.171.20 1.00 .961.04 1.06 1.021.09 1.31 1.271.36 1.23 1.201.26
2009 1.19 1.181.21 1.05 1.011.09 1.10 1.061.13 1.30 1.271.34 1.21 1.191.24
a
Reference group: urban veterans
24 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1
of benzodiazepine prescribing. How-
ever, these factors may have played
an important role in the decline in
prescribing variation over time.
One potential driver with national
scope may be the 2004 clinical practice
guideline from the U.S. Department
of Veterans Affairs and the Depart-
ment of Defense. Anecdotally, the
largest biannual decrease in benzo-
diazepine prescribing variation, at
both the VISN and the medical
center levels, occurred between 2003
and 2005. However, our study was not
designed to measure the impact of the
guidelines on prescribing practices,
and drawing a causal connection
remains speculative.
With benzodiazepine prescribing
variation significantly diminished at
the regional and VISN levels, most of
the remaining variation seems to be
attributable to local differences among
individual medical centers. Further
research is needed to determine the
extent to which prescribing variation
may be accounted for by differences in
patient-level characteristics across fa-
cilities and in organizational character-
istics of individual facilities. Facility
characteristics could include specific
local policies as well as differences
across facilities in the prescribing
culture regarding benzodiazepine use
for PTSD. However, facility-level pre-
scribing variation is ultimately the
aggregate behavior of individual pre-
scribers. Each prescriber caring for
veterans with PTSD has an individ-
ual propensity to prescribe benzo-
diazepines. Although administrative
data are useful in characterizing
patterns of prescribing, they offer
little toward explaining why these
variations occur. Future qualitative
work will be needed to gain a richer
understanding of what factors drive
facility-level variation, including lo-
cal policies, prescribing culture, and
individual prescriber decision mak-
ing. An additional opportunity is
to examine the relative contribution
of prescribers in primary care versus
mental health care toward the fre-
quency and variability of benzodiaz-
epine prescribing. Primary care
physicians awareness of PTSD
guidelines could be evaluated along
with likelihood of prescribing ben-
zodiazepines and understanding of
the risk for potential harms among
veterans.
Our second objective was to de-
termine whether benzodiazepine pre-
scribing was more common for rural
veterans and for patients receiving care
at community-based outpatient clinics.
On a national basis, rural veterans were
more likely to receive benzodiaze-
pines, but this difference was limited
to the Midwest and South. This finding
has important implications for studies
of urban-rural discrepancies, which
often look only at national estimates
and may miss relevant regional differ-
ences. Urban-rural differences re-
mained consistent throughout the
study period, which is noteworthy
given the overall backdrop of declining
variation. However, we again face
the limitations of administrative data
to identify the underlying reasons
for these associations. One important
consideration is that rural veterans
are disproportionately represented
among combat troops, which may
predispose these individuals to de-
veloping more severe or treatment-
refractory PTSD and lead prescribers
to resort to treatment options with
less supporting evidence (2729). It
is also possible that urban veterans
had better access compared with
rural veterans to evidenced-based
psychotherapy treatment, which could
have decreased benzodiazepine pre-
scribing. A further consideration is
whether higher benzodiazepine pre-
scribing among rural veterans was
explained by a greater reliance on
community-based outpatient clinics.
However, we found that veterans with
PTSD receiving care at community-
based outpatient clinics were actually
less likely to receive benzodiazepines
than individuals treated at medical
centers. This finding is important given
the VHAs ongoing efforts to ensure
access to high-quality mental health
services.
It is important to outline the limi-
tations of this study. First, the study
population was limited to veterans who
received care within the VHA, and our
findings may not be generalizable to
nonveterans or to veterans receiving
PTSD care outside the VHA. The
relative quality and impact of PTSD
treatment outside the VHA will be of
increasing importance because VHA
enrollment is below 50% for veterans
returning from recent conflicts abroad
(30). Second, we identified veterans
with PTSD by using administrative
diagnostic codes, which are suscepti-
ble to sensitivity and specificity prob-
lems. Diagnostic misclassification could
have multiple competing effects on
the absolute frequency of benzodiaz-
epine prescribing but are unlikely
to explain the wide variation across
the VHA or the declining variation
over time. Third, we do not know
the clinical indication for which
the benzodiazepine was prescribed.
There are certainly case examples
where benzodiazepine use could be
clinically appropriate, such as with
severe comorbid panic disorder. We
do not advocate a target rate of zero
Table 4
Benzodiazepine prescribing among veterans receiving PTSD care at
a CBOC versus VAMC in fiscal years 19992009, by rural and urban
residence
a
All veterans Rural veterans Urban veterans
Fiscal year CBOC VAMC CBOC VAMC CBOC VAMC
1999 36.8* 36.3 40.5 40.3 35.8** 35.0
2001 35.2 35.3 38.4 38.8 34.2 34.0
2003 33.3 33.9** 35.4 37.4** 32.6 32.6
2005 31.8 32.2* 32.5 36.2** 30.8 31.6**
2007 31.5 32.1** 32.7 36.4** 31.0 30.7
2009 30.2 30.6** 31.3 35.1** 29.8** 29.1
a
Values are in percentages. PTSD, posttraumatic stress disorder; CBOC, community-based
outpatient clinic; VAMC, Veterans Affairs medical center
*p,.05
**p,.01
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' January 2013 Vol. 64 No. 1 25
for benzodiazepine use, because this
practice would disallow individual cir-
cumstances to drive patient-centered
care. However, it seems unreason-
able that the one medication class that
clinical practice guidelines recom-
mend avoiding in this population would
be the second most commonly pre-
scribed (4).
Regardless of how absolute ben-
zodiazepine prescribing frequencies
are interpreted, it seems clear that
substantial facility-level variation is
indicative of uncertainty regarding best
practices. Further research is necessary
to identify potential subgroups of vet-
erans with PTSD for whom the benefit
of benzodiazepines may outweigh risks.
A final limitation was that we did not
include case-mix adjustment to account
for potential differences across facilities
in patient-level characteristics related
to benzodiazepine prescribing. For
example, one prior cross-sectional
study found that a comorbid anxiety
disorder increased the likelihood of
benzodiazepine use among veterans
with PTSD (20). Although case-mix
differences seem unlikely to account
for the extent of prescribing variation
observed in our study, future research
examining patient- and facility-level
correlates of benzodiazepine use would
be informative.
Conclusions
Benzodiazepine prescribing among
veterans with PTSD remains common
despite clinical practice guideline
recommendations. Wide variation
across the VHA health care system
reflects uncertainty among providers
regarding best practices and is ulti-
mately due to the limited number of
effective PTSD treatments supported
by a strong evidence base. Our
findings also serve to highlight the
challenges faced by veterans with
PTSD in working toward recovery,
as well as the providers involved in
their care. As the number of veterans
affected by PTSD continues to climb,
expanding our understanding of
evidence-based treatments becomes
ever more important. Benzodiaze-
pine use among veterans with PTSD
remains controversial, and further
research is crucial to maximize
guideline-concordant prescribing prac-
tices in the VHA.
Acknowledgments and disclosures
This project was supported by the U.S. De-
partment of Veterans Affairs Mental Health
Quality Enhancement Research Initiative
(QUERI) (RRP 11-001). Additional support
was provided by career development awards
from the VA Health Services Research and
Development Service (Dr. Lund, CDA 10-017;
Dr. Abrams, CDA 10-016), the VA Office of
Rural Health, and the National Center for
PTSD at the White River Junction VA Medical
Center. None of these sponsors had any role in
the study design, methods, analyses, or in-
terpretation or in the preparation of the
manuscript and the decision to submit it for
publication. The views expressed in this article
are those of the authors and do not necessarily
reflect the position or policy of the VHA.
The authors report no competing interests.
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