Veteran Response to Dosage in Chiropractic Therapy (VERDICT): Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain.

BACKGROUND: Low back pain is a leading cause of disability in veterans. Chiropractic care is a well-integrated, nonpharmacological therapy in Veterans Affairs health care facilities, where doctors of chiropractic provide therapeutic interventions focused on the management of low back pain and other musculoskeletal conditions. However, important knowledge gaps remain regarding the effectiveness of chiropractic care in terms of the number and frequency of treatment visits needed for optimal outcomes in veterans with low back pain. DESIGN: This pragmatic, parallel-group randomized trial at four Veterans Affairs sites will include 766 veterans with chronic low back pain who are randomly allocated to a course of low-dose (one to five visits) or higher-dose (eight to 12 visits) chiropractic care for 10 weeks (Phase 1). After Phase 1, participants within each treatment arm will again be randomly allocated to receive either monthly chiropractic chronic pain management for 10 months or no scheduled chiropractic visits (Phase 2). Assessments will be collected electronically. The Roland Morris Disability Questionnaire will be the primary outcome for Phase 1 at week 10 and Phase 2 at week 52. SUMMARY: This trial will provide evidence to guide the chiropractic dose in an initial course of care and an extended-care approach for veterans with chronic low back pain. Accurate information on the effectiveness of different dosing regimens of chiropractic care can greatly assist health care facilities, including Veterans Affairs, in modeling the number of doctors of chiropractic that will best meet the needs of patients with chronic low back pain.

Identification of Military Veterans Upon Implementation of a Standardized Screening Process in a Federally Qualified Health Center.

The identification of veterans receiving care in community-based settings is important and has implications for healthcare delivery and workforce training and development. As part of a larger collaboration regarding the delivery of behavioral health services, this project partnered a Midwest Veterans Affairs Medical Center with a state primary care association and large federally qualified health center (FQHC) to standardize the method in which veteran status is captured in clinic. Before adapting the screening item and implementing it as a required field in the electronic medical record, the number of veterans reported was 56, or 0.32% of total patients. After implementation, that number increased to 506, or 3.01% of total patients. This suggests there is a need to standardize the method in which veteran status is collected, which has implications for awareness of conditions likely to impact veterans and may inform opportunities for providers to engage in veteran-centric education and training.

An individually-tailored smoking cessation intervention for rural Veterans: a pilot randomized trial.

BACKGROUND: Tobacco use remains prevalent among Veterans of military service and those residing in rural areas. Smokers frequently experience tobacco-related issues including risky alcohol use, post-cessation weight gain, and depressive symptoms that may adversely impact their likelihood of quitting and maintaining abstinence. Telephone-based interventions that simultaneously address these issues may help to increase treatment access and improve outcomes. METHODS: This study was a two-group randomized controlled pilot trial. Participants were randomly assigned to an individually-tailored telephone tobacco intervention combining counseling for tobacco use and related issues including depressive symptoms, risky alcohol use, and weight concerns or to treatment provided through their state tobacco quitline. Selection of pharmacotherapy was based on medical history and a shared decision interview in both groups. Participants included 63 rural Veteran smokers (mean age = 56.8 years; 87 % male; mean number of cigarettes/day = 24.7). The primary outcome was self-reported 7-day point prevalence abstinence at 12 weeks and 6 months. RESULTS: Twelve-week quit rates based on an intention-to-treat analysis did not differ significantly by group (Tailored = 39 %; Quitline Referral = 25 %; odds ratio [OR]; 95 % confidence interval [CI] = 1.90; 0.56, 5.57). Six-month quit rates for the Tailored and Quitline Referral conditions were 29 and 28 %, respectively (OR; 95 % CI = 1.05; 0.35, 3.12). Satisfaction with the Tailored tobacco intervention was high. CONCLUSIONS: Telephone-based treatment that concomitantly addresses other health-related factors that may adversely affect quitting appears to be a promising strategy. Larger studies are needed to determine whether this approach improves cessation outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier number NCT01592695 registered 11 April 2012.

Patterns of illness explaining the associations between posttraumatic stress disorder and the use of CT.

PURPOSE: To examine the relationship between posttraumatic stress disorder (PTSD) and computed tomography (CT) utilization and to determine whether there were patterns of comorbid illness that could explain the relationship. MATERIALS AND METHODS: The study was approved by the University of Iowa Institutional Review Board and the Iowa City Veterans Affairs Medical Center Research and Development Committee. By using a retrospective cohort design, a national sample of new veteran enrollees aged 18-35 years was studied. Associations were examined between the presence of PTSD, receipt of at least one and multiple CT scans, comorbid medical conditions (eg, abdominal pain, headaches), and measures of health care utilization (eg, primary care, emergency room, and mental health visits) and the daily probability of the receipt of at least one CT scan before and after a diagnosis of PTSD. Analyses included sequential multivariable generalized linear mixed models to examine the independent relationship between PTSD and CT scan utilization. RESULTS: Among the full cohort, 13.0% (10 018 of 76 812) received at least one CT scan. PTSD was identified in 21.1% (16 182 of 76 812) of the cohort, and 22.9% (3711 of 16 182) of veterans with PTSD received at least one CT scan as compared with 10.4% (6307 of 60 630) of veterans without PTSD (P < .0001). In sequential modeling, comorbid factors explaining the relationship between CT scans and PTSD were traumatic brain injury (odds ratio, 3.54; P < .0001), abdominal pain (odds ratio, 4.01; P < .0001), and headaches (odds ratio, 3.07; P < .0001). Associations were also strong for high levels of emergency room (odds ratio, 2.73; P < .0001) and primary care (odds ratio, 2.38; P < .0001) utilization. The daily chance of receiving a CT scan was seven times higher prior to the recognition of PTSD (daily chance, 0.007 before vs 0.001 after; P < .0001). CONCLUSION: Young veterans with PTSD are receiving more CT scans compared with those without PTSD; the daily probability of receiving CT scans is higher prior to recognition of PTSD. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121593/-/DC1.

Geographic isolation and the risk for chronic obstructive pulmonary disease-related mortality: a cohort study.

BACKGROUND: Little is known about the possible differences in outcomes between patients with chronic obstructive pulmonary disease (COPD) who live in rural areas and those who live in urban areas of the United States. OBJECTIVE: To determine whether COPD-related mortality is higher in persons living in rural areas, and to assess whether hospital characteristics influence any observed associations. DESIGN: Retrospective cohort study. SETTING: 129 acute care Veterans Affairs hospitals. PATIENTS: Hospitalized patients with a COPD exacerbation. MEASUREMENTS: Patient rurality (primary exposure); 30-day mortality (primary outcome); and hospital volume and hospital rurality, defined as the mean proportion of hospital admissions coming from rural areas (secondary exposures). RESULTS: 18,809 patients (71% of the study population) lived in urban areas, 5671 (21%) in rural areas, and 1919 (7%) in isolated rural areas. Mortality was increased in patients living in isolated rural areas compared with urban areas (5.0% vs. 3.8%; P = 0.002). The increase in mortality associated with living in an isolated rural area persisted after adjustment for patient characteristics and hospital rurality and volume (odds ratio [OR], 1.42 [95% CI, 1.07 to 1.89]; P = 0.016). Adjusted mortality did not seem to be higher in patients living in nonisolated rural areas (OR, 1.09 [CI, 0.90 to 1.32]; P = 0.47). Results were unchanged in analyses assessing the influence of an omitted confounder on estimates. LIMITATIONS: The study population was limited to mostly male inpatients who were veterans. Results were based on administrative data. CONCLUSION: Patients with COPD living in isolated rural areas of the United States seem to be at greater risk for COPD exacerbation-related mortality than those living in urban areas, independent of hospital rurality and volume. Mortality was not increased for patients living in nonisolated rural areas. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.

Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center.

Many rural veterans receive care in community settings but could benefit from VA services for certain needs, presenting an opportunity for coordination across systems. This article details the Collaborative Systems of Care (CSC) program, a novel, nurse-led care coordination program identifying and connecting veterans presenting for care in a Federally Qualified Health Center to VA behavioral health and other services based upon the veteran's preferences and eligibility. The CSC program systematically identifies veteran patients, screens for common behavioral health issues, explores VA eligibility for interested veterans, and facilitates coordination with VA to improve healthcare access. While the present program focuses on behavioral health, there is a unique emphasis on assisting veterans with the eligibility and enrollment process and coordinating additional care tailored to the patient. As VA expands its presence in community care, opportunities for VA-community care coordination will increase, making the development and implementation of such interventions important.

Acute exacerbations of chronic obstructive pulmonary disease and the effect of existing psychiatric comorbidity on subsequent mortality.

OBJECTIVES: Studies investigating associations between chronic obstructive pulmonary disease (COPD) outcomes and psychiatric comorbidity have yielded mixed findings. We examined a national sample of hospitalized COPD patients to evaluate the impact of three psychiatric conditions on mortality and readmission. METHODS: Department of Veterans Affairs (VA) administrative and laboratory data were used to identify 26,591 consecutive patients admitted for COPD during October 2006 to September 2008. Associations between psychiatric comorbidity and both 30-day mortality and readmission were examined using generalized estimating equations and Cox proportional hazards regression, respectively, with adjustments for patient demographics, medical comorbidities, illness severity, and clustering within hospitals. RESULTS: Unadjusted 30-day mortality was higher in patients with anxiety (5.3% vs. 3.8% [P < 0.001]) and depression (6.2% vs. 3.8% [<0.001]). In multivariable analyses, adjusted odds of 30-day mortality were higher for patients with depression (OR, 1.53; 95% CI, 1.28-1.82) and anxiety (OR, 1.72; 1.42 -2.10), but not for patients with PTSD (OR, 1.19; 0.92-1.55). Unadjusted 30-day readmission rates also varied by diagnosis; depression and PTSD were associated with lower rates of readmission (10.4% vs. 11.6% [<0.05] and 8.6% vs. 11.6% [<0.001], respectively), whereas anxiety was not (11.3% vs. 11.5% [NS]). However, after covariate adjustment using multivariable models, anxiety and depression (but not PTSD) were associated with increased risk for readmission (HR, 1.22; 1.03 -1.43 and HR, 1.35; 1.18 -1.54, respectively). CONCLUSION: Comorbid anxiety and depression may have an adverse impact on COPD hospital prognosis or may be indicative of more severe illness.

Lifetime History of Sexual Assault and Emergency Department Service Use among Women Veterans.

BACKGROUND: Although sexual assault survivors are at increased risk for adverse physical and mental health outcomes and tend to use more health care services, little is known about women veterans' lifetime history of experiencing sexual assault (lifetime sexual assault [LSA]) and emergency department (ED) use. We sought to examine associations between experiencing LSA, mental health diagnoses, and ED use among women veterans. METHODS: Computer-assisted telephone interviews were conducted with 980 women veterans enrolled at two Veterans Affairs (VA) Medical Centers to assess history of experiencing LSA, health care use, sociodemographic characteristics, and military history. Administrative data provided VA use, mental health, and medical diagnoses. Logistic regression analyses examined associations between experiencing LSA and mental health diagnoses and past 5-year ED use. Classification tree analysis characterized ED use in participant subgroups. RESULTS: Sixty-four percent of participants visited a VA or non-VA ED during the previous 5 years. Women veterans with histories of mental health diagnoses and who experienced sexual assault had an odds of ED use almost two times greater than those with no history of experiencing sexual assault and no mental health diagnoses. The odds were similar for experiencing attempted (adjusted odds ratio, 1.85) and completed (adjusted odds ratio, 1.95) sexual assault. Classification tree analysis identified reliance on VA care and the composite variable representing experiencing LSA and mental health diagnoses as factors that best discriminated ED users from nonusers. CONCLUSIONS: Experiencing LSA is associated with greater ED use in women veterans enrolled in the VA. Whether finding this reflects greater emergent health care needs, suboptimal access and treatment for conditions that could be managed in other settings, lack of health care coordination, or some combination of these factors is unclear.

Variations in the associations between psychiatric comorbidity and hospital mortality according to the method of identifying psychiatric diagnoses.

OBJECTIVE: Little is known about associations between psychiatric comorbidity and hospital mortality for acute medical conditions. This study examined if associations varied according to the method of identifying psychiatric comorbidity and agreement between the different methods. PATIENTS/PARTICIPANTS: The sample included 31,218 consecutive admissions to 168 Veterans Affairs facilities in 2004 with a principle diagnosis of congestive heart failure (CHF) or pneumonia. Psychiatric comorbidity was identified by: (1) secondary diagnosis codes from index admission, (2) prior outpatient diagnosis codes, (3) and prior mental health clinic visits. Generalized estimating equations (GEE) adjusted in-hospital mortality for demographics, comorbidity, and severity of illness, as measured by laboratory data. MEASUREMENTS AND MAIN RESULTS: Rates of psychiatric comorbidities were 9.0% using inpatient diagnosis codes, 27.4% using outpatient diagnosis codes, and 31.0% using mental health visits for CHF and 14.5%, 33.1%, and 34.1%, respectively, for pneumonia. Agreement was highest for outpatient codes and mental health visits (kappa = 0.51 for pneumonia and 0.50 for CHF). In GEE analyses, the adjusted odds of death for patients with psychiatric comorbidity were lower when such comorbidity was identified by mental health visits for both pneumonia (odds ratio [OR] = 0.85; P = .009) and CHF (OR = 0.70; P < .001) and by inpatient diagnosis for pneumonia (OR = 0.63; P < or = .001) but not for CHF (OR = 0.75; P = .128). The odds of death were similar (P > .2) for psychiatric comorbidity as identified by outpatient codes for pneumonia (OR = 1.04) and CHF (OR = 0.93). CONCLUSIONS: The method used to identify psychiatric comorbidities in acute medical populations has a strong influence on the rates of identification and the associations between psychiatric illnesses with hospital mortality.

PTSD, Psychotropic Medication Use, and the Risk of Dementia Among US Veterans: A Retrospective Cohort Study.

OBJECTIVE: To determine the associations between PTSD, psychotropic medication use, and the risk for dementia. DESIGN: Retrospective cohort. PARTICIPANTS: Nationwide sample of US veterans (N = 417,172) aged ≥56 years during fiscal year (FY) 2003 without a diagnosis of dementia or mild cognitive impairment at baseline (FY02-03) and ≥1 clinical encounter every 2 years during follow-up (FY04-12). MEASURES: Demographic characteristics; diagnosis of PTSD, dementia, and medical and psychiatric comorbidity (defined by ICD-9 codes); and psychotropic medication use including selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), novel antidepressants (NA), benzodiazepines (BZA), and atypical antipsychotics (AA). Cox proportional hazard models examined for associations between PTSD diagnosis, psychotropic medication use, and risk for a dementia diagnosis. RESULTS: PTSD diagnosis significantly increased the risk for dementia diagnosis (HR = 1.35; [95% CI = 1.27-1.43]). However, there were significant interactions between PTSD diagnosis and use of SSRIs (P < .001), NAs (P = .014), and AAs (P < .001) on the risk for dementia diagnosis. HR for dementia diagnosis among veterans diagnosed with PTSD and not using psychotropic medications was 1.55 [1.45-1.67]. Among veterans diagnosed with PTSD prescribed SSRI, SNRI, or AA, HR for dementia diagnosis varied by drug class use ranging from 1.99 for SSRI to 4.21 for AA, relative to veterans without a PTSD diagnosis and no psychotropic medication receipt. BZAs or SNRIs use at baseline was associated with a significantly increased risk for dementia diagnosis independent of a PTSD diagnosis. CONCLUSION: PTSD diagnosis is associated with an increased risk for dementia diagnosis that varied with receipt of psychotropic medications. Further research would help to delineate if these findings are due to differences in PTSD severity, psychiatric comorbidity, or independent effects of psychotropic medications on cognitive decline.

Systemic and localized extra-central nervous system bacterial infections and the risk of dementia among US veterans: A retrospective cohort study.

INTRODUCTION: Emerging evidence indicates associations between extra-central nervous system (CNS) bacterial infections and an increased risk for dementia; however, epidemiological evidence is still very limited. METHODS: This study involved a retrospective cohort of a national sample of US veterans (N = 417,172) aged ≥56 years. Extended Cox proportional hazard models adjusted for demographic characteristics and medical and psychiatric comorbidities determined the associations between systemic and localized extra-CNS bacterial infections occurring >2 years before the initial dementia diagnosis and the risk for dementia. RESULTS: Exposure to any extra-CNS bacterial infection was associated with a significantly increased risk for dementia (hazard ratio [HR] = 1.20 [95% confidence interval = 1.16-1.24]). Independently, septicemia (HR = 1.39 [1.16-1.66]), bacteremia (HR = 1.22 [1.00-1.49]), osteomyelitis (HR = 1.20 [1.06-1.37]), pneumonia (HR = 1.10 [1.02-1.19]), urinary tract infections (HR = 1.13 [1.08-1.18]), and cellulitis (HR = 1.14 [1.09-1.20]) were associated with a significantly increased risk for dementia. DISCUSSION: Both systemic and localized extra-CNS bacterial infections are associated with an increased risk for developing dementia.

Validating administrative records in post-traumatic stress disorder.

There is insufficient data on the accuracy of administrative coding data (ACD) for post-traumatic stress disorder (PTSD). Medical records were reviewed for (1) a diagnosis of PTSD; (2) treatment for PTSD. The records were compared against the Veterans Health Administration (VHA) data in order to determine the positive predictive value (PPV) and negative predictive value (NPV) of three commonly used approaches. The PPV and NPV varied according to the ACD approach. Relative to a medical records review, the ACD approach of one or two PTSD coded outpatient encounters had a PPV of 78% and an NPV of 91%; whereas the PPV was 97% and the NPV was 98% for three or more PTSD codes. For pharmacotherapy, the ACD approach with one or two codes for PTSD had a PPV of 33% (NPV = 93%), whereas three or more PTSD coded encounters improved the PPV to 85% (NPV = 100%). When using VHA data, we recommend tailoring the identification strategy according to the research aims. An ACD approach identifying one or more PTSD outpatient encounters should be considered sufficient for a diagnosis of PTSD. Assessments for PTSD associated pharmacotherapy require using an ACD approach that identifies veterans with the presence ≥ 3 outpatient PTSD encounters. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Chronic obstructive lung disease and posttraumatic stress disorder: current perspectives.

BACKGROUND: Several studies have reported on the co-occurrence of chronic obstructive pulmonary disease (COPD) and psychiatric conditions, with the most robust evidence base demonstrating an impact of comorbid anxiety and depression on COPD-related outcomes. In recent years, research has sought to determine if there is a co-occurrence between COPD and posttraumatic stress disorder (PTSD) as well as for associations between PTSD and COPD-related outcomes. To date, there have been no published reviews summarizing this emerging literature. OBJECTIVES: The primary objective of this review was to determine if there is adequate evidence to support a co-occurrence between PTSD and COPD. Secondary objectives were to: 1) determine if there are important clinical considerations regarding the impact of PTSD on COPD management, and 2) identify targeted areas for further research. METHODS: A structured review was performed using a systematic search strategy limited to studies in English, addressing adults, and to articles that examined: 1) the co-occurrence of COPD and PTSD and 2) the impact of PTSD on COPD-related outcomes. To be included, articles must have addressed some type of nonreversible obstructive lung pathology. RESULTS: A total of 598 articles were identified for initial review. Upon applying the inclusion and exclusion criteria, n=19 articles or abstracts addressed our stated objectives. Overall, there is inconclusive evidence to support the co-occurrence between PTSD and COPD. Studies finding a significant co-occurrence generally had inferior methods of identifying COPD; in contrast, studies that utilized more robust COPD measures (such as a physician exam) generally failed to find a relationship. Among studies that examined the impact of PTSD on COPD-related outcomes, there was more consistent evidence that PTSD affects the perception of respiratory symptom burden and management. In addition, methods for measuring an important confounder (smoking) were generally lacking. CONCLUSION: There is inconclusive evidence to support the co-occurrence of COPD and PTSD. There was stronger evidence implicating PTSD as an important comorbidity impacting COPD management. Further research is needed to: 1) determine whether or not COPD and PTSD are likely to be comorbid, and 2) further elucidate the mechanisms connecting PTSD and COPD-related outcomes.

Geographical diffusion of prazosin across Veterans Health Administration: Examination of regional variation in daily dosing and quality indicators among veterans with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is a high-priority treatment area for the Veterans Health Administration (VHA), and dissemination patterns of innovative, efficacious therapies can inform areas for potential improvement of diffusion efforts and quality prescribing. In this study, we replicated a prior examination of the period prevalence of prazosin use as a function of distance from Puget Sound, Washington, where prazosin was first tested as an effective treatment for PTSD and where prazosin use was previously shown to be much greater than in other parts of the United States. We tested the following three hypotheses related to prazosin geographic diffusion: (1) a positive geographical correlation exists between the distance from Puget Sound and the proportion of users treated according to a guideline recommended minimum therapeutic target dose (>/=6 mg/d), (2) an inverse geographic correlation exists between prazosin and benzodiazepine use, and (3) no geographical correlation exists between prazosin use and serotonin reuptake inhibitor/serotonin norepinephrine reuptake inhibitor (SSRI/SNRI) use. Among a national sample of veterans with PTSD, overall prazosin utilization increased from 5.5 to 14.8% from 2006 to 2012. During this time period, rates at the Puget Sound VHA location declined from 34.4 to 29.9%, whereas utilization rates at locations a minimum of 2,500 miles away increased from 3.0 to 12.8%. Rates of minimum target dosing fell from 42.6 to 34.6% at the Puget Sound location. In contrast, at distances of at least 2,500 miles from Puget Sound, minimum threshold dosing rates remained stable (range, 18.6 to 17.7%). No discernible association was demonstrated between SSRI/SNRI or benzodiazepine utilization and the geographic distance from Puget Sound. Minimal threshold dosing of prazosin correlated positively with increased diffusion of prazosin use, but there was still a distance diffusion gradient. Although prazosin adoption has improved, geographic differences persist in both prescribing rates and minimum target dosing. Importantly, these regional disparities appear to be limited to prazosin prescribing and are not meaningfully correlated with SSRI/SNRI and benzodiazepine use as indicators of PTSD prescribing quality.

Aligning clinical practice to PTSD treatment guidelines: medication prescribing by provider type.

OBJECTIVE: Veterans with posttraumatic stress disorder (PTSD) are frequently prescribed psychiatric medications that are currently not supported by a guideline developed by the U.S. Department of Veterans Affairs and the U.S. Department of Defense. To better understand this practice, this study examined prescribing frequencies for three classes of psychiatric medications and the proportion of prescribing attributable to various provider types. METHODS: This cross-sectional study analyzed fiscal year 2009 electronic pharmacy data from the Veterans Health Administration (VHA) for 356,958 veterans with PTSD who were receiving medications from VHA prescribers. Veterans had at least one VHA encounter with a diagnostic code of PTSD and evidence of continuous medication use. Medications of interest were selective serotonin-norepinephrine reuptake inhibitors (SSRI/SNRIs), second-generation antipsychotic medications, and benzodiazepines. Analyses described the proportion of prescribing attributable to mental health care providers and primary care providers for each medication class. RESULTS: In 2009, among all veterans with PTSD who had continuous VA medication use, 65.7% were prescribed SSRI/SNRIs, and 70.2% of this prescribing was attributable to mental health care providers. Second-generation antipsychotics were prescribed for 25.6% of these veterans, and 80.2% of the prescribing was attributable to mental health care providers. Benzodiazepines were prescribed for 37.0% of the sample, and 68.8% of the prescribing was attributable to mental health care providers. CONCLUSIONS: The findings indicate that veterans with PTSD were frequently prescribed medications not supported by existing guidelines. Most of these prescriptions were written by mental health care providers. Interventions to align prescribing with PTSD treatment guidelines should emphasize provider type.

Benzodiazepine prescribing variation and clinical uncertainty in treating posttraumatic stress disorder.

OBJECTIVE: Despite guideline recommendations against their use, benzodiazepines 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 prescribing variation in the VHA across multiple levels of geographic aggregation and over time. METHODS: Veterans with PTSD were identified from national VHA administrative data in fiscal years 1999 through 2009. Benzodiazepine 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 between 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 centers. 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.