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QUERI – Quality Enhancement Research Initiative

Feature Articles

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Feature Articles

VA Providers Prescribe Benzodiazepines at Higher Rates to Veterans with PTSD and Mild Traumatic Brain Injury

The "VA/DoD Clinical Practice Guideline for the Management of Post-traumatic Stress Disorder" (PTSD) and the VA/DoD guidelines for the Management of Concussion/Mild Traumatic Brain Injury (mTBI) both recommend against the use of benzodiazepines for brain-injured patients who may be more sensitive to side-effects such as confusion. However, a formative evaluation performed by Polytrauma & Blast-Related Injury-QUERI investigators (PT/BRI-QUERI) showed that VA clinicians prescribe benzodiazepines at higher rates to those with co-occurring PTSD and a history of mild TBI in both male and female Veterans than in Veterans with PTSD without a history of mTBI. Thus, there appears to be a clear gap between VA clinical recommendations and clinical practice.

It is uncertain if clinicians are unaware of the recommendations, if there are symptoms related to a brain injury that they are trying to treat with the benzodiazepines, or if Veterans are asking for these medications but are unaware of their risks. These factors highlight the need for educational materials - aimed at clinicians, patients and their family members - that:

  • Discourage the prescribing of benzodiazepines in Veterans with this comorbidity,
  • Explain the risks, and
  • Offer better, safer treatment alternatives to improve treatment decision-making.

Through support from PT/BRI-QUERI, investigators developed educational materials that provide general safety information about benzodiazepines and treatment options for Veterans with a history of co-occurring mTBI and PTSD. The materials are aimed at Veterans and their family members, as well as at prescribing clinicians, to help facilitate shared-decision making discussions around treatment planning. The materials were evaluated through focus groups and individual interviews with Veterans with PTSD and a history of mTBI and their family members. The evaluation explored Veterans' and family members' thoughts about and understanding of the materials, as well as their:

  • Beliefs about benzodiazepines and what symptoms these medications may be helping,
  • Understanding of the benefits/harms of these medications, and
  • Knowledge about alternative treatment options.

The interviews revealed a clear lack of awareness among Veterans and their family members of the evidence-based psychotherapies available to treat PTSD. Another common theme that emerged was that Veterans felt that their doctors were "throwing pills at them." The Veterans reported understanding that some of the medications prescribed to patients with PTSD might not be optimal treatment choices, and they were interested in learning about more effective treatment options. However, they wanted to learn about these options through positive messaging and suggested healthcare providers avoid using fear tactics. Moreover, Veterans felt that even though the materials were "readable," they were filled with clinical "jargon" and should be re-worded to reflect how patients in VA actually talk about treatments (e.g., use brand-name examples for medication classes, and use the word "counseling" instead of psychotherapies).

All educational materials are available on the PT/BRI-QUERI website, and on the National Center for PTSD website. Investigators also are beginning work on a Mental Health-QUERI and PT/BRI QUERI-supported study using academic detailing as a strategy to implement these and other materials to support decisions to decrease benzodiazepine use and identify appropriate treatments. For more information or questions, please contact Nancy Bernardy, Ph.D., at


Development of a Skin Health Reminder Checklist in Spinal Cord Injury Care

Spinal cord injury (SCI) is a permanent condition affecting every aspect of life including health, daily activities, participation and quality of life. SCI is among the most costly medical conditions in VA. Persons with SCI are at high risk of pressure ulcers (PrUs) throughout their lifetimes due to decreased mobility, lack of sensation and other physiologic changes. PrU prevalence, morbidity, mortality, and recurrence rates are high. Veterans with SCI and PrUs had more inpatient days on average (61 vs. 9.2) and higher mean healthcare costs ($100,935 vs. $27,914) than their counterparts without PrUs due primarily to higher inpatient days.

Spinal Cord Injury-QUERI investigators recently completed a study examining PrU preventive care during annual evaluations, an assessment that includes clinical practice guideline-recommended (CPG) skin and PrU prevention assessments. Of the CPG skin health/PrU prevention items, mean completion rates were 78% for inpatient vs. 61.5% for outpatient annual evaluations. As most PrUs in Veterans with SCI are community-acquired, focusing on provider-patient interactions in outpatient settings represents the best opportunity for improving skin health and PrU prevention.

Widely-accepted quality improvement strategies and tools to increase the spread of evidence include standardized reminder tools to improve consistency, improve safety and reduce costs. Checklists facilitate the grouping of essential information (e.g., indicators, action items, criteria) in a systematic manner, reminding and ensuring that all relevant factors be considered and addressed to support clinical decision-making. About 25% of SCI PrU CPG recommendations focus on PrU prevention, including routine skin inspection, repositioning, use of pressure-reducing support surfaces, improving management of chronic conditions, nutrition, and moisture.

The objective of a recently funded QUERI study is to implement a Skin Health Reminder Checklist (SHRC) to increase provision of guideline recommended pressure ulcer preventive care in an SCI outpatient clinic setting at two VA Spinal Cord Injury Centers. Working with SCI Center clinicians, QUERI investigators will:

  • Develop actionable criteria for each checklist item,
  • Examine barriers and facilitators to implementing the SHRC in the outpatient setting,
  • Implement the SHRC in the outpatient setting,
  • Describe skin health problems identified with the SHRC and action taken by providers, and
  • Share this information with all SCI Centers.
  • It is expected that use of the SHRC will increase skin health assessment and PrU prevention for Veterans with spinal cord injury.

For more information, please contact Marylou Guihan, Ph.D., at