title: Cultivating change door to door: Educational outreach to improve prescribing practices in rural veterans with posttraumatic stress disorder.
abstract: Clinical guidelines for the management of posttraumatic stress disorder (PTSD) recommend against the use of benzodiazepines. Benzodiazepines and PTSD are both associated with addiction-related risks. The Department of Veterans Affairs (VA) prescribing trends show continued use of benzodiazepines and polysedative use in veterans with PTSD, particularly in rural areas. The authors examine the use of an educational intervention to improve pharmacologic management of veterans with PTSD in rural clinics.
  
  
  
  The VA Academic Detailing Service Informatics Toolset provides prescribing, demographic and risk factor data for veterans with PTSD treated at the White River Junction VA Medical Center (WRJ VA) and affiliated rural clinics in Vermont and New Hampshire. Individualized academic detailing visits were provided to clinicians identified by the informatics tool with the aim of increasing guideline-concordant care. Other educational efforts included traditional, didactic group education on evidence-based PTSD care and the development and dissemination of educational materials for clinicians and patients. Prescribing trends of benzodiazepines, off-label atypical antipsychotics, and prazosin were collected quarterly for 3 years (October 1, 2013, to September 30, 2016).
  
  
  
  Prescribing rates of benzodiazepines during the educational intervention decreased from 13% to 9.3%. Use of off-label atypical antipsychotics, a class of medications not recommended for PTSD, stayed relatively flat at about 10%. Prescribing of prazosin, a medication recommended for treatment of trauma nightmares, increased from 9.8% to 14.3%.
  
  
  
  Academic detailing and other educational programming appear to be effective for addressing gaps and lag in quality PTSD care and are associated with a positive trend of decreased benzodiazepine use. Efforts will continue, now with added focus on concurrent use of benzodiazepines and opioids and the use of off-label atypical antipsychotics in rural veterans with PTSD.
authors.affiliation: a Veterans Affairs Medical Center, White River Junction , Vermont , USA.
authors.forename: Macgregor
authors.initials: M
authors.lastname: Montaño
authors.affiliation: b National Center for PTSD , Veteran Affairs Medical Center, White River Junction , Vermont , USA.|c Department of Psychiatry , Geisel School of Medicine at Dartmouth , Hanover , New Hampshire , USA.
authors.forename: Nancy C
authors.initials: NC
authors.lastname: Bernardy
authors.affiliation: b National Center for PTSD , Veteran Affairs Medical Center, White River Junction , Vermont , USA.|d Department of Sociology , Dartmouth College , Hanover , New Hampshire , USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Sherrieb
mesh_terms: D004502:Education, Medical, Continuing; D006801:Humans; D010820:Physicians / Q000523:psychology*; D010818:Practice Patterns, Physicians' / Q000639:trends*; D012424:Rural Population; D013313:Stress Disorders, Post-Traumatic / Q000188:drug therapy*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans
keywords: Benzodiazepines; academic detailing; educational outreach; posttraumatic stress disorder; quality improvement; rural health