Tracing the flow of knowledge: geographic variability in the diffusion of prazosin use for the treatment of posttraumatic stress disorder nationally in the Department of Veterans Affairs.
ABSTRACT Passive diffusion of new medical innovations is an important mechanism by which knowledge transitions from research to clinical practice. Preliminary evidence has emerged about the effectiveness of the alpha(1)-adrenergic blocker prazosin hydrochloride in the treatment of nightmares and hyperarousal among patients with posttraumatic stress disorder (PTSD). This treatment has been neither widely accepted nor the subject of active dissemination efforts, and its efficacy was discovered in a discrete geographic location.
To evaluate the pace and reach of the passive dissemination of a promising technology within a national health care system.
Geographic surveillance data study.
We tracked the use of prazosin in the treatment of patients diagnosed as having PTSD in the Department of Veterans Affairs during fiscal years 2004 (n = 203 414) and 2006 (n = 319 670).
The percentage of patients diagnosed as having PTSD who received a prescription for prazosin.
Whereas 37.6% of patients with PTSD treated within the Veterans Affairs Puget Sound Health Care System, Tacoma, Washington, in 2004 were prescribed prazosin, only 18.2% were treated with prazosin at medical centers up to 499 miles (to convert miles to kilometers, multiply by 1.6) away, 6.7% at centers 500 to 999 miles away, 4.0% at centers 1000 to 2499 miles away, and 1.9% at centers 2500 miles away or farther. Adjusting for patient characteristics, patients with PTSD treated up to 499 miles from Puget Sound were about 49% less likely in 2006 and about 63% less likely in 2004 to be prescribed prazosin than their counterparts treated within Puget Sound, while those who were treated 2500 miles away or farther were about 94% less likely in 2006 and about 97% less likely in 2004 to be treated with prazosin than patients within Puget Sound.
Passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and enduring even when cost and organizational barriers are minimal.
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ABSTRACT: In most countries, physicians and other health-care providers play key roles in promoting health. Accumulating scientific evidence suggests that providers may soon want to include cognitive health among the areas they promote. Cognitive health is the maintenance of cognitive abilities that enable social connectedness, foster a sense of purpose, promote independent living, allow recovery from illness or injury and promote effective coping with functional deficits. The US Centers for Disease Control and Prevention has established health promotion about cognitive health as a policy priority, with health providers included as one key group to participate in this effort. This study presents results from focus groups and interviews with primary care physicians (n = 28) and midlevel health-care providers (physician assistants and nurse practitioners, n = 21) in three states of the US. Providers were asked about their sources of information on cognitive health and for their ideas on how best to communicate with primary care providers about research on cognitive health. In results, providers cited online sources, popular media and continuing medical education as their most common sources of information about cognitive health. Popular media sources were used both proactively and reactively to respond to patient inquiries. Differences in sources of information were noted for physicians as compared with midlevel providers, and for rural and urban providers. Several potential ways to disseminate information about cognitive health were identified. Effective messaging is likely to require multiple strategies to reach diverse groups of primary care providers, and to include continuing medical education.Health Promotion International 12/2010; 25(4):464-73. DOI:10.1093/heapro/daq043 · 1.94 Impact Factor
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ABSTRACT: Serotonin reuptake-inhibiting (SRI) antidepressants are the only FDA-approved pharmacotherapies for the treatment of posttraumatic stress disorder (PTSD). To determine efficacy of the second-generation antipsychotic risperidone as an adjunct to ongoing pharmacologic and psychosocial treatments for veterans with chronic military-related PTSD. A 6-month, randomized, double-blind, placebo-controlled multicenter trial conducted between February 2007 and February 2010 at 23 Veterans Administration outpatient medical centers. Of the 367 patients screened, 296 were diagnosed with military-related PTSD and had ongoing symptoms despite at least 2 adequate SRI treatments, and 247 contributed to analysis of the primary outcome measure. Risperidone (up to 4 mg once daily) or placebo. The Clinician-Administered PTSD Scale (CAPS) (range, 0-136). Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Scale (HAMA), Clinical Global Impression scale (CGI), and Veterans RAND 36-Item Health Survey (SF-36V). Change in CAPS scores from baseline to 24 weeks in the risperidone group was -16.3 (95% CI, -19.7 to -12.9) and in the placebo group, -12.5 (95% CI, -15.7 to -9.4); the mean difference was 3.74 (95% CI, -0.86 to 8.35; t = 1.6; P = .11). Mixed model analysis of all time points also showed no significant difference in CAPS score (risperidone: mean, 64.43; 95% CI, 61.98 to 66.89, vs placebo: mean, 67.16; 95% CI, 64.71 to 69.62; mean difference, 2.73; 95% CI, -0.74 to 6.20; P = .12). Risperidone did not reduce symptoms of depression (MADRS mean difference, 1.19; 95% CI, -0.29 to 2.68; P = .11) or anxiety (HAMA mean difference, 1.16; 95% CI, -0.18 to 2.51; P = .09; patient-rated CGI mean difference, 0.20; 95% CI, -0.06 to 0.45; P = .14; observer-rated CGI mean difference, 0.18; 95% CI, 0.01 to 0.34; P = .04), or increase quality of life (SF-36V physical component mean difference, -1.13, 95% CI, -2.58 to 0.32; P = .13; SF-36V mental component mean difference, -0.26; 95% CI, -2.13 to 1.61; P = .79). Adverse events were more common with risperidone vs placebo, including self-reported weight gain (15.3% vs 2.3%), fatigue (13.7% vs 0.0%), somnolence (9.9% vs 1.5%), and hypersalivation (9.9% vs 0.8%), respectively. Among patients with military-related PTSD with SRI-resistant symptoms, 6-month treatment with risperidone compared with placebo did not reduce PTSD symptoms. clinicaltrials.gov Identifier: NCT00099983.JAMA The Journal of the American Medical Association 08/2011; 306(5):493-502. DOI:10.1001/jama.2011.1080 · 30.39 Impact Factor
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ABSTRACT: Clinical practice guidelines issued by the US Department of Veterans Affairs (VA) and the Department of Defense caution against benzodiazepine use among veterans with posttraumatic stress disorder (PTSD) because of insufficient evidence for efficacy and emerging safety concerns. We examined recent trends in benzodiazepine prescribing among veterans with PTSD in terms of frequency of use, duration of use, and dose. Administrative VA data from fiscal years 1999 through 2009 were used to identify veterans with PTSD according to ICD-9 codes extracted from inpatient discharges and outpatient encounters. Benzodiazepine use among these individuals was determined for each fiscal year by using prescription drug files. Modal daily doses were examined by using standard daily dosage units. The number of veterans receiving care for PTSD in the VA increased from 170,685 in 1999 to 498,081 in 2009. The proportion of individuals receiving a benzodiazepine decreased during this time period from 36.7% to 30.6%. In addition, the proportion of long-term users (> 90 days) decreased from 69.2% to 64.1%, and daily dose decreased from 2.1 to 1.8 standard daily dosage units. Decreasing benzodiazepine use among veterans with PTSD is encouraging. However, the frequency of use remains above 30%, and focused interventions may be required to achieve further reductions. Given the growing number of veterans being diagnosed and treated for PTSD, minimizing benzodiazepine exposure will remain a vital policy issue for the VA.The Journal of Clinical Psychiatry 11/2011; 73(3):292-6. DOI:10.4088/JCP.10m06775 · 5.14 Impact Factor