DOD and VA Health Care:
Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices
GAO-16-158: Published: Jan 5, 2016. Publicly Released: Jan 5, 2016.
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What GAO Found
The Department of Defense (DOD) and the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) have collaborated to develop clinical practice guidelines for post-traumatic stress disorder (PTSD) and mild traumatic brain injury (TBI). The mild TBI guideline does not include recommendations based on scientific evidence regarding the use of medications to treat symptoms because of a lack of available research; however, the PTSD guideline discourages the use of benzodiazepines (a sedative) and states that the use of antipsychotics to treat PTSD lacks support, based on available research. VHA monitors the prescribing of benzodiazepines and antipsychotics to treat PTSD nationally and by VA medical centers (VAMC) and requires VAMCs to implement improvement plans if their prescribing is significantly higher than the average of all VAMCs. GAO found that DOD relies on each military service to review the medication prescribing practices of its providers and that the Army does not monitor the prescribing of medications to treat PTSD on an ongoing basis. Without such monitoring, the Army may be unable to identify and address practices that are inconsistent with the guideline. Federal internal control standards require agencies to have control activities to establish performance measures, implement ongoing monitoring to assess performance, and ensure that the findings of reviews are promptly resolved.
As of August 2015, VA's formulary included 57 percent of the psychiatric, pain, and sleep medications on DOD's formulary. These medications are prescribed to treat symptoms common among servicemembers and veterans with PTSD or mild TBI, and most of the DOD prescriptions in fiscal year 2014 for these medications (88 percent) were on both formularies. In addition, DOD and VHA officials GAO interviewed agreed that the differences did not affect the continuation of medications for servicemembers transitioning from DOD to VHA.
VHA has two key efforts to help ensure continuation of medications for transitioning servicemembers, including those with PTSD or mild TBI, but a lack of clarity of one effort may limit its effectiveness. VHA's nonformulary request process is one key effort that helps ensure newly transitioned veterans avoid medication discontinuations due to differences between the DOD and VA formularies. VHA monitors nonformulary requests. VHA data show that 81 percent of requests submitted from fiscal years 2012 through 2014 were approved, and 98 percent of requests were adjudicated within VHA's required time frame of 96 hours. The other key effort is VHA's 2015 policy instructing its providers not to discontinue mental health medications initiated by DOD providers due to formulary differences. However, VHA providers GAO interviewed had varying interpretations of which medications are covered by this policy, and VHA officials acknowledged that the definition of a mental health medication could be subjective. Federal internal control standards state that agencies should establish control activities, such as developing clear policies. Because VHA's policy lacks clarity, VHA providers may be inappropriately discontinuing mental health medications due to formulary differences, which could increase the risk of adverse health effects for transitioning servicemembers.
Why GAO Did This Study
Medication continuation, when clinically appropriate, is critical for transitioning servicemembers with PTSD or TBI who have been prescribed psychiatric, pain, or sleep medications. Adverse health effects may occur if these medications are inappropriately discontinued.
The National Defense Authorization Act for Fiscal Year 2015 included a provision for GAO to assess transitions of care, particularly medication continuation for servicemembers with PTSD or TBI transitioning to VHA. GAO examined (1) the extent to which DOD and VHA developed and monitored recommended medication practices for PTSD and TBI; (2) the extent to which psychiatric, pain, and sleep medications on DOD's formulary are on VA's formulary, and how differences might affect medication continuation; and (3) key efforts VHA has to help ensure medication continuation, and the extent it is monitoring these efforts. GAO reviewed documents and analyzed DOD and VHA data from fiscal years 2012 through 2015; and interviewed DOD and VHA officials from headquarters and five Army and DOD facilities, selected for variation in size and location. GAO focused on the Army as the largest number of its servicemembers served in recent conflicts.
What GAO Recommends
GAO recommends that the Army monitor prescribing practices of medications discouraged under the PTSD guideline and that VHA clarify its medication continuation policy. DOD and VHA concurred with the recommendations.
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Recommendations for Executive Action
Comments: DOD concurred with this recommendation. In its September 30, 2020 response, DOD provided documentation that the Defense Health Agency, Behavioral Health Clinical Community, and Pharmacy Analytics, Pharmacy Operations Division (POD) completed an initial review of prescribing practices for the treatment of PTSD in 2017. In addition, POD continued to monitor practices on a quarterly basis and sent the results to the Service Directors of Psychological Health and the Clinical Community Advisory Councils until June 2020. DOD stated in its response that it stopped sending the quarterly reports to stakeholders because the data have shown a decrease in benzodiazepine and atypical antipsychotic prescriptions. Further, DOD stated that no further intervention was necessary given the decrease and that it plans to send the quarterly reports to relevant stakeholders only if data show a reverse in this trend. To close this recommendation, DOD needs to provide documentation that it has a process in place to address identified deviations among providers who continue to prescribe medications discouraged under the PTSD guideline.
Recommendation: The Secretary of Defense should direct the Secretary of the Army to implement processes to review and monitor the Army military treatment facility prescribing practices for medications discouraged under the PTSD guideline and address identified deviations.
Agency Affected: Department of Defense
Status: Closed - Implemented
Comments: VHA developed, jointly with DOD, a list of medications for transitioning service members that includes medications for the control of pain, sleep disorders, and psychiatric conditions, including post-traumatic stress disorder, as well as alcohol deterrents/narcotic antagonists and smoking cessation agents. The list clarifies which medications are covered by VHA's January 2015 policy on continuation of mental health medications.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to clarify which types of medications are covered by VHA's January 2015 policy on medication continuation.
Agency Affected: Department of Veterans Affairs