Changing patterns of care for war-related post-traumatic stress disorder at Department of Veterans Affairs medical centers: the use of performance data to guide program development.

This study traces the development of services for war-related post-traumatic stress disorder (PTSD) provided at Department of Veterans Affairs (VA) medical centers. During the 1980s, long-stay inpatient programs were the major source of specialized VA treatment for PTSD, and an initial effort at development of specialized outpatient clinics resulted in incomplete implementation. In 1988, a full continuum of inpatient and outpatient services was designed and a national program of performance monitoring and outcome assessment was implemented to standardize program structure, monitor delivery, and evaluate outcomes. A series of multisite outcome studies showed significant but modest improvement in association with specialized outpatient treatment; they also showed that traditional long-term inpatient programs were no more effective and were far more costly than short-term specialized inpatient programs. Since 1995, the VA has shifted the emphasis of care substantially from inpatient to outpatient settings. National monitoring efforts have documented maintenance of specialized PTSD treatment capacity, increased access, improvement on available administrative measures of quality of care, and improved inpatient outcomes. Although there have been major changes in the treatment of mental illness in most health care systems in recent years, change in the treatment of PTSD at VA medical centers is unique in that it has been guided by the results of multisite outcome studies conducted in a "real-world" setting and has been supported by ongoing nationwide performance monitoring.