Long-term improvement from intensive training for STI clinicians Kitty K. Corbett 1,2, Sharon Devine 2, Christine Shure 2, Susan Dreisbach 2, John Fitch 3, Teri Anderson 3, Terry Lee 3, Cornelis Rietmeijer 3 1 Simon Fraser University, Burnaby, BC, Canada; 2 University of Colorado at Denver & Health Sciences Center; 3 Denver Public Health, Colorado 1 Simon Fraser University, Burnaby, BC, Canada; 2 University of Colorado at Denver & Health Sciences Center; 3 Denver Public Health, Colorado Presented at National STD Prevention Meeting Jacksonville FL, May 9, 2006

Agenda Question: Does training result in sustained practice improvements? Findings: Evaluation of a 3-day intensive STD Prevention Training Course Discussion: Training as a key but under- recognized vehicle for transforming providers’ STI practices Acknowledgements: CDC, NNPTC, Denver Health

Problem Improvements in practice needed (IOM ‘97) Training programs exist nationwide to teach clinicians how to diagnose, treat, manage, and prevent STIs. Long-term effectiveness of training depends on clinicians applying and sustaining improved practices in clinical settings.

Goal of the study: to assess whether STI training is associated with sustained changes 6 months later TRAINING PROVIDERS Improved knowledge & skills [PATIENTS Better Outcomes] PROVIDERS Better practices

The National Network of STD/HIV Prevention Training Centers (PTCs) 25+ years; funded by CDC Improve clinicians’ skills to diagnose, treat, manage, prevent STIs Didactic and hands-on clinical training Evaluation NNPTC

The 3-Day STD Intensive Course Didactic review Practicum rotations Case management Lab demos Limit 5 clinicians / training Travel scholarships if distant (from Denver PTC marketing materials)

Participants in 27 Trainings CO (61%), UT (17%),WY (11%), other (11%) Occupations NP (41%)MD/DO (10%)PA (7%) RN (34%) CNM (9%) Provided clinical care in past 3 months 83% female 62 of 110 (56%) eligible participants completed at least part of 6 month follow-up

Assessments Pre coursePost courseLongterm Demographic √ N=95 -- √ N=62 Knowledge √ N=105 √ N=106 √ N=60 Skills √ N=75 √ N=102 √ N=53 Practices √ N= √ N=57 -- No significant differences in demographic characteristics between responders & non-responders at the 6-month assessment.

Knowledge Assessment 20 items 5 vignettes or “cases” each with 4 questions related to diagnosis, treatment, and/or management for each case. Example: An 18 year old presents to your clinic with a rash all over her body. She has had this rash for almost a week. A stat RPR is done and the results are positive. Given the above information, which of the following is the most likely diagnosis? 1) Early latent syphilis 2) Primary syphilis 3) Late latent syphilis 4) Secondary syphilis

59.4% 73.2% 66.8% 23.3% gain pre to post, p< % gain pre to long-term, p<.01 Improvements in Knowledge PREPOST LONG- TERM

Skills Assessment Self-assessed proficiency on 27 items Diagnostic skills (6 items) Technical skills (15 items) Communication skills (6 items) 5-Excellent 4-Very good 3-Good 2-Fair 1-Poor

Increases in Self-Assessed Skills DX: 53% pre-post* 67% pre-LT* TECH: 57% pre-post* 54% pre-LT* COMMUNIC: 19% pre-post* 22% pre-LT* *P<.001

7 of 27 Practices had Significant Changes Communication with adolescents about condoms Appropriate lab tests for syphilis for patients who report risk behaviors but have no STI symptoms Appropriate lab tests for HIV if patient has ulcerative lesion Screening for GC or CT of asymptomatic females:  Who had new sex partners in last 3 mo: GC  Who were sexually active <25 yrs old: GC  With exclusively female partner(s): GC  With exclusively female partner(s): CT

Longterm Changes in Screening for Gonorrhea in Asymptomatic Females 5-Always 4-Often 3-Sometimes 2-Rarely 1-Never *p<.05 **p<.01

Respondents’ assessment of how much their overall STD-related care to patients improved

Participants endorse the course This course brings the practice and theory information together, which is very helpful! This is the best CME course I have taken in 20 years of taking CME courses. I have learned some great pearls to help me improve my technique. The hands on experience was invaluable.

Limitations Pre-post design without control group Self reports for skills & practices Knowledge assessment at longterm: some may have used in-office materials (?) Self-assessed (vs. observed) skills confounded by self-efficacy Preceptor observations, standardized patient instructors, and other validation and assessment modes were not used Response bias

Conclusion (1): Training works Training appears effective for improving quality of information and skills providers draw on for STI diagnosis, management, counseling, and prevention. Providers appear to use the new knowledge and skills 6 months later in dealing with their patients.

Conclusion (2): Training is key This project supports the assertion that training is a critical underpinning for interventions known to be effective. Training should have a more central position in discussions of translational endeavors and diffusion of innovations in practice. Although a key piece in transforming STI practice, training is neglected as a research focus.

Conclusion (3): Lingering concerns How good are providers’ self-reports, and what is the best way to assess and validate STD provider performance? Which provider behaviors & skills are critical for affecting patient outcomes? What are the characteristics of effective training? –e.g., delivery modes, content, trainers, duration, boosters What are effective, efficient ways to disseminate training? e.g., TOT