OBJECTIVE: We examined California pediatric residents' knowledge, practices, and comfort of providing expedited partner therapy (EPT) for sexually transmitted infections, by postgraduate year of training and presence of an adolescent medicine fellowship. We hypothesized that few residents are aware of EPT, and fewer are comfortable providing it; knowledge, practices, and comfort increase during residency; and presence of an adolescent medicine fellowship increases knowledge, practices, and comfort.
METHODS: Online anonymous questionnaires were completed by pediatric residents from 14 California programs.
RESULTS: Two hundred eighty-nine pediatric residents (41% response; mean age, 29.4 ± 2.7 years; 78% female) responded. Twenty-two percent reported being moderately or very familiar with EPT. Most correctly identified several EPT methods. Incorrectly identified as EPT included patient (55%), health department (42%), and provider (37%) referrals. Only 8% were aware of California’s legal status regarding EPT. Sixty-nine percent knew that California law allows EPT for chlamydia and gonorrhea, but 38% incorrectly stated that EPT can be used to treat trichomoniasis. Fifty-two percent reported ever providing EPT, but 30% of them were uncomfortable doing so. Postgraduate year 1 residents were significantly more likely to report lack of experience as a barrier to prescribing EPT. Residents in programs with the presence of an adolescent medicine fellowship had significantly higher global knowledge scores and were more likely to practice EPT with fewer concerns.
CONCLUSIONS: California pediatric residents have knowledge gaps and discomfort providing EPT, and the presence of adolescent medicine fellowship is associated with increased EPT knowledge, use, and comfort among residents. Our findings demonstrate a need to improve EPT education in pediatric residencies.
- EPT —
- expedited partner therapy
- PGY —
- postgraduate year
- STIs —
- sexually transmitted infections
What’s Known on This Subject:
Expedited partner therapy (EPT) is an effective method of partner treatment of sexually transmitted infections but is not used frequently. There are limited data on provider knowledge, practices, and comfort with EPT use in adolescents.
What This Study Adds:
California pediatric residents have knowledge gaps and discomfort providing EPT and presence of an adolescent medicine fellowship is associated with increased EPT knowledge, use, and comfort among residents. Our findings support the need to improve EPT education in pediatric residencies.
Approximately half of all new sexually transmitted infections (STIs) are diagnosed in sexually active adolescents, with 25% of adolescents diagnosed with an STI within 1 year of initiating sexual activity, and up to 50% diagnosed with an STI within 2 years.1,2 Genital Chlamydia trachomatis and Neisseria gonorrhoeae are substantial public health concerns in adolescents and young adults. In the United States, chlamydia and gonorrhea rates are highest among adolescents and young adults 15 to 24 years of age and are particularly high in adolescents in juvenile corrections facilities, blacks, American Indian/Alaskan Natives, and Hispanics.3,4 In adolescent girls, chlamydia and gonorrhea reinfection rates are as high as 40% within 12 months of the initial infection.5–7 Although multiple risk factors for reinfection exist, one major risk factor is continued sexual contact with the untreated infected partner.8 Untreated chlamydia and gonorrhea infections are associated with adverse reproductive outcomes such as recurrent pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, and infertility, as well as adverse perinatal outcomes, including prematurity, neonatal conjunctivitis, and pneumonia infections.7,9 Treatment of STIs, including testing for reinfection 3 months after treatment,10 is vital to prevent potential adverse health outcomes.
Expedited partner therapy (EPT) is the treatment of sex partners of patients diagnosed with a STI without an intervening medical evaluation by a health care provider through prescription and/or dispensation of antibiotics to the partners. EPT is an effective method of partner notification and treatment when the index patient believes the partner(s) will not present for evaluation and treatment.10,11 The Society for Adolescent Health and Medicine, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and American Medical Association endorse use of EPT especially when partner evaluation and treatment by a provider is impractical or unsuccessful.12–15 Currently, EPT is allowed in 31 states and potentially allowable in 12 more states.16 California was the first state to pass legislation in 2001 to legalize EPT for treatment of chlamydia and amended the legislation to include treatment of gonorrhea in 2007.17 It is highly recommended as part of EPT, although not mandated in California, that counseling and educational materials are provided to the partner(s) along with the prescription or medication.11
Currently, few published studies exist assessing provider use and comfort with EPT for adolescents. A 2002 survey of chlamydia treatment practices among 1603 California providers in 5 specialties that treat patients <30 years of age demonstrated that up to half of providers routinely provide EPT, that the majority felt that EPT protects patients from reinfection, but that multiple concerns remain about EPT. Concerns included adverse drug reactions in partner(s) treated without direct medical supervision, perceived liability risk as a result of prescribing or dispensing antibiotics to partner(s) without a previous examination, missed medical care opportunities in the partner(s), partner(s)’ noncompliance with treatment, and legal requirements to report sexual activity involving a minor.18 Less is known about EPT practices for gonorrhea, because the California law approving EPT went into effect just 4 years ago.
Because they are the future providers, resident physicians who will treat adolescents and who will practice in states where EPT is legal should receive training about EPT. To date, no published research exists describing pediatric residents’ knowledge and practices regarding EPT.
The primary aim of our study was to assess California pediatric residents’ knowledge, clinical practice, and comfort of EPT use among adolescent patients. We hypothesized that few residents are aware of EPT, and even fewer are comfortable providing it. The secondary aims were to determine whether knowledge, practices, and comfort increased during residency training and with exposure to an adolescent medicine fellowship program. We hypothesized that residents’ knowledge, practices, and comfort with providing EPT would increase during residency training and that residents at programs with an adolescent medicine fellowship would have increased knowledge, practice, and comfort about EPT in comparison with those at residency programs without an adolescent medicine fellowship.
Program directors of all pediatric residency training programs in California were contacted by e-mail and then with a follow-up telephone call for permission to recruit the program’s pediatric residents. When permission was obtained, the program coordinator and/or program chief resident(s) were requested to distribute an e-mail to their residents informing them of the study and requesting their participation. A link to the questionnaire was attached. The e-mail was sent 3 times over 6 weeks to all residents at participating pediatric residency programs to maximize recruitment. Residents were assured that their participation would remain anonymous and would have no impact on evaluations of their performance as a pediatric resident. All postgraduate year (PGY) 1, 2, and 3 residents were invited to participate. There were no exclusion criteria.
An incentive of winning an iPad2 through a random drawing was offered to encourage participation. All residents who clicked on the link to the online questionnaire received an entry into the random drawing, with an option to enter without completing the questionnaire. Residents received additional entries when they completed the questionnaire sooner.
A 57-item questionnaire was developed to assess pediatric residents’ current knowledge, clinical practices, and personal comfort providing EPT. Ten physicians who were not residents piloted the questionnaire, taking ∼10 minutes to complete it. A combination of forced-choice questions and 4-point Likert scales was used. Demographic information was obtained. Global knowledge scores were derived from 22 separate items. Knowledge questions asked whether specific partner treatments are methods of EPT, which STIs may be treated by EPT under California law, and the effectiveness of EPT compared with other partner treatment methods. Clinical practices, such as the frequency of treating adolescents with STIs, conditions in which EPT was used, and frequency of specific STI treatment practices for their patient’s partner(s) were assessed. The level of comfort with providing EPT was assessed, and respondents identified their level of concern (from “not at all concerned” to “very concerned”) with various barriers cited in previous studies on EPT utilization. These barriers included potential medication side effects, liability, cost, and compliance issues. Residents were also asked to identify 1 educational modality that would be most useful to increase their comfort with providing EPT.
The protocol and questionnaire were approved by the Stanford University Panel on Medical Human Subjects Research. A waiver of written consent was granted. The residents were informed by e-mail that consent was given when they completed the online survey and submitted their responses.
χ2 analyses were used for categorical variables. For analysis by PGY groups, analysis of variance was used for continuous variables, and the Kruskal-Wallis test was used for ordinal variables. For analysis by presence of an adolescent medicine fellowship, the t test was used for continuous variables and the Wilcoxon rank-sum test was used for ordinal variables. Data are presented as mean ± SD. SPSS 19.0 (SPSS, IBM Inc., Chicago, IL) was used for the analyses.
Fourteen of 17 pediatric residency training programs in California participated in this study, which comprised a total of 708 residents. There were 289 participants (41% response rate), with ∼33% in each PGY of training and 41% in a program with an adolescent medicine fellowship affiliation. Mean age was 29.4 years ± 2.7 years, and 78% of respondents were female (Table 1).
Almost all participants reported providing care to adolescent and young adult patients (aged 12–21 years) multiple times a month, with only 2% of the participants reporting that they interacted with this population less than once a month. Most (83%) had diagnosed an STI in this patient population.
Thirty-eight percent reported that they were not at all familiar with EPT for STIs, 41% had heard of EPT, and only 21% were moderately or very familiar with EPT. Only 24% of residents recalled ever being taught about EPT. Of those who received education about EPT, 85% reported they learned about EPT via direct patient care with a faculty preceptor, and 43% learned about it at a didactic lecture at resident educational conferences. Other methods of learning about EPT included independent reading in medical textbooks or journals (22%), use of online medical sources (22%), direct patient care with a fellow preceptor (15%), use of online lay sources (7%), direct patient care with a senior resident preceptor (7%), and being taught in medical school (4%).
Even though the majority of residents had not formally received training about EPT, most identified that writing a prescription for the partner(s) in the patient or partner’s name and providing the antibiotic directly to the patient to give to the partner(s) are methods of EPT. However, other partner treatment methods were incorrectly identified as EPT, including patient referral (55%), health department referral (42%), and provider referral (37%). The majority answered that EPT is equally effective or more effective than other methods of partner STI treatment.19–21 Although only 8% of respondents were aware of the legal status of EPT in California, almost 69% correctly identified that, under California law, EPT can be used for the treatment of chlamydial and gonococcal infections. Others incorrectly stated EPT can be used to treat trichomoniasis (38%), bacterial vaginosis (13%), and candidiasis (10%). In addition, 16% to 48% of residents responded that they “didn’t know” whether certain methods of partner treatment are considered EPT, the effectiveness of EPT as compared with other partner treatment referral methods, and which STIs are treatable via EPT in California (Fig 1).
When confronted with the need to treat the sexual partner(s) of an adolescent patient with an STI, 76% of pediatric residents reported having used patient referral, 34% reported having used health department referral, and 8% reported having used provider referral. In addition, 22% have written a prescription for the partner(s) in the partner’s name, 16% have written a prescription for the partner(s) in the patient’s name, and 14% have provided the antibiotic to the patient to give to the partner(s). Thus, 52% of the respondents reported having used at least 1 method of EPT for the treatment of either chlamydia or gonorrhea. Of these, 43% used EPT rarely (<10% of treatment), 31% sometimes (10%–49% of treatment), 19% usually (59%–90% of treatment), and 7% often (>90% of treatment). Residents also reported using EPT primarily for chlamydia (40%) and gonorrhea (30%), although a small number reported using EPT for trichomoniasis (4%), bacterial vaginosis (2%), and candidiasis (1%) (Fig 2). It is interesting that residents reported using EPT even when they were not aware of their clinic policy regarding EPT, as 83% reported not being aware of a clinic policy, 13% reported that they have no clinic policy, and only 4% reported being aware of a policy.
Although 52% of the residents reported ever providing EPT, 30% of these residents also reported being uncomfortable with it. Three areas of concern with providing EPT were identified: the possibility of an adverse drug event, concerns about the partner(s)’ ability to fill the prescription, and missed opportunities to provide medical care to the partner(s). The major barrier identified by pediatric residents that prevented them from providing EPT was unfamiliarity with the law (87%). Other barriers included a lack of confidence that the partner(s) would fill the prescription (47%) or take the antibiotic (47%), and a lack of knowledge of how to document EPT in the medical record (44%) (Table 2). Residents indicated that didactic lectures during resident teaching conferences (54%) and additional direct patient care in STIs and EPT (18%) as the 2 learning methods most likely to increase their comfort in providing EPT.
Global knowledge about EPT and frequency of EPT use did not differ by PGY groups. Significant differences were found in other clinical practices of partner treatment. PGY-1s were less likely to have used any method of partner treatment compared with PGY-2s (P = .042) and PGY-3s (P = .027). PGY-3s used health department referrals more than PGY-1s (P = .004). PGY-1s were more likely to identify a lack of experience in diagnosis and treatment of STIs as a barrier to EPT use compared with PGY-2s (P = .013). No other differences were found in concerns or barriers to EPT use.
Pediatric residents in programs with an adolescent medicine fellowship had significantly higher global knowledge scores compared with residents at programs without an adolescent medicine fellowship (11.5 ± 5.7 vs 10.0 ± 5.8; P = .037). They were also more likely to provide EPT (P = .018), more likely to have written a prescription for the partner(s) in the patient’s name (P = .005), and more likely to have provided an antibiotic directly to the patient to give to the partner(s) (P = .002) compared with those who were at programs without an adolescent medicine fellowship. They were less concerned about partner(s)’ ability to fill the prescription (P = .042) or compliance in taking the antibiotic (P = .002). They also were more likely to identify that a lack of adequate experience in diagnosing and treating STIs was a barrier in providing EPT (P = .029).
This study demonstrated that many California pediatric residents have knowledge gaps regarding EPT. Only 8% of residents were aware of the legal status of EPT in California, but approximately half of all respondents had reported having used EPT. The legal status and laws regarding the specifics of EPT vary from state to state, and providers should be aware of them before practicing EPT. For example, writing a single prescription with the names of the patient and partner(s) is permitted in California but may not be legal in some states. Under California law, EPT is only allowed for the treatment of chlamydia and gonorrhea infections.11 Almost 69% of respondents correctly answered this question, but others also incorrectly thought that EPT could be used for other STIs, such as trichomoniasis. These discrepancies between knowledge and clinical practice point to a need to improve residents’ education and training about EPT.
Other methods of partner treatment of STIs are patient referral, health department referral, and provider referral. Patient referral places the responsibility on the patient for contacting and notifying their partner(s) of the need for evaluation and treatment of an STI. Health department referral refers to the process whereby the provider contacts the health department, the health department contacts the patient, obtains the partner’s information and then contacts and notifies the partner(s). If the provider’s office directly contacts and notifies the partner(s) of the index patient, then it is considered a provider referral.
The optimal partner treatment strategy is for the partner(s) to present for a full STI evaluation, which is most effective through direct provider notification by either a health department disease intervention specialist or a health care provider. All state health departments mandate reporting cases of chlamydia and gonorrhea and have a disease intervention specialist notify, test, and treat sex partner(s). Unfortunately, most health departments do not have the capacity to offer this service to all patients. A 2003 study of 60 metropolitan health departments in cities with the highest rates of gonorrhea, chlamydia, and syphilis demonstrated that partner notification was offered in only 12% of chlamydia and 17% of gonorrhea cases, primarily because of lack of personnel and resources.22 With the use of patient referral, it is estimated that only half of all partners of those diagnosed with chlamydia or gonorrhea receive treatment.10 Finally, provider referral requires office staff and resources, which may not be available. Thus, all 3 methods are suboptimal in notifying partner(s) for treatment of STIs and increase the risk of reinfection in the treated patient. EPT is as effective as traditional partner treatment methods.10
Our survey found that 76% of the pediatrics residents primarily used patient referral to treat STIs in sexual partner(s), 34% used health department referral, and 8% used provider referral. These findings are consistent with those of studies surveying US physicians in multiple specialties where 80% to 97% of physicians use patient referral, 10% use health department referral, and 4% use provider referral.23,24 Continuing medical education of supervising physicians involved in pediatric residency programs about EPT, such as through STI prevention clinical training courses sponsored by the Centers for Disease Control and Prevention, may increase comfort in providing EPT and improve resident training. Many state or local health departments offer STI prevention courses, and programs and providers are encouraged to contact these departments to inquire about the courses offered.
No significant improvements in EPT knowledge, clinical practices, or comfort were noted by year of pediatric training, which refuted our second hypothesis. This survey was conducted in the last 2 months of the academic year, when all PGY-3s, most PGY-2s, and few PGY-1s would have completed their Accreditation Council for Graduate Medical Education mandated adolescent medicine rotation, where they are likely to receive the most exposure to patients with STIs and partner treatment. In addition, at the time of the survey, PGY-3s were only weeks away from graduating residency. It is concerning that knowledge and comfort did not improve over the course of pediatric residency training. Our findings highlight the need to improve resident education about EPT during residency. Although our survey did not evaluate optimal methods to educate residents about EPT, some suggestions from the residents include providing didactic sessions on STIs and EPT and/or providing educational materials online or on CDs for independent review.
EPT knowledge, practices, and comfort were higher in residents exposed to an adolescent medicine fellowship program, which supported our third hypothesis. Residents in these programs may have increased teaching by adolescent medicine fellows and attending physicians about STIs and treatment methods and more opportunities to care for adolescent patients who have tested positive for an STI, and therefore have more experience and comfort with providing EPT. Adolescent medicine fellows and attending physicians may also be more aware and up to date on new laws regarding EPT. In the United States, there are 198 pediatric residency programs and only 26 adolescent medicine fellowship programs.25 It is therefore not practical for all pediatric residency programs to have exposure to an adolescent medicine fellowship. Targeted efforts should be made to include education about EPT in the residents’ Accreditation Council for Graduate Medical Education–mandated adolescent medicine rotations and could be done through modalities suggested by the residents above.
The major limitation of any survey is selection bias. Only 41% of our targeted population responded, although that is a reasonable rate for an online survey. In addition, although 14 of 17 pediatric programs participated in this survey, 3 did not, further contributing to selection bias. All pediatric residency programs with the presence of an adolescent medicine fellowship program participated, and thus our results may overestimate of the levels of resident knowledge, practices, and comfort. Another limitation is responder bias, because residents who were interested in this topic were possibly more likely to participate. However, we have no information on nonresponders to determine this. A third limitation is recall bias regarding clinical practices, because the data were collected from self-reported surveys. Strengths of our study include participation of pediatric residents from the majority of programs in the state, with participants well distributed between PGY groups.
Future research may consider exploring EPT knowledge, practices, and comfort of pediatric residents in other states that allow EPT. If other states’ pediatric residents have higher knowledge, practices, and comfort using EPT compared with our results in California, randomized trials of different EPT learning modalities in residency may lead to improved EPT training in all pediatric residency programs in the United States.
California pediatric residents have limited knowledge regarding EPT. Few residents reported ever being taught about EPT. Despite lack of EPT knowledge, discomfort with EPT, and lack of awareness of its legal status, approximately half the residents have provided EPT. There were no significant differences in knowledge, practices, or comfort by year of training, but residents in programs with an adolescent medicine fellowship program had higher knowledge scores and used EPT more frequently. Our findings demonstrate a need to improve EPT education for all pediatric residents, especially in programs without an adolescent medicine fellowship.
- Accepted June 4, 2012.
- Address correspondence to Anne Hsii, MD, Department of Pediatrics, Division of Adolescent Medicine, Stanford University School of Medicine, 1174 Castro St, Suite 250A, Mountain View, CA 94040. E-mail:
All authors (Drs Hsii, Hillard, Yen, and Golden) have contributed significantly to the study design, data acquisition, analysis, interpretation, and writing. In addition, all authors have consented to have their names on this manuscript and take responsibility for the contents of this manuscript.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
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- Statement of Endorsement–expedited partner therapy for adolescents diagnosed with chlamydia or gonorrhea
- ↵Opinion 8.07 – Expedited Partner Therapy. AMA Code of Medical Ethics. Available at: www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion807.page. Accessed February 22, 2012
- ↵Centers for Disease Control and Prevention. Legal status of expedited partner therapy (EPT). Available at: www.cdc.gov/std/ept/legal/default.htm. Accessed May 22, 2012
- ↵California Department of Public Health, Sexually Transmitted Disease Control Branch, California STD Controllers Association, California STD/HIV Prevention Training Center. Patient-Delivered Partner Therapy (PDPT) for Chlamydia trachomatis and Neisseria gonorrhoeae: Interim Guidance for Medical Providers in California. Sacramento, CA: California Department of Public Health; 2011
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- Copyright © 2012 by the American Academy of Pediatrics