DOI: 10.1542/peds.2011-3764; originally published online September 17, 2012; 2012;130;705Pediatrics

Anne Hsii, Paula Hillard, Sophia Yen and Neville H. GoldenTherapy for STIs

Pediatric Residents' Knowledge, Use, and Comfort With Expedited Partner  

  http://pediatrics.aappublications.org/content/130/4/705.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

Pediatric Residents’ Knowledge, Use, and ComfortWith Expedited Partner Therapy for STIs

WHAT’S KNOWN ON THIS SUBJECT: Expedited partner therapy (EPT)is an effective method of partner treatment of sexually transmittedinfections but is not used frequently. There are limited data on pro-vider knowledge, practices, and comfort with EPT use in adolescents.

WHAT THIS STUDY ADDS: California pediatric residents haveknowledge gaps and discomfort providing EPT and presence of anadolescent medicine fellowship is associated with increased EPTknowledge, use, and comfort among residents. Our findingssupport the need to improve EPT education in pediatricresidencies.

abstractOBJECTIVE: We examined California pediatric residents’ knowledge,practices, and comfort of providing expedited partner therapy (EPT)for sexually transmitted infections, by postgraduate year of trainingand presence of an adolescent medicine fellowship. We hypothesizedthat few residents are aware of EPT, and fewer are comfortable pro-viding it; knowledge, practices, and comfort increase during residency;and presence of an adolescent medicine fellowship increases knowl-edge, practices, and comfort.

METHODS: Online anonymous questionnaires were completed by pe-diatric residents from 14 California programs.

RESULTS: Two hundred eighty-nine pediatric residents (41% response;mean age, 29.4 6 2.7 years; 78% female) responded. Twenty-twopercent reported being moderately or very familiar with EPT. Mostcorrectly identified several EPT methods. Incorrectly identified as EPTincluded 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 chlamydiaand gonorrhea, but 38% incorrectly stated that EPT can be used to treattrichomoniasis. Fifty-two percent reported ever providing EPT, but 30%of them were uncomfortable doing so. Postgraduate year 1 residentswere significantly more likely to report lack of experience as a barrierto prescribing EPT. Residents in programs with the presence of anadolescent medicine fellowship had significantly higher global knowledgescores and were more likely to practice EPT with fewer concerns.

CONCLUSIONS: California pediatric residents have knowledge gapsand discomfort providing EPT, and the presence of adolescent medicinefellowship is associated with increased EPT knowledge, use, and com-fort among residents. Our findings demonstrate a need to improve EPTeducation in pediatric residencies. Pediatrics 2012;130:705–711

AUTHORS: Anne Hsii, MD,a Paula Hillard, MD,b Sophia Yen,MD, MPH,a and Neville H. Golden, MDa

aDivision of Adolescent Medicine, Department of Pediatrics, andbDepartment of Obstetrics and Gynecology, Division ofGynecologic Specialties, Stanford University School of Medicine,Palo Alto, California

KEY WORDSsexually transmitted diseases, partner treatment, expeditedpartner therapy, adolescents

ABBREVIATIONSEPT—expedited partner therapyPGY—postgraduate yearSTIs—sexually transmitted infections

All authors (Drs Hsii, Hillard, Yen, and Golden) have contributedsignificantly to the study design, data acquisition, analysis,interpretation, and writing. In addition, all authors haveconsented to have their names on this manuscript and takeresponsibility for the contents of this manuscript.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-3764

doi:10.1542/peds.2011-3764

Accepted for publication Jun 4, 2012

Address correspondence to Anne Hsii, MD, Department ofPediatrics, Division of Adolescent Medicine, Stanford UniversitySchool of Medicine, 1174 Castro St, Suite 250A, Mountain View, CA94040. E-mail: annepeds@gmail.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: No external funding.

PEDIATRICS Volume 130, Number 4, October 2012 705

ARTICLE

at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

Approximately half of all new sexuallytransmitted infections (STIs) are di-agnosed in sexually active adolescents,with 25%of adolescentsdiagnosedwithan STI within 1 year of initiating sexualactivity, and up to 50% diagnosed withan STI within 2 years.1,2 Genital Chla-mydia trachomatis and Neisseria gon-orrhoeae are substantial public healthconcerns in adolescents and youngadults. In the United States, chlamydiaand gonorrhea rates are highest amongadolescents and young adults 15 to 24years of age and are particularly high inadolescents in juvenile corrections fa-cilities, blacks, American Indian/AlaskanNatives, and Hispanics.3,4 In adolescentgirls, chlamydia and gonorrhea re-infection rates are as high as 40%within12 months of the initial infection.5–7 Al-though multiple risk factors for reinfec-tion exist, one major risk factor iscontinued sexual contact with the un-treated infected partner.8 Untreatedchlamydia and gonorrhea infections areassociated with adverse reproductiveoutcomes such as recurrent pelvic in-flammatory disease, chronic pelvic pain,ectopic pregnancy, and infertility, as wellas adverse perinatal outcomes, includingprematurity, neonatal conjunctivitis, andpneumonia infections.7,9 Treatment ofSTIs, including testing for reinfection 3months after treatment,10 is vital to pre-vent potential adverse health outcomes.

Expedited partner therapy (EPT) is thetreatment of sex partners of patientsdiagnosed with a STI without an in-tervening medical evaluation by a healthcare provider through prescription and/or dispensation of antibiotics to thepartners. EPT is an effective method ofpartner notification and treatment whenthe index patient believes the partner(s)will not present for evaluation andtreatment.10,11 The Society for AdolescentHealth and Medicine, American Academyof Pediatrics, American College of Ob-stetricians and Gynecologists, andAmerican Medical Association endorse

use of EPT especially when partnerevaluation and treatment by a provideris impractical or unsuccessful.12–15

Currently, EPT is allowed in 31 statesand potentially allowable in 12 morestates.16 California was the first stateto pass legislation in 2001 to legalizeEPT for treatment of chlamydia andamended the legislation to includetreatment of gonorrhea in 2007.17 It ishighly recommended as part of EPT,although not mandated in California,that counseling and educational mate-rials are provided to the partner(s)along with the prescription or medi-cation.11

Currently, few published studies existassessing provider use and comfortwith EPT for adolescents. A 2002 sur-vey of chlamydia treatment practicesamong 1603 California providers in 5specialties that treat patients ,30years of age demonstrated that up tohalf of providers routinely provide EPT,that the majority felt that EPT protectspatients from reinfection, but thatmultiple concerns remain about EPT.Concerns included adverse drug reac-tions in partner(s) treated without di-rect medical supervision, perceivedliability risk as a result of prescribingor dispensing antibiotics to partner(s)without a previous examination, missedmedical care opportunities in the partner(s), partner(s)’ noncompliance with treat-ment, and legal requirements to reportsexual activity involving a minor.18 Less isknown about EPT practices for gonorrhea,because the California law approving EPTwent into effect just 4 years ago.

Because they are the future providers,resident physicians who will treat ado-lescents and who will practice in stateswhere EPT is legal should receive trainingabout EPT. To date, no published researchexists describing pediatric residents’knowledge and practices regarding EPT.

The primary aim of our study was toassess California pediatric residents’knowledge, clinical practice, and comfort

of EPT use among adolescent patients.We hypothesized that few residentsare aware of EPT, and even fewer arecomfortable providing it. The second-ary aims were to determine whetherknowledge, practices, and comfortincreased during residency trainingand with exposure to an adolescentmedicine fellowship program. We hy-pothesized that residents’ knowledge,practices, and comfort with providingEPT would increase during residencytraining and that residents at programswith an adolescent medicine fellow-ship would have increased knowledge,practice, and comfort about EPT incomparison with those at residencyprograms without an adolescentmedicine fellowship.

METHODS

Program directors of all pediatricresidency training programs in Cal-ifornia were contacted by e-mail andthen with a follow-up telephone call forpermission to recruit the program’spediatric residents. When permissionwas obtained, the program coordina-tor and/or program chief resident(s)were requested to distribute an e-mailto their residents informing them ofthe study and requesting their partici-pation. A link to the questionnairewas attached. The e-mail was sent 3times over 6 weeks to all residentsat participating pediatric residencyprograms to maximize recruitment.Residents were assured that theirparticipation would remain anonymousand would have no impact on evaluationsof their performance as a pediatric resi-dent. All postgraduate year (PGY) 1, 2, and3 residents were invited to participate.There were no exclusion criteria.

An incentive of winning an iPad2through a random drawing was offeredto encourage participation. All resi-dents who clicked on the link to theonline questionnaire received an entryinto therandomdrawing,withanoption

706 HSII et al at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

to enter without completing the ques-tionnaire. Residents received addi-tional entries when they completed thequestionnaire sooner.

A 57-item questionnaire was developedto assess pediatric residents’ currentknowledge, clinical practices, and per-sonal comfort providing EPT. Ten phy-sicians who were not residents pilotedthe questionnaire, taking ∼10 minutesto complete it. A combination of forced-choice questions and 4-point Likertscales was used. Demographic infor-mation was obtained. Global knowl-edge scores were derived from 22separate items. Knowledge questionsasked whether specific partner treat-ments are methods of EPT, which STIsmay be treated by EPT under Californialaw, and the effectiveness of EPT com-pared with other partner treatmentmethods. Clinical practices, such as thefrequency of treating adolescents withSTIs, conditions in which EPTwas used,and frequency of specific STI treatmentpractices for their patient’s partner(s)were assessed. The level of comfortwith providing EPT was assessed, andrespondents identified their level ofconcern (from “not at all concerned” to“very concerned”) with various bar-riers cited in previous studies on EPTutilization. These barriers includedpotential medication side effects, lia-bility, cost, and compliance issues.Residents were also asked to identify 1educational modality that would bemost useful to increase their comfortwith providing EPT.

The protocol and questionnaire wereapproved by the Stanford UniversityPanel on Medical Human Subjects Re-search. Awaiver of written consent wasgranted. The residents were informedby e-mail that consent was given whenthey completed the online survey andsubmitted their responses.

x2 analyses were used for categoricalvariables. For analysis by PGY groups,analysis of variance was used for

continuous variables, and the Kruskal-Wallis test was used for ordinal varia-bles. For analysis by presence of anadolescent medicine fellowship, the ttest was used for continuous variablesand the Wilcoxon rank-sum test wasused for ordinal variables. Data arepresented as mean 6 SD. SPSS 19.0(SPSS, IBM Inc., Chicago, IL) was usedfor the analyses.

RESULTS

Fourteen of 17 pediatric residencytraining programs in California par-ticipated in this study, which compriseda total of 708 residents. There were 289participants (41% response rate), with∼33% in each PGY of training and 41%in a program with an adolescent med-icine fellowship affiliation. Mean agewas 29.4 years6 2.7 years, and 78% ofrespondents were female (Table 1).

Almost all participants reported pro-vidingcaretoadolescentandyoungadultpatients (aged 12–21 years) multipletimes a month, with only 2% of the par-ticipants reporting that they interactedwith this population less than oncea month. Most (83%) had diagnosed anSTI in this patient population.

Thirty-eight percent reported that theywere not at all familiar with EPT for STIs,41%hadheardof EPT, andonly21%weremoderately or very familiar with EPT.Only24%ofresidentsrecalledeverbeingtaught about EPT. Of those who receivededucation about EPT, 85% reported theylearned about EPTvia direct patient carewith a faculty preceptor, and 43%learned about it at a didactic lecture atresident educational conferences. Othermethods of learning about EPT includedindependent reading in medical text-books or journals (22%), use of onlinemedical sources (22%), direct patientcare with a fellow preceptor (15%), useof online lay sources (7%), direct patientcare with a senior resident preceptor(7%), andbeing taught inmedical school(4%).

Even though the majority of residentshad not formally received trainingabout EPT, most identified that writinga prescription for the partner(s) in thepatient or partner’s name and pro-viding the antibiotic directly to the pa-tient to give to the partner(s) aremethods of EPT. However, other partnertreatment methods were incorrectlyidentified as EPT, including patient re-ferral (55%), health department re-ferral (42%), and provider referral(37%). The majority answered that EPTis equally effective or more effectivethan other methods of partner STItreatment.19–21 Although only 8% ofrespondents were aware of the legalstatus of EPT in California, almost 69%correctly identified that, under Cal-ifornia law, EPT can be used for thetreatment of chlamydial and gonococ-cal infections. Others incorrectly statedEPT can be used to treat trichomoniasis(38%), bacterial vaginosis (13%), andcandidiasis (10%). In addition, 16% to48% of residents responded that they“didn’t know” whether certain methodsof partner treatment are consideredEPT, the effectiveness of EPT as com-pared with other partner treatment

TABLE 1 Demographics of ParticipatingCalifornia Pediatric Residents

n (%)

SexMale 64 (22)Female 225 (78)

RaceWhite 157 (55)Asian 77 (27)Black 7 (2)Native Hawaiian/Pacific Islander 3 (1)Mixed 21 (7)Other 22 (8)

Professional degreeMD 272 (94DO 17 (6%)

Postgraduate year of trainingPGY-1 92 (32)PGY-2 102 (35)PGY-3 95 (33)

Adolescent medicine fellowshipaffiliationYes 119 (41)No 170 (59)

ARTICLE

PEDIATRICS Volume 130, Number 4, October 2012 707 at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

referral methods, and which STIs aretreatable via EPT in California (Fig 1).

When confronted with the need to treatthe sexual partner(s) of an adolescentpatient with an STI, 76% of pediatricresidents reported having used patientreferral, 34% reported having usedhealth department referral, and 8%reported having usedprovider referral.In addition, 22% have written a pre-scription for the partner(s) in thepartner’s name, 16% have writtena prescription for the partner(s) in thepatient’s name, and 14% have providedthe antibiotic to the patient to give tothe partner(s). Thus, 52% of therespondents reported having used atleast 1 method of EPT for the treatmentof either chlamydia or gonorrhea. Ofthese, 43% used EPT rarely (,10% oftreatment), 31% sometimes (10%–49%of treatment), 19% usually (59%–90%of treatment), and 7% often (.90% oftreatment). Residents also reportedusing EPT primarily for chlamydia(40%) and gonorrhea (30%), althougha small number reported using EPT fortrichomoniasis (4%), bacterial vagi-nosis (2%), and candidiasis (1%) (Fig 2).It is interesting that residents reported

using EPT even when they were notaware of their clinic policy regardingEPT, as 83% reported not being aware ofa clinic policy, 13% reported that theyhave no clinic policy, and only 4%reported being aware of a policy.

Although 52% of the residents reportedeverprovidingEPT,30%of theseresidentsalso reported being uncomfortable withit. Three areas of concern with providingEPT were identified: the possibility of anadverse drug event, concerns about thepartner(s)’ability to fill the prescription,and missed opportunities to providemedical care to the partner(s). Themajor barrier identified by pediatricresidents that prevented them fromproviding EPT was unfamiliarity withthe law (87%). Other barriers includeda lack of confidence that the partner(s)would fill the prescription (47%) ortake the antibiotic (47%), and a lack ofknowledge of how to document EPT inthe medical record (44%) (Table 2).Residents indicated that didactic lec-tures during resident teaching confer-ences (54%) and additional directpatient care in STIs and EPT (18%) asthe 2 learning methods most likely toincrease their comfort in providing EPT.

Global knowledge about EPT and fre-quency of EPT use did not differ by PGYgroups. Significant differences werefound in other clinical practices ofpartner treatment. PGY-1s were lesslikely to have used any method ofpartner treatment compared with PGY-2s (P = .042) and PGY-3s (P = .027). PGY-3s used health department referralsmore than PGY-1s (P = .004). PGY-1swere more likely to identify a lack ofexperience in diagnosis and treatmentof STIs as a barrier to EPT use com-pared with PGY-2s (P = .013). No otherdifferences were found in concerns orbarriers to EPT use.

Pediatric residents in programswith anadolescent medicine fellowship hadsignificantly higher global knowledgescores compared with residents atprograms without an adolescent med-icine fellowship (11.5 6 5.7 vs 10.0 65.8; P = .037). They were also morelikely to provide EPT (P = .018), morelikely to have written a prescription forthe partner(s) in the patient’s name(P = .005), and more likely to haveprovided an antibiotic directly to thepatient to give to the partner(s) (P =.002) compared with those who were atprograms without an adolescent med-icine fellowship. They were less con-cerned about partner(s)’ ability to fillthe prescription (P = .042) or compli-ance in taking the antibiotic (P = .002).They also were more likely to identifythat a lack of adequate experience indiagnosing and treating STIs wasa barrier in providing EPT (P = .029).

DISCUSSION

This study demonstrated that manyCalifornia pediatric residents haveknowledge gaps regarding EPT. Only 8%of residents were aware of the legalstatus of EPT in California, but approx-imately half of all respondents hadreported having used EPT. The legalstatus and laws regarding the specificsof EPT vary from state to state, and

FIGURE 1Knowledge about EPT among California pediatric residents, N = 289.

708 HSII et al at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

providers should be aware of thembefore practicing EPT. For example,writing a single prescription with thenames of the patient and partner(s) ispermitted in California but may not belegal in some states. Under Californialaw, EPT is only allowed for the treat-ment of chlamydia and gonorrheainfections.11 Almost 69% of respondentscorrectly answered this question, butothers also incorrectly thought that EPTcould be used for other STIs, such as

trichomoniasis. These discrepancies be-tween knowledge and clinical practicepoint to a need to improve residents’education and training about EPT.

Other methods of partner treatmentof STIs are patient referral, health de-partmentreferral,andproviderreferral.Patient referral places the responsi-bility on the patient for contacting andnotifying their partner(s) of the needfor evaluation and treatment of an STI.Healthdepartment referral refers tothe

process whereby the provider contactsthe health department, the health de-partment contacts the patient, obtainsthe partner’s information and thencontacts and notifies the partner(s). Ifthe provider’s office directly contactsand notifies the partner(s) of the indexpatient, then it is considered a providerreferral.

The optimal partner treatment strategyis for the partner(s) to present for a fullSTI evaluation, which is most effectivethrough direct provider notification byeither a health department diseaseintervention specialist or a health careprovider. All state health departmentsmandate reporting cases of chlamydiaand gonorrhea and have a disease in-tervention specialist notify, test, andtreat sex partner(s). Unfortunately,most health departments do not havethe capacity to offer this service to allpatients. A 2003 study of 60 metropoli-tan healthdepartments in citieswith thehighest rates of gonorrhea, chlamydia,and syphilis demonstrated that part-nernotificationwasoffered inonly 12%of chlamydia and 17% of gonorrheacases, primarily because of lack ofpersonnel and resources.22 With theuse of patient referral, it is estimatedthat only half of all partners of thosediagnosed with chlamydia or gonorrheareceive treatment.10 Finally, providerreferral requires office staff andresources, which may not be available.Thus, all 3 methods are suboptimal innotifying partner(s) for treatment of STIsand increase the risk of reinfection in thetreated patient. EPT is as effective astraditional partner treatment methods.10

Our survey found that 76% of the pedi-atrics residents primarily used patientreferral to treat STIs in sexual partner(s), 34% used health department re-ferral, and 8% used provider referral.These findings are consistent with thoseof studies surveying US physicians inmultiple specialtieswhere 80% to 97% ofphysicians use patient referral, 10% use

FIGURE 2Clinical practices of California pediatric residents for the treatment of sexually transmitted infections insex partner(s) of patients, N = 289 unless indicated. *May report .1 practice used; †N = 288.

TABLE 2 Perceived Concerns and Barriers among California Pediatric Residents With EPT Use,N = 289 unless indicated

n (%)

Perceived concernsa

Possibility of an adverse drug effect 235 (83)Partner(s)’ ability to fill the prescription 225 (79)Missed care opportunities in the medical care of the partner(s) 223 (78)Mandatory child abuse reporting 214 (75)Proper documentation of EPT 208 (73)Liability due to prescribing medication to patients you have not seen 199 (70)Partner(s)’ compliance in taking the prescribed medication 198 (69)Liability due to prescribingmedication to minorswithout parental consent 176 (62)Extra cost to clinical practice 62 (22)

Perceived barriersNot familiar with the law 252 (87)Not confident the partner(s) will fill the prescription 137 (47)Not confident the partner(s) will be compliant with taking the antibiotic(s) 135 (47)Don’t know how to document use of EPT 126 (44)Missed medical care and health education opportunities in the partner(s) 115 (40)Do not diagnose and treat STIs in adolescents/young adults enough 98 (34)Patients do not want to provide the partner(s)’ name for the prescription 86 (30)Risk of malpractice if the partner(s) has an adverse reaction to the

antibiotic(s)85 (29)

Cost of paying for antibiotics dispensed for the partner(s) 32 (11)Other 3 (1)

a N = 285.

ARTICLE

PEDIATRICS Volume 130, Number 4, October 2012 709 at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

health department referral, and 4% useprovider referral.23,24 Continuingmedicaleducation of supervising physicians in-volved in pediatric residency programsabout EPT, such as through STI pre-vention clinical training courses spon-sored by the Centers for Disease Controland Prevention, may increase comfort inproviding EPT and improve residenttraining. Many state or local health de-partments offer STI prevention courses,and programs and providers are en-couraged to contact these depart-ments to inquire about the coursesoffered.

No significant improvements in EPTknowledge, clinical practices, or com-fort were noted by year of pediatrictraining, which refuted our second hy-pothesis. This survey was conducted inthe last 2 months of the academic year,when all PGY-3s, most PGY-2s, and fewPGY-1s would have completed theirAccreditation Council for GraduateMedical Education mandated adoles-cent medicine rotation, where they arelikely to receive the most exposure topatients with STIs and partner treat-ment. In addition, at the time of thesurvey, PGY-3s were only weeks awayfrom graduating residency. It is con-cerning that knowledge and comfortdid not improve over the course ofpediatric residency training. Our find-ings highlight the need to improveresident education about EPT duringresidency. Although our survey did notevaluate optimal methods to educateresidents about EPT, some suggestionsfrom the residents include providingdidacticsessionsonSTIsandEPTand/orproviding educational materials onlineor on CDs for independent review.

EPT knowledge, practices, and comfortwere higher in residents exposed to anadolescent medicine fellowship pro-gram, which supported our third hy-pothesis. Residents in these programsmay have increased teaching by ado-lescent medicine fellows and attendingphysicians about STIs and treatmentmethods and more opportunities tocare for adolescent patients who havetested positive for an STI, and thereforehavemoreexperienceandcomfortwithproviding EPT. Adolescent medicinefellows and attending physicians mayalso be more aware and up to date onnew laws regarding EPT. In the UnitedStates, there are 198 pediatric resi-dency programsandonly 26 adolescentmedicine fellowship programs.25 It istherefore not practical for all pediatricresidency programs to have exposureto an adolescent medicine fellowship.Targeted efforts should be made toinclude education about EPT in theresidents’ Accreditation Council forGraduate Medical Education–man-dated adolescent medicine rotationsand could be done through modalitiessuggested by the residents above.

The major limitation of any survey isselection bias. Only 41% of our targetedpopulation responded, although that isa reasonable rate for an online survey.In addition, although 14 of 17 pediatricprograms participated in this survey, 3did not, further contributing to selec-tion bias. All pediatric residency pro-grams with the presence of anadolescent medicine fellowship pro-gramparticipated, and thus our resultsmay overestimate of the levels of resi-dent knowledge, practices, and comfort.Another limitation is responder bias,

because residentswhowere interestedin this topic were possibly more likelyto participate. However, we have noinformation on nonresponders to de-termine this. A third limitation is recallbias regarding clinical practices, be-cause the datawere collected fromself-reported surveys. Strengths of ourstudy include participation of pediatricresidents from the majority of pro-grams in the state, with participantswell distributed between PGY groups.

Future research may consider exploringEPTknowledge, practices, andcomfort ofpediatric residents in other states thatallow EPT. If other states’ pediatric resi-dents have higher knowledge, practices,and comfort using EPT compared withour results in California, randomizedtrials of different EPT learning modali-ties in residency may lead to improvedEPT training in all pediatric residencyprograms in the United States.

CONCLUSIONS

California pediatric residents havelimited knowledge regarding EPT. Fewresidents reported ever being taughtabout EPT. Despite lack of EPT knowl-edge, discomfort with EPT, and lack ofawareness of its legal status, approxi-mately half the residents have providedEPT. There were no significant differ-ences in knowledge, practices, or com-fort by year of training, but residents inprograms with an adolescent medicinefellowship program had higher knowl-edge scores and used EPT more fre-quently. Our findings demonstrate aneed to improve EPT education for allpediatric residents, especially in pro-grams without an adolescent medicinefellowship.

REFERENCES

1. Forhan SE, Gottlieb SL, Sternberg MR, et al.Prevalence of sexually transmitted infectionsamong female adolescents aged 14 to 19 in theUnited States. Pediatrics. 2009;124(6):1505–1512

2. Weinstock H, Berman S, Cates W Jr. Sexuallytransmitted diseases among American youth:incidence and prevalence estimates 2000.Perspect Sex Reprod Health. 2004;36(1):6–10

3. Centers for Disease Control and Preven-tion. Sexually Transmitted Diseases Treat-ment Guidelines, 2010. MMWR. 2010;59(RR-12):1–110

710 HSII et al at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

4. Centers for Disease Control and Preven-tion. Sexually Transmitted Disease Sur-veillance 2010. Atlanta, GA: US Departmentof Health and Human Services; 2011

5. Gaydos CA, Wright C, Wood BJ, Waterfield G,Hobson S, Quinn TC. Chlamydia trachoma-tis reinfection rates among female ado-lescents seeking rescreening in school-based health centers. Sex Transm Dis.2008;35(3):233–237

6. Anschuetz GL, Beck JN, Asbel L, Goldberg M,Salmon ME, Spain CV. Determining riskmarkers for gonorrhea and chlamydialinfection and reinfection among adoles-cents in public high schools. Sex TransmDis. 2009;36(1):4–8

7. Hosenfeld CB, Workowski KA, Berman S,et al. Repeat infection with Chlamydia andgonorrhea among females: a systematicreview of the literature. Sex Transm Dis.2009;36(8):478–489

8. Datta SD, Sternberg M, Johnson RE, et al.Gonorrhea and chlamydia in the UnitedStates among persons 14 to 39 years ofage, 1999 to 2002. Ann Intern Med. 2007;147(2):89–96

9. Workowski KA, Levine WC, Wasserheit JN;Centers for Disease Control and Pre-vention, Atlanta, Georgia. U.S. Centers forDisease Control and Prevention guidelinesfor the treatment of sexually transmitteddiseases: an opportunity to unify clinicaland public health practice. Ann Intern Med.2002;137(4):255–262

10. Centers for Disease Control and Pre-vention. Expedited Partner Therapy inthe Management of Sexually Trans-mitted Diseases. Atlanta, GA: US De-partment of Health and Human Services;2006

11. Bauer HM, Wohlfeiler D, Klausner JD,Guerry S, Gunn RA, Bolan G; California STDControllers Association. California guide-lines for expedited partner therapy forChlamydia trachomatis and Neisseria gon-orrhoeae. Sex Transm Dis. 2008;35(3):314–319

12. Burstein GR, Eliscu A, Ford K, et al. Expeditedpartner therapy for adolescents diagnosedwith chlamydia or gonorrhea: a positionpaper of the Society for Adolescent Medi-cine. J Adolesc Health. 2009;45(3):303–309

13. Statement of Endorsement–expedited part-ner therapy for adolescents diagnosed withchlamydia or gonorrhea. Pediatrics. 2009;124(4):1264

14. Committee opinion no. 506: expedited partnertherapy in the management of gonorrheaand chlamydia by obstetrician-gynecologists.Obstet Gynecol. 2011;118(3):761–766

15. Opinion 8.07 – Expedited Partner Therapy. AMACode of Medical Ethics. Available at: www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion807.page. Accessed February 22, 2012

16. Centers for Disease Control and Prevention.Legal status of expedited partner therapy(EPT). Available at: www.cdc.gov/std/ept/le-gal/default.htm. Accessed May 22, 2012

17. California Department of Public Health, Sex-ually Transmitted Disease Control Branch,California STD Controllers Association, Cal-ifornia STD/HIV Prevention Training Center.Patient-Delivered Partner Therapy (PDPT) forChlamydia trachomatis and Neisseria gonor-rhoeae: Interim Guidance for Medical Pro-viders in California. Sacramento, CA: CaliforniaDepartment of Public Health; 2011

18. Packel LJ, Guerry S, Bauer HM, et al. Patient-delivered partner therapy for chlamydial

infections: attitudes and practices of Cal-ifornia physicians and nurse practi-tioners. Sex Transm Dis. 2006;33(7):458–463

19. Golden MR, Whittington WL, Handsfield HH,et al. Effect of expedited treatment of sexpartners on recurrent or persistent gon-orrhea or chlamydial infection. N Engl JMed. 2005;352(7):676–685

20. Schillinger JA, Kissinger P, Calvet H, et al.Patient-delivered partner treatment withazithromycin to prevent repeated Chlamydiatrachomatis infection among women: a ran-domized, controlled trial. Sex Transm Dis.2003;30(1):49–56

21. Trelle S, Shang A, Nartey L, Cassell JA, LowN. Improved effectiveness of partner noti-fication for patients with sexually trans-mitted infections: systematic review. BMJ.2007;334(7589):354–360

22. Golden MR, Hogben M, Handsfield HH, StLawrence JS, Potterat JJ, Holmes KK. Part-ner notification for HIV and STD in theUnited States: low coverage for gonorrhea,chlamydial infection, and HIV. Sex TransmDis. 2003;30(6):490–496

23. Niccolai LM, Winston DM. Physicians’ opin-ions on partner management for nonviralsexually transmitted infections. Am J PrevMed. 2005;28(2):229–233

24. St Lawrence JS, Montaño DE, Kasprzyk D,Phillips WR, Armstrong K, Leichliter JS. STDscreening, testing, case reporting, andclinical and partner notification practices:a national survey of US physicians. Am JPublic Health. 2002;92(11):1784–1788

25. Online FREIDA. www.ama-assn.org/ama/pub/education-careers/graduate-medical-education/freida-online.page. Accessed February 29,2012

ARTICLE

PEDIATRICS Volume 130, Number 4, October 2012 711 at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from

DOI: 10.1542/peds.2011-3764; originally published online September 17, 2012; 2012;130;705Pediatrics

Anne Hsii, Paula Hillard, Sophia Yen and Neville H. GoldenTherapy for STIs

Pediatric Residents' Knowledge, Use, and Comfort With Expedited Partner  

ServicesUpdated Information &

mlhttp://pediatrics.aappublications.org/content/130/4/705.full.htincluding high resolution figures, can be found at:

References

ml#ref-list-1http://pediatrics.aappublications.org/content/130/4/705.full.htat:This article cites 19 articles, 3 of which can be accessed free

Permissions & Licensing

tmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtables) or in its entirety can be found online at: Information about reproducing this article in parts (figures,

Reprints http://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at UNIV OF CHICAGO on May 16, 2013pediatrics.aappublications.orgDownloaded from