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IIR 08-323 – HSR&D Study

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IIR 08-323
PE-Web: Online Training for VA Providers in Prolonged Exposure for PTSD
Kenneth J Ruggiero Jr. PhD MA BA
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: April 2010 - September 2013

BACKGROUND/RATIONALE:
The Veterans Health Administration (VHA) has identified Prolonged Exposure therapy (PE) as a "best practice" treatment for Veterans with PTSD, underscoring the importance of disseminating PE to VA providers. Online training courses for providers have increased in popularity in recent years, but little research has examined the utility of these programs. The current project aimed to develop and evaluate a new training course for VA providers in PE for PTSD.

OBJECTIVE(S):
The primary objectives of this project were to develop PE-Web, a Web-based VA provider-training protocol in PE; and evaluate PE-Web to examine its utility as a VA provider-training resource. We hypothesized that we would detect improved knowledge and improved fidelity in the context of role-play assessments among VA providers assigned to the PE-Web vs. "no refresher" condition.

METHODS:
During phase 2 of the project, we used RCT methodology to examine the utility of PE-Web (developed during Phase 1). We recruited 33 VA providers who had previously attended a 4-day workshop as part of the PE dissemination initiative, a national effort funded by the Office of Mental Health Services in VHA Central Office. Prior to randomization, all providers completed a baseline assessment that measured demographics, attitudes/knowledge about evidence-based practices and PE, and role-plays of PE skills via teleconference. After completing the baseline assessment, participants were randomized to PE-Web refresher training vs. no-refresher training. Two weeks after randomization, providers participated in a second role-play assessment to test change in PE skills following the intervention/waiting period. Providers in the no-refresher condition were given access to PE-Web after their post-assessment. Each of the 13 learning modules on the website included a 3-5 question pre- and post-test that assessed understanding of key elements presented in the module. Changes in knowledge as measured by pre/post tests are featured in the results in this report.

FINDINGS/RESULTS:
Participants were 33 VA providers who had previously completed the intensive 4-day PE workshop and 2-case consultation training through the PE Dissemination Initiative at least one year prior to recruitment in the study. Participants were predominantly female (72.7%), Caucasian (81.8%), and had a mean age of 44.4 years (SD=11.11). Most were doctoral level psychologists (66.7%); others were social workers (30.3%) and master's level counselors (3.0%). As expected, this group had considerable prior experience conducting therapy with Veterans with trauma-related disorders. This is, unfortunately, a weakness in our design that we anticipated at the proposal stage for this study. Specifically, it was not possible to recruit VA providers prior to workshop/consultation training due to regulations and oversight around the VA PE dissemination initiative. This led to recruitment of already highly trained VA providers, which limited variability and restricted our sample to providers who already had tremendous knowledge and high fidelity prior to enrollment in our study.

On average, providers reported working with Veterans for 9 years and seeing approximately 100 patients a year for trauma-focused treatment. Participants were already very knowledgeable about PE at baseline, scoring an average of 23 out of a possible 26 points on the baseline knowledge questionnaire. Further, providers reported very favorable attitudes toward using research-supported, manualized treatments with patients. We conducted paired samples t-tests to assess change in knowledge from pre- to post-test for each of the 13 modules. Although providers in our sample were already highly trained in PE, they still demonstrated knowledge gains from pre- to post-test on 12 of 13 modules. These improvements were statistically significant or approaching statistical significance for 8 of the 13 modules: Basics (Pre-test M=2.17, SD=.92; Post-test M=3.21, SD=.78; t=-5.35, p<.01), Rationale and Trauma Interview (Pre-test M=1.47, SD=1.00; Post-test M=2.00, SD=1.00; t=-2.73, p=.015), Processing (Pre-test M=2.65, SD=.79; Post-test M=3.24, SD=.75; t=-2.58, p=.02), Special Issues (Pre-test M=1.63, SD=1.26; Post-test M=2.44, SD=1.26; t=-2.36, p=.03), Telehealth (Pre-test M=2.00, SD=.73; Post-test M=2.38, SD=.89; t=-3.0, p<.01), Assessment (Pre-test M=3.78, SD=.92; Post-test M=4.18, SD=.80; t=-2.00, p=.06), Treatment Components (Pre-test M=3.10, SD=1.14; Post-test M=3.62, SD=.50; t=-2.06, p=.05) and Imaginal Exposure (Pre-test M=3.21, SD=.63; Post-test M=3.47, SD=.61; t=-2.04, p=.06).

IMPACT:
PE-Web can facilitate the dissemination of PE to VA clinical settings, thereby increasing the availability of effective services for Veterans with PTSD. To date, few studies have tested strategies to enhance providers' fidelity to exposure protocols. Further, little research has examined the impact of web-based training programs on provider practices. To the extent that these programs are self-directed, self-paced, and easily accessible to providers in geographically diverse locations, PE-Web may be used to lower costs of workshop, consultation, and booster trainings. Despite having already completed formal training in PE, providers in our sample had meaningful gains in knowledge across 8 of the 13 modules. Hence, results support the potential benefits of PE-Web as a useful training resource for VA clinicians. The PE-Web course is now freely available to all providers nationally. The site populates a downloadable continuing education certificate, which many licensing boards accept. This will support our efforts to have significant reach into the population with PE-Web. Dr. Ruzek, Director of the National Center for PTSD Dissemination branch, is actively engaged in maximizing the use of this resource, which will now be used in a new Cooperative Studies Program (#591). Dr. Ruggiero will also work closely with Dr. Ruzek in forthcoming launch announcements.

PUBLICATIONS:

Journal Articles

  1. Grubaugh AL, Gros K, Frueh C, Davidson T, Ruggiero KJ. Providers' Perspectives Regarding the Feasibility and Utility of an Internet-Based Mental Health Intervention for Veterans. Psychological trauma : theory, research, practice and policy. 2014 Nov 30; 6(6):624-631.
  2. Hanson RF, Gros KS, Davidson TM, Barr S, Cohen J, Deblinger E, Mannarino AP, Ruggiero KJ. National trainers' perspectives on challenges to implementation of an empirically-supported mental health treatment. Administration and policy in mental health. 2014 Jul 1; 41(4):522-34.
  3. Price M, Gros DF, Strachan M, Ruggiero KJ, Acierno R. Combat experiences, pre-deployment training, and outcome of exposure therapy for post-traumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom veterans. Clinical psychology & psychotherapy. 2013 Jul 1; 20(4):277-85.
  4. Ruggiero KJ, Resnick HS, Paul LA, Gros K, McCauley JL, Acierno R, Morgan M, Galea S. Randomized controlled trial of an internet-based intervention using random-digit-dial recruitment: the Disaster Recovery Web project. Contemporary clinical trials. 2012 Jan 1; 33(1):237-46.
HSR&D or QUERI Articles

  1. Ruggiero KJ, Gros DF, Acierno RE, Frueh BC, Grubaugh AL, Egede LE. Telehealth Technologies for the Delivery of Mental Health Services. HSR&D Forum Translating research into quality health care for Veterans. 2010 Nov 1; 6(1): 1-6.
Center Products

  1. Ruggiero KJ, Acierno RE, Strachan MK, Ruzek J. PE Web website. [Website]. 2013 Nov 1.
VA Cyberseminars

  1. Ruggiero KJ. PE-Web: A Web-Based Training Program for Providers in Prolonged Exposure for PTSD. [Cyberseminar]. 2014 Jan 21.
Conference Presentations

  1. Carlbring P, Cooper DC, Mohr DC, Rizvi SL, Ritterband LM, Ruggiero KJ. Developing web-based and mobile applications for mental health interventions: Benefits, challenges, and recommendations. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2013 Nov 15; Nashville, TN.
  2. Grubaugh AL, Focht K, Ellis C. Perceptions of stroke recovery: Is communication part of the equation? Poster session presented at: American Speech-Language-Hearing Association Annual Convention; 2012 Nov 1; Atlanta, GA.
  3. Ruggiero KJ, Acierno R, Strachan MK, Welsh K, Rheingold A, Foa E. PE-Web: Disseminating evidence based practice. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 10; Toronto, Canada.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Acute and Combat-Related Injury
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Dissemination, Education (provider), PTSD
MeSH Terms: none

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