The effects of a prolonged exposure workshop with and without consultation on provider and patient outcomes: a randomized implementation trial

Abstract

Background: Prolonged exposure therapy (PE) is an evidence-based treatment for posttraumatic stress disorder (PTSD) that is underutilized in the military health system. Standard workshop training in PE may not be sufficient to alter provider behavior, but post-workshop consultation requires significant resources. Therefore, it is important to determine the incremental utility of post-workshop consultation. Methods: This study used a hybrid type III randomized implementation trial at 3 US Army installations. Providers were randomized to receive a 4-day prolonged exposure workshop (Standard training condition, n = 60), or the prolonged exposure workshop followed by 6-8 months of post-workshop expert case consultation (Extended training condition, n = 43). The effects training condition were examined on provider attitudes (self-efficacy in delivering PE, expectations for patient improvement, and beliefs about PE), use of PE and PE components, and clinical outcomes of patients with PTSD (using the Clinician-Administered PTSD Scale (CAPS-5)). Results: Extended condition providers reported greater improvements in self-efficacy, b =.83, 95% CI [.38, 1.27], t(79) = 3.71, p =.001, and d =.63. A greater proportion of patients in the Extended condition (44%) than in the Standard condition (27%) received at least 1 PE session, b =.76, t(233) = 2.53, p =.012, and OR = 2.13. Extended condition providers used more PE components (M =.9/session) than did Standard condition providers (M =.5/session), b =.54, 95% CI [.15,.93], t(68) = 2.70, p =.007, and d =.68. Finally, decrease in patients' PTSD symptoms was faster for patients of Extended condition providers than for patients of Standard condition providers, b = - 1.81, 95% CI [- 3.57, -.04], t(263) = - 2.02, p =.045, and d =.66, and their symptoms were lower at the second assessment, b = - 5.47, 95% CI [- 9.30, - 1.63], t(210) = - 2.81, p =.005, and d =.66. Conclusions: Post-workshop consultation improved self-efficacy for delivering PE, greater use of PE, faster PTSD reduction, and lower PTSD severity at the second assessment. To our knowledge, this is the first demonstration that post-workshop case consultation for PE improves patient outcomes. Trial registration: Clinicaltrials.gov, NCT02982538. Registered December 5, 2016; retrospectively registered