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McDaniel AM, Cooley ME, Andrews JO, Bialous S, Buettner-Schmidt K, Heath J, Okoli C, Timmerman GM, Sarna L. Nursing leadership in tobacco dependence treatment to advance health equity: An American Academy of Nursing policy manuscript. Nurs Outlook 2024; 72:102236. [PMID: 39043053 DOI: 10.1016/j.outlook.2024.102236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 06/15/2024] [Accepted: 06/22/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Tobacco use remains the leading cause of preventable disease, disability, and death in the United States and is a significant cause of health disparities. PURPOSE The purpose of this paper is to update the Tobacco Control policy paper published over a decade ago by the American Academy of Nursing's Health Behavior Expert Panel Tobacco Control subcommittee. METHODS Members reviewed and synthesized published literature from 2012 to 2024 to identify the current state of the science related to nurse-led tobacco dependence treatment and implications for nursing practice, education, and research. FINDINGS The results confirmed that nurse-led tobacco dependence treatment interventions are successful in enhancing cessation outcomes across settings. DISCUSSION Recommendations for nursing leaders include: promote tobacco dependence treatment as standard care, accelerate research on implementation of evidence-based treatment guidelines, reduce health disparities by extending access to evidence-based treatment, increase nursing competency in providing tobacco treatment, and drive equity-focused tobacco control policies.
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Affiliation(s)
- Anna M McDaniel
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC.
| | - Mary E Cooley
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
| | - Jeannette O Andrews
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
| | - Stella Bialous
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
| | - Kelly Buettner-Schmidt
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
| | - Janie Heath
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
| | - Chizimuzo Okoli
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
| | - Gayle M Timmerman
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
| | - Linda Sarna
- Health Behavior Expert Panel (Tobacco Control Sub-group), American Academy of Nursing, Washington, DC
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Thrul J, Howe CL, Devkota J, Alexander A, Allen AM, Businelle MS, Hébert ET, Heffner JL, Kendzor DE, Ra CK, Gordon JS. A Scoping Review and Meta-analysis of the Use of Remote Biochemical Verification Methods of Smoking Status in Tobacco Research. Nicotine Tob Res 2023; 25:1413-1423. [PMID: 36449414 PMCID: PMC10347976 DOI: 10.1093/ntr/ntac271] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 09/30/2022] [Accepted: 11/28/2022] [Indexed: 07/20/2023]
Abstract
INTRODUCTION Increasing digital delivery of smoking cessation interventions has resulted in the need to employ novel strategies for remote biochemical verification. AIMS AND METHODS This scoping review and meta-analysis aimed to investigate best practices for remote biochemical verification of smoking status. The scientific literature was searched for studies that reported remotely obtained (not in-person) biochemical confirmation of smoking status (ie, combustible tobacco). A meta-analysis of proportions was conducted to investigate key outcomes, which included rates of returned biological samples and the ratio of biochemically verified to self-reported abstinence rates. RESULTS A total of 82 studies were included. The most common samples were expired air (46%) and saliva (40% of studies), the most common biomarkers were carbon monoxide (48%) and cotinine (44%), and the most common verification methods were video confirmation (37%) and mail-in samples for lab analysis (26%). Mean sample return rates determined by random-effects meta-analysis were 70% for smoking cessation intervention studies without contingency management (CM), 77% for CM studies, and 65% for other studies (eg, feasibility and secondary analyses). Among smoking cessation intervention studies without CM, self-reported abstinence rates were 21%, biochemically verified abstinence rates were 10%, and 47% of individuals who self-reported abstinence were also biochemically confirmed as abstinent. CONCLUSIONS This scoping review suggests that improvements in sample return rates in remote biochemical verification studies of smoking status are needed. Recommendations for reporting standards are provided that may enhance confidence in the validity of reported abstinence rates in remote studies. IMPLICATIONS This scoping review and meta-analysis included studies using remote biochemical verification to determine smoking status. Challenges exist regarding implementation and ensuring high sample return rates. Higher self-reported compared to biochemically verified abstinence rates suggest the possibility that participants in remote studies may be misreporting abstinence or not returning samples for other reasons (eg, participant burden, inconvenience). Remote biochemical confirmation of self-reported smoking abstinence should be included in smoking cessation studies whenever feasible. However, findings should be considered in the context of challenges to sample return rates. Better reporting guidelines for future studies in this area are needed.
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Affiliation(s)
- Johannes Thrul
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Carol L Howe
- University of Arizona Health Sciences Library, Tucson, AZ, USA
| | - Janardan Devkota
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adam Alexander
- Department of Family and Preventive Medicine and TSET Health Promotion Research Center, Stephenson Cancer Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Alicia M Allen
- Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Michael S Businelle
- Department of Family and Preventive Medicine and TSET Health Promotion Research Center, Stephenson Cancer Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Emily T Hébert
- Department of Health Promotion and Behavioral Science, The University of Texas Health Science Center at Houston School of Public Health, Austin, TX, USA
| | - Jaimee L Heffner
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Darla E Kendzor
- Department of Family and Preventive Medicine and TSET Health Promotion Research Center, Stephenson Cancer Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Chaelin K Ra
- Section of Behavioral Sciences, Rutgers Cancer Institute of New Jersey, NJ, USA
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Grable JC, Lin JK, Peltzer K, Schultz R, Bugbee D, Pilipenko M, Levy SC, Hawkins S. Integrating Tobacco Dependence Treatment into Hospital Practice Using the Rochester Model. J Multidiscip Healthc 2023; 16:905-911. [PMID: 37038455 PMCID: PMC10082598 DOI: 10.2147/jmdh.s400615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/23/2023] [Indexed: 04/07/2023] Open
Abstract
Purpose Delivering evidence-based tobacco dependence treatments to hospital patients in real-world settings continues to be a challenge. To achieve long-term abstinence, a program should provide both bedside counseling and post-discharge contacts. These program features are necessary but difficult to implement due to lack of training, time and low administrative support. The Rochester Model is a tobacco treatment program using existing staff and medical students to reduce the barriers for treating hospitalized smokers. Patients and Methods Any smoking patient admitted to a participating hospital unit can participate. Staff nurses, mid-level providers and physicians deliver the counseling steps during the admission. Nurses hold two bedside counseling sessions, while providers give quitting advice and encourage pharmacotherapy. Nurses also contribute as unit champions and post-discharge call counselors. New York State quit line counselors combined with a University of Rochester call team fulfill the post-discharge calls. The latter call team is composed of staff nurses, respiratory therapists and medical students. Results The number of smoking patients screened was 2610 while 385 enrolled after a proof-of-concept period. The 7-day point prevalence quit rates using the as treated (patients contacted) analysis is 50% at 4 weeks, 42% at 3 months and 38% at 6 months. The 7-day point prevalence quit rates using the intent-to-treat (all patients) analysis is 23% at 4 weeks, 16% at 3 months and 14% at 6 months. Conclusion Preliminary data on the Rochester Model is showing an effective yet affordable tobacco treatment program using hospital staff and medical students. Nurses serve as bedside counselors, unit champions and post-discharge call counselors. Hospitals, even with limited resources, can implement tobacco treatment programs using existing staff.
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Affiliation(s)
- John C Grable
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
- Correspondence: John C Grable, University of Rochester School of Medicine, 601 Elmwood Avenue, Rochester, NY, 14642, USA, Tel +1 585-275-7424, Fax +1 585-276-2820, Email
| | - Jonathan K Lin
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kenneth Peltzer
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Rebecca Schultz
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Doris Bugbee
- Department of Nursing, University of Rochester School of Medicine, Rochester, NY, USA
| | - Mikhail Pilipenko
- Department of Nursing, University of Rochester School of Medicine, Rochester, NY, USA
| | - Scott C Levy
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Shayne Hawkins
- Department of Nursing, University of Rochester School of Medicine, Rochester, NY, USA
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Ward CE, Hall SV, Barnett PG, Jordan N, Duffy SA. Cost-effectiveness of a nurse-delivered, inpatient smoking cessation intervention. Transl Behav Med 2020; 10:1481-1490. [PMID: 31228196 PMCID: PMC7796705 DOI: 10.1093/tbm/ibz101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Randomized controlled trials have shown that inpatient tobacco cessation interventions are highly efficacious and cost-effective. However, the degree to which smoking interventions implemented in nonrandomized, real-world practice settings are effective, and consequently, cost-effective, remains unclear. This study evaluated the cost-effectiveness of a nurse-delivered, inpatient smoking cessation intervention, Tobacco Tactics, compared with usual care within the context of an observational, real-world study design. In this quasi-experimental study, five Michigan hospitals (N = 1,370 patients) were assigned to implement either Tobacco Tactics or usual care during October 2011-May 2013. Statistical analysis was conducted during January 2017-February 2018. Controlling for confounding using stabilized inverse probability of treatment weights, incremental cost-effectiveness ratios were calculated and cost-effectiveness acceptability curves were generated. The per person cost of tobacco cessation services in the intervention group exceeded that of usual care ($175.52 vs. $67.80; p < .001). The intervention group had a higher propensity-adjusted self-reported quit rate compared to the control group (15.7% vs. 7.0%; p < .0001). The propensity-adjusted incremental cost-effectiveness ratio was $1,325 per quit (95% confidence interval: $751-$2,462), with 99.9% probability of being cost-effective at a willingness to pay of $5,000 per quit. The Tobacco Tactics intervention was found to be cost-effective and well within the range of incremental cost-per-quit findings from other studies of tobacco cessation interventions, which range from $918 to $23,200, adjusted for inflation.
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Affiliation(s)
- Charlotte E Ward
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Health Statistics, Departments of Medicine and Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Stephanie V Hall
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Paul G Barnett
- Veterans Affairs Health Economics Resource Center, Menlo Park, CA, USA
| | - Neil Jordan
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Departments of Psychiatry and Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Hines VA Hospital, Center of Innovation for Complex Chronic Healthcare, Evanston, IL, USA
| | - Sonia A Duffy
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
- College of Nursing, The Ohio State University, Columbus, OH, USA
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Nurse Counseling as Part of a Multicomponent Tobacco Treatment Intervention: An Integrative Review. J Addict Nurs 2020; 31:161-179. [PMID: 32868609 DOI: 10.1097/jan.0000000000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Although tobacco use is widely recognized as a major cause of preventable morbidity and mortality, tobacco treatment remains challenging. PURPOSE The purpose of this integrative review is to synthesize the research findings regarding multicomponent tobacco treatment interventions combining nurse counseling and nicotine replacement therapy (NRT). METHODS Published literature from 1990 through April 2019 was searched using the databases PubMed, CINAHL, PsycINFO, and Scopus. We extracted data into a literature matrix to facilitate comparison across primary sources and make conclusions about this body of literature as a whole. FINDINGS This integrative review includes 21 publications that investigated the effects of tobacco treatment interventions incorporating both nurse counseling and NRT. Articles were reviewed for quality indicators. RESULTS The evidence from this set of studies indicates that nurse counseling is an effective intervention when combined with NRT. The most successful interventions included long-term face-to-face counseling with a nurse. In addition, interventions in which longer courses of NRT were offered for free or at subsidized rates were most successful at engendering smoking cessation. Moreover, interventions that maximized social support for participants attempting to quit smoking resulted in favorable outcomes. DISCUSSION The findings can provide useful guidance regarding the designing and implementation of effective tobacco treatment interventions that incorporate various components. CONCLUSION Nurse counseling augmented by additional effective tobacco treatment therapies including NRT leads to beneficial outcomes in smoking cessation. Future researchers should capitalize on this apparent synergistic relationship between multiple tobacco treatment components.
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Blok AC, Sadasivam RS, Hogan TP, Patterson A, Day N, Houston TK. Nurse-Driven mHealth Implementation Using the Technology Inpatient Program for Smokers (TIPS): Mixed Methods Study. JMIR Mhealth Uhealth 2019; 7:e14331. [PMID: 31588908 PMCID: PMC6818438 DOI: 10.2196/14331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/19/2019] [Accepted: 07/21/2019] [Indexed: 12/20/2022] Open
Abstract
Background Smoking is the leading cause of preventable death and disease, yet implementation of smoking cessation in inpatient settings is inconsistent. The Technology Inpatient Program for Smokers (TIPS) is an implementation program designed to reach smokers with a mobile health (mHealth) intervention using stakeholder-supported strategies. Objective The purpose of this study was to determine the impact of the TIPS implementation strategies on smoker-level engagement of the mHealth intervention during care transition. Methods We examined varying intensities (passive motivational posters only and posters + active nurse-led facilitation) of TIPS strategies on four hospital units located in two sites. Unit-level and smoker-level adoption was monitored during active implementation (30 weeks) and sustainability follow-up (30 weeks). Process measures reflecting the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework, stakeholder reported adaptations of strategies, and formative evaluation data were collected and analyzed. Results For our smoker-level reach, 103 smokers signed up for the mHealth intervention in-hospital, with minimal decline during sustainability follow-up. While posters + nurse facilitation did not lead to higher reach than posters alone during active implementation (27 vs 30 signed up), it did lead to higher engagement of smokers (85.2% vs 73.3% completion of the full 2-week intervention). TIPS strategy adoption and fidelity varied by unit, including adoption of motivational posters (range: weeks 1 and 5), fidelity of posters (0.4% to 16.2% of posters missing per unit weekly) and internal facilitation of nurse training sessions (average of 2 vs 7.5 by site). Variable maintenance costs of the program totaled US $6.63 (US $683.28/103) per smoker reached. Reported family-member facilitation of mHealth sign-up was an observation of unintended behavior. Conclusions TIPS is a feasible and low-cost implementation program that successfully engages smokers in an mHealth intervention and sustains engagement after discharge. Further testing of nurse facilitation and expanding reach to patient family and friends as an implementation strategy is needed.
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Affiliation(s)
- Amanda C Blok
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, United States Department of Veterans Affairs, Ann Arbor, MI, United States.,Systems, Populations and Leadership Department, School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Rajani S Sadasivam
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Timothy P Hogan
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Veterans Affairs Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Medical Center, United States Department of Veterans Affairs, Bedford, MA, United States
| | - Angela Patterson
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Nicole Day
- University of Massachusetts Memorial Health Center, Worcester, MA, United States
| | - Thomas K Houston
- Learning Health Systems, Department of Medicine, Wake Forest University, Winston-Salem, NC, United States
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Abstract
BACKGROUND Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions. OBJECTIVES To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017. SELECTION CRITERIA Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months. DATA COLLECTION AND ANALYSIS Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI). MAIN RESULTS Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I2 = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings. AUTHORS' CONCLUSIONS There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.
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Affiliation(s)
- Virginia Hill Rice
- Wayne State UniversityCollege of Nursing5557 Cass AvenueDetroitMichiganUSA48202
| | - Laura Heath
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | - Jonathan Livingstone‐Banks
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | - Jamie Hartmann‐Boyce
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
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Sarna L, Bialous SA, Wells M, Brook J. Impact of a webcast on nurses' delivery of tobacco dependence treatment. J Clin Nurs 2017; 27:e91-e99. [PMID: 28493616 DOI: 10.1111/jocn.13875] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2017] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To evaluate an educational programme about nurses' role in tobacco dependence treatment, and its webcast component, on the long-term impact of increasing the frequency of nurses' self-reported changes in practice related to delivery of smoking cessation interventions. BACKGROUND Healthcare professionals' knowledge about evidence-based tobacco dependence treatment using the 5As framework (Ask about tobacco use, Advise users to quit, Assess willingness to quit, Assist in making a quit plan and Arrange for follow-up, including referral to a quitline) is essential to increase smoking cessation rates in the United States. DESIGN A 6-month pre-post design. METHODS A convenience sample of nurses (N = 283) from Kentucky and Louisiana was provided access to the webcast and printed toolkit. Responses from those who completed an online survey at baseline, and at 3 or 6 months postimplementation of the educational programme were included in an analysis of changes in the consistent (always/usually) delivery of the 5As plus referral to the quitline. RESULTS After 3 months, the intervention had a significant impact on increasing nurses' reports of consistently providing the 5As to patients who smoked, which was largely sustained at 6 months. Nurses who viewed the webcast were three times more likely to refer smokers to a quitline at 3 months; and four times more likely at 6 months than those who did not. CONCLUSIONS An online educational programme, plus printed toolkit about tobacco dependence treatment increased nurses' delivery of smoking cessation interventions over time. This study provided preliminary evidence that including a webcast in a nurse-targeted educational programme could significantly increase the proportion of nurses who referred smokers to a quitline beyond the benefit of access to printed materials and web-based resources. RELEVANCE TO CLINICAL PRACTICE Distance learning is a feasible mechanism for enhancing nurses' involvement in tobacco dependence treatment and promoting evidence-based clinical practice.
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Affiliation(s)
- Linda Sarna
- School of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
| | - Stella A Bialous
- School of Nursing, University of California, San Francisco, San Francisco, CA, USA
| | - Marjorie Wells
- School of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jenny Brook
- David Geffin School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Henry JA, Thielman EJ, Zaugg TL, Kaelin C, Schmidt CJ, Griest S, McMillan GP, Myers P, Rivera I, Baldwin R, Carlson K. Randomized Controlled Trial in Clinical Settings to Evaluate Effectiveness of Coping Skills Education Used With Progressive Tinnitus Management. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2017; 60:1378-1397. [PMID: 28418492 DOI: 10.1044/2016_jslhr-h-16-0126] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 10/07/2016] [Indexed: 06/07/2023]
Abstract
PURPOSE This randomized controlled trial evaluated, within clinical settings, the effectiveness of coping skills education that is provided with progressive tinnitus management (PTM). METHOD At 2 Veterans Affairs medical centers, N = 300 veterans were randomized to either PTM intervention or 6-month wait-list control. The PTM intervention involved 5 group workshops: 2 led by an audiologist (teaching how to use sound as therapy) and 3 by a psychologist (teaching coping skills derived from cognitive behavioral therapy). It was hypothesized that PTM would be more effective than wait-list control in reducing functional effects of tinnitus and that there would be no differences in effectiveness between sites. RESULTS At both sites, a statistically significant improvement in mean Tinnitus Functional Index scores was seen at 6 months for the PTM group. Combined data across sites revealed a statistically significant improvement in Tinnitus Functional Index relative to wait-list control. The effect size for PTM using the Tinnitus Functional Index was 0.36 (small). CONCLUSIONS Results suggest that PTM is effective at reducing tinnitus-related functional distress in clinical settings. Although effect sizes were small, they provide evidence of clinical effectiveness of PTM in the absence of stringent research-related inclusion criteria and with a relatively small number of sessions of cognitive behavioral therapy.
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Affiliation(s)
- James A Henry
- Veterans Affairs Rehabilitation Research and Development National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, ORDepartment of Otolaryngology - Head & Neck Surgery, Oregon Health & Science University, Portland
| | - Emily J Thielman
- Veterans Affairs Rehabilitation Research and Development National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, OR
| | - Tara L Zaugg
- Veterans Affairs Rehabilitation Research and Development National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, OR
| | - Christine Kaelin
- Veterans Affairs Rehabilitation Research and Development National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, OR
| | - Caroline J Schmidt
- Psychology Service and Audiology Service, Veterans Affairs Connecticut Healthcare System, West HavenDepartment of Psychiatry, Yale University, New Haven, CT
| | - Susan Griest
- Veterans Affairs Rehabilitation Research and Development National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, ORDepartment of Otolaryngology - Head & Neck Surgery, Oregon Health & Science University, Portland
| | - Garnett P McMillan
- Veterans Affairs Rehabilitation Research and Development National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, OR
| | - Paula Myers
- Department of Audiology, James A. Haley Veterans Hospital, Tampa, FL
| | - Izel Rivera
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO
| | | | - Kathleen Carlson
- Veterans Affairs Rehabilitation Research and Development National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, ORVeterans Affairs Health Services Research and Development Center of Innovation, Veterans Affairs Portland Health Care System, ORSchool of Public Health, Oregon Health & Science University, Portland
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Vander Weg MW, Holman JE, Rahman H, Sarrazin MV, Hillis SL, Fu SS, Grant KM, Prochazka AV, Adams SL, Battaglia CT, Buchanan LM, Tinkelman D, Katz DA. Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial. J Subst Abuse Treat 2017; 77:79-88. [PMID: 28476277 DOI: 10.1016/j.jsat.2017.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers. DESIGN Pre-post quasi-experimental trial. SETTING General medical units of four US Department of Veterans Affairs hospitals. SUBJECTS 898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively). INTERVENTION The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback. MEASURES The primary outcome was self-reported 7-day point prevalence abstinence at six months. ANALYSIS Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression. RESULTS Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI95)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI95=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001). CONCLUSIONS Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.
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Affiliation(s)
- Mark W Vander Weg
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, United States; University of Iowa Department of Medicine, United States; University of Iowa Department of Psychological and Brain Sciences, United States.
| | - John E Holman
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, United States
| | - Hafizur Rahman
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, United States
| | - Mary Vaughan Sarrazin
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, United States; University of Iowa Department of Medicine, United States
| | - Stephen L Hillis
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, United States; University of Iowa Department of Biostatistics, United States; University of Iowa Department of Radiology, United States
| | - Steven S Fu
- Center for Chronic Disease and Outcomes Research (CCDOR), Minneapolis VA Health Care System, United States
| | - Kathleen M Grant
- Mental Health and Behavioral Sciences Department, VA Nebraska-Western Iowa Health Care System, United States; The Department of Internal Medicine, University of Nebraska Medical Center, United States
| | - Allan V Prochazka
- Department of Medicine, VA Eastern Colorado Health Care System, United States; The Denver Seattle Center for Veteran-centric Value-based Research (DiSCoVVR), United States
| | - Susan L Adams
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, United States
| | - Catherine T Battaglia
- Department of Medicine, VA Eastern Colorado Health Care System, United States; The Denver Seattle Center for Veteran-centric Value-based Research (DiSCoVVR), United States
| | | | | | - David A Katz
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, United States; University of Iowa Department of Medicine, United States; University of Iowa Department of Epidemiology, United States
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Duffy SA, Ronis DL, Ewing LA, Waltje AH, Hall SV, Thomas PL, Olree CM, Maguire KA, Friedman L, Klotz S, Jordan N, Landstrom GL. Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals. Implement Sci 2016; 11:147. [PMID: 27814722 PMCID: PMC5097410 DOI: 10.1186/s13012-016-0511-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 10/17/2016] [Indexed: 01/24/2023] Open
Abstract
Background Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework. Methods This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention. Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended). Results Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated; 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. Implementation: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive (“user friendly,” “streamlined,” or “saves time”), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended. Conclusions Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation. Trial registration ClinicalTrials.gov, NCT01309217 Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0511-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sonia A Duffy
- College of Nursing, Ohio State University, Newton Hall, 1585 Neil Ave, Columbus, OH, 43210, USA. .,Veterans Affairs (VA) Center for Clinical Management Research, HSR&D Center of Excellence, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.
| | - David L Ronis
- University of Michigan School of Nursing, 400 North Ingalls Building Room 4330, Ann Arbor, MI, 48109-0482, USA
| | - Lee A Ewing
- VA Center for Clinical Management Research, HSR&D Center of Excellence, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Andrea H Waltje
- Internal Medicine, Brehm Tower, University of Michigan, Room 6115, 1000 Wall Street, Ann Arbor, MI, 48109-5714, USA
| | - Stephanie V Hall
- VA Center for Clinical Management Research, HSR&D Center of Excellence, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | | | - Christine M Olree
- The Lacks Cancer Center, Mercy Health Saint Mary's, 200 Jefferson SE, Grand Rapids, MI, 49503, USA
| | | | - Lisa Friedman
- Saint Joseph Mercy Health System, 5305 E. Huron River Dr., Ann Arbor, MI, 48106-0995, USA
| | - Sue Klotz
- Saint Mary Mercy Hospital, 36475 Five Mile Road, Livonia, MI, 48154-1988, USA
| | - Neil Jordan
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Feinberg School of Medicine, Abbott Hall 710 North Lake Shore Drive, Suite 904, Chicago, IL, 60611, USA.,Center for Management of Complex Chronic Care, Hines VA Hospital, 5000 S 5th Ave., Hines, IL, 60141, USA
| | - Gay L Landstrom
- Dartmouth-Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH, 03756, USA
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12
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Duffy SA, Ronis DL, Karvonen-Gutierrez CA, Ewing LA, Hall SV, Yang JJ, Thomas PL, Olree CM, Maguire KA, Friedman L, Gray D, Jordan N. Effectiveness of the Tobacco Tactics Program in the Trinity Health System. Am J Prev Med 2016; 51:551-65. [PMID: 27647056 PMCID: PMC5031413 DOI: 10.1016/j.amepre.2016.03.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/01/2016] [Accepted: 03/15/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION This study determined the effectiveness of the Tobacco Tactics intervention. DESIGN/SETTING/PARTICIPANTS This was a pragmatic, quasi-experimental study conducted from 2010 to 2013 and analyzed from 2014 to 2015 in five Michigan community hospitals; three received the Tobacco Tactics intervention, and two received usual care. Smokers (N=1,528) were identified during hospitalization, and sent surveys and cotinine tests after 6 months. Changes in pre- to post-intervention quit rates in the intervention sites were compared with usual care control sites. INTERVENTION The toolkit for nurses included: (1) 1 continuing education unit contact hour for training; (2) a PowerPoint presentation on behavioral and pharmaceutical interventions; (3) a pocket card entitled "Helping Smokers Quit: A Guide for Clinicians"; (4) behavioral and pharmaceutical protocols; and (5) a computerized template for documentation. The toolkit for patients included: (1) a brochure; (2) a cessation DVD; (3) the Tobacco Tactics manual; (4) a 1-800-QUIT-NOW card; (5) nurse behavioral counseling and pharmaceuticals; (6) physician reminders to offer brief advice to quit coupled with medication sign-off; and (7) follow-up phone calls by trained hospital volunteers. MAIN OUTCOME MEASURES The effectiveness of the intervention was measured by 6-month 30-day point prevalence; self-reported quit rates with NicAlert(®) urinary biochemical verification (48-hour detection period); and the use of electronic medical record data among non-responders. RESULTS There were significant improvements in pre- to post-intervention self-reported quit rates (5.7% vs 16.5%, p<0.001) and cotinine-verified quit rates (4.3% vs 8.0%, p<0.05) in the intervention sites compared with no change in the control sites. Propensity-adjusted multivariable analyses showed a significant improvement in self-reported 6-month quit rates from the pre- to post-intervention time periods in the intervention sites compared to the control sites (p=0.044) and a non-statistically significant improvement in the cotinine-verified 6-month quit rate. CONCLUSIONS The Tobacco Tactics intervention, which meets the Joint Commission standards for inpatient smoking, has the potential to significantly decrease smoking among inpatient smokers. TRIAL REGISTRATION This study is registered at www.clinicaltrial.gov NCT01309217.
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Affiliation(s)
- Sonia A Duffy
- College of Nursing, The Ohio State University, Columbus, Ohio; Ann Arbor VA Center for Clinical Management Research, Ann Arbor, Michigan.
| | - David L Ronis
- School of Nursing, University of Michigan, Ann Arbor, Michigan
| | | | - Lee A Ewing
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Stephanie V Hall
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - James J Yang
- School of Nursing, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Lisa Friedman
- Saint Joseph Mercy Health System, Ann Arbor, Michigan
| | - Donna Gray
- St. Mary Mercy Hospital, Livonia, Michigan
| | - Neil Jordan
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, and Hines VA Hospital, Center of Innovation for Complex Chronic Healthcare, Hines, Illinois
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Wolff KB, Soncrant C, Mills PD, Hemphill RR. Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement. Am J Med Qual 2016; 32:445-452. [DOI: 10.1177/1062860616658343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.
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Affiliation(s)
- Kristina B. Wolff
- VA National Center for Patient Safety Field Office (NCPS), White River Junction, VT
| | - Christina Soncrant
- VA National Center for Patient Safety Field Office (NCPS), White River Junction, VT
| | - Peter D. Mills
- VA National Center for Patient Safety Field Office (NCPS), White River Junction, VT
- The Geisel School of Medicine at Dartmouth College, Hanover, NH
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Duffy SA, Noonan D, Karvonen-Gutierrez CA, Ronis DL, Ewing LA, Waltje AH, Dalack GW, Smith PM, Carmody TP, Hicks T, Hermann C. Effectiveness of the tobacco tactics program for psychiatric inpatient veterans: an implementation study. Arch Psychiatr Nurs 2015; 29:120-6. [PMID: 25858205 DOI: 10.1016/j.apnu.2014.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the effectiveness of the inpatient, nurse-administered Tobacco Tactics program for patients admitted for psychiatric conditions in two Veterans Affairs (VA) hospitals compared to a control hospital. METHODS This is a subgroup analysis of data from the inpatient tobacco tactics effectiveness trial, which was a longitudinal, pre- post-nonrandomized comparison design with 6-month follow-up in the three large Veterans Integrated Service Networks (VISN) 11 hospitals. RESULTS Six-month self-reported quit rates for patients admitted for psychiatric conditions increased from 3.5% pre-intervention to 10.2% post-intervention compared to a decrease in self-reported quit rates in the control hospital (12% pre-intervention to 1.6% post-intervention). There was significant improvement in self-reported quit rates for the pre- versus post-intervention time periods in the Detroit and Ann Arbor intervention sites compared to the Indianapolis control site (P=0.01) and cotinine results were in the same direction. CONCLUSION The implementation of the Tobacco Tactics intervention has the potential to significantly decrease smoking and smoking-related morbidity and mortality among smokers admitted to VA hospitals for psychiatric disorders.
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Affiliation(s)
- Sonia A Duffy
- Ann Arbor VA Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI; Ohio State University, College of Nursing; University of Michigan, Department of Psychiatry, Ann Arbor, MI.
| | | | - Carrie A Karvonen-Gutierrez
- Ann Arbor VA Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI
| | - David L Ronis
- University of Michigan, School of Nursing, Ann Arbor, MI
| | - Lee A Ewing
- Ann Arbor VA Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI
| | | | | | | | | | - Thomas Hicks
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Duffy SA, Ewing LA, Louzon SA, Ronis DL, Jordan N, Harrod M. Evaluation and costs of volunteer telephone cessation follow-up counseling for Veteran smokers discharged from inpatient units: a quasi-experimental, mixed methods study. Tob Induc Dis 2015; 13:4. [PMID: 25674045 PMCID: PMC4324430 DOI: 10.1186/s12971-015-0028-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/10/2015] [Indexed: 11/21/2022] Open
Abstract
Background The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate the volunteer telephone smoking cessation counseling follow-up program implemented as part of the inpatient Tobacco Tactics intervention in a Veterans Affairs (VA) hospital. Methods This was a quasi-experimental, mixed methods design that collected data through electronic medical records (EMR), observations of telephone smoking cessation counseling calls, interviews with staff and Veterans involved in the program, and intervention costs. Results Reach: Of the 131 Veterans referred to the smoking cessation telephone follow-up program, 19% were reached 0–1 times, while 81% were reached 2–4 times. Effectiveness: Seven-day point-prevalence 60-day quit rates (abstracted from the EMR) for those who were reached 2–4 times were 26%, compared to 8% among those who were reached 0–1 times (p = 0.06). Sixty-day 24-hour point-prevalence quit rates were 33% for those reached 2–4 times, compared to 4% of those reached 0–1 times (p < 0.01). Adoption and Implementation: The volunteers correctly followed protocol and were enthusiastic about performing the calls. Veterans who were interviewed reported positive comments about the calls. The cost to the hospital was $21 per participating Veteran, and the cost per quit was $92. Maintenance: There was short-term maintenance (about 1 year), but the program was not sustainable long term. Conclusions Quit rates were higher among those Veterans that had greater participation in the calls. Joint Commission standards for inpatient smoking with follow-up calls are voluntary, but should these standards become mandatory, there may be more motivation for VA administration to institute a hospital-based, volunteer telephone smoking cessation follow-up program. Trial registration ClinicalTrials.Gov NCT01359371.
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Affiliation(s)
- Sonia A Duffy
- Ohio State University, College of Nursing, Columbus, USA ; Ann Arbor VA Center for Clinical Management Research, Health Services Research and Development, P.O. Box 130170, Ann Arbor, MI 48113-0170 USA ; University of Michigan, Department of Psychiatry, Ann Arbor, USA
| | - Lee A Ewing
- Ann Arbor VA Center for Clinical Management Research, Health Services Research and Development, P.O. Box 130170, Ann Arbor, MI 48113-0170 USA
| | - Samantha A Louzon
- Ann Arbor VA Center for Clinical Management Research, Health Services Research and Development, P.O. Box 130170, Ann Arbor, MI 48113-0170 USA
| | - David L Ronis
- University of Michigan, School of Nursing, Ann Arbor, USA
| | - Neil Jordan
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, USA ; Center for Healthcare Studies and Departments of Psychiatry & Behavioral Sciences and Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, USA
| | - Molly Harrod
- Ann Arbor VA Center for Clinical Management Research, Health Services Research and Development, P.O. Box 130170, Ann Arbor, MI 48113-0170 USA
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