Fax referrals, academic detailing, and tobacco quitline use: a randomized trial

Enabling tobacco treatment for gastroenterology patients via a novel low-burden point-of-care model

BACKGROUND & AIM

Smoking is a major risk factor for multiple gastrointestinal cancers, and adversely affects peptic ulcer disease, gastroesophageal reflux, pancreatitis and Crohn's disease. Despite key recommendations for diagnosing and treating tobacco use disorder in healthcare settings, the degree to which this is implemented in Gastroenterology (GI) clinics is unknown. We aimed to assess our providers' practices, identify barriers for implementing evidence-based smoking cessation treatments, and address these barriers by implementing a novel low-burden point of care Electronic health record-enabled evidence-based tobacco treatment (ELEVATE), in GI clinics.

METHODS

An online survey was distributed to clinic gastroenterologists. ELEVATE module training was implemented in 1/2021. Data were evaluated during pre (7/2020-12/2020) and post (1/2021-12/2021) implementation periods to evaluate the reach and effectiveness of ELEVATE. Generalized estimating equations (GEE) were used to generate rate ratios (RR) to evaluate the intervention.

RESULTS

91% (20/22) of GI physicians responded to our survey, and only 20% often assisted patients who smoke with counseling. Lack of a systematic program to offer help to patients was reported by 80% of providers as an extremely/very important barrier limiting their smoking cessation practices. The proportion of current patients who smoke receiving cessation treatment increased from pre-ELEVATE to post-ELEVATE (14.36-27.47%, RR = 1.90, 95% CI 1.60-2.26, p < .001). Post-ELEVATE, 14.4% (38/264) of patients with treatment quit smoking, compared to 7.9% (55/697) of patients without treatment (RR = 1.89, 95% CI 1.26-2.82, p = .0021).

CONCLUSION

Smoking practices are frequently assessed in GI clinics but barriers limiting cessation treatment exist. The use of a low burden point of care EHR enabled smoking cessation treatment module has led to a significant improvement in the treatment of smoking and subsequent cessation in our clinics. This study sheds light on an often under-recognized source of morbidity in GI patients and identifies an efficient, effective, and scalable strategy to combat tobacco use and improve clinical outcomes in our patients.

A comprehensive electronic health record-enabled smoking treatment program: Evaluating reach and effectiveness in primary care in a multiple baseline design

Effective treatments for smoking cessation exist but are underused. Proactive chronic care approaches may enhance the reach of cessation treatment and reduce the prevalence of smoking in healthcare systems. This pragmatic study evaluated a population-based Comprehensive Tobacco Intervention Program (CTIP) implemented in all (6) adult primary care clinics in a Madison, Wisconsin, USA healthcare cooperative, assessing treatment reach, reach equity, and effectiveness in promoting smoking cessation. CTIP launched in 3 waves of 2 clinics each in a multiple baseline design. Electronic health record (EHR) tools facilitated clinician-delivered pharmacotherapy and counseling; guiding tobacco care managers in phone outreach to all patients who smoke; and prompting multimethod bulk outreach to all patients on a smoking registry using an opt-out approach. EHR data were analyzed to assess CTIP reach and effectiveness among 6894 adult patients between January 2018 and February 2020. Cessation treatment reach increased significantly after CTIP launch in 5 of 6 clinics and was significantly higher when clinics were active vs. inactive in CTIP [Odds Ratio (OR) range = 2.0-3.0]. Rates of converting from current to former smoking status were also higher in active vs. inactive clinics (OR range = 2.2-10.5). Telephone treatment reach was particularly high in historically underserved groups, including African-American, Hispanic, and Medicaid-eligible patients. Implementation of a comprehensive, opt-out, chronic-care program aimed at all patients who smoke was associated with increases in the rates of pharmacotherapy and counseling delivery and quitting smoking. Proactive outreach may help reduce disparities in treatment access.

A Pragmatic Cluster-Randomized Trial of Provider Education and Community Health Worker Support for Tobacco Cessation

OBJECTIVE

Individuals with serious mental illness have a high prevalence of tobacco use disorder and related early mortality but underutilize smoking cessation medication. The authors determined whether clinician-delivered education to primary care providers regarding safety, efficacy, and importance of cessation medication (provider education [PE]) alone or combined with community health worker (CHW) support would increase tobacco abstinence in this population, compared with usual care.

METHODS

All adult current tobacco smokers receiving psychiatric rehabilitation for serious mental illness through two community agencies in Greater Boston were eligible, regardless of readiness to quit smoking. Primary care clinics were cluster randomized to PE or usual care, with a nested, participant-level randomization to CHW or no CHW in PE-assigned clinics. The primary outcome was blindly assessed, biochemically verified tobacco abstinence at year 2.

RESULTS

Overall, 1,010 eligible participants were enrolled. PE was delivered to providers in 53 of 55 assigned clinics; 220 of 336 CHW-assigned participants consented to CHW support. Year 2 abstinence rates were significantly higher among participants assigned to PE+CHW versus usual care (12% vs. 5%; adjusted odds ratio [AOR]=2.40, 95% confidence interval [CI]=1.20-4.79) or PE alone (12% vs. 7%; AOR=1.84, 95% CI=1.04-3.24). No effect of PE alone on abstinence was detected. Compared with participants assigned to usual care, those assigned to PE+CHW had greater odds of varenicline use (OR=2.77, 95% CI=1.61-4.75), which was associated with higher year 2 abstinence (OR=1.97, 95% CI=1.16-3.33).

CONCLUSIONS

Combined PE and CHW tobacco cessation support increased tobacco abstinence rates among adults with serious mental illness.

Adapting a tobacco cessation treatment intervention and implementation strategies to enhance implementation effectiveness and clinical outcomes in the context of HIV care in Vietnam: a case study

BACKGROUND

Smoking rates remain high in Vietnam, particularly among people living with HIV/AIDS (PLWH), but tobacco cessation services are not available in outpatient HIV clinics (OPCs). The research team is conducting a type II hybrid randomized controlled trial (RCT) comparing the cost-effectiveness of three tobacco cessation interventions among PLWH receiving care in HIV clinics in Vietnam. The study is simultaneously evaluating the implementation processes and outcomes of strategies aimed at increasing the implementation of tobacco dependence treatment (TDT) in the context of HIV care. This paper describes the systematic, theory-driven process of adapting intervention components and implementation strategies with demonstrated effectiveness in high-income countries, and more recently in Vietnam, to a new population (i.e., PLWH) and new clinical setting, prior to launching the trial.

METHODS

Data collection and analyses were guided by two implementation science frameworks and the socio-ecological model. Qualitative interviews were conducted with 13 health care providers and 24 patients in three OPCs. Workflow analyses were conducted in each OPC. Qualitative data were analyzed using rapid qualitative analysis procedures. Based on findings, components of the intervention and implementation strategies were adapted, followed by a 3-month pilot study in one OPC with 16 patients randomized to one of two intervention arms.

RESULTS

The primary adaptations included modifying the TDT intervention counseling content to address barriers to quitting among PLWH and Vietnamese sociocultural norms that support smoking cessation. Implementation strategies (i.e., training and system changes) were adapted to respond to provider- and clinic-level determinants of implementation effectiveness (e.g., knowledge gaps, OPC resource constraints, staffing structure, compatibility).

CONCLUSIONS

Adaptations were facilitated through a mixed method, stakeholder (patient and health care provider, district health leader)-engaged evaluation of context-specific influences on intervention and implementation effectiveness. This data-driven approach to refining and adapting components aimed to optimize intervention effectiveness and implementation in the context of HIV care. Balancing pragmatism with rigor through the use of rapid analysis procedures and multiple methods increased the feasibility of the adaptation process.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05162911 . Registered on December 16, 2021.

Developments in smoking cessation interventions for patients with chronic obstructive pulmonary disease in the past 5 years: a scoping review

INTRODUCTION

Smoking cessation is the most effective strategy for slowing the progression of chronic obstructive pulmonary disease (COPD). However, COPD patients find it difficult to quit smoking with standard cessation interventions.

AREAS COVERED

A scoping review of smoking cessation for COPD patients was conducted by searching the MEDLINE, Embase, and Cochrane Library databases for all studies published between 1 January 2016 and 22 September 2021. Four themes were set up and 47 studies were included eventually. The majority of the included studies (61.7%, 29/47) investigated efficacy and effectiveness, including new strategies for extended treatment and mobile health (mHealth) delivery approach. Studies examining accessibility and utilization (31.9%, 15/47), safety (10.6%, 5/47), and health economics (6.4%, 3/47) were also reviewed. The quality of the included randomized controlled trials was also evaluated.

EXPERT OPINION

Pharmacotherapy combined with behavioral interventions delivered via mHealth may be a promising strategy to help COPD smokers quit. However, the overall quality of the current studies is poor, making it challenging for clinicians to make informed decisions. Future high-quality studies are needed to provide conclusive evidence on the optimal pharmacotherapies and the most cost-effective comprehensive smoking cessation interventions, particularly those integrated into disease management for smokers with COPD.

Effectiveness of a multicomponent strategy for implementing guidelines for treating tobacco use in Vietnam Commune Health Centers

INTRODUCTION

Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs).

METHODS

We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n=26) in Vietnam. Arm 1 included training and a tool kit (e.g., reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As+R). Provider surveys were conducted at baseline, six- and 12-months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As.

RESULTS

Adoption of the 4As increased significantly across both study arms (all p<.001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling.

CONCLUSION

The study demonstrated the effectiveness of a multicomponent and multilevel strategy (i.e., provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam.

IMPLICATIONS

Improving implementation of evidence-based tobacco dependence treatment (TDT) guidelines is a necessary step towards reducing the growing burden of non-communicable disease (NCDs) and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam, and offers a potentially scalable model for meeting FCTC Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a community health worker for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use.

Strategies to improve smoking cessation rates in primary care

BACKGROUND

Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).

OBJECTIVES

To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

Care-paradigm shift promoting smoking cessation treatment among cancer center patients via a low-burden strategy, Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment

Tobacco smoking is an important risk factor for cancer incidence, an effect modifier for cancer treatment, and a negative prognostic factor for disease outcomes. Inadequate implementation of evidence-based smoking cessation treatment in cancer centers, a consequence of numerous patient-, provider-, and system-level barriers, contributes to tobacco-related morbidity and mortality. This study provides data for a paradigm shift from a frequently used specialist referral model to a point-of-care treatment model for tobacco use assessment and cessation treatment for outpatients at a large cancer center. The point-of-care model is enabled by a low-burden strategy, the Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment program, which was implemented in the cancer center clinics on June 2, 2018. Five-month pre- and post-implementation data from the electronic health record (EHR) were analyzed. The percentage of cancer patients assessed for tobacco use significantly increased from 48% to 90% (z = 126.57, p < .001), the percentage of smokers referred for cessation counseling increased from 0.72% to 1.91% (z = 3.81, p < .001), and the percentage of smokers with cessation medication significantly increased from 3% to 17% (z = 17.20, p < .001). EHR functionalities may significantly address barriers to point-of-care treatment delivery, improving its consistent implementation and thereby increasing access to and quality of smoking cessation care for cancer center patients.

The effectiveness of generic emails versus a remote knowledge broker to integrate mood management into a smoking cessation programme in team-based primary care: a cluster randomised trial

BACKGROUND

Knowledge brokering is a knowledge translation approach that has been gaining popularity in Canada although the effectiveness is unknown. This study evaluated the effectiveness of generalised, exclusively email-based prompts versus a personalised remote knowledge broker for delivering evidence-based mood management interventions within an existing smoking cessation programme in primary care settings.

METHODS

The study design is a cluster randomised controlled trial of 123 Ontario Family Health Teams participating in the Smoking Treatment for Ontario Patients programme. They were randomly allocated 1:1 for healthcare providers to receive either: a remote knowledge broker offering tailored support via phone and email (group A), or a generalised monthly email focused on tobacco and depression treatment (group B), to encourage the implementation of an evidence-based mood management intervention to smokers presenting depressive symptoms. The primary outcome was participants' acceptance of a self-help mood management resource. The secondary outcome was smoking abstinence at 6-month follow-up, measured by self-report of smoking abstinence for at least 7 previous days. The tertiary outcome was the costs of delivering each intervention arm, which, together with the effectiveness outcomes, were used to undertake a cost minimisation analysis.

RESULTS

Between February 2018 and January 2019, 7175 smokers were screened for depression and 2765 (39%) reported current/past depression. Among those who reported current/past depression, 29% (437/1486) and 27% (345/1277) of patients accepted the mood management resource in group A and group B, respectively. The adjusted generalised estimating equations showed that there was no significant difference between the two treatment groups in patients' odds of accepting the mood management resource or in the patients' odds of smoking abstinence at follow-up. The cost minimisation analysis showed that the email strategy was the least costly option.

CONCLUSIONS

Most participants did not accept the resource regardless of remote knowledge broker strategy. In contexts with an existing KT infrastructure, decision-makers should consider an email strategy when making changes to a programme given its lower cost compared with other strategies. More research is required to improve remote knowledge broker strategies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03130998 . Registered April 18, 2017, (Archived on WebCite at www.webcitation.org/6ylyS6RTe ).

Acceptability of real-time video counselling compared to other behavioural interventions for smoking cessation in rural and remote areas

BACKGROUND

This study evaluated the acceptability of real-time video counselling compared to a) telephone counselling and b) written materials in assisting rural and remote residents to quit smoking.

METHODS

Participants were recruited into a three-arm, parallel group randomised trial and randomly allocated to either: a) real-time video counselling; b) telephone counselling; or c) written materials. At 4-months post-baseline participants completed an online survey that examined self-reported acceptability and helpfulness of the support.

RESULTS

Overall, 93.5 % of video counselling participants and 96.2 % of telephone counselling participants who received support thought it was acceptable for a smoking cessation advisor to contact them via video software or telephone respectively. There were significant differences between video counselling and telephone counselling groups on three of 10 acceptability or helpfulness measures. Video counselling participants had significantly lower odds of reporting the number of calls were about right (OR 0.50, 95 % CI 0.27-0.93), recommending the support to family and friends (OR 0.18, 95 % CI 0.04-0.85) and reporting the support helped with motivation to try quitting (OR 0.24, 95 % CI 0.07-0.76) compared to telephone counselling participants. Video counselling participants had significantly greater odds than written materials participants of rating the support favourably on all seven acceptability and helpfulness items compared.

CONCLUSIONS

Real-time video counselling for smoking cessation is acceptable and well-received by those living in rural and remote locations. Further research is required to enhance the three attributes that were less acceptable for video counselling than telephone counselling.

Low Burden Strategies Are Needed to Reduce Smoking in Rural Healthcare Settings: A Lesson from Cancer Clinics

Rural populations face significant smoking-related health disparities, such as a higher prevalence of lung cancer and cancer mortality, higher prevalence of smoking, and lower likelihood of receiving cessation treatment than urban counterparts. A significant proportion of health disparities in rural populations could be eliminated with low-barrier, easy-access treatment delivery methods for smoking cessation. In this study, we assessed treatment engagement among patients in rural and urban settings. Then, we examined the effect of an electronic health record-based smoking cessation module on patient receipt of evidence-based cessation care. As part of a quality improvement project, we retrospectively observed 479,798 unique patients accounting for 1,426,089 outpatient clinical encounters from June 2018-March 2019 across 766 clinics in the greater St. Louis, southern Illinois, and mid-Missouri regions. Smoking prevalence was higher in rural versus urban clinics (20.7% vs. 13.9%, 6.7% [6.3, 7.1], odds ratio = 1.6 [1.6, 1.6], p < 0.0001), and yet rural smokers were nearly three times less likely than their urban counterparts to receive any smoking cessation treatment after adjusting for patients clustering within clinics (9.6% vs. 25.8%, -16.2% [-16.9, -15.5], odds ratio = 0.304 [0.28, 0.33], p < 0.0001). Although not yet scaled up in the rural setting, we examined the effects of a low-burden, point-of-care smoking module currently implemented in cancer clinics. After adjusting for patient clustering within clinics, patients were more likely to receive smoking treatment in clinics that implemented the module versus clinics that did not implement the module (31.2% vs. 17.5%, 13.7% [10.8, 16.6], odds ratio = 2.1 [1.8, 2.6], p < 0.0001). The point-of-care treatment approach offers a promising solution for rural settings, both in and outside the context of cancer care.

Systematic review and meta-analysis of the provision of preventive care for modifiable chronic disease risk behaviours by mental health services

People with mental illness experience increased chronic disease burden, contributed to by a greater prevalence of modifiable chronic disease risk behaviours. Policies recommend mental health services provide preventive care for such risk behaviours. Provision of such care has not previously been synthesised. This review assessed the provision of preventive care for modifiable chronic disease risk behaviours by mental health services. Four databases were searched from 2006 to 2017. Eligible studies were observational quantitative study designs conducted in mental health services, where preventive care was provided to clients for tobacco smoking, harmful alcohol consumption, inadequate nutrition, or inadequate physical activity. Two reviewers independently screened studies, conducted data extraction and critical appraisal. Results were pooled as proportions of clients receiving or clinicians providing preventive care using random effects meta-analyses, by risk behaviour and preventive care element (ask/assess, advise, assist, arrange). Subgroup analyses were conducted by mental health service type (inpatient, outpatient, other/multiple). Narrative synthesis was used where meta-analysis was not possible. Thirty-eight studies were included with 26 amenable to meta-analyses. Analyses revealed that rates of assessment were highest for smoking (78%, 95% confidence interval [CI]:59%-96%) and lowest for nutrition (17%, 95% CI:1%-35%); with variable rates of care provision for all behaviours, care elements, and across service types, with substantial heterogeneity across analyses. Findings indicated suboptimal and variable provision of preventive care for modifiable chronic disease risk behaviours in mental health services, but should be considered with caution due to the very low quality of cumulative evidence. PROSPERO registration: CRD42016049889.

Effectiveness of Village Health Worker-Delivered Smoking Cessation Counseling in Vietnam

INTRODUCTION

Smoking prevalence is high in Vietnam, yet tobacco dependence treatment (TDT) is not widely available.

METHODS

We conducted a quasiexperimental study that compared the effectiveness of health care provider advice and assistance (ARM 1) versus ARM 1 plus village health worker (VHW) counseling (ARM 2) on abstinence at 6-month follow-up. This study was embedded in a larger two-arm cluster randomized controlled trial conducted in 26 community health centers (CHCs) in Vietnam. Subjects (N = 1318) were adult patients who visited any participating CHC during the parent randomized controlled trial intervention period and were self-identified as current tobacco users (cigarettes and/or water pipe).

RESULTS

At 6-month follow-up, abstinences rates in ARM 2 were significantly higher than those in ARM 1 (25.7% vs. 10.5%; p < .001). In multivariate analyses, smokers in ARM 2 were almost three times more likely to quit compared with those in ARM 1 (adjusted odds ratio [AOR] = 2.96, 95% confidence interval [CI] = 1.78% to 4.92%). Compared to cigarette-only smokers, water pipe-only smokers (AOR = 0.4, 95% CI = 0.26% to 0.62%) and dual users (AOR = 0.62, 95% CI = 0.45% to 0.86%) were less likely to achieve abstinence; however, the addition of VHW counseling (ARM 2) was associated with higher quit rates compared with ARM 1 alone for all smoker types.

CONCLUSION

A team approach in TDT programs that offer a referral system for health care providers to refer smokers to VHW-led cessation counseling is a promising and potentially scalable model for increasing access to evidence-based TDT and increasing quit rates in low middle-income countries (LMICs). TDT programs may need to adapt interventions to improve outcomes for water pipe users.

IMPLICATIONS

The study fills literature gaps on effective models for TDT in LMICs. The addition of VHW-led cessation counseling, available through a referral from primary care providers in CHCs in Vietnam, to health care provider's brief cessation advice, increased 6-month biochemically validated abstinence rates compared to provider advice alone. The study also demonstrated the potential effectiveness of VHW counseling on reducing water pipe use. For LMICs, TDT programs in primary care settings with a referral system to VHW-led cessation counseling might be a promising and potentially scalable model for increasing access to evidence-based treatment.

Comparing different intensities of active referral to smoking cessation services in promoting smoking cessation among community smokers: a study protocol of a cluster randomized controlled trial

BACKGROUND

Actively referring smokers to smoking cessation (SC) services could increase quitting and is scalable for the population. The objective of this study is to compare 2 different intensities of SC active referral for smokers in the community of Hong Kong.

METHODS/DESIGN

This is a single-blind, parallel 3-armed cluster randomized controlled trial (cRCT) consisting of high-intensity SC active referral (HAR Group), low-intensity SC referral by text messaging on promoting SC services use (Text Group) and a control group receives general very brief advice. Biochemically validated daily smokers will be proactively recruited in the community from 68 clusters (recruitment sessions). The primary outcome is self-reported 7-days point prevalence abstinence (PPA) at the 3- and 6- month follow-ups. Secondary outcomes are SC service use, smoking reduction rate (SRR, daily cigarette consumption reduced by ≥50%; excluding quitters) and biochemically validated quit rate (exhaled CO < 4 ppm and salivary cotinine < 10 ng/ml). Outcome assessors and data analysts will be blinded to group allocation. Intention-to-treat principle and Generalized Estimating Equation (GEE) regressions will be used for data analysis.

DISCUSSION

This will be the first trial on evaluating the efficacy of the 2 different intensities of SC active referral on smoking cessation in community smokers. It is anticipated that the results from this trial can provide evidence to the effectiveness of high-intensity active referral to SC services and low intensity SC referral by using text messaging in achieving smoking abstinence.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02804880 , June 17, 2016.

Outcomes of a randomized trial evaluating two approaches for promoting pharmacy-based referrals to the tobacco quitline

OBJECTIVES

To evaluate the long-term impact of 2 promising intervention approaches to engage pharmacy personnel (pharmacists, technicians) in referring patients who want to quit smoking to the tobacco quitline.

DESIGN

Randomized trial.

SETTING

Community pharmacies in Connecticut (n = 32) and Washington (n = 32).

INTERVENTION

Two intervention approaches were evaluated: academic detailing (AD), which involved on-site training for pharmacy staff about the quitline, versus mailed quitline materials (MM).

MAIN OUTCOME MEASURES

Changes in the overall percentage of quitline registrants who reported hearing about the quitline from any pharmacy during the 6-month baseline monitoring period versus the 12-month intervention period, and between-group comparisons of a) the number of quitline registrants who reported hearing about the quitline from one of the study pharmacies during the 12-month intervention period, and b) the number of quitline cards and brochures distributed to patients during the first 6 months of the intervention period.

RESULTS

The percentage of quitline callers who reported having heard about the quitline from a pharmacy increased significantly, from 2.2% during the baseline monitoring period to 3.8% during the 12-month intervention (P < 0.0001). In addition, comparisons controlled for seasonal effects also revealed significant increases in referrals. Across all 64 pharmacies, 10,013 quitline cards and 4755 brochures were distributed. The number of quitline cards distributed and the number registrants who reported hearing about the quitline from a pharmacy did not differ by intervention approach (AD vs. MM), although AD pharmacies distributed more quitline brochures (P = 0.022).

CONCLUSION

Brief cessation interventions are feasible in community pharmacies, and the 2 approaches evaluated for engaging pharmacy personnel were similarly effective and collectively led to meaningful increases in the number and proportion of all patients who called the quitline. Involvement of community pharmacy personnel in tobacco cessation presents a significant opportunity to promote quitline services by connecting patients with an effective publicly available resource.

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Background

External change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings.

Methods

We searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.

Results

Academic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.

Conclusions

Our results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

Offering smoking treatment to primary care patients in two Wisconsin healthcare systems: Who chooses smoking reduction versus cessation?

Smokers unwilling to make a quit attempt can still benefit from smoking intervention. However, it is unclear what proportion of smokers will enter such a Motivation phase intervention, and whether such an intervention attracts different types of smokers than does abstinence oriented treatment. We conducted a study from June 2010 to October 2013 based on a chronic care model of tobacco treatment among study eligible primary care patients (N=1579; 58% women, 89% White) presenting for regular health care visits in southern Wisconsin, U.S. Medical assistants, prompted via the electronic health record (EHR), invited smokers (n=10,242) to learn more about treatment options to help them either reduce their smoking or quit. Of those invited to learn more who were then reached by study staff, 10.2% (n=1046) reported interest in reduction treatment and 24% (n=2465) reported interest in cessation treatment. Patients who selected and ultimately entered reduction (n=492) versus cessation (n=1087) were more likely to report: older age; a history of anxiety; lower motivation to quit; lower primary dependence motives; more close friends or family who smoke; and a greater interval since their last quit attempt. Results suggest that Motivation phase treatment aimed at smoking reduction may increase the proportion and range of smokers inducted into tobacco treatment.

Patterns of and reasons for electronic cigarette use in primary care patients

BACKGROUND

Electronic cigarette (e-cigarette) use is rising in both the general and clinical populations. Little is known about e-cigarette use in primary care, where physicians report discussing e-cigarette use with patients.

OBJECTIVE

Identify how and why smokers in primary care use e-cigarettes.

DESIGN

Cross-sectional secondary data analysis from a randomized controlled trial of a tablet intervention to deliver the 5As for smoking cessation in primary care.

PARTICIPANTS

Current smokers aged 18 and older in three primary care clinics in San Francisco, CA (N = 788).

MAIN MEASURES

Patients reported sociodemographics, cigarette smoking habits, quitting readiness, and ever and current use of e-cigarettes. We also asked reasons they have used or would use e-cigarettes. ICD-9 codes from the medical record determined comorbidities.

KEY RESULTS

Fifty-two percent (n = 408) of patients reported ever using an e-cigarette, and 20% (n = 154) reported past-30-day use. Ever e-cigarette use was associated with younger age and negatively associated with being seen at practices at a public safety-net hospital compared to a practice at University-affiliated hospital. The most common reason for having used e-cigarettes among ever e-cigarette users, and for interest in future use of e-cigarettes among never e-cigarette users, was to cut down cigarette use. The mean number of days of e-cigarette use in the past 30 increased with duration of e-cigarette use. Most current e-cigarette users did not know the nicotine content of their e-cigarettes.

CONCLUSIONS

Over half of smokers in primary care have ever used e-cigarettes, and one-fifth are currently using them. Most reported using e-cigarettes to cut down or quit cigarettes. Primary care providers should be prepared to discuss e-cigarettes with patients. Screening for e-cigarette use may help identify and treat patients interested in changing their cigarette smoking habits.

Increasing the provision of preventive care by community healthcare services: a stepped wedge implementation trial

BACKGROUND

Although clinical guidelines recommend the provision of care to reduce client chronic disease risk behaviours, such care is provided sub-optimally by primary healthcare providers. A study was undertaken to determine the effectiveness of an intervention in increasing community-based clinician implementation of multiple elements of recommended preventive care for four risk behaviours.

METHODS

A three-group stepped-wedge trial was undertaken with all 56 community-based primary healthcare facilities in one health district in New South Wales, Australia. A 12-month implementation intervention was delivered sequentially in each of three geographically and administratively defined groups of facilities. The intervention consisted of six key strategies: leadership and consensus processes, enabling systems, educational meetings and training, audit and feedback, practice change support, and practice change information and resources. Client-reported receipt of three elements of preventive care: assessment; brief advice; referral for four behavioural risks: smoking, inadequate fruit and/or vegetable consumption, alcohol overconsumption, and physical inactivity, individually, and for all such risks combined were collected for 56 months (October 2009-May 2014). Segmented logistic regression models were developed to assess intervention effectiveness.

RESULTS

A total of 5369 clients participated in data collection. Significant increases were found for receipt of four of five assessment outcomes (smoking OR 1.53; fruit and/or vegetable intake OR 2.18; alcohol consumption OR 1.69; all risks combined OR 1.78) and two of five brief advice outcomes (fruit and/or vegetable intake OR 2.05 and alcohol consumption OR 2.64). No significant increases in care delivery were observed for referral for any risk behaviour, or for physical inactivity.

CONCLUSIONS

The implementation intervention was effective in enhancing assessment of client risk status but less so for elements of care that could reduce client risk: provision of brief advice and referral. The intervention was ineffective in increasing care addressing physical inactivity. Further research is required to identify barriers to the provision of preventive care and the effectiveness of practice change interventions in increasing its provision.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN12611001284954 . Registered 15 December 2011. Retrospectively registered.

Tobacco cessation in Vietnam: Exploring the role of village health workers

The purpose of this study was to explore current tobacco use treatment (TUT) practice patterns, and attitudes and beliefs among Village Health Workers (VHWs) about expanding their role to include delivering smoking cessation interventions and the perceived barriers. We conducted a survey of 449 VHWs from 26 communes in Thai Nguyen province, Vietnam. We assessed TUT practice patterns including asking about tobacco use, advising smokers to quit, offering assistance (3As) and attitudes, self-efficacy, and norms related to TUT. Seventy two per cent of VHWs reported asking patients if they use tobacco, 78.6% offered advice to quit, and 41.4% offered cessation assistance to few or more patients in the past month. Self-efficacy was low, with 53.2% agreeing that they did not have the skills to counsel patients about smoking cessation. The most commonly reported barriers to offering TUT were a lack of training and perceived lack of patient interest. Greater awareness of their commune health centre's smoke-free policy and higher levels of self-efficacy were associated with screening and offering cessation assistance. VHWs support an expanded role in tobacco cessation, but require additional resources and training to increase their self-efficacy and skills to provide effective treatment.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial

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.

Implementation of an Inpatient Electronic Referral System (Opt-to-Quit) From the Electronic Health Record to the New York State Smokers' Quitline: First Steps

OBJECTIVES

(1) To implement a new policy-driven referral program, Opt-to-Quit, using electronic data transfer from the electronic health record (EHR) to the New York State Smokers' Quitline (NYSSQL) and (2) to improve referrals to the NYSSQL for smoking caregivers of children admitted to a children's hospital.

METHODS

Smoking caregivers of pediatric patients were referred to the NYSSQL through a standardized template built into the EHR, during the child's hospitalization or emergency department encounter. Direct data exchange was based on a point-to-point protocol, without dependence on any external centralized processing service. Input and oversight were provided by a multidisciplinary task force, which included physician and nursing leadership, information technology specialists, Health Insurance Portability and Accountability Act compliance personnel and legal counsel, and NYSSQL staff. The process was refined through several iterative plan-do-study-act cycles, using a single-armed, prospective cohort study design, including surveys of nursing staff and continued input of information technology experts on both hospital and Quitline sides.

RESULTS

In 2013, 193 smokers were identified in 2 pilot units; 62% (n= 119) accepted referral to the NYSSQL. In 2014, after expansion to all inpatient units and the emergency department, 745 smokers were identified, and 36% (n = 266) accepted referral. Over the 2 years, overall increase in referrals was 124%; as of the first quarter of 2015, referral rate was sustained at 34%.

CONCLUSIONS

Hospital-wide implementation of the Opt-to-Quit program through our EHR was feasible and sustainable and has significantly improved referrals to the NYSSQL.

Proactive enrollment of parents to tobacco quitlines in pediatric practices is associated with greater quitline use: a cross-sectional study

BACKGROUND

Every U.S. state has a free telephone quitline that tobacco users can access to receive cessation assistance, yet referral rates for parents in the pediatric setting remain low. This study evaluates, within pediatric offices, the impact of proactive enrollment of parents to quitlines compared to provider suggestion to use the quitline and identifies other factors associated with parental quitline use.

METHODS

As part of a cluster randomized controlled trial (Clinical Effort Against Secondhand Smoke Exposure), research assistants completed post-visit exit interviews with parents in 20 practices in 16 states. Parents' quitline use was assessed at a 12-month follow-up interview. A multivariable analysis was conducted for quitline use at 12 months using a logistic regression model with generalized estimating equations to account for provider clustering. Self-reported cessation rates were also compared among quitline users based on the type of referral they received at their child's doctor's office.

RESULTS

Of the 1980 parents enrolled in the study, 1355 (68 %) completed a 12-month telephone interview and of those 139 (10 %) reported talking with a quitline (15 % intervention versus 6 % control; p < .0001). Parents who were Hispanic (aOR 2.12 (1.22, 3.70)), black (aOR 1.57 (1.14, 2.16)), planned to quit smoking in the next 30 days (aOR 2.32 (1.47, 3.64)), and had attended an intervention practice (aOR 2.37 (1.31, 4.29)) were more likely to have talked with a quitline. Parents who only received a suggestion from a healthcare provider to use the quitline (aOR 0.45 (0.23, 0.90)) and those who were not enrolled and did not receive a suggestion (aOR 0.33 (0.17, 0.64)) were less likely to talk with a quitline than those who were enrolled in the quitline during the baseline visit. Self-reported cessation rates among quitline users were similar regardless of being proactively enrolled (19 %), receiving only a suggestion (25 %), or receiving neither a suggestion nor an enrollment (17 %) during a visit (p = 0.47).

CONCLUSIONS

These results highlight the enhanced clinical effectiveness of not just recommending the quitline to parents but also offering them enrollment in the quitline at the time of their child's visit to the pediatric office.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT00664261.

Mental health clinician attitudes to the provision of preventive care for chronic disease risk behaviours and association with care provision

BACKGROUND

Preventive care for chronic disease risk behaviours by mental health clinicians is sub-optimal. Little research has examined the association between clinician attitudes and such care delivery. This study aimed to explore: i) the attitudes of a multi-disciplinary group of community mental health clinicians regarding their perceived role, perception of client interest, and perceived self-efficacy in the provision of preventive care, ii) whether such attitudes differ by professional discipline, and iii) the association between these attitudes and clinician provision of such care.

METHOD

A telephone survey was conducted with 151 Australian community mental health clinicians regarding their attitudes towards provision of assessment, advice and referral addressing smoking, nutrition, alcohol, and physical activity, and their reported provision of such care. Logistic regression was used to examine the association between attitudes and care delivery, and attitudinal differences by professional discipline.

RESULTS

Most clinicians reported that: their manager supported provision of preventive care; such care was part of their role; it would not jeopardise their practitioner-client relationships, clients found preventive care acceptable, and that they had the confidence, knowledge and skills to modify client health behaviours. Half reported that clients were not interested in changing their health behaviours, and one third indicated that the provision of preventive care negatively impacted on time available for delivery of acute care. The following attitudes were positively associated with the provision of preventive care: role congruence, client interest in change, and addressing health risk behaviours will not jeopardise the client-clinician relationship.

CONCLUSIONS

Strategies are required to translate positive attitudes to improved client care and address attitudes which may hinder the provision of preventive care in community mental health.

Implementing tobacco use treatment guidelines in community health centers in Vietnam

Background

Vietnam has a smoking prevalence that is the second highest among Southeast Asian countries (SEACs). According to the World Health Organization (WHO), most reductions in mortality from tobacco use in the near future will be achieved through helping current users quit. Yet, largely due to a lack of research on strategies for implementing WHO-endorsed treatment guidelines in primary care settings, services to treat tobacco dependence are not readily available to smokers in low middle-income countries (LMICs) like Vietnam. The objective of this study is to conduct a cluster randomized controlled trial that compares the effectiveness of two system-level strategies for implementing evidence-based guidelines for the treatment of tobacco use in 26 public community health centers (CHCs) in Vietnam.

Methods/Design

The current study will use a cluster-randomized design and multiple data sources (patient exit interviews, provider and village health worker (VHW) surveys, and semi-structured provider/VHW interviews) to study the process of adapting and implementing clinical practice guidelines in Vietnam and theory-driven mechanisms hypothesized to explain the comparative effectiveness of the two strategies for implementation. CHCs will be randomly assigned to either of the following: (1) training plus clinical reminder system (TC) or (2) TC + referral to a VHW (TCR) for three in person counseling sessions. The primary outcome is provider adherence to tobacco use treatment guidelines. The secondary outcome is 6-month biochemically verified smoking abstinence.

Discussion

The proposed implementation strategies draw on evidence-based approaches and a growing literature that supports the effectiveness of integrating community health workers as members of the health care team to improve access to preventive services. We hypothesize that the value of these implementation strategies is additive and that incorporating a referral resource that allows providers to delegate the task of offering counseling (TCR) will be superior to TC alone in improving delivery of cessation assistance to smokers. The findings of this research have potential to guide large-scale adoption of promising strategies for implementing and disseminating tobacco use treatment guidelines throughout the public health system in Vietnam and will serve as a model for similar action in other LMICs.

Trial registration

NCT01967654

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0328-8) contains supplementary material, which is available to authorized users.

Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: views of general practitioners and practice nurses

BACKGROUND

Support in primary care can assist smokers to quit successfully, but there are barriers to general practitioners (GPs) providing this support routinely. Practice nurses (PNs) may be able to effectively take on this role.

OBJECTIVES

The aim of this study was to perform a process evaluation of a PN-led smoking cessation intervention being tested in a randomized controlled trial in Australian general practice.

METHODS

Process evaluation was conducted by means of semi-structured telephone interviews with GPs and PNs allocated in the intervention arm (Quit with PN) of the Quit in General Practice trial. Interviews focussed on nurse training, content and implementation of the intervention.

RESULTS

Twenty-two PNs and 15 GPs participated in the interviews. The Quit with PN intervention was viewed positively. Most PNs were satisfied with the training and the materials provided. Some challenges in managing patient data and follow-up were identified.

CONCLUSION

The Quit with PN intervention was acceptable to participating PNs and GPs. Issues to be addressed in the planning and wider implementation of future trials of nurse-led intervention in general practice include providing ongoing mentoring support, integration into practice management systems and strategies to promote greater collaboration in GPs and PN teams in general practice. The ongoing feasibility of the intervention was impacted by the funding model supporting PN employment and the competing demands on the PNs time.

Persistence of smoking-cessation decision support use in a dental practice

INTRODUCTION

A computer-assisted tobacco decision support tool increased dental practitioners' (dentists and dental hygienists) advice to quit smoking and referral to a quitline during a group randomized trial. The purpose of this study is to document the extent to which use persisted after the trial.

METHODS

Electronic dental record (EDR) data from 2010 to 2013 were analyzed in 2014 for use of computer-assisted tobacco intervention tool advice scripts and referral to a quitline during four periods: during the trial and post-trial when only intervention clinic dental practitioners had access to the tool, and during full deployment, both before and after an EDR modification.

RESULTS

Intervention clinic dental practitioners (18.5 dentist full-time equivalents [FTEs] and 27.8 dental hygienist FTEs practicing in seven clinics) referred 19.0% of 1,368 smokers to a quitline during the trial and referred 15.4% of 4,011 smokers post-trial. After full tool deployment but pre-EDR change, these dental practitioners referred 15.6% of 2,214 intervention clinic smokers, whereas 18.3 dentist FTEs and 29.7 dental hygienist FTEs practicing in eight clinics referred 8.5% of 2,113 smokers. Post-EDR change, dental practitioners referred 12.2% of 2,214 intervention clinic smokers and 8.1% of 2,399 control clinic smokers to a quitline. In the last three quarters of observation, clinic script use ranged from 15.4% to 65.8% and referral to a quitline ranged from 2.0% to 18.7% of visits.

CONCLUSIONS

Although EDR design affected rates of referral, dental practitioners persisted in using a computer-assisted tobacco intervention tool to refer smokers to a quitline.

Comparative and cost effectiveness of telemedicine versus telephone counseling for smoking cessation

Background

In rural America, cigarette smoking is prevalent and health care providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services in rural areas, but they are poorly integrated with local health care resources.

Objective

The intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering expert tobacco treatment at a distance: telemedicine counseling that was integrated into smokers’ primary care clinics (Integrated Telemedicine—ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes (Phone).

Methods

Smokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling, similar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered the counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both groups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome was verified 7-day point prevalence smoking abstinence at month 12, using an intent-to-treat analysis.

Results

There were no significant baseline differences between groups, and the trial achieved 88% follow-up at 12 months. Verified abstinence at 12 months did not significantly differ between ITM or Phone (9.8%, 27/280 vs 12%, 34/286; P=.406). Phone participants completed somewhat more counseling sessions than ITM (mean 2.6, SD 1.5 vs mean 2.4, SD 1.5; P=.0837); however, participants in ITM were significantly more likely to use cessation medications than participants in Phone (55.9%, 128/280 vs 46.1%, 107/286; P=.03). Compared to Phone participants, ITM participants were significantly more likely to recommend the program to a family member or friend (P=.0075). From the combined provider plus participant (societal) perspective, Phone was significantly less costly than ITM. Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions. From the provider perspective, counseling costs were similar between ITM (US $45.46, SD 31.50) and Phone (US $49.58, SD 33.35); however, total provider costs varied widely depending on how the clinic space for delivering ITM was valued.

Conclusions

Findings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking. ITM increased utilization of cessation pharmacotherapy and produced higher participant satisfaction, but Phone counseling was significantly less expensive. Future interventions could combine elements of both approaches to optimize pharmacotherapy utilization, counseling adherence, and satisfaction. Such an approach could commence with a telemedicine-delivered clinic office visit for pharmacotherapy guidance, and continue with telephone or real-time video counseling delivered via mobile phones to flexibly deliver behavioral support to patients where they most need it—in their homes and communities.

Trial Registration

Clinicaltrials.gov NCT00843505; http://clinicaltrials.gov/ct2/show/NCT00843505 (Archived by WebCite at http://www.webcitation.org/6YKSinVZ9).

Care provision to prevent chronic disease by community mental health clinicians

BACKGROUND

People with a mental illness have higher prevalence of behavioral risks for chronic disease than the general population. Despite recommendations regarding the provision of preventive care by mental health services, limited research has examined the extent to which such care is provided.

PURPOSE

To examine mental health clinician provision of care for preventable chronic disease risks, and whether such care was associated with the availability of practice support strategies.

METHODS

A cross-sectional survey was undertaken of 151 community mental health clinicians in New South Wales, Australia regarding the provision of three elements of preventive care (i.e., assessment, brief advice, and referral/follow-up) for four health risk behaviors (i.e., tobacco smoking, inadequate fruit and vegetable consumption, harmful alcohol consumption, and inadequate physical activity). Clinicians reported the availability of 16 strategies to support such care delivery. Data were collected in 2010 and analyzed in 2012-2013.

RESULTS

Preventive care provision varied by both care element and risk behavior. Optimal care (each care element provided to at least 80% of clients for all health behaviors) was provided by few clinicians: assessment (8.6%), brief advice (24.5%), and referral/follow-up (9.9%). Less than half of clinicians reported more than four support strategies were available (44.4%). The availability of five or more strategies was associated with increased optimal preventive care.

CONCLUSIONS

The provision of preventive care focused on chronic disease prevention in community mental health services is suboptimal. Interventions to increase the routine provision of such care should involve increasing the availability of evidence-based strategies to support care provision.

Barriers and facilitators to expanding the role of community health workers to include smoking cessation services in Vietnam: a qualitative analysis

BACKGROUND

Despite high smoking rates, cessation services are largely unavailable in Vietnam. This study explored attitudes and beliefs of community health workers (CHWs) towards expanding their role to include delivering tobacco use treatment (TUT), and potential barriers and facilitators associated with implementing a strategy in which health centers would refer patients to CHWs for cessation services.

METHODS

We conducted four focus groups with 29 CHWs recruited from four district community health centers (CHCs) in Hanoi, Vietnam.

RESULTS

Participants supported expanding their role saying that it fit well with their current responsibilities. They further endorsed the feasibility of serving as a referral resource for providers in local CHCs expressing the belief that CHWs were "more suitable than their clinical colleagues" to offer cessation assistance. The most frequently cited barrier to routinely offering cessation services was that despite enacting a National Tobacco Control Action plan, cessation is not one of the national prevention priorities. As a result, CHWs have not been "assigned" to help smokers quit by the Ministry of Health. Additional barriers included lack of training and time constraints.

CONCLUSION

Focus groups suggest that implementing a systems-level intervention that allows providers to refer smokers to CHWs is a promising model for extending the treatment of tobacco use beyond primary care settings and increasing access to smoking cessation services in Vietnam. There is a need to test the cost-effectiveness of this and other strategies for implementing TUT guidelines to support and inform national tobacco control policies in Vietnam and other low-and middle-income countries.

Increasing preventive care by primary care nursing and allied health clinicians: a non-randomized controlled trial

BACKGROUND

Although primary care nurse and allied health clinician consultations represent key opportunities for the provision of preventive care, it is provided suboptimally.

PURPOSE

To assess the effectiveness of a practice change intervention in increasing primary care nursing and allied health clinician provision of preventive care for four health risks.

DESIGN

Two-group (intervention versus control), non-randomized controlled study assessing the effectiveness of the intervention in increasing clinician provision of preventive care.

SETTING/PARTICIPANTS

Randomly selected clients from 17 primary healthcare facilities participated in telephone surveys that assessed their receipt of preventive care prior to (September 2009-2010, n=876) and following intervention (October 2011-2012, n=1,113).

INTERVENTION

The intervention involved local leadership and consensus processes, electronic medical record system modification, educational meetings and outreach, provision of practice change resources and support, and performance monitoring and feedback.

MAIN OUTCOME MEASURES

The primary outcome was differential change in client-reported receipt of three elements of preventive care (assessment, brief advice, referral/follow-up) for each of four behavioral risks individually (smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, physical inactivity) and combined. Logistic regression assessed intervention effectiveness.

RESULTS

Analyses conducted in 2013 indicated significant improvements in preventive care delivery in the intervention compared to the control group from baseline to follow-up for assessment of fruit and vegetable consumption (+23.8% vs -1.5%); physical activity (+11.1% vs -0.3%); all four risks combined (+16.9% vs -1.0%) and for brief advice for inadequate fruit and vegetable consumption (+19.3% vs -2.0%); alcohol overconsumption (+14.5% vs -8.9%); and all four risks combined (+14.3% vs +2.2%). The intervention was ineffective in increasing the provision of the remaining forms of preventive care.

CONCLUSIONS

The intervention's impact on the provision of preventive care varied by both care element and risk type. Further intervention is required to increase the consistent provision of preventive care, particularly referral/follow-up.

Real-world impact of quitline interventions for provider-referred smokers

BACKGROUND

The healthcare provider-referral quitline model has potential to help identify and connect more smokers to effective cessation services as compared to the self-referral model alone. However, research is limited as to whether provider-referred smokers, who may have more barriers to quitting, can have similar rates of quit success using traditional quitline interventions as self-referred smokers.

PURPOSE

To (1) determine how provider-referred smokers may differ from self-referred smokers in their demographics, service utilization, and quit rates and (2) quantify the impact of traditional quitline services on provider-referred smokers' ability to quit.

METHODS

Data were collected for 2,737 provider-referred and 530 self-referred Massachusetts quitline clients between November 2007 and February 2012. Analysis was performed in 2012. Wald chi-square tests and two-sample t-tests were used to identify differences between the two referral populations. A multivariable logistic regression model was used for each referral population, and smoker quit status at follow-up was the primary outcome. Tests and models were weighted using inverse probability of treatment weights propensity score weighting method.

RESULTS

Compared with self-referred smokers, provider-referred smokers were more likely to be non-white, less educated, and have public insurance. They were less ready to quit and had lower service utilization and quit rates. In both referral populations, clients who used services had greater odds of quitting than those who did not.

CONCLUSIONS

Expanding the provider-referral model may require quitlines to address the various risk factors associated with this population. Providers serve critical roles in preparing patients for quitline participation prior to referral.

Enhancing the electronic health record to increase counseling and quit-line referral for parents who smoke

OBJECTIVE

To assess the impact of an electronic health record (EHR) modification and brief clinician training on tobacco smoke exposure (TSE) management in pediatric primary care.

METHODS

Within a teaching hospital-based, urban primary care setting, we modified the EHR to include TSE screening prompts, decision support, educational literature, and simplified referral to the state quit line (QuitWorks). A brief training was conducted for the 48 clinic physicians (34 residents and 14 attendings). We collected cross-sectional, independent, random samples of EHR data from well-child visits for children ≤12 years old seen 3 months before (2024 visits) and 3 months after (1895 visits) the intervention and pooled client data from QuitWorks to evaluate TSE screening, counseling, and quit-line referrals. A needs assessment questionnaire examined preintervention attitudes and practice around TSE management; follow-up questionnaires explored satisfaction and subjective changes in skills.

RESULTS

The baseline needs assessment revealed that although most clinicians agreed that it is appropriate for pediatricians to conduct TSE screening, counseling, and referral during well-child visits, only about half screened, 42% counseled, and 28% routinely offered to refer smoking parents. In pre-post analyses of 117 and 112 EHR-documented positive screens, the intervention was associated with a 16-fold greater likelihood of counseling among positive screens (adjusted odds ratio 16.12; 95% confidence interval 7.28, 35.68). Referrals to QuitWorks increased from 1 before to 31 after the intervention.

CONCLUSIONS

Implementation of EHR modifications and a brief training to support TSE management was associated with higher rates of counseling and quit-line referrals for parents who smoke.

Factors influencing tobacco use treatment patterns among Vietnamese health care providers working in community health centers

Background

Almost half of adult men in Viet Nam are current smokers, a smoking prevalence that is the second highest among South East Asian countries (SEAC). Although Viet Nam has a strong public health delivery system, according to the 2010 Global Adult Tobacco Survey, services to treat tobacco dependence are not readily available to smokers. The purpose of this study was to characterize current tobacco use treatment patterns among Vietnamese health care providers and factors influencing adherence to guideline recommended tobacco use screening and cessation interventions.

Methods

A cross sectional survey of 134 health care providers including physicians, nurses, midwives, physician assistants and pharmacists working in 23 community health centers in Viet Nam.

Results

23% of providers reported screening patients for tobacco use, 33% offered advice to quit and less than 10% offered assistance to half or more of their patients in the past three months. Older age, attitudes, self-efficacy and normative beliefs were associated with screening for tobacco use. Normative beliefs were associated with offering advice to quit. However in the logistic regression analysis only normative beliefs remained significant for both screening and offering advice to quit. Over 90% of providers reported having never received training related to tobacco use treatment. Major barriers to treating tobacco use included lack of training, lack of referral resources and staff to support counseling, and lack of patient interest.

Conclusions

Despite ratifying the FCTC, Viet Nam has not made progress in implementing policies and systems to ensure that smokers are receiving evidence-based treatment. This study suggests a need to change organizational norms through changes in national policies, training and local system-level changes that facilitate treatment.

Prevalence and correlates of quitline awareness and utilization in the United States: an update from the 2009-2010 National Adult Tobacco Survey

INTRODUCTION

Tobacco quitlines are evidence-based cessation resources that have been underutilized. The purpose of this study is to provide population-level data about quitline awareness and utilization in the United States and to assess correlates of awareness and utilization.

METHODS

Data were from the 2009-2010 National Adult Tobacco Survey. Descriptive statistics were produced for national- and state-level quitline awareness and for national quitline utilization. Bivariate and multivariable logistic regressions were used to identify correlates of quitline awareness and utilization.

RESULTS

Quitline awareness among the total sample was 33.9% (current smokers 53.9%, former smokers 34.0%, never-smokers 27.0%). Awareness varied by state (range: 35.8%-84.6% for current smokers). Among current smokers who tried to quit in the past year, correlates of lower awareness included being Black, non-Hispanic, and making <$50,000 annually; correlates of higher awareness included having seen a health professional, higher state tobacco program expenditures, and being female. Among smokers who made at least one quit attempt in the previous year and were aware of the quitline, quitline utilization was 7.8%. Higher state tobacco program expenditure, health professional advice, and being Black, non-Hispanic were correlated with higher utilization; older age was correlated with lower utilization. Awareness was significantly associated with use at the state level (r = .98, p < .01).

CONCLUSION

Although the majority of smokers in the United States are aware of quitlines, only a small percentage of those trying to quit utilize them. State tobacco program expenditures and receipt of advice from a health professional were associated with both higher quitline awareness and higher utilization.

Implementing smoking cessation guidelines for hospitalized veterans: effects on nurse attitudes and performance

BACKGROUND

A minority of hospitalized smokers actually receives assistance in quitting during hospitalization or cessation counseling following discharge. This study aims to determine the impact of a guideline-based intervention on 1) nurses' delivery of the 5A's (Ask-Advise-Assess-Assist-Arrange follow-up) in hospitalized smokers, and 2) nurses' attitudes toward the intervention.

METHODS

We conducted a pre-post guideline implementation trial involving 205 hospitalized smokers on the inpatient medicine units at one US Department of Veterans Affairs (VA) medical center. The intervention included: 1) academic detailing of nurses on delivery of brief cessation counseling, 2) modification of the admission form to facilitate 5A's documentation, and 3) referral of motivated inpatients to receive proactive telephone counseling. Based on subject interviews, we calculated a nursing 5A's composite score for each patient (ranging from 0 to 9). We used linear regression with generalized estimating equations to compare the 5A's composite score (and logistic regression to compare individual A's) across periods. We compared 29 nurses' ratings of their self-efficacy and decisional balance ("pros" and "cons") with regard to cessation counseling before and after guideline implementation. Following implementation, we also interviewed a purposeful sample of nurses to assess their attitudes toward the intervention.

RESULTS

Of 193 smokers who completed the pre-discharge interview, the mean nursing 5A's composite score was higher after guideline implementation (3.9 vs. 3.1, adjusted difference 1.0, 95 % CI 0.5-1.6). More patients were advised to quit (62 vs. 48 %, adjusted OR = 2.1, 95 % CI = 1.2-3.5) and were assisted in quitting (70 vs. 45 %, adjusted OR = 2.9, 95 % CI = 1.6-5.3) by a nurse during the post-implementation period. Nurses' attitudes toward cessation counseling improved following guideline implementation (35.3 vs. 32.7 on "pros" subscale, p = 0.01), without significant change on the "cons" subscale.

CONCLUSIONS

A multifaceted intervention including academic detailing and adaptation of the nursing admission template is an effective strategy for improving nurses' delivery of brief cessation counseling in medical inpatients.

Promoting a smokers' quitline in Ontario, Canada: an evaluation of an academic detailing approach

This study assesses the impact of an academic detailing quitline promotional outreach program on integration of patient referrals to the quitline by fax in healthcare settings and quitline utilization in Ontario, Canada. The study employed a mixed methods approach for evaluation, with trend analysis of quitline administrative data from the year before program inception (2005) to 2011 and qualitative interviews with quitline stakeholders. Participants in the qualitative interviews included academic detailing program staff, regional tobacco control stakeholders and quitline promotion experts. Quantitative outcomes included the number of fax referral partners and fax referrals received, and quitline reach. Trends in proximal and distal outreach program outcomes were assessed. The qualitative data were analysed through a process of data coding involving the constant comparative technique derived from grounded theory methods. The study identified that the outreach program has had some success in integrating the fax referral program in healthcare settings through evidence of increased fax referrals since program inception. However, organizational barriers to program partner engagement have been encountered. While referral from health professionals through the fax referral programs has increased since the inception of the outreach program, the overall reach of the quitline has not increased. The study findings highlight that an academic detailing approach to quitline promotion can have some success in achieving increased fax referral program integration in healthcare settings. However, findings suggest that investment in a comprehensive promotional strategy, incorporating academic detailing, media and the provision of free cessation medications may be a more effective approach to quitline promotion.

The emergency department action in smoking cessation (EDASC) trial: impact on cessation outcomes

INTRODUCTION

The focus on acute care, time pressure, and lack of resources hamper the implementation of smoking cessation guidelines in the emergency department (ED). The purpose of this study was to determine whether an emergency nurse- initiated intervention based on the 5A's (Ask-Advise-Assess-Assist-Arrange) framework improves quit rates.

METHODS

We conducted a pre-post implementation trial in 789 adult smokers who presented to two EDs in Iowa between August 13, 2008 and August 4, 2010. The intervention focused on improving delivery of the 5A's by ED nurses and physicians using academic detailing, charting/reminder tools, and group feedback. Performance of ED cessation counseling was measured using a 5A's composite score (ranging from 0 to 5). Smoking status was assessed by telephone interview at 3- and 6-month follow-up (with biochemical confirmation in those participants who reported abstinence at 6-month follow-up).

RESULTS

Based on data from 650 smokers who completed the post-ED interview, there was a significant improvement in the mean 5A's composite score for emergency nurses during the intervention period at both hospitals combined (1.51 vs. 0.88, difference = 0.63, 95% confidence interval [CI] [0.41, 0.85]). At 6-month follow-up, 7-day point prevalence abstinence (PPA) was 6.8 and 5.1% in intervention and preintervention periods, respectively (adjusted odds ratio [OR] = 1.7, 95% CI [0.99, 2.9]).

CONCLUSIONS

It is feasible to improve the delivery of brief smoking cessation counseling by ED staff. The observed improvements in performance of cessation counseling, however, did not translate into statistically significant improvements in cessation rates. Further improvements in the effectiveness of ED cessation interventions are needed.

Factors affecting human papillomavirus vaccine use among White, Black and Latino parents of sons

BACKGROUND

Although human papillomavirus (HPV) vaccination has been available for males since 2009, its uptake remains low. In light of new recommendations for universal vaccination of males, understanding parental attitudes toward this vaccine is important. This study aimed to describe HPV-related knowledge and intention to accept HPV vaccination among White, Black and Latino parents of sons and to assess vaccination rates among their sons.

METHODS

We interviewed parents (68 Black, 28 Latino and 24 White; mean age, 43.5) of sons (mean age, 14) attending an urban academic medical center and a community health center. Eligible parents self-identified as White, Black or Latino and spoke English, Spanish or Haitian-Creole. We collected demographic information, knowledge related to HPV vaccination, parents' intent to vaccinate sons and HPV vaccination rates. Descriptive statistics and multivariable logistic regression were used to describe data.

RESULTS

Most parents were mothers, married, expressed a religious affiliation and had completed high school or college. Parents had limited knowledge about HPV; White parents were more knowledgeable than Black parents. Most parents (75%) intended to accept HPV vaccination if recommended by physicians; no racial differences were noted. However, only 30% of sons were vaccinated. Logistic regression indicated that internet use was negatively associated with intention to vaccinate. Intention to vaccinate, clinical site of care and having an older son were associated with vaccine receipt.

CONCLUSIONS

Although parents in our study had limited understanding of HPV disease in males, most would vaccinate their sons if recommended by their physicians.

Interventions for recruiting smokers into cessation programmes

BACKGROUND

Tobacco control is a top public health priority around the globe due to the high prevalence of cigarette smoking and its associated morbidity and mortality. Much effort has been focused on establishing the effectiveness of different smoking cessation strategies. This review, however, aims to address the initial challenge faced by smoking cessation programmes: recruitment of smokers.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of different strategies for recruiting smokers into cessation programmes. The secondary objective was to determine the impact that these strategies had on smoking cessation rates at least six months after enrolment into a cessation programme.

SEARCH METHODS

We searched the specialised register of the Cochrane Tobacco Addiction Group using a search strategy which included the terms ('recruit$', 'invit$', 'enter', 'entry', 'enrolment') combined with ('smok$', 'cigarette', 'smoking cessation', 'tobacco') in the title, abstract or keyword fields. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and registers of current and ongoing trials. We also searched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials and cluster randomised controlled trials that compared at least two different methods of recruiting current smokers into a smoking cessation programme. We also included those studies which focused on the effectiveness of a smoking cessation programme as long as the study involved multiple recruitment methods and reported results of the recruitment phase.

DATA COLLECTION AND ANALYSIS

From each included study, we extracted data on the type of participants, type of recruitment strategies (i.e., setting, mode of communication used, intensity and duration) and comparisons, and on randomisation, allocation concealment, and blinding procedures.Our primary outcome was the proportion of smokers successfully recruited to each cessation programme compared to alternative modalities of recruitment. Our secondary outcome was smoking cessation for at least six months. Given the substantial heterogeneity across recruitment interventions and participants, we adopted a narrative synthesis approach for summarising results.

MAIN RESULTS

This review includes 19 studies with a total of 14,890 participants. We categorised the included studies according to the modes used to deliver the recruitment strategy: head to head comparison of individual recruitment strategies; comparison of the same delivery mode but with different content or intensity; and the addition of another mode to an existing recruitment method.We identified three studies that made head-to-head comparisons of different types of recruitment strategies. Of these, only one study detected a significant effect, finding that a personal phone call was more effective than a generic invitation letter (RR 40.73, 95% CI 2.53 to 654.74). Five studies compared interventions using the same delivery modes but different content. Results showed that tailored messages through an interactive voice response system resulted in a higher recruitment rate than assessment of smoking status alone using the same system (RR 8.64, 95% CI 4.41 to 16.93), and that text messages indicating scarcity of places available were more effective than generic text message reminders (RR 1.45, 95% CI 1.07 to 1.96). One study compared interventions using the same delivery mode but different intensity and found that allowing for more phone call attempts to reach potential participants can result in better recruitment (RR 1.87, 95% CI 1.61 to 2.18). Finally, 10 studies investigated the effect of adding a recruitment mode to existing recruitment strategies. Findings showed that: adding a text message reminder or real quotes from participants to a personal phone call improved recruitment of participants (RR 3.38, 95% CI 1.26 to 9.08 and RR 29.07, 95% CI 1.74 to 485.70, respectively); that adding a personal phone call to an existing newsletter can also increase recruitment rates (RR 65.12, 95% CI 4.06 to 1045.4]); that a reactive-proactive recruitment phase is more effective than a proactive phase alone (63.8% versus 47.5%, RR not available); and that active recruitment at schools is more effective than passive recruitment (p < 0.001, denominator not available for calculation of RR). Additionally, a number of studies in this category showed that providing incentives can effectively increase the number of participants recruited into smoking cessation programmes.Out of the 19 included studies, only four reported on the effect of recruitment strategy on smoking cessation at six months or longer. Three of these studies compared strategies that used the same delivery mode with different content. Their results were non-significant. The remaining three studies evaluated adding an additional mode to an existing recruitment intervention. Only one of them showed a significant difference in the levels of smoking cessation that favoured the enhanced recruitment strategy, but this may have reflected the offer of incentives once in the programme rather than the recruitment strategy itself (RR at 15 or 18 months 2.60, 95% CI 1.48 to 4.56).

AUTHORS' CONCLUSIONS

The substantial heterogeneity across the included studies restricts our ability to draw firm conclusions about the effectiveness of different recruitment strategies in relation to recruitment of participants into smoking cessation programmes or levels of smoking cessation. The limited evidence, however, suggests that the following elements may improve the recruitment of smokers into cessation programmes: personal, tailored interventions; recruitment methods that are proactive in nature; and more intensive recruitment strategies (i.e., those strategies that require increased contact with potential participants).

Implementation of an electronic health record-based care management system to improve tobacco treatment

BACKGROUND

Tobacco treatment is underused in primary care. We designed a Tobacco Care Management system to increase the delivery of treatment and reduce the burden on primary care providers (PCPs). A one-click functionality added to the electronic health record (EHR) allowed PCPs to refer smokers to a centralized tobacco treatment coordinator (TTC) who called smokers, provided brief counseling, connected them to ongoing treatment and gave feedback to PCPs.

OBJECTIVE

To study the system's feasibility and acceptability among PCPs, and its utilization by smokers.

DESIGN

Using a mixed methods design, we documented system utilization quantitatively from February 1, 2010 to July 31, 2011, and conducted two focus groups with PCPs in June 2011.

PARTICIPANTS

Thirty-six PCPs and 2,894 smokers from two community health centers in Massachusetts.

MAIN MEASURES

Quantitative: One-click referral utilization by PCPs, proportion of smokers referred and connected to treatment. Qualitative: PCPs' reasons for use, barriers to use, and experiences with feedback.

KEY RESULTS

Twenty-nine PCPs (81 %) used the functionality more than once, generating 466 referrals for 15 % of known smokers seen during the study. The TTC reached 260 (56 %) of the referrals and connected 135 (29 %) to additional treatment. The director of one center sent PCPs monthly feedback about their utilization compared to peers. These PCPs referred a greater proportion of their known smokers (18 % vs. 9 %, p<0.0001) and reported that monthly feedback motivated referrals. PCPs attending focus groups (n=24) appreciated the system's simplicity, access to updated resources, and time-efficient way to address smoking, and wanted more feedback about cessation outcomes. They collectively supported the system's continuation.

CONCLUSIONS

A novel EHR-based Tobacco Care Management system was adopted by PCPs, especially those receiving performance feedback, and connected one-third of referred smokers to treatment. The model has the potential to improve the delivery and outcomes of evidence-based tobacco treatment in primary care.