Smoking-Cessation Assistance: Before and After Stage 1 Meaningful Use Implementation

Factors Associated with Smoking Cessation and the Receipt of Cessation Services in a Public, Safety-Net Primary Care System

BACKGROUND

Prevalence of smoking is high among patients receiving care in safety-net settings, and there is a need to better understand patient factors associated with smoking cessation and receipt of cessation services.

OBJECTIVE

To identify patient factors associated with smoking cessation attempts and receipt of cessation counseling and pharmacotherapy in a large safety-net health system.

DESIGN

We conducted a retrospective cohort analysis using EHR data in a safety-net system in San Francisco, CA.

PARTICIPANTS

We included 7384 adult current smokers who had at least three unique primary care encounters with documented smoking status between August 2019 and April 2022.

MAIN MEASURES

We assessed four outcomes using multivariate generalized estimating equation models: (1) any cessation attempt, indicating a transition in smoking status from "current smoker" to "former smoker"; (2) sustained cessation, defined as transition in smoking status from current smoker to former smokers for two or more consecutive visits; (3) receipt of smoking cessation counseling from healthcare providers; and (4) receipt of pharmacotherapy.

KEY RESULTS

Of 7384 current adult smokers, 17.6% had made any cessation attempt, and of those 66.5% had sustained cessation. Most patients (81.1%) received counseling and 41.8% received pharmacotherapy. Factors associated with lower odds of any cessation attempt included being aged 45-64, non-Hispanic black, and experiencing homelessness. The factor associated with lower odds of sustained cessation was being male. Factors associated with lower odds of receiving counseling were being insured by Medicaid or being uninsured. Factors associated with lower odds of receiving pharmacotherapy included speaking languages other than English, being male, and identifying as racial and ethnic minorities.

CONCLUSIONS

Health system interventions could close the gap in access to smoking cessation services for unhoused and racial/ethnic minority patients in safety-net settings, thereby increasing cessation among these populations.

Rationale, design, and protocol for a hybrid type 1 effectiveness-implementation trial of a proactive smoking cessation electronic visit for scalable delivery via primary care: the E-STOP trial

BACKGROUND

Cigarette smoking remains the leading cause of preventable disease and death in the United States. Primary care offers an ideal setting to reach adults who smoke cigarettes and improve uptake of evidence-based cessation treatment. Although U.S. Preventive Services Task Force Guidelines recommend the 5As model (Ask, Advise, Assess, Assist, Arrange) in primary care, there are many barriers to its implementation. Automated, comprehensive, and proactive tools are needed to overcome barriers. Our team developed and preliminarily evaluated a proactive electronic visit (e-visit) delivered via the Electronic Health Record patient portal to facilitate evidence-based smoking cessation treatment uptake in primary care, with promising initial feasibility and efficacy. This paper describes the rationale, design, and protocol for an ongoing Hybrid Type I effectiveness-implementation trial that will simultaneously assess effectiveness of the e-visit intervention for smoking cessation as well as implementation potential across diverse primary care settings.

METHODS

The primary aim of this remote five-year study is to examine the effectiveness of the e-visit intervention vs. treatment as usual (TAU) for smoking cessation via a clinic-randomized clinical trial. Adults who smoke cigarettes are recruited across 18 primary care clinics. Clinics are stratified based on their number of primary care providers and randomized 2:1 to either e-visit or TAU. An initial baseline e-visit gathers information about patient smoking history and motivation to quit, and a clinical decision support algorithm determines the best evidence-based cessation treatment to prescribe. E-visit recommendations are evaluated by a patient's own provider, and a one-month follow-up e-visit assesses cessation progress. Main outcomes include: (1) cessation treatment utilization (medication, psychosocial cessation counseling), (2) reduction in cigarettes per day, and (3) biochemically verified 7-day point prevalence abstinence (PPA) at six-months. We hypothesize that patients randomized to the e-visit condition will have better cessation outcomes (vs. TAU). A secondary aim evaluates e-visit implementation potential at patient, provider, and organizational levels using a mixed-methods approach. Implementation outcomes include acceptability, adoption, fidelity, implementation cost, penetration, and sustainability.

DISCUSSION

This asynchronous, proactive e-visit intervention could provide substantial benefits for patients, providers, and primary care practices and has potential to widely improve reach of evidence-based cessation treatment.

TRIAL REGISTRATION

NCT05493254.

The incidence and mortality of lung cancer in China: a trend analysis and comparison with G20 based on the Global Burden of Disease Study 2019

Background

Lung cancer is a significant health concern in China. There is limited available data of its burden and trends. This study aims to evaluate the trends of lung cancer across different age groups and genders in China and the Group of Twenty (G20) countries, explore the risk factors, and predict the future trends over a 20-year period.

Methods

The data were obtained from the GBD study 2019. The number of cases, age standardized rate (ASR), and average annual percentage changes (AAPC) were used to estimate the trend in lung cancer by age, gender, region and risk factor. The trend of lung cancer was predicted by autoregressive integrated moving average (ARIMA) model by the "xtarimau" command. The joinpoint regression analysis was conducted to identify periods with the highest changes in incidence and mortality. Additionally, the relationship between AAPCs and socio-demographic index (SDI) was explored.

Results

From 1990 to 2019, both the incidence and mortality of lung cancer in China and G20 significantly increased, with China experiencing a higher rate of increase. The years with the highest increase in incidence of lung cancer in China were 1998-2004 and 2007-2010. Among the G20 countries, the AAPC in incidence and mortality of lung cancer in the Republic of Korea was the highest, followed closely by China. Although India exhibited similarities, its AAPC in lung cancer incidence and mortality rates was lower than that of China. The prediction showed that the incidence in China will continue to increase. In terms of risk factors, smoking was the leading attributable cause of mortality in all countries, followed by occupational risk and ambient particulate matter pollution. Notably, smoking in China exhibited the largest increase among the G20 countries, with ambient particulate matter pollution ranking second.

Conclusion

Lung cancer is a serious public health concern in China, with smoking and environmental particulate pollution identified as the most important risk factors. The incidence and mortality rates are expected to continue to increase, which places higher demands on China's lung cancer prevention and control strategies. It is urgent to tailor intervention measures targeting smoking and environmental pollution to contain the burden of lung cancer.

Implementation strategies to increase smoking cessation treatment provision in primary care: a systematic review of observational studies

BACKGROUND

Internationally, there is an 'evidence-practice gap' in the rate healthcare professionals assess tobacco use and offer cessation support in clinical practice, including primary care. Evidence is needed for implementation strategies enacted in the 'real-world'.

AIM

To identify implementation strategies aiming to increase smoking cessation treatment provision in primary care, their effectiveness, cost-effectiveness and any perceived facilitators and barriers for effectiveness.

METHODS

'Embase', 'Medline', 'PsycINFO', 'CINAHL', 'Global Health', 'Social Policy & Practice', 'ASSIA Applied Social Sciences Index and Abstracts' databases, and grey literature sources were searched from inception to April 2021. Studies were included if they evaluated an implementation strategy implemented on a nation-/state-wide scale, targeting any type of healthcare professional within the primary care setting, aiming to increase smoking cessation treatment provision.

PRIMARY OUTCOME MEASURES

implementation strategy identification, and effectiveness (practitioner-/patient-level).

SECONDARY OUTCOME MEASURES

perceived facilitators and barriers to effectiveness, and cost-effectiveness. Studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was conducted using the Expert Recommendations for Implementing Change (ERIC) compilation and the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Of 49 included papers, half were of moderate/low risk of bias. The implementation strategy domains identified involved utilizing financial strategies, changing infrastructure, training and educating stakeholders, and engaging consumers. The first three increased practitioner-level smoking status recording and cessation advice provision. Interventions in the utilizing financial strategies domain also appeared to increase smoking cessation (patient-level). Key facilitator: external policies/incentives (tobacco control measures and funding for public health and cessation clinics). Key barriers: time and financial constraints, lack of free cessation medications and follow-up, deprioritisation and unclear targets in primary care, lack of knowledge of healthcare professionals, and unclear messaging to patients about available cessation support options. No studies assessed cost-effectiveness.

CONCLUSIONS

Some implementation strategy categories increased the rate of smoking status recording and cessation advice provision in primary care. We found some evidence for interventions utilizing financial strategies having a beneficial impact on cessation. Identified barriers to effectiveness should be reduced. More pragmatic approaches are recommended, such as hybrid effectiveness-implementation designs and utilising Multiphase Optimization Strategy methodology.

PROTOCOL REGISTRATION

PROSPERO:CRD42021246683.

Smoking Cessation May Reduce Risk of Visual Field Progression in Heavy Smokers

PRCIS

The earlier a person quits smoking the more likely is the optic nerve be spared from damage.

PURPOSE

To investigate the effect of smoking cessation on visual field (VF) progression in glaucoma.

METHODS

Primary open angle glaucoma patients with a minimum of 3 years follow-up and 5 VFs were included. Linear mixed models were used to investigate the effects of smoking on the rates of 24-2 VF mean deviation loss after adjusting for confounding factors. Cox proportional hazard regression was used to identify whether different levels of smoking intensity were associated with VF progression with respect to different duration of quitting.

RESULTS

Five hundred eleven eyes of 354 patients were included over the mean follow-up of 12.4 years. Mean baseline age (95% confidence interval) was 62.3 (61.2, 63.4) years. One hundred forty nine (42.1%) patients were smokers. In a multivariable model, smoking intensity was associated with faster VF loss (-0.06, 95% confidence interval (-0.10, -0.01) dB/year per 10 pack-years, P =0.01) among smokers. Heavy smokers (≥20 pack-years) who had quit ˂25 years prior had significantly greater odds of VF progression compared with never smokers (odds ratio=2.49 (1.01, 6.08); P =0.046). There was no significant difference in odds of VF progression in heavy smokers who had quit smoking more than 25 years compared with never smokers ( P =0.43). A significantly higher proportion of VF progression was found in heavy smokers who quit < 25 years compared with heavy smokers who quit ≥25 years by Kaplan-Meier analysis ( P =<0.001).

CONCLUSIONS

After ≥25 years of smoking cessation, the risk of VF progression in former heavy smokers becomes similar to never smokers. Long-term smoking cessation may be associated with lower VF progression in glaucoma patients.

Use of electronic health records to manage tobacco screening and treatment in rural primary care

PURPOSE

Electronic health records (EHRs) can facilitate primary care providers' (PCPs) use of best practices in addressing tobacco dependence. It is unknown whether rural PCPs reap the same benefits as their urban counterparts when employing EHRs for this purpose. Our study examines this issue.

METHODS

This cross-sectional investigation based on the 2012-2015 National Ambulatory Medical Care Survey used chi-square tests and adjusted logistic regression models to explore how rurality and use of tobacco-related EHR functions were related to smoking status documentation (SSD) and cessation treatment at adult primary care visits.

FINDINGS

SSD rates were similar in visits to rural- and urban-based PCPs (88.2% rural-based vs 81.1% urban-based, P = .5819). Use of EHRs for SSD was associated with higher SSD odds at visits to both rural- and urban-based PCPs, but this increase was greater for visits to rural-based PCPs (428% vs 220% urban-based, P = .0443). Rates of cessation treatment at smokers' visits were low in rural and urban contexts (19.3% rural vs 19.6% urban, P = .9430). Odds of cessation treatment were 68% higher where EHRs were used to remind PCPs of treatment guidelines (P = .001), with no rural-urban difference in the size of the increase. Access to EHRs with tobacco-related functions was similar across rural and urban practices.

CONCLUSIONS

Rural-based PCPs were at least as successful as urban-based PCPs in leveraging EHRs to enhance tobacco-related services. Even where EHRs are used, opportunities exist to expand cessation treatment in rural primary care.

Community Health Centers' Performance in Cancer Screening and Prevention

INTRODUCTION

Little is known about what clinic-level factors differentiate community health centers that achieve high performance on cancer-preventive care metrics. This study aims to describe the longitudinal trends in the delivery of 3 cancer-preventive care metrics (cervical and colorectal cancer screenings and tobacco-cessation intervention) and define and compare community health centers with high cancer-preventive care performance with those with low cancer-preventive care performance.

METHODS

This observational study used 2012-2019 community health center data (N=933) from the Uniform Data System. High/low performance was based on Healthy People 2020 targets and sample distribution. For each cancer-preventive care metric, the percentage of community health centers that met high (≥70.5% at cervical or colorectal cancer screening or >80% tobacco-cessation intervention) and low thresholds at 1, 2, and all the 3 screenings was estimated. Multivariable generalized estimating equations logistic regression modeling was used to assess the community health center‒level factors associated with screening performance.

RESULTS

The community health centers' performance for tobacco-cessation intervention remained at ≥80%, with a small increase over time. Performance for cervical cancer screening remained unchanged with about 50% of patients screened. Colorectal cancer screening performance increased from around 30% in 2012 to 44% in 2019. Very few community health centers reached high performance (3%) in all the 3 indicators, and 13% of community health centers were high in any 2 of the outcomes in 2019. Higher patient volume, a greater proportion of Hispanic patients, fewer uninsured patients, and community health centers located in the Northeast region were associated with high performance in 2019.

CONCLUSIONS

Very few community health centers meet all Healthy People 2020 goals in cancer screenings and may struggle to achieve the 2030 goals. Very few indicators differentiated high performers from low performers.

Concordance Between Electronic Health Record and Tumor Registry Documentation of Smoking Status Among Patients With Cancer

PURPOSE

Patients with cancer who use tobacco experience reduced treatment effectiveness, increased risk of recurrence and mortality, and diminished quality of life. Accurate tobacco use documentation for patients with cancer is necessary for appropriate clinical decision making and cancer outcomes research. Our aim was to assess agreement between electronic health record (EHR) smoking status data and cancer registry data.

MATERIALS AND METHODS

We identified all patients with cancer seen at University of Florida Health from 2015 to 2018. Structured EHR smoking status was compared with the tumor registry smoking status for each patient. Sensitivity, specificity, positive predictive values, negative predictive values, and Kappa statistics were calculated. We used logistic regression to determine if patient characteristics were associated with odds of agreement in smoking status between EHR and registry data.

RESULTS

We analyzed 11,110 patient records. EHR smoking status was documented for nearly all (98%) patients. Overall kappa (0.78; 95% CI, 0.77 to 0.79) indicated moderate agreement between the registry and EHR. The sensitivity was 0.82 (95% CI, 0.81 to 0.84), and the specificity was 0.97 (95% CI, 0.96 to 0.97). The logistic regression results indicated that agreement was more likely among patients who were older and female and if the EHR documentation occurred closer to the date of cancer diagnosis.

CONCLUSION

Although documentation of smoking status for patients with cancer is standard practice, we only found moderate agreement between EHR and tumor registry data. Interventions and research using EHR data should prioritize ensuring the validity of smoking status data. Multilevel strategies are needed to achieve consistent and accurate documentation of smoking status in cancer care.

Tobacco-Related Counseling and Documentation in Adolescent Primary Care Practice: Challenges and Opportunities

INTRODUCTION

Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices.

METHODS

Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently.

RESULTS

In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes.

CONCLUSIONS

Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers.

IMPLICATIONS

Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.

Evaluation of a Proactive Smoking Cessation Electronic Visit to Extend the Reach of Evidence-Based Cessation Treatment via Primary Care

Background: Best practice guidelines for smoking cessation treatment through primary care advise the 5As model. However, compliance with these guidelines is poor, leaving many smokers untreated. The purpose of this study was to develop and preliminarily evaluate an asynchronous smoking cessation electronic visit (e-visit) that could be delivered proactively through the electronic health record (EHR) to adult smokers treated within primary care. The goal of the e-visit is to automate 5As delivery to ensure that all smokers receive evidence-based cessation treatment. As such, the aims of this study were twofold: (1) to examine acceptability, feasibility, and treatment metrics associated with e-visit utilization and (2) to preliminarily examine efficacy relative to treatment as usual (TAU) within primary care. Methods: Participants (n = 51) were recruited from primary care practices between November 2018 and October 2019 and randomized 2:1 to receive either the smoking cessation e-visit or TAU. Participants completed assessments of cessation outcomes 1-month and 3-months postenrollment and e-visit analytics data were gathered from the EHR. Results: Self-report feedback from e-visit participants indicated satisfaction with the intervention and interest in using e-visits again in the future. Nearly all e-visits resulted in prescription of a U.S. Food and Drug Administration (FDA)-approved smoking cessation medication. In general, smoking cessation outcomes favored the e-visit condition at both 1 (odds ratios [ORs]: 2.10-5.39) and 3 months (ORs: 1.31-4.67). Conclusions: These results preliminarily indicate the feasibility, acceptability, and efficacy of this smoking cessation e-visit within primary care. Future studies should focus on larger scale examination of effectiveness and implementation across settings. The clinicaltrials.gov registration number for this trial is NCT04316260.

Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation

INTRODUCTION

Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention.

STUDY DESIGN

The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019.

SETTING/PARTICIPANTS

A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves.

INTERVENTION

The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines.

MAIN OUTCOME MEASURES

The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite).

RESULTS

The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002).

CONCLUSIONS

Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02646488.

Trends in smoking documentation rates in safety net clinics

OBJECTIVE

To assess the impact of provider incentive policy on smoking status documentation.

DATA SOURCES

Primary data were extracted from structured electronic medical records (EMRs) from 15 community health centers (CHCs).

STUDY DESIGN

This was an observational study of data from 2006 to 2013, assessing changes in documentation of smoking status over time.

DATA EXTRACTION METHODS

We extracted structured EMR data for patients age 18 and older with at least one primary care visit.

PRINCIPAL FINDINGS

Rates of documented smoking status rose from 30 percent in 2006 to 90 percent in 2013; the largest increase occurred from 2011 to 2012 following policy changes (21.3% [95% CI, 8.2%, 34.4%] from the overall trend). Rates varied by clinic and across patient subgroups.

CONCLUSIONS

Documentation of smoking status improved markedly after introduction of new federal standards. Further improvement in documentation is still needed, especially for males, nonwhite patients, those using opioids, and HIV + patients. More research is needed to study whether changes in documentation lead to improvements in counseling, cessation, and patient outcomes.

Patients' self-reported receipt of brief smoking cessation interventions based on a decision support tool embedded in the healthcare information system of a large general hospital in China

INTRODUCTION

Healthcare information systems (HIS) are used to aid healthcare providers delivering brief smoking cessation interventions. However, evidence regarding the effectiveness of intervention models in developing countries remains limited. A smoking cessation intervention model based on a decision support tool embedded in HIS (an 'e-information model', including Ask, Advise, Assess, Inform, Refer and Print components) was applied in a large urban general hospital in Beijing, China. The current study was a preliminary evaluation of the implementation and effectiveness of this model.

METHODS

We conducted a retrospective investigation in the outpatient department of the hospital in the period June-July 2017. Using a paper questionnaire, patients' self-reported receipt of the e-information model in the past 2 months and their plans to quit within 1 month were collected. Multivariate logistic regression analysis was used to examine the association between receiving the e-information model and patients' plans to quit.

RESULTS

Among 656 currently smoking patients, the proportion of patients receiving the Ask, Advise, Assess, Refer and Print components were 73.2%, 65.4%, 49.8%, 16.0% and 10.4%, respectively. The results revealed a dose-response relationship between the number of components received and the proportion of patients planning to quit (p-trend=0.006). The likelihood of patients planning to quit within 1 month was highest among those receiving all five components (OR=2.79, 95% CI: 1.31-5.94). Moreover, a simplified model composed of two or three components also revealed a potential effect on increasing the proportion of patients planning to quit.

CONCLUSIONS

The e-information model was applied effectively in the study hospital and appeared to encourage patients to plan to quit smoking. This model could be generalized to other hospitals in China and other developing countries. However, many components of this model were less utilized, and comprehensive measures will be required to improve its application in the future.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics?

INTRODUCTION

To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics.

METHODS

We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016.

RESULTS

Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics.

CONCLUSIONS

Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Electronic medical record documentation of tobacco cessation support at eight community safety-net clinics with a high prevalence of tobacco use

OBJECTIVES

The high prevalence of tobacco use at primary care safety-net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting agencies to demonstrate care quality. This study examines tobacco cessation support rates and patient characteristics using electronic medical record (EMR) data.

METHODS

This cross-sectional study engaged eight community health centers affiliated with a county hospital system in NE Ohio where adult tobacco use rates exceed 30%. EMR data from June 2014 through May 2016 were analysed to assess rates of tobacco cessation counselling, order of cessation medications, or both. The association of tobacco cessation support with patient characteristics and quit attempts was assessed using multivariable logistic regression models.

RESULTS

Among 21 702 current tobacco users, 74% had no intervention documented; 15.4% had counselling documented, 6.4% were prescribed tobacco cessation medication, and 4.2% had both documented. Males, those aged 18 to 34, and African Americans were more likely to have no documented intervention. Of current tobacco users with at least two visits, 5.6% had a quit attempt. Medication alone was associated with a greater likelihood of a quit attempt (AOR: 1.72 [95% CI: 1.36-2.17]) as well as counselling and medication combined (AOR: 1.95 [95% CI: 1.48-2.56]).

CONCLUSIONS

Tobacco cessation support was lacking for 74% of current smokers and was less likely in subgroups including males, younger adults, and African Americans. Ordering tobacco cessation medication combined with counselling nearly doubled the likelihood of a quit attempt.

Disparities in the Receipt of Tobacco Treatment Counseling within the US Context of the Affordable Care Act and Meaningful Use Implementation

Introduction

Disparities in receiving advice to quit smoking and other tobacco use from health professionals may contribute to the continuing gap in smoking prevalence among priority populations. Under the Affordable Care Act (ACA), beginning in 2010, tobacco cessation services are currently covered in private and public health insurance plans. Providers and hospitals are also incentivized through the Meaningful Use of Electronic Health Records (EHRs) to screen and document patients' tobacco use and deliver brief cessation counseling. This study analyzes trends and correlates of receiving health professionals' advice to quit and potential disparities among US adult smokers from 2010 to 2015.

Methods

Data were from the National Health Interview Survey in 2010 and 2015. We analyzed the weighted prevalence of smokers' receipt of advice to quit smoking and other tobacco use from a health professional in 2010 and 2015 and correlates of receiving advice to quit.

Results

Prevalence of receiving advice to quit from a health professional increased from 51.4% in 2010 to 60.6% in 2015. This positive trend was observed across tobacco disparity population groups. Survey year (2015), age (older), ethnicity (non-Hispanic), region (Northeast), poverty level (above 100% poverty level), past quit attempt, daily smoking, cigarettes per day (11+ per day), and psychological distress were associated with higher odds of receiving advice to quit.

Conclusion

Based on national level data, receipt of advice to quit from health professionals increased between 2010 and 2015. However, disparities in receiving advice to quit from health professionals persist in certain populations.

Implications

This study provides important data on the national trends in receipt of health professional advice to quit smoking and other tobacco use in the context of the ACA and Meaningful Use implementation and whether these policies helped to narrow the gaps in receipt of health professional advice among vulnerable populations.

Trends in Utilization, Spending, and Prices of Smoking-Cessation Medications in Medicaid Programs: 25 Years Empirical Data Analysis, 1991-2015

BACKGROUND

Smoking remains the single largest preventable cause of death and disease. Smoking-cessation medications provide patients a multitude of benefits and can prevent certain diseases, including some cancers. Because of the limited amount of studies on smoking-cessation medications, we wanted to find general trends about the use of these medications.

OBJECTIVE

To examine trends in the utilization, pharmacy reimbursement, and prices of smoking-cessation medications and nicotine replacement therapy in the US Medicaid-covered population.

METHODS

Using national summary files for outpatient drug utilization and expenditure, we extracted data on smoking-cessation medications from the Centers for Medicare & Medicaid Services in the 25 years from January 1991 through June 2015. We conducted a retrospective drug utilization study to examine the annual (or quarterly) trends of the number of prescriptions, reimbursement expenditures, and the prices of smoking-cessation medications. The study drugs included varenicline (Chantix), bupropion (Zyban), and nicotine. We calculated per-prescription pharmacy reimbursement, which was used as a proxy for drug price, as the total quarterly expenditure for the drug, divided by the total number of prescriptions. All expenditures were inflated to 2015 US dollars using the medical services component of the Consumer Price Index.

RESULTS

The total number of prescriptions for smoking-cessation medications increased rapidly from 46,396 in 1991 to 942,562 in 2014, an increase of more than 1931%. During the same period, the total pharmacy reimbursement for smoking-cessation medications in Medicaid increased by 3562%, from approximately $2.8 million in 1991 to approximately $101 million in 2014. The use of the nonnicotine prescription drugs varenicline and bupropion also increased rapidly, with a high cost expenditure. The price per nonnicotine prescription drug increased over time, ranging from approximately $169 for bupropion to approximately $251 for varenicline in 2015.

CONCLUSIONS

The substantial increase in nonnicotine prescription drugs and nicotine replacement therapy between 2007 and 2015 may be attributed to smoking-cessation participants nationwide. Cost-containment policies might have inadvertently prevented Medicaid-covered smokers from obtaining appropriate pharmacotherapy.

Sensitivity of Claims-Based Algorithms to Ascertain Smoking Status More Than Doubled with Meaningful Use

BACKGROUND

The "meaningful use of certified electronic health record" policy requires eligible professionals to record smoking status for more than 50% of all individuals aged 13 years or older in 2011 to 2012.

OBJECTIVES

To explore whether the coding to document smoking behavior has increased over time and to assess the accuracy of smoking-related diagnosis and procedure codes in identifying previous and current smokers.

METHODS

We conducted an observational study with 5,423,880 enrollees from the year 2009 to 2014 in the Truven Health Analytics database. Temporal trends of smoking coding, sensitivity, specificity, positive predictive value, and negative predictive value were measured.

RESULTS

The rate of coding of smoking behavior improved significantly by the end of the study period. The proportion of patients in the claims data recorded as current smokers increased 2.3-fold and the proportion of patients recorded as previous smokers increased 4-fold during the 6-year period. The sensitivity of each International Classification of Diseases, Ninth Revision, Clinical Modification code was generally less than 10%. The diagnosis code of tobacco use disorder (305.1X) was the most sensitive code (9.3%) for identifying smokers. The specificities of these codes and the Current Procedural Terminology codes were all more than 98%.

CONCLUSIONS

A large improvement in the coding of current and previous smoking behavior has occurred since the inception of the meaningful use policy. Nevertheless, the use of diagnosis and procedure codes to identify smoking behavior in administrative data is still unreliable. This suggests that quality improvements toward medical coding on smoking behavior are needed to enhance the capability of claims data for smoking-related outcomes research.