Increasing smoking cessation care in a preoperative clinic: a randomized controlled trial

What Is Dissemination and Implementation Science?: An Introduction and Opportunities to Advance Behavioral Medicine and Public Health Globally

There has been a well-documented gap between research (e.g., evidence-based programs, interventions, practices, policies, guidelines) and practice (e.g., what is routinely delivered in real-world community and clinical settings). Dissemination and implementation (D&I) science has emerged to address this research-to-practice gap and accelerate the speed with which translation and real-world uptake and impact occur. In recent years, there has been tremendous development in the field and a growing global interest, but much of the introductory literature has been U.S.-centric. This piece provides an introduction to D&I science and summarizes key concepts and progress of the field for a global audience, provides two case studies that highlight examples of D&I research globally, and identifies opportunities and innovations for advancing the field of D&I research globally.

Local opinion leaders: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011.

OBJECTIVES

To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field.

SELECTION CRITERIA

We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention.

MAIN RESULTS

We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs.

AUTHORS' CONCLUSIONS

Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.

Evaluation of a Pilot Perioperative Smoking Cessation Program: A Pre-Post Study

BACKGROUND

Surgical clinic and perioperative settings are critical touchpoints for treating smoking, yet health care systems have not typically prioritized smoking cessation among surgical patients. We evaluated the implementation of a pilot smoking cessation intervention integrated into standard perioperative care.

MATERIALS AND METHODS

English-speaking adult smokers undergoing elective surgery in Kaiser Permanente San Francisco before (2015) and after (2016-2017) the implementation of a smoking cessation intervention were included. Provider outcomes included counseling referrals, cessation medication orders (between surgery scheduling and surgery), and preoperative carbon monoxide testing. Patient outcomes included counseling and medication use, smoking status at surgery and 30 d after discharge, and surgical complications. Multivariable logistic regression analyses examined pre-to-post intervention changes in outcomes using electronic health record data and 30-d postdischarge telephone surveys.

RESULTS

The sample included 276 patients (70% male; 59% non-Hispanic white; mean age = 50 y). There were significant pre-to-post increases in tobacco cessation counseling referrals (3% to 28%, adjusted odds ratio [AOR] = 11.12, 95% confidence interval [CI] = 3.78-32.71) and preoperative carbon monoxide testing (38% to 50%, AOR = 1.83, 95% CI = 1.10-3.06). At ∼30 d after discharge, patients in the postintervention period were more likely to report smoking abstinence in the previous 7 d (24% pre, 44% post; AOR = 2.39, 95% CI = 1.11-5.13) and since hospital discharge (18% pre, 39% post; AOR = 3.20, 95% CI = 1.42-7.23). Cessation medication orders and patient use of counseling and medications increased, whereas surgical complications decreased, but pre-to-post differences were not significant.

CONCLUSIONS

A perioperative smoking cessation program integrated into standard care demonstrated positive smoking-related outcomes; however, larger studies are needed to evaluate the effectiveness of these programs.

Interventions to improve screening and appropriate referral of patients with cancer for psychosocial distress: systematic review

OBJECTIVES

The primary aim of the review was to determine the effectiveness of strategies to improve clinician provision of psychosocial distress screening and referral of patients with cancer.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched until July 2016.

INCLUSION CRITERIA

Population: adult patients with cancer and clinical staff members.

INTERVENTION

any strategy that aimed to improve the rate of routine screening and referral for detected distress of patients with cancer. Comparison: no intervention controls, 'usual' practice or alternative interventions.

OUTCOME

(primary) any measure of provision of screening and/or referral for distress, (secondary) psychosocial distress, unintended adverse effects.

DESIGN

trials with or without a temporal comparison group, including randomised and non-randomised trials, and uncontrolled pre-post studies.

DATA EXTRACTION AND ANALYSIS

Two review authors independently extracted data. Heterogeneity across studies precluded quantitative assessment via meta-analysis and so a narrative synthesis of the results is presented.

RESULTS

Five studies met the inclusion criteria. All studies were set in oncology clinics or departments and used multiple implementation strategies. Using the Grades of Recommendation, Assessment, Development and Evaluation, the overall rating of the certainty of the body of evidence reported in this review was assessed as very low. Three studies received a methodological quality rating of weak and two studies received a rating of moderate. Only one of the five studies reported a significant improvement in referrals.

CONCLUSIONS

The review identified five studies of predominantly poor quality examining the effectiveness of strategies to improve the routine implementation of distress screening and referral for patients with cancer. Future research using robust research designs, including randomised assignment, are needed to identify effective support strategies to maximise the potential for successful implementation of distress screening and referral for patients with cancer.

PROSPERO REGISTRATION NUMBER

CRD42015017518.

Smoking, Quitting, and the Provision of Smoking Cessation Support: A Survey of Orthopaedic Trauma Patients

OBJECTIVE

This study investigates orthopaedic trauma patients smoking cessation history, intentions to quit, receipt of smoking cessation care during hospital admission, and patient-related factors associated with receipt of smoking cessation care.

METHODS

An online cross-sectional survey of orthopaedic trauma patients was conducted in 2 public hospitals in New South Wales, Australia. Prevalence of smoking and associated variables were described. Logistic regressions were used to examine whether patient characteristics were associated with receipt of smoking cessation care.

RESULTS

Eight hundred nineteen patients (response rate 73%) participated. More than 1 in 5 patients (21.8%) were current smokers (n = 175). Of the current smokers, more than half (55.3%) indicated making a quit attempt in the last 12 months and the majority (77.6%) were interested in quitting. More than a third of smokers (37.4%) were not advised to quit; 44.3% did not receive any form of nicotine replacement therapy; and 24.1% reported that they did not receive any of these 3 forms of smoking cessation care during their admission. Provision of care was not related to patient characteristics.

CONCLUSIONS

The prevalence of smoking among the sample was high. Respondents were interested in quitting; however, the provision of care during admission was low. Smoking cessation interventions need to be developed to increase the provision of care and to promote quit attempts in this Australian population.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

System change interventions for smoking cessation

BACKGROUND

System change interventions for smoking cessation are policies and practices designed by organizations to integrate the identification of smokers and the subsequent offering of evidence-based nicotine dependence treatments into usual care. Such strategies have the potential to improve the provision of smoking cessation support in healthcare settings, and cessation outcomes among those who use them.

OBJECTIVES

To assess the effectiveness of system change interventions within healthcare settings, for increasing smoking cessation or the provision of smoking cessation care, or both.

SEARCH METHODS

We searched databases including the Cochrane Tobacco Addiction Group Specialized Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO in February 2016. We also searched clinical trial registries: WHO clinical trial registry, US National Institute of Health (NIH) clinical trial registry. We checked 'grey' literature, and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, quasi-RCTs and interrupted time series studies that evaluated a system change intervention, which included identification of all smokers and subsequent offering of evidence-based nicotine dependence treatment.

DATA COLLECTION AND ANALYSIS

Using a standardized form, we extracted data from eligible studies on study settings, participants, interventions and outcomes of interest (both cessation and system-level outcomes). For cessation outcomes, we used the strictest available criteria to define abstinence. System-level outcomes included assessment and documentation of smoking status, provision of advice to quit or cessation counselling, referral and enrolment in quitline services, and prescribing of cessation medications. We assessed risks of bias according to the Cochrane Handbook and categorized each study as being at high, low or unclear risk of bias. We used a narrative synthesis to describe the effectiveness of the interventions on various outcomes, because of significant heterogeneity among studies.

MAIN RESULTS

We included seven cluster-randomized controlled studies in this review. We rated the quality of evidence as very low or low, depending on the outcome, according to the GRADE standard. Evidence of efficacy was equivocal for abstinence from smoking at the longest follow-up (four studies), and for the secondary outcome 'prescribing of smoking cessation medications' (two studies). Four studies evaluated changes in provision of smoking cessation counselling and three favoured the intervention. There were significant improvements in documentation of smoking status (one study), quitline referral (two studies) and quitline enrolment (two studies). Other secondary endpoints, such as asking about tobacco use (three studies) and advising to quit (three studies), also indicated some positive effects.

AUTHORS' CONCLUSIONS

The available evidence suggests that system change interventions for smoking cessation may not be effective in achieving increased cessation rates, but have been shown to improve process outcomes, such as documentation of smoking status, provision of cessation counselling and referral to smoking cessation services. However, as the available research is limited we are not able to draw strong conclusions. There is a need for additional high-quality research to explore the impact of system change interventions on both cessation and system-level outcomes.

Improving the translation of health promotion interventions using effectiveness-implementation hybrid designs in program evaluations

Bridging the gap between research-based evidence and public health policy and practice is a considerable challenge to public health improvement this century, requiring a rethinking of conventional approaches to health research production and use. Traditionally the process of research translation has been viewed as linear and unidirectional, from epidemiological research to identify health problems and determinants, to efficacy and effectiveness trials and studies of strategies to maximise the implementation and dissemination of evidence-based interventions in practice. A criticism of this approach is the considerable time it takes to achieve translation of health research into practice. Hybrid evaluation designs provide one means of accelerating the research translation process by simultaneously collecting information regarding intervention impacts and implementation and dissemination strategy. However, few health promotion research trials employ such designs and often fail to report information to enable assessment of the feasibility and potential impact of implementation and dissemination strategies. In addition to intervention effects, policy makers and practitioners also want to know the impact of implementation strategies. This commentary will define the three categories of effectiveness-implementation hybrid designs, describe their application in health promotion evaluation, and discuss the potential implications of more systematic use of such designs for the translation of health promotion and evaluation.So what?Greater use of effectiveness-implementation hybrid designs may accelerate research translation by providing more practice- and policy-relevant information to end-users, more quickly.

Effectiveness of an intervention in increasing the provision of preventive care by community mental health services: a non-randomized, multiple baseline implementation trial

BACKGROUND

Relative to the general population, people with a mental illness are more likely to have modifiable chronic disease health risk behaviours. Care to reduce such risks is not routinely provided by community mental health clinicians. This study aimed to determine the effectiveness of an intervention in increasing the provision of preventive care by such clinicians addressing four chronic disease risk behaviours.

METHODS

A multiple baseline trial was undertaken in two groups of community mental health services in New South Wales, Australia (2011-2014). A 12-month practice change intervention was sequentially implemented in each group. Outcome data were collected continuously via telephone interviews with a random sample of clients over a 3-year period, from 6 months pre-intervention in the first group, to 6 months post intervention in the second group. Outcomes were client-reported receipt of assessment, advice and referral for tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption and inadequate physical activity and for the four behaviours combined. Logistic regression analyses examined change in client-reported receipt of care.

RESULTS

There was an increase in assessment for all risks combined following the intervention (18 to 29 %; OR 3.55, p = 0.002: n = 805 at baseline, 982 at follow-up). No significant change in assessment, advice or referral for each individual risk was found.

CONCLUSIONS

The intervention had a limited effect on increasing the provision of preventive care. Further research is required to determine how to increase the provision of preventive care in community mental health services.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12613000693729.

Increasing smoking cessation care across a network of hospitals: an implementation study

BACKGROUND

Despite clinical practice guidelines recommending the provision of smoking cessation care to all smokers in hospital, the provision of such care can be sub-optimal. A study was conducted to assess the impact of an intervention on the provision of smoking cessation care to nicotine-dependent smokers across a network of hospitals.

METHODS

A 4-year interrupted time series study was undertaken in a single health district in New South Wales, Australia. A multi-component intervention was implemented over a 2-year period in all 37 public general hospitals. Outcome data were collected from eight randomly selected hospitals via medical record audit. Logistic regression analyses assessed differences between baseline, intervention and follow-up periods in the provision of seven measures of care: brief advice, offer and provision of inpatient and discharge nicotine replacement therapy, and offer and acceptance of referral to a Quitline.

RESULTS

Approximately 164,250 patients were discharged from the hospitals during the study, 16 % of whom were smokers. Of the selected smokers, 56.12 % (n = 2072) were nicotine-dependent. The prevalence of smoking cessation care increased significantly for all seven measures between baseline and intervention periods, and for six of the seven measures between the baseline and follow-up periods. The odds of receiving care at follow-up were between 1.7 (CI 1.18-2.58, p = 0.0004) and 6.2 (CI 2.84-13.85, p < 0.0001) times greater than at baseline. At follow-up, 53, 16 and 7 of smokers were offered inpatient NRT, discharge NRT and a Quitline referral, respectively.

CONCLUSIONS

Significant gains in the provision of smoking cessation care were indicated. However, at best, slightly more than half of the patients received smoking cessation care. Additional care enhancement strategies are required if all smokers are to obtain the intended benefits of smoking cessation care guidelines.

Response to a mobile health decision-support system for screening and management of tobacco use

PURPOSE/OBJECTIVES

To describe the predictors of nurse actions in response to a mobile health decision-support system (mHealth DSS) for guideline-based screening and management of tobacco use.

DESIGN

Observational design focused on an experimental arm of a randomized, controlled trial.

SETTING

Acute and ambulatory care settings in the New York City metropolitan area.

SAMPLE

14,115 patient encounters in which 185 RNs enrolled in advanced practice nurse (APN) training were prompted by an mHealth DSS to screen for tobacco use and select guideline-based treatment recommendations.

METHODS

Data were entered and stored during nurse documentation in the mHealth DSS and subsequently stored in the study database where they were retrieved for analysis using descriptive statistics and logistic regressions.

MAIN RESEARCH VARIABLES

Predictor variables included patient gender, patient race or ethnicity, patient payer source, APN specialty, and predominant payer source in clinical site. Dependent variables included the number of patient encounters in which the nurse screened for tobacco use, provided smoking cessation teaching and counseling, or referred patients for smoking cessation for patients who indicated a willingness to quit.

FINDINGS

Screening was more likely to occur in encounters where patients were female, African American, and received care from a nurse in the adult nurse practitioner specialty or in a clinical site in which the predominant payer source was Medicare, Medicaid, or State Children's Health Insurance Program. In encounters where the patient payer source was other, nurses were less likely to provide tobacco cessation teaching and counseling.

CONCLUSIONS

mHealth DSS has the potential to affect nurse provision of guideline-based care. However, patient, nurse, and setting factors influence nurse actions in response to an mHealth DSS for tobacco cessation.

IMPLICATIONS FOR NURSING

The combination of a reminder to screen and integration of guideline-based recommendations into the mHealth DSS may reduce racial or ethnic disparities to screening, as well as clinician barriers related to time, training, and familiarity with resources.

A randomised controlled trial of an intervention to increase the implementation of a healthy canteen policy in Australian primary schools: study protocol

BACKGROUND

The implementation of healthy school canteen policies has been recommended as a strategy to help prevent unhealthy eating and excessive weight gain. Internationally, research suggests that schools often fail to implement practices consistent with healthy school canteen policies. Without a population wide implementation, the potential benefits of these policies will not be realised. The aim of this trial is to assess the effectiveness of an implementation intervention in increasing school canteen practices consistent with a healthy canteen policy of the New South Wales (NSW), Australia, government known as the 'Fresh Tastes @ School NSW Healthy School Canteen Strategy'.

METHODS/DESIGN

The parallel randomised trial will be conducted in 70 primary schools located in the Hunter region of New South Wales, Australia. Schools will be eligible to participate if they are not currently meeting key components of the healthy canteen policy. Schools will be randomly allocated after baseline data collection in a 1:1 ratio to either an intervention or control group using a computerised random number function in Microsoft Excel. Thirty-five schools will be selected to receive a multi-component intervention including implementation support from research staff, staff training, resources, recognition and incentives, consensus and leadership strategies, follow-up support and implementation feedback. The 35 schools allocated to the control group will not receive any intervention support as part of the research trial. The primary outcome measures will be i) the proportion of schools with a canteen menu that does not contain foods or beverages restricted from regular sale ('red' and 'banned' items) and ii) the proportion of schools where healthy canteen items ('green' items) represent the majority (>50%) of products listed on the menu. Outcome data will be collected via a comprehensive menu audit, conducted by dietitians blind to group allocation. Intervention effectiveness will be assessed using logistic regression models adjusting for baseline values.

DISCUSSION

The proposed trial will represent a novel contribution to the literature, being the first randomised trial internationally to examine the effectiveness of an intervention to facilitate implementation of a healthy canteen policy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000311752.

Mobile health-based approaches for smoking cessation resources

PURPOSE/OBJECTIVES

To describe how the National Cancer Institute's Cancer Information Service (CIS) smoking-related resources on a mobile health (mHealth) platform were integrated into the workflow of RNs in advanced practice nurse (APN) training and to examine awareness and use of CIS resources and nurses' perceptions of the usefulness of those CIS resources.

DESIGN

Descriptive analyses.

SETTING

Acute and primary care sites affiliated with the School of Nursing at Columbia University.

SAMPLE

156 RNs enrolled in APN training.

METHODS

The integration was comprised of (a) inclusion of CIS information into mHealth decision support system (DSS) plan of care, (b) addition of infobutton in the mHealth DSS, (c) Web-based information portal for smoking cessation accessible via desktop and the mHealth DSS, and (d) information prescriptions for patient referral.

MAIN RESEARCH VARIABLES

Use and perceived usefulness of the CIS resources.

FINDINGS

86% of nurses used the mHealth DSS with integrated CIS resources. Of the 145 care plan items chosen, 122 were referrals to CIS resources; infobutton was used 1,571 times. Use of CIS resources by smokers and healthcare providers in the metropolitan area of New York City increased during the study period compared to the prestudy period. More than 60% of nurses perceived CIS resources as useful or somewhat useful.

CONCLUSIONS

Integration of CIS resources into an mHealth DSS was seen as useful by most participants.

IMPLICATIONS FOR NURSING

Implementation of evidence into workflow using an mHealth DSS can assist nurses in managing smoking cessation in patients and may expand their roles in referring smokers to reliable sources of information.

KNOWLEDGE TRANSLATION

mHealth DSS and information prescriptions may support smoking cessation interventions in primary care settings. Smoking cessation interventions can be facilitated through informatics methods and mHealth platforms. Nurses' referrals of patients to smoking-related CIS resources may result in patients' use of the resources and subsequent smoking cessation.

The delivery of preventive care to clients of community health services

Background

Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients.

Methods

In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care.

Results

Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%).

Conclusions

Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.

Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes

Research in the United States and Australia acknowledges the potential of non-government social and community service organizations (SCSOs) for reaching socially disadvantaged smokers. This study aimed to describe SCSO smoking policies and practices, and attitudes of senior staff towards smoking and cessation. It also investigated factors associated with positive tobacco control attitudes. In 2009, a cross-sectional telephone survey was undertaken of senior staff in Australian SCSOs, 149 respondents representing 93 organizations completed the survey (response rate=65%; 93/142). Most service clients (60%) remained in programs for 6 months plus, and 77% attended at least weekly. Although 93% of respondents indicated they had an organizational smoking policy, it often did not include the provision of smoking cessation support. Most respondents indicated that client smoking status was not recorded on case notes (78%). Attitudes were mostly positive towards tobacco control in SCSOs, with a mean (standard deviation) score of 8.3 (2.9) of a possible 13. The practice of assessing clients' interest in quitting was the only statistically significant factor associated with high tobacco control attitude scores. The results suggest that SCSOs are appropriate settings for reaching socially disadvantaged smokers with cessation support. Although generally receptive to tobacco control, organizations require further support to integrate smoking cessation support into usual care. In particular, education, training and support for staff to enable them to help their clients quit smoking is important.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

A cluster randomised trial of a school-based resilience intervention to decrease tobacco, alcohol and illicit drug use in secondary school students: study protocol

Background

Whilst schools provide a potentially appropriate setting for preventing substance use among young people, systematic review evidence suggests that past interventions in this setting have demonstrated limited effectiveness in preventing tobacco, alcohol and other drug use. Interventions that adopt a mental wellbeing approach to prevent substance use offer considerable promise and resilience theory provides one method to impact on adolescent mental well-being. The aim of the proposed study is to examine the efficacy of a resilience intervention in decreasing the tobacco, alcohol and illicit drug use of adolescents.

Methods

A cluster randomised controlled trial with schools as the unit of randomisation will be undertaken. Thirty two schools in disadvantaged areas will be allocated to either an intervention or a control group. A comprehensive resilience intervention will be implemented, inclusive of explicit program adoption strategies. Baseline surveys will be conducted with students in Grade 7 in both groups and again three years later when the student cohort is in Grade 10. The primary outcome measures will include self-reported tobacco, alcohol, marijuana and other illicit drug use. Comparisons will be made post-test between Grade 10 students in intervention and control schools to determine intervention effectiveness across all measures.

Discussion

To the authors’ knowledge this is the first randomised controlled trial to evaluate the effectiveness of a comprehensive school-based resilience intervention, inclusive of explicit adoption strategies, in decreasing tobacco, alcohol and illicit drug use of adolescents attending disadvantaged secondary schools.

Trial registration

ACTRN12611000606987

The effectiveness of an intervention in increasing community health clinician provision of preventive care: a study protocol of a non-randomised, multiple-baseline trial

BACKGROUND

The primary behavioural risks for the most common causes of mortality and morbidity in developed countries are tobacco smoking, poor nutrition, risky alcohol use, and physical inactivity. Evidence, guidelines and policies support routine clinician delivery of care to prevent these risks within primary care settings. Despite the potential afforded by community health services for the delivery of such preventive care, the limited evidence available suggests it is provided at suboptimal levels. This study aims to assess the effectiveness of a multi-strategic practice change intervention in increasing clinician's routine provision of preventive care across a network of community health services.

METHODS/DESIGN

A multiple baseline study will be conducted involving all 56 community health facilities in a single health district in New South Wales, Australia. The facilities will be allocated to one of three administratively-defined groups. A 12 month practice change intervention will be implemented in all facilities in each group to facilitate clinician risk assessment of eligible clients, and clinician provision of brief advice and referral to those identified as being 'at risk'. The intervention will be implemented in a non-random sequence across the three facility groups. Repeated, cross-sectional measurement of clinician provision of preventive care for four individual risks (smoking, poor nutrition, risky alcohol use, and physical inactivity) will occur continuously for all three facility groups for 54 months via telephone interviews. The interviews will be conducted with randomly selected clients who have visited a community health facility in the last two weeks. Data collection will commence 12 months prior to the implementation of the intervention in the first group, and continue for six months following the completion of the intervention in the last group. As a secondary source of data, telephone interviews will be undertaken prior to and following the intervention with randomly selected samples of clinicians from each facility group to assess the reported provision of preventive care, and the acceptability of the practice change intervention and implementation.

DISCUSSION

The study will provide novel evidence regarding the ability to increase clinician's routine provision of preventive care across a network of community health facilities.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN12611001284954 UNIVERSAL TRIAL NUMBER (UTN): U1111-1126-3465.

Local opinion leaders: effects on professional practice and health care outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one method that holds promise as a strategy to bridge evidence-practice gaps.

OBJECTIVES

To assess the effectiveness of the use of local opinion leaders in improving professional practice and patient outcomes.

SEARCH STRATEGY

We searched Cochrane EPOC Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HMIC, Science Citation Index, Social Science Citation Index, ISI Conference Proceedings and World Cat Dissertations up to 5 May 2009. In addition, we searched reference lists of included articles.

SELECTION CRITERIA

Studies eligible for inclusion were randomised controlled trials investigating the effectiveness of using opinion leaders to disseminate evidence-based practice and reporting objective measures of professional performance and/or health outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each study and assessed its risk of bias. For each trial, we calculated the median risk difference (RD) for compliance with desired practice, adjusting for baseline where data were available. We reported the median adjusted RD for each of the main comparisons.

MAIN RESULTS

We included 18 studies involving more than 296 hospitals and 318 PCPs. Fifteen studies (18 comparisons) contributed to the calculations of the median adjusted RD for the main comparisons. The effects of interventions varied across the 63 outcomes from 15% decrease in compliance to 72% increase in compliance with desired practice. The median adjusted RD for the main comparisons were: i) Opinion leaders compared to no intervention, +0.09; ii) Opinion leaders alone compared to a single intervention, +0.14; iii) Opinion leaders with one or more additional intervention(s) compared to the one or more additional intervention(s), +0.10; iv) Opinion leaders as part of multiple interventions compared to no intervention, +0.10. Overall, across all 18 studies the median adjusted RD was +0.12 representing a 12% absolute increase in compliance in the intervention group.

AUTHORS' CONCLUSIONS

Opinion leaders alone or in combination with other interventions may successfully promote evidence-based practice, but effectiveness varies both within and between studies. These results are based on heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders.

Computerized clinical decision support systems for drug prescribing and management: a decision-maker-researcher partnership systematic review

Background

Computerized clinical decision support systems (CCDSSs) for drug therapy management are designed to promote safe and effective medication use. Evidence documenting the effectiveness of CCDSSs for improving drug therapy is necessary for informed adoption decisions. The objective of this review was to systematically review randomized controlled trials assessing the effects of CCDSSs for drug therapy management on process of care and patient outcomes. We also sought to identify system and study characteristics that predicted benefit.

Methods

We conducted a decision-maker-researcher partnership systematic review. We updated our earlier reviews (1998, 2005) by searching MEDLINE, EMBASE, EBM Reviews, Inspec, and other databases, and consulting reference lists through January 2010. Authors of 82% of included studies confirmed or supplemented extracted data. We included only randomized controlled trials that evaluated the effect on process of care or patient outcomes of a CCDSS for drug therapy management compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.

Results

Sixty-five studies met our inclusion criteria, including 41 new studies since our previous review. Methodological quality was generally high and unchanged with time. CCDSSs improved process of care performance in 37 of the 59 studies assessing this type of outcome (64%, 57% of all studies). Twenty-nine trials assessed patient outcomes, of which six trials (21%, 9% of all trials) reported improvements.

Conclusions

CCDSSs inconsistently improved process of care measures and seldomly improved patient outcomes. Lack of clear patient benefit and lack of data on harms and costs preclude a recommendation to adopt CCDSSs for drug therapy management.

A cluster randomised controlled trial of a comprehensive accreditation intervention to reduce alcohol consumption at community sports clubs: study protocol

Introduction Excessive alcohol consumption is responsible for considerable harm from chronic disease and injury. Within most developed countries, members of sporting clubs consume alcohol at levels above that of communities generally. Despite the potential benefits of interventions to address alcohol consumption in sporting clubs, there have been no randomised controlled trials to test the effectiveness of these interventions. The aim of this study is to examine the effectiveness of a comprehensive accreditation intervention with community football clubs (Rugby League, Rugby Union, soccer/association football and Australian Rules football) in reducing excessive alcohol consumption by club members. Methods and analysis The study will be conducted in New South Wales, Australia, and employ a cluster randomised controlled trial design. Half of the football clubs recruited to the trial will be randomised to receive an intervention implemented over two and a half winter sporting seasons. The intervention is based on social ecology theory and is comprehensive in nature, containing multiple elements designed to decrease the supply of alcohol to intoxicated members, cease the provision of cheap and free alcohol, increase the availability and cost-attractiveness of non-alcoholic and low-alcoholic beverages, remove high alcohol drinks and cease drinking games. The intervention utilises a three-tiered accreditation framework designed to motivate intervention implementation. Football clubs in the control group will receive printed materials on topics unrelated to alcohol. Outcome data will be collected pre- and postintervention through cross-sectional telephone surveys of club members. The primary outcome measure will be alcohol consumption by club members at the club, assessed using a graduated frequency index and a seven day diary. Ethics and dissemination The study was approved by The University of Newcastle Human Research Ethics Committee (reference: H-2008-0432). Study findings will be disseminated widely through peer-reviewed publications and conference presentations. Trial registration number Australian New Zealand Clinical Trials Registry: ACTRN12609000224224.

Providing comprehensive smoking cessation care to surgical patients: the case for computers

INTRODUCTION AND AIMS

The provision of smoking cessation care to surgical patients before admission can reduce post-operative complications and encourage long-term smoking cessation. Our aim was to show how a comprehensive computer-based smoking cessation intervention, developed to enhance smoking cessation care to surgical patients, addresses barriers to care provision.

DESIGN AND METHODS

Consultations with preoperative clinic staff and reviews of the scientific literature were conducted and identified the following barriers to the provision of effective smoking cessation care: a lack of organisational support, perceived patient objection, a lack of systems to identify smokers, a lack of staff time and skill, perceived inability to change care practices, a perceived lack of efficacy of cessation care and the cost of providing care. Based on positive findings of a pilot trial, a comprehensive computer-based smoking cessation intervention was implemented in a preoperative clinic. Data from previous evaluations of the intervention were used to assess the extent to which the intervention addressed clinician barriers to care.

RESULTS

The computer-based intervention was found to provide a means to accurately and systematically identify smokers; it required little clinical staff time or skill; it was considered an acceptable form of care by staff and patients; it was effective in encouraging patient cessation and it was inexpensive to deliver relative to other surgical costs. Furthermore, the computer-based intervention continues to operate in the preoperative clinic in the absence of ongoing research support.

DISCUSSION AND CONCLUSIONS

The implementation of such a model of care should be considered by clinical services interested in reducing the smoking related morbidity and mortality of patients.

Increasing hospital-wide delivery of smoking cessation care for nicotine-dependent in-patients: a multi-strategic intervention trial

AIMS, DESIGN AND INTERVENTION: Smoking care provision to in-patients is important in assisting smoking cessation and for management of nicotine withdrawal. Limited studies have reported the effectiveness of interventions designed to increase the hospital-wide provision of such care. A quasi-experimental matched-pair trial, involving two intervention and two control hospitals in NSW, Australia, investigated whether a multi-strategic intervention increased hospital-wide smoking care provision.

PARTICIPANTS AND MEASUREMENTS

Patient surveys (n = 274-347 per experimental condition), medical notes audits (n = 181-228) and health professional surveys (n = 229-302) were used to collect outcome data at baseline and follow-up.

FINDINGS

Significantly greater increases in intervention hospitals compared to control hospitals were found for patient-reported offer of nicotine replacement therapy (NRT) (intervention 34% versus control 12%), provision of NRT (16% versus 4%) and provision of written resources (11% versus 2%), and for the recording in medical notes of smoking management discussion (13% versus 3%), offer of NRT (24% versus 3%) and provision of NRT (21% versus 5%). Intervention group health professionals reported significantly greater increases in the mean estimate of patients who: had their smoking management discussed (30% versus 17%); were offered or provided with NRT (30% versus 18%); were asked their intention to smoke post-discharge (22% versus 10%); and were provided with discharge NRT (21% versus 4%).

CONCLUSIONS

Implementation of a multi-strategic intervention is effective in increasing hospital smoking care delivery, particularly the provision of NRT. Research is required to identify methods to increase further the delivery of this and other forms of smoking care.

Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation

Background

The aim of this study was to examine the effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation itself.

Methods

Relevant databases were searched for randomized controlled trials (RCTs) of preoperative smoking cessation interventions. Trial inclusion, risk of bias assessment and data extraction were performed by two authors. Risk ratios for the above outcomes were calculated and pooled effects estimated using the fixed-effect method.

Results

Eleven RCTs were included containing 1194 patients. Smoking interventions were intensive, medium intensity and less intensive. Follow-up for postoperative complications was 30 days. For smoking cessation it was from the day of surgery to 12 months thereafter. Overall, the interventions significantly reduced the occurrence of complications (pooled risk ratio 0·56 (95 per cent confidence interval 0·41 to 0·78); P &lt; 0·001). Intensive interventions increased smoking cessation rates both before operation and up to 12 months thereafter. The effects of medium to less intensive interventions were not significant. Meta-analysis of the effect on smoking cessation was not done owing to heterogeneity of data.

Conclusion

Surgical patients may benefit from intensive preoperative smoking cessation interventions. These include individual counselling initiated at least 4 weeks before operation and nicotine replacement therapy.

Surgical patient education related to smoking

Estimates indicate that one million patients who smoke present annually in the United States for some form of surgical intervention. Smoking is a known cause of respiratory complications, hemodynamic fluctuations, and delayed wound healing. A literature search revealed a small number of available studies that address the education provided to surgical patients who smoke. Information about the effects of smoking on surgical outcomes is not routinely provided to smokers. Determining the best methods by which to provide smoking cessation counseling will help increase patients' chances for a positive surgical outcome.

Provision of smoking care in NSW hospitals: opportunities for further enhancement

The provision of smoking care, including the management of nicotine withdrawal and assistance with a quitting attempt, is identified as an important part of the overall care of hospitalised patients. Levels of smoking care delivery in hospitals have been less than optimal. Increasing this care across multiple facilities and units within NSW Health represents a significant challenge. This article examines levels of smoking care delivery in NSW hospitals, and research evidence and best practice recommendations to inform potential strategies to increase such care. It also reviews statewide initiatives implemented by NSW Health to enhance the delivery of smoking care and suggests further strategies that could facilitate this.

Tobacco dependence in surgical patients

PURPOSE OF REVIEW

Many patients who smoke cigarettes require anesthesia and surgery. Their smoking can have profound consequences for perioperative management. Efforts to help them quit will be rewarded by both improved immediate postoperative outcomes and the long-term health benefits after surgery. This review will introduce basic concepts important to perioperative tobacco control and cover recent advances in the field.

RECENT FINDINGS

Evidence continues to accumulate regarding how smoking increases perioperative risk, especially of wound-related complications. There is also new information regarding how abstinence from smoking reduces risk, including how the timing of preoperative abstinence affects outcome. Methods to help surgical patients continue to be developed, taking advantage of surgery as a teachable moment for intervention. There is a need to develop methods practical in the surgical setting. Several pharmacological tools to help surgical patients quit smoking are available, including a new partial acetylcholine receptor agonist.

SUMMARY

The fact that the perioperative period represents an excellent opportunity to help surgical patients quit smoking is becoming increasingly apparent. Although these efforts, and the evidence base to support them, are still at an early stage of development, seizing this opportunity will benefit both the short and long-term health of our patients who smoke.

Tobacco control for anesthesiologists

Anesthesiologists daily witness the consequences of tobacco use, the most common preventable cause of death. Smoking-related diseases such as atherosclerosis and chronic obstructive pulmonary disease increase anesthetic risk, and even smokers without overt disease are at increased risk for morbidity such as pulmonary and wound-related complications. Evidence suggests that stopping smoking will reduce the frequency of these complications. Nicotine and the other constituents of cigarette smoke, such as carbon monoxide, have important physiologic effects that may affect perioperative management. In addition, it is now apparent that the scheduling of elective surgery represents an excellent opportunity for smokers to quit in the long term. This review serves as an introduction to tobacco control for anesthesiologists, first examining issues of importance to perioperative management. It then discusses how anesthesiologists and other perioperative physicians can help address tobacco use, both at an individual level with their patients, and by contributing to the implementation of effective public health strategies in their countries. Anesthesiologists can play a key role in helping their patients quit smoking. Effective tobacco control measures applied to surgical patients will not only improve immediate perioperative outcomes but also long-term health.

Strategies of smoking cessation intervention before hernia surgery—effect on perioperative smoking behavior

BACKGROUND

Although it is now generally accepted that patients should be advised to quit smoking before surgery, the effect of low-intensive smoking cessation intervention, both on preoperative smoking behavior and on risk reduction, remains unclear. Our objective was to study the effect on perioperative smoking behavior and on postoperative wound infection of different types of low-intensive intervention before herniotomy.

METHODS

Between October 1998 and October 2000, 180 consecutive smokers scheduled for elective herniotomy were advised to quit smoking perioperatively and subsequently allocated randomly to three low-intensive smoking cessation groups: a standard (control) group, a telephone group, which was reminded by telephone, and an out-patient group, which was reminded by means of an out-patient talk and demonstration of nicotine replacement drugs. Spontaneous perioperative smoking behavior was recorded for 64 consecutive non-advised smokers. Postoperative wound infection was evaluated by independent assessors.

RESULTS

Of the advised patients, 19% (29/149) stopped smoking before surgery compared with 2% (1/64) in the non-advised cohort (P < 0.01). In the standard group 13% (6/48) quit smoking compared with 23% (23/101) in the pooled telephone and outpatient group (NS). In the last group 64% (65/101) reduced or stopped smoking compared with 42% (20/48) in the standard group (P < 0.05). Predictors of failed perioperative cessation of smoking were a CO breath-test at inclusion above 20 ppm (OR: 0.11; 0.02-0-57) and low motivation to quit smoking (OR: 0.25; 0.09-0.70). Wound infection occurred in 6% (13/213) and there was no difference between the groups.

CONCLUSION

Low-intensive smoking cessation intervention helps approximately one fifth of patients to stop smoking perioperatively. Patients who are reminded in addition to preoperative advice are more likely to stop or reduce smoking. Failure to stop smoking is greater if the patients are not motivated and if the CO breath test is high at the time of the preoperative advice.

Computerized assessment of surgical patients for tobacco use: accuracy and acceptability

BACKGROUND

Despite increased risks of postoperative complications among patients who use tobacco, a number of barriers hinder the systematic identification of surgical patients who smoke. The study investigated the accuracy and acceptability of a patient-completed touchscreen computer program, which assessed patient smoking status during attendance at a surgical pre-operative clinic.

METHODS

One thousand and four patients participated in the study and completed a touchscreen computer smoking assessment program.

RESULTS

The sensitivity and specificity measures of the computerized assessment were 93% and 95% respectively. Patients, and clinic receptionists, nurses and anaesthetists found the touchscreen computer-based assessment acceptable.

CONCLUSIONS

The findings suggest that computerized assessment of smoking status is an accurate and acceptable way to identify tobacco users in a pre-operative clinic setting.

Local opinion leaders: effects on professional practice and health care outcomes

BACKGROUND

Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one innovative method that holds promise as a strategy to bridge evidence-practice gaps.

OBJECTIVES

To assess the effectiveness of the use of local opinion leaders in improving the behaviour of health care professionals and patient outcomes.

SEARCH STRATEGY

We searched MEDLINE, Health Star, SIGLE and the Cochrane Effective Practice and Organisation of Care Group Trials Register. We did not apply date restrictions to our search strategy. Searches were last updated in February 2005. In addition, we searched reference lists of all potential studies that were identified.

SELECTION CRITERIA

Studies eligible for inclusion were randomized controlled trials that used objective measures of performance/provider behaviour and/or patient health outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data from each study and assessed its methodological quality. We calculated the absolute difference in the risk of 'non-compliance' with desired practice, adjusting for baseline levels of non-compliance where these data were available.

MAIN RESULTS

Twelve studies met our eligibility criteria. The adjusted absolute risk difference of non-compliance with desired practice varied from -6% (favouring control) to +25% (favouring opinion leader intervention). Overall, the median adjusted risk difference (ARD) was 0.10 representing a 10% absolute decrease in non-compliance in the intervention group.

AUTHORS' CONCLUSIONS

The use of local opinion leaders can successfully promote evidence-based practice. However the feasibility of its widespread use remains uncertain.

The anesthesia preoperative assessment: an opportunity for smoking cessation intervention

Smoking is the single most cause of preventable disease and premature death in the United States. We discuss potential hazards that the anesthesiologist should be aware of when caring for patients who abuse tobacco. A review of recent preoperative smoking cessation initiatives is also provided in addition to recommendations on how anesthesiologists may use the preoperative visit as an opportunity to play a more active role in reducing the burden of tobacco-related disease.

Translation as a function of modality: the potential of brief interventions

The purpose of this article is to examine the potential of brief intervention (BI) as a modality for translating health behavior intervention research into practice. We discuss common definitions of BI, applications within common models of translation research, effects of BI on a range of health behaviors and across various populations, current and potential mechanisms, and uses for dissemination to practice. A number of advantages of BI suggest they are well suited for translating behavioral research. In addition, findings from 13 systematic reviews of BI effects show their potential versatility. Basic research on motivation, decision making, and persuasion may be applied to the design of BIs (Type 1 translation). Suggestions for translating BI research into practice are discussed (Type 2 translation). The article concludes that efforts to use BIs to translate research into practice are currently underdeveloped. Recommendations are provided for using BI in translating research into practice.