Impact of Telephone-Based Care Coordination on Use of Cessation Medications Posthospital Discharge: A Randomized Controlled Trial

Clinical impacts of an integrated electronic health record-based smoking cessation intervention during hospitalisation

OBJECTIVE

To assess the effects of an electronic health record (EHR) intervention that prompts the clinician to prescribe nicotine replacement therapy (NRT) at hospital admission and discharge in a large integrated health system.

DESIGN

Retrospective cohort study using interrupted time series (ITS) analysis leveraging EHR data generated before and after implementation of the 2015 EHR-based intervention.

SETTING

Kaiser Permanente Northern California, a large integrated health system with 4.2 million members.

PARTICIPANTS

Current smokers aged ≥18 hospitalised for any reason.

EXPOSURE

EHR-based clinical decision supports that prompted the clinician to order NRT on hospital admission (implemented February 2015) and discharge (implemented September 2015).

MAIN OUTCOMES AND MEASURES

Primary outcomes included the monthly percentage of admitted smokers with NRT orders during admission and at discharge. A secondary outcome assessed patient quit rates within 30 days of hospital discharge as reported during discharge follow-up outpatient visits.

RESULTS

The percentage of admissions with NRT orders increased from 29.9% in the year preceding the intervention to 78.1% in the year following (41.8% change, 95% CI 38.6% to 44.9%) after implementation of the admission hard-stop intervention compared with the baseline trend (ITS estimate). The percentage of discharges with NRT orders increased acutely at the time of both interventions (admission intervention ITS estimate 15.5%, 95% CI 11% to 20%; discharge intervention ITS estimate 13.4%, 95% CI 9.1% to 17.7%). Following the implementation of the discharge intervention, there was a small increase in patient-reported quit rates (ITS estimate 5.0%, 95% CI 2.2% to 7.8%).

CONCLUSIONS

An EHR-based clinical decision-making support embedded into admission and discharge documentation was associated with an increase in NRT prescriptions and improvement in quit rates. Similar systemic EHR interventions can help improve smoking cessation efforts after hospitalisation.

Impact of Adding Telephone-Based Care Coordination to Standard Telephone-Based Smoking Cessation Counseling Post-hospital Discharge: a Randomized Controlled Trial

BACKGROUND

Cessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation.

OBJECTIVE

To compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation.

DESIGN

Unblinded, randomized clinical trial PARTICIPANTS: Hospitalized smokers referred from primarily rural hospitals INTERVENTIONS: Counseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker's health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C.

MAIN MEASURES

Utilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge.

KEY RESULTS

Among 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6-12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)).

CONCLUSION

Supplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications.

TRIAL REGISTRATION

NCT01063972.

Adherence to Pharmacological Smoking Cessation Interventions: A Literature Review and Synthesis of Correlates and Barriers

Introduction

Efficacious pharmacological interventions for smoking cessation are available, but poor adherence to these treatments may limit these interventions overall impact. To improve adherence to smoking cessation interventions, it is first necessary to identify and understand smoker-level characteristics that drive nonadherence (ie, nonconformance with a provider's recommendation of timing, dosage, or frequency of medication-taking during the prescribed length of time).

Methods

We present a literature review of studies examining correlates of, or self-reported reasons for, nonadherence to smoking cessation pharmacotherapies. Studies were identified through PubMed-using MeSH terms, Embase-using Emtree terms, and ISI Web of Science.

Results and Conclusions

This literature review included 50 studies that examined nonpreventable (eg, sociodemographics) and preventable (eg, forgetfulness) factors associated with adherence to smoking cessation medication and suggestions for overcoming some of the identified barriers. Systematic study of this topic would be facilitated by consistent reporting of adherence and correlates thereof in the literature, development of consistent definitions of medication adherence across studies, utilization of more objective measures of adherence (eg, blood plasma levels vs. self-report) in addition to reliance on self-reported adherence.

Implications

This article provides the most comprehensive review to date on correlates of adherence to pharmacological smoking cessation interventions. Challenges and specific gaps in the literature that should be a priority for future research are discussed. Future priorities include additional research, particularly among vulnerable populations of smokers, developing standardized definitions of adherence and methods for measuring adherence, regular assessment of cessation pharmacotherapy adherence in the context of research and clinical practice, and development of novel treatments aimed at preventable barriers to medication adherence.