Intervention study to evaluate pilot health promotion payment aimed at increasing general practitioners' antismoking advice to smokers

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

Tobacco smoking is the leading preventable cause of death worldwide, which makes it essential to stimulate smoking cessation. The financial cost of smoking cessation treatment can act as a barrier to those seeking support. We hypothesised that provision of financial assistance for people trying to quit smoking, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. This is an update of the original 2005 review.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs for tobacco smokers or healthcare providers for using or providing smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use or prescription of smoking cessation treatment, or both, and on the number of smokers making a quit attempt (quitting smoking for at least 24 hours). We also assessed the cost effectiveness of different financial interventions, and analysed the costs per additional quitter, or per quality-adjusted life year (QALY) gained.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in September 2016.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers, or both.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the quality of the included studies. We calculated risk ratios (RR) for individual studies on an intention-to-treat basis and performed meta-analysis using a random-effects model.

MAIN RESULTS

In the current update, we have added six new relevant studies, resulting in a total of 17 studies included in this review involving financial interventions directed at smokers or healthcare providers, or both.Full financial interventions directed at smokers had a favourable effect on abstinence at six months or longer when compared to no intervention (RR 1.77, 95% CI 1.37 to 2.28, I² = 33%, 9333 participants). There was no evidence that full coverage interventions increased smoking abstinence compared to partial coverage interventions (RR 1.02, 95% CI 0.71 to 1.48, I² = 64%, 5914 participants), but partial coverage interventions were more effective in increasing abstinence than no intervention (RR 1.27 95% CI 1.02 to 1.59, I² = 21%, 7108 participants). The economic evaluation showed costs per additional quitter ranging from USD 97 to USD 7646 for the comparison of full coverage with partial or no coverage.There was no clear evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%, 2311 participants).Full financial interventions increased the number of participants making a quit attempt when compared to no interventions (RR 1.11, 95% CI 1.04 to 1.17, I² = 15%, 9065 participants). There was insufficient evidence to show whether partial financial interventions increased quit attempts compared to no interventions (RR 1.13, 95% CI 0.98 to 1.31, I² = 88%, 6944 participants).Full financial interventions increased the use of smoking cessation treatment compared to no interventions with regard to various pharmacological and behavioural treatments: nicotine replacement therapy (NRT): RR 1.79, 95% CI 1.54 to 2.09, I² = 35%, 9455 participants; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%, 6321 participants; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65, I² = 75%, 9215 participants.There was evidence that partial coverage compared to no coverage reported a small positive effect on the use of bupropion (RR 1.15, 95% CI 1.03 to 1.29, I² = 0%, 6765 participants). Interventions directed at healthcare providers increased the use of behavioural therapy (RR 1.69, 95% CI 1.01 to 2.86, I² = 85%, 25820 participants), but not the use of NRT and/or bupropion (RR 0.94, 95% CI 0.76 to 1.18, I² = 6%, 2311 participants).We assessed the quality of the evidence for the main outcome, abstinence from smoking, as moderate. In most studies participants were not blinded to the different study arms and researchers were not blinded to the allocated interventions. Furthermore, there was not always sufficient information on attrition rates. We detected some imprecision but we judged this to be of minor consequence on the outcomes of this study.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting. There was no clear and consistent evidence of an effect on smoking cessation from financial incentives directed at healthcare providers. We are only moderately confident in the effect estimate because there was some risk of bias due to a lack of blinding in participants and researchers, and insufficient information on attrition rates.

Smoking cessation interventions for patients with coronary heart disease and comorbidities: an observational cross-sectional study in primary care

BACKGROUND

Little is known about how smoking cessation practices in primary care differ for patients with coronary heart disease (CHD) who have different comorbidities.

AIM

To determine the association between different patterns of comorbidity and smoking rates and smoking cessation interventions in primary care for patients with CHD.

DESIGN AND SETTING

Cross-sectional study of 81 456 adults with CHD in primary care in Scotland.

METHOD

Details of eight concordant physical comorbidities, 23 discordant physical comorbidities, and eight mental health comorbidities were extracted from electronic health records between April 2006 and March 2007. Multilevel binary logistic regression models were constructed to determine the association between these patterns of comorbidity and smoking status, smoking cessation advice, and smoking cessation medication (nicotine replacement therapy) prescribed.

RESULTS

The most deprived quintile had nearly three times higher odds of being current smokers than the least deprived (odds ratio [OR] 2.76; 95% confidence interval [CI] = 2.49 to 3.05). People with CHD and two or more mental health comorbidities had more than twice the odds of being current smokers than those with no mental health conditions (OR 2.11; 95% CI = 1.99 to 2.24). Despite this, those with two or more mental health comorbidities (OR 0.77; 95% CI = 0.61 to 0.98) were less likely to receive smoking cessation advice, but absolute differences were small.

CONCLUSION

Patterns of comorbidity are associated with variation in smoking status and the delivery of smoking cessation advice among people with CHD in primary care. Those from the most deprived areas and those with mental health problems are considerably more likely to be current smokers and require additional smoking cessation support.

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background

This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.

Aims

The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.

Methods

We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.

Findings

Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.

Future Research

Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effect of pay-for-outcomes and encouraging new providers on national health service smoking cessation services in England: a cluster controlled study

Background

Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services.

Methods

Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs (representing 2,138,947 adult population) matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level.

Results

The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs (incident rate ratio 1∙108, p<0∙001, 95% CI 1∙059 to 1∙160). Eighty-five providers held ‘any qualified provider’ contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings.

Conclusions

Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services.

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use and/or prescription of smoking cessation treatment and on the number of smokers making a quit attempt.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2012.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers or both.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the quality of the included studies. Risk ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random-effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives.

MAIN RESULTS

We found eleven trials involving financial interventions directed at smokers and healthcare providers.Full financial interventions directed at smokers had a statistically significant favourable effect on abstinence at six months or greater when compared to no intervention (RR 2.45, 95% CI 1.17 to 5.12, I² = 59%, 4 studies). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.11, 95% CI 1.04 to 1.32, I² = 15%) and use of smoking cessation treatment (NRT: RR 1.83, 95% CI 1.55 to 2.15, I² = 43%; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65). There was no evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%). Comparisons of full coverage with partial coverage, partial coverage with no coverage, and partial coverage with another partial coverage intervention did not detect significant effects. Comparison of full coverage with partial or no coverage resulted in costs per additional quitter ranging from $119 to $6450.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting.  The absolute differences are small but the costs per additional quitter are low to moderate. We did not detect an effect on smoking cessation from financial incentives directed at healthcare providers. The methodological qualities of the included studies need to be taken into consideration when interpreting the results.

Adoption, reach and effectiveness of computer-based, practitioner delivered and combined smoking interventions in general medical practices: a three-arm cluster randomized trial

BACKGROUND

Brief advice for smoking patients has not been sufficiently integrated in routine care. Computer-based interventions emerged as a time saving option that might help to exhaust the potential population impact of the general practice setting.

METHOD

151 practices were randomly assigned to one of three intervention programs consisting in the delivery of: (1) brief advice by the practitioner; (2) individually tailored computer-generated letters; or (3) a combination of both interventions. We assessed three dimensions of population impact: (1) adoption, i.e., the rate of practices participating in the program; (2) reach, measured as the number of interventions provided within 7 months; (3) effectiveness, measured as smoking abstinence at 12-months follow-up.

RESULTS

Among the practices, 70% adopted the program with no significant differences across study groups. Treatment was provided to 3086 adult smokers. Negative binomial regression analysis revealed that the number of interventions provided was higher in practices allocated to the tailored letter and combination intervention groups by 215% (p<.01) and 127% (p=.02), respectively, compared to the brief advice intervention group. Among the patients who received the combination of both intervention, the odds of point abstinence from smoking was increased by 65% (p=.02) and 32% (p=.01) compared to the brief advice and tailored letters intervention respectively. Comparing the number of abstinent patients at follow-up revealed that the tailored letter and combination interventions were superior to the brief advice intervention.

CONCLUSIONS

Computer-based interventions alone or in addition to conventional practitioner-delivered advice can foster the participation of general medical practices in tobacco control.

Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and meta-analysis

OBJECTIVES

A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics.

METHODS

The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies.

RESULTS

Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 9.3 [95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions [OR 2.2; 95% CI 1.7-2.8] were found to significantly increase smoking abstinence.

CONCLUSION

Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.

Do financial incentives for delivering health promotion counselling work? Analysis of smoking cessation activities stimulated by the quality and outcomes framework

BACKGROUND

A substantial fraction of UK general practitioners' salaries is now intended to reflect the quality of care provided. This performance-related pay system has probably improved aspects of primary health care but, using the observational data available, disentangling the impacts of different types of targets set within this unique payment system is challenging.

DISCUSSION

Financial incentives undoubtedly influence GPs' activities, however, those aimed at encouraging GPs' delivery of health promotion counselling may not always have the effects intended. There is strong, observational evidence that targets and incentives intended to increase smoking cessation counselling by GPs have merely increased their propensity to record this activity in patients' medical records. The limitations of using financial incentives to stimulate the delivery of counselling in primary care are discussed and a re-appraisal of their use within UK GPs' performance-related pay system is argued for.

SUMMARY

The utility of targets employed by the system for UK General Practitioners' performance related pay may be inappropriate for encouraging the delivery of health promotion counselling interventions. An evaluation of these targets is essential before they are further developed or added to.

‘Do your best for me’: The difficulties of finding a clinically effective endpoint in smoking cessation consultations in primary care

In recent years in the UK there has been a shift towards doctors practising preventative medicine. Research suggests, however, that doctors are more comfortable in their traditional role, and may be reluctant to engage in discussion of lifestyle issues with patients. In this article, we use data from GPs’ consultations about smoking, recorded prior to the availability of Nicotine Replacement Therapy on NHS prescription, to demonstrate how they attempt to negotiate behaviour change. Using a discursive analytic approach, and drawing particularly on some of the conversation analytic literature on advice giving, we suggest that there are two kinds of difficulties for doctors to overcome: an ambiguity about the interactional endpoint of a discussion about smoking; and the inability to offer ‘expert’ medical help. As a result, doctors struggle with following through their advice to stop in terms of talking about how to do it. We suggest that the efficacy of nicotine addiction treatments may be due not only to their clinical effects, but also because their prescription legitimizes the difficulty in stopping reported by most smokers as an appropriate problem for medical treatment. We discuss the implications of these findings for the management of smoking and other lifestyle issues within primary care consultations.

Factors influencing European GPs' engagement in smoking cessation: a multi-country literature review

BACKGROUND

Smoking cessation advice by GPs is an effective and cost-effective intervention, but is not implemented as widely as it could be.

AIM

This wide-ranging Europe-wide literature review, part of the European Union (EU) PESCE (General Practitioners and the Economics of Smoking Cessation in Europe) project, explored the extent of GPs' engagement in smoking cessation and the factors that influence their engagement.

METHOD

Two searches were conducted, one for grey literature, across all European countries, and one for academic studies. Data from eligible studies published from 1990 onwards were synthesised and reported under four categories of influencing factors: GP characteristics, patient characteristics, structural factors, and cessation-specific knowledge and skills.

RESULTS

The literature showed that most GPs in Europe question the smoking status of all new patients but fewer routinely ask this of regular patients, or advise smokers to quit. The proportion offering intensive interventions or prescribing treatments is lower still. Factors influencing GPs' engagement in smoking cessation include GPs' own smoking status and their attitudes towards giving smoking cessation advice; whether patients present with smoking-related symptoms, are pregnant, or heavy smokers; time, training, and reimbursement are important structural factors; and some GPs lack knowledge and skills regarding the use of specific cessation methods and treatments, or have limited awareness of specialist cessation services. No single factor or category of factors explains the variations in GPs' engagement in smoking cessation.

CONCLUSION

Strategies to improve the frequency and quality of GPs' engagement in smoking cessation need to address the multifaceted influences on GPs' practice and to reflect the widely differing contexts across Europe.

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment by health care financing interventions on abstinence from smoking and utilization of smoking cessation treatment.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group specialized register; the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008; MEDLINE (from January 1966 to August 2008) and EMBASE (from January 1980 to August 2008) to identify trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and controlled trials involving financial benefit interventions to smokers or their health care providers or both.

DATA COLLECTION AND ANALYSIS

Three reviewers independently extracted data and assessed the quality of the included studies. Rate ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives.

MAIN RESULTS

We found nine trials involving financial interventions directed at smokers and two studies directed at health care providers.There was a statistically significant favourable effect of full financial interventions directed at smokers on continuous abstinence compared to no interventions with a risk ratio (RR) of 4.38 (95% CI 1.94 to 9.87). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.19; 95% CI 1.07 to 1.32; N = 3). There was a significant effect of financial interventions directed at health care providers in increasing the utilization of behavioural interventions for smoking cessation (RR 1.33; 95% CI 1.01 to 1.77). Comparison of full benefit with partial or no benefit resulted in costs per additional quitter ranging from $260 to $1453.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions could increase the proportion quitting, quit attempts and utilization of pharmacotherapy by smokers. Although the absolute differences were small the costs per additional quitter were low. The methodological qualities of the included studies need to be taken into consideration in interpreting the conclusions.

The potential to improve ascertainment and intervention to reduce smoking in primary care: a cross sectional survey

Background

Well established clinical guidelines recommend that systematic ascertainment of smoking status and intervention to promote cessation in all smokers should be a fundamental component of all health care provision. This study aims to establish the completeness and accuracy of smoking status recording in patients' primary care medical records and the level of interest in receiving smoking cessation support amongst primary care patients in an inner city UK population.

Methods

Postal questionnaires were sent to all patients aged over 18 from 24 general practices in Nottingham UK who were registered as smokers or had no smoking status recorded in their medical notes.

Results

The proportion of patients with a smoking status recorded varied between practices from 42.4% to 100% (median 90%). Of the recorded smokers who responded to our questionnaire (35.5% of the total), a median of 20.3% reported that they had not smoked cigarettes or tobacco in the last 12 months. Of respondents with no recorded smoking status, 29.8% reported themselves to be current smokers. Of the 6856 responding individuals thus identified as current smokers, 41.4% indicated that they would like to speak to a specialist smoking adviser to help them stop smoking. This proportion increased with socioeconomic disadvantage (measured by the Townsend Index) from 39.1% in the least deprived to 44.6% in the most deprived quintile.

Conclusion

Whilst in many practices the ascertainment of smoking status is incomplete and/or inaccurate, failure to intervene appropriately on known status still remains the biggest challenge.

Trial registration

Current Controlled Trials ISRCTN71514078.

Effects of practitioner education, practitioner payment and reimbursement of patients' drug costs on smoking cessation in primary care: a cluster randomised trial

OBJECTIVE

To evaluate new strategies to enhance the promotion of smoking cessation in general practice.

DESIGN

Cluster randomised trial, 2x2 factorial design.

SETTING

82 medical practices in Germany, including 94 general practitioners.

PARTICIPANTS

577 patients who smoked at least 10 cigarettes per day (irrespective of their intention to stop smoking) and were aged 36-75 years.

INTERVENTIONS

Provision of a 2-h physician group training in smoking cessation methods and direct physician payments for every participant not smoking 12 months after recruitment (TI, training+incentive); provision of the same training and direct participant reimbursements for pharmacy costs associated with nicotine replacement therapy or bupropion treatment (TM, training+medication).

MAIN OUTCOME MEASURE

Self-reported smoking abstinence obtained at 12 months follow-up and validated by serum cotinine.

RESULTS

In intention-to-treat analysis, smoking abstinence at 12 months follow-up was 3% (2/74), 3% (5/144), 12% (17/140) and 15% (32/219) in the usual care, and interventions TI, TM and TI+TM, respectively. Applying a mixed logistic regression model, no effect was identified for intervention TI (odds ratio (OR) 1.26, 95% confidence interval (CI) 0.65 to 2.43), but intervention TM strongly increased the odds of cessation (OR 4.77, 95% CI 2.03 to 11.22).

CONCLUSION

Providing cost-free effective drugs to patients along with improved training opportunities for general practitioners could be an effective measure to achieve successful promotion of smoking cessation in general practice.

Distributing questionnaires about smoking to patients: impact on general practitioners' recording of smoking advice

BACKGROUND

Little is known about the impact of questionnaire-based data collection methods on the consulting behaviour of general practitioners (family physicians) who participate in research. Here data collected during a research project which involved questionnaires on smoking being distributed to patients before and after appointments with general practitioners (GPs) is analyzed to investigate the impact of this data collection method on doctors' documenting of smoking advice in medical records.

METHODS

Researchers distributed questionnaires on smoking behaviour to 6775 patients who attended consultations during surgery sessions with 32 GPs based in Leicestershire, UK. We obtained the medical records for patients who had attended these surgery sessions and also for a comparator group, during which no researcher had been present. We compared the documenting of advice against smoking in patient's medical records for consultations within GPs' surgery sessions where questionnaires had been distributed with those which occurred when no questionnaires had been given out.

RESULTS

We obtained records for 77.9% (5276/6775) of all adult patients who attended GPs' surgery sessions, with 51.9% (2739) being from sessions during which researchers distributed questionnaires. Discussion of smoking was recorded in 8.0% (220/2739) of medical records when questionnaires were distributed versus 4.6% (116/2537) where these were not. After controlling for relevant potential confounders including patients' age, gender, the odds ratio for recording of information in the presence of questionnaire distribution (versus none) was 1.78 (95% CI, 1.36 to 2.34).

CONCLUSION

Distributing questionnaires about smoking to patients before and after they consult with doctors significantly increases GPs' recording of discussions about smoking medical records. This has implications for the design of some types of research into addictive behaviours and further research into how data collection methods may affect patients' and doctors' behaviours is warranted.

Impact of contractual financial incentives on the ascertainment and management of smoking in primary care

BACKGROUND

The April 2004 contract for UK general practitioners (GPs) is an ambitious attempt to produce substantial changes in clinical practice. We investigated the impact of this on delivery of primary care smoking cessation interventions.

METHODS

We analysed data from patients' medical records that were held within a large database called The Health Improvement Network (THIN). We calculated for each year between 1990 and 2005 and for each quarter-year from 2003 the incidence of recording of smoking status in medical records and, in smokers, the receipt of GPs' smoking cessation advice and prescriptions for nicotine addiction treatments.

FINDINGS

Recording of smoking status increased temporarily around 1993-4 and then rose gradually from the year 2000. This rise was more marked from 2003, with an 88% increase between the first quarters of 2003 and 2004. The latter quarter was just prior to the introduction of the GP contract and higher rates of recording smoking status were sustained for the subsequent year. In smokers, there was a broadly similar pattern for the proportion recorded as having received brief cessation advice. However, while there was a sharp increase in prescriptions for nicotine addiction treatments from 2000, no comparable acceleration in this trend from 2003 was apparent.

INTERPRETATION

The 2004 GP contract increased primary care rates of smoking status ascertainment and recording of advice against smoking. The public health impact of this contract could be maximized if it also improved GPs' prescribing of nicotine addiction treatments.

A behavioral model of clinician responses to incentives to improve quality

The use of pay for performance (P4P) and public reporting of performance (PR) in health care is increasing rapidly worldwide. The rationale for P4P and PR comes from experience in other industries and from theories about incentive use from psychology, economics, and organizational behavior. This paper reviews the major themes from this prior research and considers how they might be applied to health care. The resulting conceptual model addresses the dual nature (combining direct financial and reputational incentives) of the initiatives many policymakers are pursuing. It also includes explicit recognition of the key contextual factors (at the levels of the markets and the provider organization) and provider and patient characteristics that can enhance or mitigate response to incentives. Evaluation of the existing literature (through June 2005) about incentive use in health care in light of the conceptual model highlights important weaknesses in the way that trials have been reported to date and suggests future research topics.

Characteristics and prevalence of hardcore smokers attending UK general practitioners

Background

Smoking remains a public health problem and although unsolicited GPs' advice against smoking causes between one and three percent of smokers to stop, a significant proportion of smokers are particularly resistant to the notion of stopping smoking. These resistant smokers have been called "hardcore smokers" and although 16% of smokers in the community are hardcore, little is known about hardcore smokers presenting to primary care physicians. Consequently, this study reports the characteristics and prevalence of hardcore smokers attending UK GPs.

Methods

A cross-sectional survey using data from two different research projects was conducted. Data for this analysis had been collected from surgery consultation sessions with 73 GPs in Leicestershire, England, (42 GPs from one project). Research assistants distributed pre-consultation questionnaires to 4147 adults attending GPs' surgery sessions. Questionnaires identified regular smokers, the proportion of hardcore smokers and their characteristics. Non-hardcore and hardcore smokers' ages, gender and nicotine addiction levels were compared.

Results

1170 regular smokers attended surgery sessions and, 16.1% (95% CI, 14.1 to 18.4) were hardcore smokers. Hardcore smokers had higher levels of nicotine addiction than others (p = 0.000), measured by the Heaviness of Smoking Index and were more likely to be male [50.5% hardcore versus 35.3% non-hardcore, (OR = 1.88, 95% CI = 1.4 to 2.6)] but no age differences were observed between groups.

Conclusion

A significant minority of the smokers who present in general practice are resistant to the notion of smoking cessation and these smokers are more heavily nicotine addicted than others. Although clinical guidelines suggest that GPs should regularly advise all smokers against smoking, it is probable that hardcore smokers do not respond positively to this and help to make up the 97%–99% of smokers who do not quit after being advised to stop smoking by GPs. General practitioners need to find approaches for raising the issue of smoking during consultations in ways that do not reinforce the negative opinions of hardcore smokers concerning smoking cessation.

Death, depression and 'defensive expansion': closing down smoking as an issue for discussion in GP consultations

This paper examines routine primary care consultations in the UK where smoking is discussed using data from a larger study of the factors influencing discussion of smoking between general practitioners (GPs) and patients. In this study, consultations have been analysed with a focus on the termination of discussion about smoking, using an approach that is informed by the conversation analytic (CA) literature on professional/client interaction. In interviews from the previous larger study, GPs suggested two main reasons for not pursuing discussion of smoking in consultations. One reason was an overarching fear of damaging the GP/patient relationship. The second reason related to clinical judgement, where it was feared that an attempt to stop smoking might exacerbate a patient's existing condition, particularly their mental health. This paper suggests that, while this latter scenario of clinical judgement is borne out by the consultation data, there are two more subtle patient behaviours which are associated with GPs abandoning further discussion of smoking: patients' 'troubles telling', where the issue of smoking is de-emphasised in the face of other 'troubles', and 'defensive expansion', where the patient over-emphasises deficiencies to curtail discussion. Greater awareness of the situations in which doctors end discussion of smoking will help GPs to develop ideas for alternative approaches in these circumstances which could result in more meaningful, effective engagement between doctors and their patients who smoke when smoking is discussed.

Smoking cessation treatment in primary care: prospective cohort study

OBJECTIVE

To compare the characteristics of smokers who do and do not receive smoking cessation treatment in primary care.

DESIGN

Prospective cohort study using practices registered with the pilot QRESEARCH database.

SETTING

156,550 patients aged 18 years and over from 39 general practices located within four strategic health authorities, representing the former Trent Region, UK.

SUBJECTS

Patients registered with practices between 1 April 2001 and 31 March 2003 aged 18 years and over who were identified as smokers before the two year study period.

OUTCOME

Prescription for smoking cessation treatment (nicotine replacement therapy (NRT) or bupropion) in the two year study period.

VARIABLES

Age, sex, deprivation score, co-morbidity.

RESULTS

Of the 29,492 patients recorded as current smokers at the start of the study period 1892 (6.4%) were given prescriptions for smoking cessation treatment during the subsequent two years. Of these, 1378 (72.8%) were given NRT alone, 406 (21.5%) bupropion alone, and 108 (5.7%) both treatments. Smokers were more likely to receive smoking cessation treatment if they lived in the most deprived areas (odds ratio (OR) for the most relative to the least deprived fifth, adjusted for sex, age, and co-morbidity, 1.50, 95% confidence interval (CI) 1.26 to 1.78), and if they were aged 25-74 years compared to 18-24 years or 75 and over. Smokers with co-morbidity were also more likely to receive smoking cessation treatment. Smokers were less likely to receive smoking cessation treatment if they were male (adjusted OR 0.68, 95% CI 0.62 to 0.75).

CONCLUSION

The low proportion of smokers being prescribed these products strongly suggests that a major public health opportunity to prevent smoking related illness is being missed.

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

Smoking cessation treatment increases the number of successful quitters compared with unaided attempts to quit. However, only a small proportion of people who smoke take up treatment. One way to increase the use of smoking cessation treatment might be to give financial support through healthcare systems.

OBJECTIVES

The primary objective of this review was to assess the effect of using healthcare financing interventions to reduce the costs of providing or using smoking cessation treatment on abstinence from smoking.

SEARCH STRATEGY

Eligible studies were identified by a search of the Cochrane Tobacco Addiction group specialized register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2003, MEDLINE (from January 1966 to August 2003) and EMBASE (from January 1980 to October 2003), screening references of relevant reviews and studies, and contacting experts in the field.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), controlled trials (CTs) and interrupted time series (ITS) in which the study population consisted of smokers or healthcare providers or both.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the quality of the included studies. We calculated odds ratios (ORs) and risk differences (RDs) for the individual studies and performed meta-analysis using a random-effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives.

MAIN RESULTS

Four RCTs and two CTs were directed at smokers. Five studies compared the effect of a full benefit with no benefit of which four reported the prolonged self-reported abstinence rate and showed an increase of 2% (95% confidence interval [CI] 0.00 to 0.05). The pooled OR for achieving abstinence for a period of six months was 1.48 (95% 1.17 to 1.88). Two studies directed at smokers compared a full benefit with a partial benefit and showed that the odds of being abstinent were 2.49 times higher with a full benefit (95% CI 1.59 to 3.90). The pooled RD showed a non-significant increase (RD 0.05; 95% CI -0.07 to 0.16). Only one study compared a partial benefit with no benefit and only one study was directed at healthcare providers. When a full benefit was compared with a partial or no benefit, the costs per quitter varied between $260 and $2330.

AUTHORS' CONCLUSIONS

There is some evidence that healthcare financing systems directed at smokers which offer a full financial benefit can increase the self-reported prolonged abstinence rates at relatively low costs when compared with a partial or no benefit. Since there were some limitations to the methodological quality of the studies the results should be interpreted with caution. More studies are needed on the effects of healthcare financing systems directed at healthcare providers.

Qualitative study investigating the process of giving anti-smoking advice in general practice

General practitioners' (GPs') anti-smoking advice promotes patients' smoking cessation but little is known about how GPs use their short consultations to give advice. We used semi-structured interviews with 27 UK GPs to investigate how GPs believe they should advise smokers to stop and the reasons underpinning these beliefs. GPs reported a limited repertoire of techniques for dealing with smokers who were not motivated to stop. They also reported using confrontational advice-giving styles with patients who continued to smoke despite suffering from smoking-related illnesses. GPs might find it easier and more rewarding to discuss smoking with patients if they possessed a greater range of skills for dealing with non-motivated smokers.

Comparison of the smoking behaviour and attitudes of smokers who believe they have smoking-related problems with those who do not

BACKGROUND

Motivation to stop smoking is associated with smokers' possessing substantial smoking-related morbidity or believing that they have symptoms caused by smoking, but it is not clear if this holds for smokers attending general practice consultations.

OBJECTIVE

Our aim was to compare the attitudes and behaviour of smokers attending their GP with symptoms that they believe are smoking related with those who do not.

METHOD

A cross-sectional, pre-consultation survey of patients attending GPs in Leicester, UK was carried out.

RESULTS

A total of 83.8% (2955/3525) of people attending GPs completed the questionnaire and 34.7% were smokers. Multiple logistic regression showed that where smokers perceived that their problems were smoking related they were more likely to have tried stopping in the past [odds ratio (OR) 1.78, 95% confidence interval (CI) 1.26-2.67], to want to stop smoking (OR 1.83, CI 1.15-2.9) or to intend to stop in the near future (OR 1.58, CI 1.03-2.43).

CONCLUSION

Smokers who attend GPs' routine consultations and believe that they have smoking-related problems are more motivated to stop than others. This suggests that it is important for GPs to ascertain patients' views about the aetiology of their symptoms before discussing smoking with them.

The role of health plans in tobacco control

Health plans play an important role in tobacco control. In this chapter we present an overview of the scientific research on health plan involvement in clinical and community interventions regarding tobacco use. Also included are interventions that have been undertaken by health plans to lower smoking rates among their members and the general population. We conclude with a new model that can be used to engage health plans in tobacco control efforts and a case study that outlines how one health plan has implemented this new model.

Paying for quality improvement: compliance with tobacco cessation guidelines

BACKGROUND

Identification and treatment of routine tobacco use in medical practice is an effective intervention but is not used consistently. A study was conducted at HealthPartners, a large network-model health plan in Minnesota, to determine the effect of an outcomes recognition strategy that involved bonus funds and the rates at which network physicians document that tobacco users are identified and advised to quit.

METHODS

Audits of 14,489 ambulatory patient records from 19-20 medical groups were conducted to determine the proportion of charts from each medical group that demonstrated identification of smoking status and counseling to encourage quitting at the most recent office visit in each year.

RESULTS

Overall mean tobacco use identification increased from 49% +/- 7% (95% confidence interval [CI]) in 1996 to 73% +/- 7% in 1999 (p < .001), while advice to quit increased from 32% +/- 10% in 1996 to 53% +/- 10% CI in 1999 (p < .005). The number of medical groups with tobacco status identified at > 80% of visits and > 80% of tobacco users advised to quit increased from 0 in 1996 to 8 in 1999.

DISCUSSION

Data feedback combined with a financial incentive appear to be an effective way for a health plan to improve physician compliance with the tobacco treatment guideline. Other health plans might consider similar reporting and incentive approaches to effectively engage medical group leadership and to improve the health of their members who use tobacco.

Factors associated with the provision of anti-smoking advice in general practice consultations

Guidelines urge general practitioners (GPs) to discuss smoking with patients as frequently as possible. Using data collected before and after consultations, this study confirms that GPs are more likely to discuss smoking in the context of smoking-related problems. Encouraging GPs to make greater use of problem-orientated opportunities to discuss smoking may have more effect on rates of advice giving than urging them to advise all smokers.

Qualitative study of pilot payment aimed at increasing general practitioners' antismoking advice to smokers

OBJECTIVES

To elicit general practitioners' and practice nurses' accounts of changes in their clinical practice or practice organisation made to claim a pilot health promotion payment. To describe attitudes towards the piloted and previous health promotion payments.

DESIGN

Qualitative, semistructured interview study.

SETTING

13 general practices in Leicester.

PARTICIPANTS

18 general practitioners and 13 practice nurses.

RESULTS

Health professionals did not report substantially changing their clinical practice to claim the new payments and made only minimal changes in practice organisation. The new health promotion payment did not overcome general practitioners' resistance towards raising the issue of smoking when they felt that doing so could cause confrontation with patients. General practitioners who made the largest number of claims altered the way in which they recorded patients' smoking status rather than raising the topic of smoking more frequently with patients. PARTICIPANTS had strong negative views on the new payment, feeling it would also be viewed negatively by patients. They were, however, more positive about health promotion payments that rewarded "extra" effort-for example, setting up practice based smoking cessation clinics.

CONCLUSIONS

General practitioners and practice nurses were negative about a new health promotion payment, despite agreeing to pilot it. Health promotion payments do not automatically generate effective health promotion activity, and policymakers should consider careful piloting and evaluation of future changes in health promotion payments.