1
|
Wendt SJ. Smoking Cessation and Exercise Promotion Counseling in Psychologists Who Practice Psychotherapy. Am J Health Promot 2016; 19:339-45. [PMID: 15895536 DOI: 10.4278/0890-1171-19.5.339] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose. Little is known about health promotion within the context of psychotherapy. The present study assessed a sample of psychologists' attitudes and behavior with their psychotherapy clients regarding smoking cessation and exercise promotion counseling. Design. This is a cross-sectional survey study. Setting. Surveys were mailed. Subjects. Licensed psychologists (1000) in Massachusetts were randomly selected to receive surveys. Psychologists practicing psychotherapy at least 5 h/wk were invited to participate. Out of 496 responses, 328 completed surveys were analyzed. Measures. Two parallel surveys were developed for smoking (N = 154) and exercise (N = 174) assessing health promotion behaviors and attitudes. Results. Approximately 43% of respondents inquire about smoking and 53% inquire about exercise with new clients. Over 45% advise smoking clients to quit and 50% advise sedentary clients to exercise. Over 80% of respondents felt smoking and exercise should be addressed in psychotherapy; however only 41% of smoking and 65% of exercise respondents felt confident in their counseling abilities. Lack of confidence, beliefs about relevance of smoking and exercise to psychological functioning, and beliefs that such personal choices should not be addressed in psychotherapy significantly predicted smoking cessation and exercise promotion behaviors. Conclusion. Many respondents are engaging in health promotion with their psychotherapy clients. Exercise promotion is occurring more frequently and is viewed more favorably compared with smoking cessation counseling. Health promotion attitudes are associated with counseling behaviors. Limitations include self-selection bias and small sample size.
Collapse
Affiliation(s)
- Sally J Wendt
- Mount Holyoke College, 50 College Street, South Hadley, MA 01075, USA.
| |
Collapse
|
2
|
McFall M, Saxon AJ, Thaneemit-Chen S, Smith MW, Joseph AM, Carmody TP, Beckham JC, Malte CA, Vertrees JE, Boardman KD, Lavori PW. Integrating smoking cessation into mental health care for post-traumatic stress disorder. Clin Trials 2016; 4:178-89. [PMID: 17456521 DOI: 10.1177/1740774507076923] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Post-traumatic stress disorder (PTSD) is associated with a high prevalence of smoking, heavy cigarette consumption and low cessation rates. Purpose This manuscript describes the design of a randomized, multisite effectiveness trial to test whether integrating smoking cessation treatment into mental health care (integrated care) improves prolonged abstinence rates among veterans with PTSD, compared with referral to specialized smoking cessation clinics (usual standard of care). Secondary objectives are to assess the cost-effectiveness of integrated care relative to usual standard of care, identify treatment variables that mediate differences between conditions in outcome and determine whether smoking cessation is associated with worsening PTSD and/or depression. Methods Following randomization, subjects (projected n = 1400) from 10 Veterans Health Administration (VHA) medical centers complete follow-up assessments every three or six months for up to four years. Endpoints include 1-year prolonged abstinence at 18 months postrandomization, 7- and 30-day point-prevalence abstinence and measures of depression, PTSD and economic outcomes. Results This study is unique in providing the largest scale test of the feasibility and effectiveness of having mental health clinicians implement evidence-based smoking cessation treatment in psychiatric care settings for veterans with PTSD. It incorporates methodological features that are desirable for cessation treatment trials, including: a) assessment of clinically meaningful long-term smoking outcomes; b) a manual guiding delivery of the experimental intervention; c) independent ratings of clinician competence and treatment adherence and d) methods for training clinicians that would enhance implementation of tobacco cessation treatment in large health care systems. Limitations Use of an exclusively VHA sample with few females limits generalizability. Conclusions The process for meeting challenges in designing this study may provide planning of other large-scale clinical effectiveness trials in tobacco control. Findings have potential to initiate system-wide change in clinical practice patterns for tobacco cessation treatment involving patients with mental disorders. Clinical Trials 2007; 4: 178—189. http://ctj.sagepub.com
Collapse
Affiliation(s)
- Miles McFall
- Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Ockene JK, Hayes RB, Churchill LC, Crawford SL, Jolicoeur DG, Murray DM, Shoben AB, David SP, Ferguson KJ, Huggett KN, Adams M, Okuliar CA, Gross RL, Bass PF, Greenberg RB, Leone FT, Okuyemi KS, Rudy DW, Waugh JB, Geller AC. Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial. J Gen Intern Med 2016; 31:172-181. [PMID: 26391030 PMCID: PMC4720645 DOI: 10.1007/s11606-015-3508-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Early in medical education, physicians must develop competencies needed for tobacco dependence treatment. OBJECTIVE To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills. DESIGN A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE). SETTING/PARTICIPANTS Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys. INTERVENTIONS The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students. MEASUREMENTS The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling. RESULTS Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p < 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p < 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps ≤0.05). LIMITATIONS Inclusion of only ten schools limits generalizability. CONCLUSIONS Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools. NIH Trial Registry Number: NCT01905618.
Collapse
Affiliation(s)
- Judith K Ockene
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Rashelle B Hayes
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Linda C Churchill
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Sybil L Crawford
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Denise G Jolicoeur
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - David M Murray
- Biostatistics and Bioinformatics Branch; Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Abigail B Shoben
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Sean P David
- Center for Education & Research in Family and Community Medicine, Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Kathryn N Huggett
- Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Michael Adams
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA
| | | | - Robin L Gross
- Department of Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Pat F Bass
- Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Ruth B Greenberg
- University of Louisville School of Medicine, Louisville, KY, USA
| | - Frank T Leone
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kola S Okuyemi
- Department of Family and Community Health, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - David W Rudy
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jonathan B Waugh
- Clinical and Diagnostics Sciences Department, School of Health Professions, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, USA
| |
Collapse
|
4
|
Cantor SB, Deshmukh AA, Luca NS, Nogueras-González GM, Rajan T, Prokhorov AV. Cost-effectiveness analysis of smoking-cessation counseling training for physicians and pharmacists. Addict Behav 2015; 45:79-86. [PMID: 25644592 DOI: 10.1016/j.addbeh.2015.01.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/18/2014] [Accepted: 01/07/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although smoking-cessation interventions typically focus directly on patients, this paper conducts an economic evaluation of a novel smoking-cessation intervention focused on training physicians and/or pharmacists to use counseling techniques that would decrease smoking rates at a reasonable cost. PURPOSE To evaluate the cost-effectiveness of interventions that train physicians and/or pharmacists to counsel their patients on smoking-cessation techniques. METHODS Using decision-analytic modeling, we compared four strategies for smoking-cessation counseling education: training only physicians, training only pharmacists, training both physicians and pharmacists (synergy strategy), and training neither physicians nor pharmacists (i.e., no specialized training, which is the usual practice). Short-term outcomes were based on results from a clinical trial conducted in 16 communities across the Houston area; long-term outcomes were calculated from epidemiological data. Short-term outcomes were measured using the cost per quit, and long-term outcomes were measured using the cost per quality-adjusted life-year (QALY). Cost data were taken from institutional sources; both costs and QALYs were discounted at 3%. RESULTS Training both physicians and pharmacists added 0.09 QALY for 45-year-old men. However, for 45-year-old women, the discounted quality-adjusted life expectancy only increased by 0.01 QALY when comparing the synergy strategy to no intervention. The incremental cost-effectiveness ratio (ICER) of the synergy strategy with respect to the non-intervention strategy was US$868/QALY for 45-year-old men and US$8953/QALY for 45-year-old women. The results were highly sensitive to the quit rates and community size. CONCLUSION Synergistic educational training for physicians and pharmacists could be a cost-effective method for smoking cessation in the community.
Collapse
Affiliation(s)
- Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Ashish A Deshmukh
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Tanya Rajan
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander V Prokhorov
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
5
|
Hayes RB, Geller A, Churchill L, Jolicoeur D, Murray DM, Shoben A, David SP, Adams M, Okuyemi K, Fauver R, Gross R, Leone F, Xiao R, Waugh J, Crawford S, Ockene JK. Teaching tobacco dependence treatment and counseling skills during medical school: rationale and design of the Medical Students helping patients Quit tobacco (MSQuit) group randomized controlled trial. Contemp Clin Trials 2014; 37:284-93. [PMID: 24486635 PMCID: PMC4048818 DOI: 10.1016/j.cct.2014.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/20/2014] [Accepted: 01/24/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Physician-delivered tobacco treatment using the 5As is clinically recommended, yet its use has been limited. Lack of adequate training and confidence to provide tobacco treatment is cited as leading reasons for limited 5A use. Tobacco dependence treatment training while in medical school is recommended, but is minimally provided. The MSQuit trial (Medical Students helping patients Quit tobacco) aims to determine if a multi-modal and theoretically-guided tobacco educational intervention will improve tobacco dependence treatment skills (i.e. 5As) among medical students. METHODS/DESIGN 10 U.S. medical schools were pair-matched and randomized in a group-randomized controlled trial to evaluate whether a multi-modal educational (MME) intervention compared to traditional education (TE) will improve observed tobacco treatment skills. MME is primarily composed of TE approaches (i.e. didactics) plus a 1st year web-based course and preceptor-facilitated training during a 3rd year clerkship rotation. The primary outcome measure is an objective score on an Objective Structured Clinical Examination (OSCE) tobacco-counseling smoking case among 3rd year medical students from schools who implemented the MME or TE. DISCUSSION MSQuit is the first randomized to evaluate whether a tobacco treatment educational intervention implemented during medical school will improve medical students' tobacco treatment skills. We hypothesize that the MME intervention will better prepare students in tobacco dependence treatment as measured by the OSCE. If a comprehensive tobacco treatment educational learning approach is effective, while also feasible and acceptable to implement, then medical schools may substantially influence skill development and use of the 5As among future physicians.
Collapse
Affiliation(s)
- Rashelle B Hayes
- Department of Medicine, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
| | - Alan Geller
- Department of Society of Human Development and Health, Harvard School of Public Health, Boston, MA, United States.
| | - Linda Churchill
- Department of Medicine, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
| | - Denise Jolicoeur
- Department of Medicine, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
| | - David M Murray
- Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Health, Bethesda, MD, United States.
| | - Abigail Shoben
- Division of Biostatics, College of Public Health, The Ohio State University, Columbus, OH, United States.
| | - Sean P David
- Center for Education & Research in Family and Community Medicine, Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States.
| | - Michael Adams
- Division of General Internal Medicine, Department of Medicine, Georgetown University Hospital, United States.
| | - Kola Okuyemi
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States.
| | - Randy Fauver
- Center for Education & Research in Family and Community Medicine, Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States.
| | - Robin Gross
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Georgetown University Hospital, Washington, DC, United States.
| | - Frank Leone
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Rui Xiao
- Department of Medicine, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
| | - Jonathan Waugh
- Department of Clinical and Diagnostics Sciences, UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Sybil Crawford
- Department of Medicine, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
| | - Judith K Ockene
- Department of Medicine, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
| |
Collapse
|
6
|
Beaty T, Dornelles AC, Sahuque T, Urrego F. Evaluation of pediatricians' adherence to tobacco prevention, control, and treatment guidelines before and after an educational outreach program. Ochsner J 2013; 13:375-379. [PMID: 24052767 PMCID: PMC3776513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Tobacco use is the world's leading single preventable cause of death. Because children exposed to second- and third-hand smoke are at risk for smoke-related morbidity, pediatricians have an obligation to address tobacco use in their practices. The purpose of this study was to measure physician adherence to the American Academy of Pediatrics' guidelines on tobacco prevention, control, and treatment before and after the implementation of an educational outreach program. METHODS Charts were randomly selected from pediatric clinics before and after the educational outreach. The intervention consisted of a review of the guidelines and available tools physicians could implement into their practices. We measured the rates of adherence to the guidelines before and after the educational outreach. RESULTS We analyzed 213 charts (116 pre- and 97 posteducation). The proportion of families screened for tobacco smoke exposure was comparable between the pre- and postintervention groups (67.2% vs 59.8%, P=0.317). The postintervention group had a higher proportion of counseling compared to the preintervention group (51.5% vs 31.9%, P<0.05). We found no statistically significant change in the rate of screening or referral to smoking cessation services. CONCLUSION Current guidelines to reduce tobacco use are underutilized. Educational outreach may increase the rate of counseling. Physician acceptance of guidelines is urgently needed to affect the tobacco epidemic.
Collapse
Affiliation(s)
- Timothy Beaty
- Department of Pediatric Pulmonology, Emory University, Atlanta, GA
| | | | - Terese Sahuque
- Department of Pediatric Pulmonology, Ochsner Clinic Foundation, New Orleans, LA
| | - Fernando Urrego
- Department of Pediatric Pulmonology, Ochsner Clinic Foundation, New Orleans, LA
| |
Collapse
|
7
|
Pbert L, Zapka J, Jolicoeur DG, White MJ, Goins KV, Reed G, Ockene JK. Implementing state tobacco treatment services: lessons from the Massachusetts experience. Health Promot Pract 2011; 12:802-10. [PMID: 21571986 PMCID: PMC4184237 DOI: 10.1177/1524839910376035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This case study was conducted between 2000 and 2003 to examine the implementation of community based tobacco treatment programs funded by the Massachusetts Department of Public Health Tobacco Control Program (MTCP). Four dimensions of implementation, drawn from several models of program evaluation are explored: (a) quantity of services, (b) quality of services, (c) implementation/use of systems, and (d) sustainability. The quantity of services delivered was high, reflecting MTCP's focus on increasing availability of services, particularly in underserved populations. The quality of physician-delivered tobacco intervention did not meet national benchmarks for delivery of all 5As (Ask, Advise, Assess, Assist, Arrange follow-up) and only about half of organizations reported routine systems for auditing tobacco use documentation. Implementation of systems to identify tobacco users and deliver tobacco treatment varied widely by community health settings, with low rates of tobacco use documentation found. Finally, in an era of greater competition for scarce prevention dollars, sustainability of services over time must be planned for from the outset, as indicated by the success of programs that sustained services by proactively and creatively incorporating tobacco treatment into their organizations. This case study can inform states' policies in their design of tobacco treatment services in community health settings.
Collapse
Affiliation(s)
- Lori Pbert
- Division of Preventive and Behavioral Medicine at the University of Massachusetts Medical School, Worcester, MA
| | - Jane Zapka
- Medical University of South Carolina, Charleston, SC
| | - Denise G. Jolicoeur
- Division of Preventive and Behavioral Medicine at the University of Massachusetts Medical School, Worcester, MA
| | - Mary Jo White
- Department of Family Medicine and Community Health at the University of Massachusetts Medical School, Worcester, MA
| | | | - George Reed
- Division of Preventive and Behavioral Medicine at the University of Massachusetts Medical School, Worcester, MA
| | - Judith K. Ockene
- Preventive and Behavioral Medicine at the University of Massachusetts Medical School, Worcester, MA
| |
Collapse
|
8
|
Windsor R, Woodby L, Miller T, Hardin M. Effectiveness of Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) methods in Medicaid-supported prenatal care: Trial III. HEALTH EDUCATION & BEHAVIOR 2011; 38:412-22. [PMID: 21551424 PMCID: PMC3313591 DOI: 10.1177/1090198110382503] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This two-phase evaluation documented the delivery and effectiveness of evidence-based health education methods by regular staff to pregnant smokers. During Phase 1, a total of 436 Medicaid patients were screened and 416 (95%) gave consent: 334 nonsmokers and 102 smokers. This historical Comparison (C) group was assessed to document the "normal" pretrial smoking prevalence, patient nondisclosure (deception), and cessation rates at the first prenatal visit and during care. After this study, a formative evaluation of SCRIPT methods was conducted among 139 experimental group patients and 126 control group patients. During Phase 2, a total of 6,514 patients were screened over a 36-month period: 1,736 (27%) were smokers and 1,340 (77%) gave consent. After randomization, 247 became ineligible. The remaining 1,093 smokers received brief routine advice to quit. The experimental group (n = 544) also received a Commit to Quit video, A Pregnant Woman's Guide to Quit Smoking, and counseling. Self-reports and saliva were collected at baseline, ≥60 days, and ≤90 days postpartum for cotinine analyses to document cessation and significant reduction (SR) rates. The Phase 1 formative evaluation documented a 24% nondisclosure rate at the onset of care. It also confirmed a significantly higher experimental (17.3%) versus control group (8.8%) cessation rate and experimental versus control group SR rates of 22% and 16%. During Phase 2, unplanned policy changes, and delivery of experimental group counseling procedures to 15% to 20% of control group patients, resulted in a final experimental group cessation rate of 12% and a control group rate of 10%. The experimental group SR rate of 18%, however, was significantly higher than the control group SR rate of 13%. Effectiveness varied by the stability of clinic infrastructure, and degree of fidelity of staff performance of assessment and intervention procedures. The methods and results of this study will assist future health education programs for pregnant smokers to plan and conduct process and impact evaluations in prenatal care.
Collapse
Affiliation(s)
- Richard Windsor
- The George Washington University School of Public Health and Health Services, Washington, DC 20037, USA.
| | | | | | | |
Collapse
|
9
|
Spanou C, Simpson SA, Hood K, Edwards A, Cohen D, Rollnick S, Carter B, McCambridge J, Moore L, Randell E, Pickles T, Smith C, Lane C, Wood F, Thornton H, Butler CC. Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): protocol for a general practice-based cluster randomised trial. BMC FAMILY PRACTICE 2010; 11:69. [PMID: 20858273 PMCID: PMC2955601 DOI: 10.1186/1471-2296-11-69] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 09/21/2010] [Indexed: 05/26/2023]
Abstract
Background Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours. Methods/Design This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted. Discussion Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention. Trial Registration ISRCTN22495456
Collapse
Affiliation(s)
- Clio Spanou
- South East Wales Trials Unit, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XN, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Succar CT, Hardigan PC, Fleisher JM, Godel JH. Survey of Tobacco Control Among Florida Dentists. J Community Health 2010; 36:211-8. [DOI: 10.1007/s10900-010-9299-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
11
|
Gokirmak M, Ozturk O, Bircan A, Akkaya A. The attitude toward tobacco dependence and barriers to discussing smoking cessation: a survey among Turkish general practitioners. Int J Public Health 2009; 55:177-83. [PMID: 20013142 DOI: 10.1007/s00038-009-0109-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 09/04/2009] [Accepted: 09/10/2009] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES To evaluate the general attitude of a sample of Turkish general practitioners (GPs) toward tobacco dependence and to assess their knowledge and behavior regarding smoking cessation (SC). METHODS A self-administered questionnaire modified from WHO, Global Health Professional Survey was distributed to GPs, working in our district, Isparta. RESULTS As much as 41% of GPs were current smokers. Ever smokers were generally less likely to agree with statements that would change their freedom to smoke in certain places. While 46% of GPs frequently inquired about tobacco use in their patients, 13.5% did not advise any of their patients to quit smoking during the month preceding the questionnaire. The most common barriers reported by GPs to discussing SC with their patients were as follows: considering the discussion not to be effective (57.8%), having low confidence in knowledge (48.1%), having unpleasant personal experience or considering it a thankless task (46.1%). CONCLUSIONS It appears essential to reduce the number of GPs who smoke and to improve GP training on SC procedures for integrating SC treatment into primary care in Turkey.
Collapse
Affiliation(s)
- Munire Gokirmak
- Department of Pulmonary Diseases, Research and Practice Hospital, Suleyman Demirel University, 32260 Isparta, Turkey.
| | | | | | | |
Collapse
|
12
|
Serious psychological distress among adults with and without disabilities. Int J Public Health 2009; 54 Suppl 1:52-60. [PMID: 19363587 DOI: 10.1007/s00038-009-0077-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES Our objective was to examine the extent to which serious psychological distress (SPD) is associated with behavioral and social correlates among US adults with self-reported disabilities. METHODS Self-reported data on disability, SPD, and behavioral and social correlates were collected from 202,383 participants (aged > or = 18 years) of the 2007 Behavioral Risk Factor Surveillance System. Adults with self-reported disabilities were identified using two standardized questions--one relating to activity limitation, the other to special equipment. RESULTS The age-adjusted prevalence of SPD among adults with disabilities was nearly seven times higher than among adults without disabilities (14.1 % vs. 1.8 %, respectively). Adults with disabilities who have both activity limitations and who use assistive technology, and those with activity limitations only consistently experienced a higher prevalence of SPD than those who used assistive technology only (age-adjusted prevalence: 21.0 % and 12.7 % vs. 4.9 %). After adjusting for age, sex, race/ethnicity, educational attainment, marital status, and employment status, in the past 30 days SPD was more common among Hispanic persons, and was significantly associated with younger age, lower educational attainment, marital history, and employment status. Adults with SPD and disabilities experienced increased levels of risk behaviors, life dissatisfaction, and inadequate social support. Most importantly, just over half of adults with disabilities and SPD (51.6 % [95 % CI = 48.6-54.6]) were receiving medical care for a mental health condition compared to 20.6 % (95 % CI = 19.9-21.3) without SPD. CONCLUSIONS Given that SPD is strongly associated with both the behavioral and psychosocial determinants of health, this work underscores the need for evidence-based interventions that may reduce its prevalence among people living with disabilities.
Collapse
|
13
|
Dolor RJ, Yancy WS, Owen WF, Matchar DB, Samsa GP, Pollak KI, Lin PH, Ard JD, Prempeh M, McGuire HL, Batch BC, Fan W, Svetkey LP. Hypertension Improvement Project (HIP): study protocol and implementation challenges. Trials 2009; 10:13. [PMID: 19245692 PMCID: PMC2654882 DOI: 10.1186/1745-6215-10-13] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Accepted: 02/26/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertension affects 29% of the adult U.S. population and is a leading cause of heart disease, stroke, and kidney failure. Despite numerous effective treatments, only 53% of people with hypertension are at goal blood pressure. The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care. METHODS AND DESIGN This paper describes the protocol of a nested 2 x 2 randomized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients and a quality improvement-type intervention for physicians. Primary care practices were randomly assigned to the physician intervention or to the physician control condition. Physician randomization occurred at the clinic level. The physician intervention included training and performance monitoring. The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension. Performance data were collected for 18 months, and feedback was provided to physicians every 3 months. Patient participants in both intervention and control clinics were individually randomized to the patient intervention or to usual care. The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions, followed by 12 monthly phone contacts by community health advisors. Follow-up measurements were performed at 6 and 18 months. The primary outcome was the mean change in systolic blood pressure at 6 months. Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months. DISCUSSION Overall, 8 practices (4 per treatment group), 32 physicians (4 per practice; 16 per treatment group), and 574 patients (289 control and 285 intervention) were enrolled. Baseline characteristics of patients and providers and the challenges faced during study implementation are presented. The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model. The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately, so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local resources. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00201136.
Collapse
Affiliation(s)
- Rowena J Dolor
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC, USA
| | - William S Yancy
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC, USA
| | - William F Owen
- President's Office, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA
| | - David B Matchar
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC, USA
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC, USA
| | - Gregory P Samsa
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - Kathryn I Pollak
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA
- Cancer Prevention, Detection, and Control Research Program, Duke University Medical Center, Durham, NC, USA
| | - Pao-Hwa Lin
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jamy D Ard
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Nutrition Sciences, University of Alabama, Birmingham, AL, USA
| | - Maxwell Prempeh
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Bryan C Batch
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Laura P Svetkey
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Hypertension Center, Duke University Medical Center, Durham, NC, USA
- Sarah W Stedman Nutrition and Metabolism Center, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
14
|
Weston CM, Sciamanna CN, Nash DB. Evaluating online continuing medical education seminars: evidence for improving clinical practices. Am J Med Qual 2009; 23:475-83. [PMID: 19001103 DOI: 10.1177/1062860608325266] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to evaluate the potential for online continuing medical education (CME) seminars to improve quality of care. Primary care physicians (113) participated in a randomized controlled trial to evaluate an online CME series. Physicians were randomized to view either a seminar about type 2 diabetes or a seminar about systolic heart failure. Following the seminar, physicians were presented with 4 clinical vignettes and asked to describe what tests, treatments, counseling, or referrals they would recommend. Physicians who viewed the seminars were significantly more likely to recommend guideline-consistent care to patients in the vignettes. For example, physicians who viewed the diabetes seminar were significantly more likely to order an eye exam for diabetes patients (63%) compared with physicians in the control group (27%). For some guidelines there were no group differences. These results provide early evidence of the effectiveness of online CME programs to improve physician clinical practice.
Collapse
|
15
|
Pinget C, Martin E, Wasserfallen JB, Humair JP, Cornuz J. Cost-effectiveness analysis of a European primary-care physician training in smoking cessation counseling. ACTA ACUST UNITED AC 2007; 14:451-5. [PMID: 17568248 DOI: 10.1097/hjr.0b013e32804955a0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Physician training in smoking cessation counseling has been shown to be effective as a means to increase quit success. We assessed the cost-effectiveness ratio of a smoking cessation counseling training programme. Its effectiveness was previously demonstrated in a cluster randomized, control trial performed in two Swiss university outpatients clinics, in which residents were randomized to receive training in smoking interventions or a control educational intervention. DESIGN AND METHODS We used a Markov simulation model for effectiveness analysis. This model incorporates the intervention efficacy, the natural quit rate, and the lifetime probability of relapse after 1-year abstinence. We used previously published results in addition to hospital service and outpatient clinic cost data. The time horizon was 1 year, and we opted for a third-party payer perspective. RESULTS The incremental cost of the intervention amounted to US$2.58 per consultation by a smoker, translating into a cost per life-year saved of US$25.4 for men and 35.2 for women. One-way sensitivity analyses yielded a range of US$4.0-107.1 in men and US$9.7-148.6 in women. Variations in the quit rate of the control intervention, the length of training effectiveness, and the discount rate yielded moderately large effects on the outcome. Variations in the natural cessation rate, the lifetime probability of relapse, the cost of physician training, the counseling time, the cost per hour of physician time, and the cost of the booklets had little effect on the cost-effectiveness ratio. CONCLUSIONS Training residents in smoking cessation counseling is a very cost-effective intervention and may be more efficient than currently accepted tobacco control interventions.
Collapse
Affiliation(s)
- Christophe Pinget
- Health Technology Assessment Unit, Lausanne University Hospital, Switzerland.
| | | | | | | | | |
Collapse
|
16
|
O'Loughlin J, Makni H, Tremblay M, Karp I. Gender differences among general practitioners in smoking cessation counseling practices. Prev Med 2007; 45:208-14. [PMID: 17631386 DOI: 10.1016/j.ypmed.2007.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 06/06/2007] [Accepted: 06/07/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe gender differences in smoking cessation counseling practices among general practitioners (GPs), and to investigate the association between training for cessation counseling and counseling practices according to gender. METHODS Data were collected in two cross-sectional mail surveys conducted in independent random samples of GPs in Montreal, the first in 1998, and the second in 2000. RESULTS Respondents included 653 GPs (71% of 916 eligible). All indicators of smoking cessation counseling practices were more favorable among female GPs. Higher proportions of female GPs had received training (28% vs. 17%, p=0.002), and were aware of mailed print educational materials related to cessation counseling (81% vs. 57%, p<0.0001). Training among male GPs was associated with higher scores for ascertainment of smoking status (odds ratio (OR) (95% confidence interval)=1.69 (0.97, 2.96)), provision of advice (OR=2.20 (1.23, 3.95)), and provision of adjunct support (OR=2.86 (1.58, 5.16)). Training was not associated with counseling practices among female GPs. CONCLUSIONS Female GPs may not benefit from formal cessation counseling training to the same extent as male GPs, possibly because they read and integrate the content of (easily available) print educational materials into their clinical practice to a greater extent than male GPs. The gender-specific impact of print educational material and formal training on cessation counseling should be evaluated among GPs.
Collapse
Affiliation(s)
- Jennifer O'Loughlin
- CR-CHUM and Department of Social and Preventive Medicine, University of Montreal, Montréal, Québec, Canada.
| | | | | | | |
Collapse
|
17
|
Solberg LI, Maciosek MV, Edwards NM, Khanchandani HS, Goodman MJ. Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness. Am J Prev Med 2006; 31:62-71. [PMID: 16777544 DOI: 10.1016/j.amepre.2006.03.013] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 03/15/2006] [Accepted: 03/17/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND This report updates 2001 estimates of disease burden prevented and cost effectiveness of tobacco-use screening and brief intervention relative to that of other clinical preventive services. It also addresses repeated counseling because the literature has focused on single episodes of treatment, while in reality that is neither desirable nor likely. METHODS Literature searches led to four models for calculating the clinically preventable burden of deaths and morbidity from smoking as well as the cost effectiveness of providing the service annually over time. The same methods were used in similar calculations for other preventive services to facilitate comparison. RESULTS Using methods consistent with existing literature for this service, an estimated 190,000 undiscounted quality-adjusted life years (QALYs) are saved at a cost of $1100 per QALY saved (discounted). These estimates exclude financial savings from smoking-attributable disease prevented and use the average 12-month quit rate in clinical practice for tobacco screening and brief cessation counseling with cessation medications (5.0%) and without (2.4%). Including the savings of prevented smoking-attributable disease and using the effectiveness of repeated interventions over the lifetime of smokers (23.1%), 2.47 million QALYs are saved at a cost savings of $500 per smoker who receives the service. CONCLUSIONS This analysis makes repeated clinical tobacco-cessation counseling one of the three most important and cost-effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.
Collapse
Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, Bloomington, Minnesota 55425, USA.
| | | | | | | | | |
Collapse
|
18
|
Braun BL, Fowles JB, Solberg LI, Kind EA, Lando H, Pine D. Smoking-related attitudes and clinical practices of medical personnel in Minnesota. Am J Prev Med 2004; 27:316-22. [PMID: 15488362 DOI: 10.1016/j.amepre.2004.07.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
CONTEXT Effective clinic-based, smoking-cessation activities are not widely implemented. OBJECTIVE To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members. DESIGN AND SETTING From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs). MAIN OUTCOME MEASURES Factors associated with limited smoking-cessation service delivery. RESULTS The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders. CONCLUSIONS Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.
Collapse
Affiliation(s)
- Barbara L Braun
- Health Research Center, Park Nicollet Institute, Minneapolis, Minnesota 55416, USA.
| | | | | | | | | | | |
Collapse
|
19
|
Anderson P, Jané-Llopis E. How can we increase the involvement of primary health care in the treatment of tobacco dependence? A meta-analysis. Addiction 2004; 99:299-312. [PMID: 14982543 DOI: 10.1111/j.1360-0443.2003.00672.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS A systematic review of studies testing the effectiveness of educational and practice base strategies to increase the involvement of primary health-care practitioners in the treatment of tobacco dependence. DATA SOURCES MEDLINE, EMBASE, CINAHL and the Cochrane Library (1966-2001). Selection criteria included studies that used randomized or controlled clinical designs, controlled before and after trials and interrupted time-series designs and that presented objective and interpretable measures of practitioners' behaviour and biochemically verified patient quit rates. REVIEW METHODS A meta-analysis, using a random effects model, of 24 programmes identified in 19 trials. Effect sizes were adjusted by inverse variance weights to control for studies' sample sizes. FINDINGS Analyses to explain the heterogeneity of effect sizes found that interventions were equally effective in changing practitioners' screening and advice-giving rates and their patients' quit rates. Absolute increases for the intervention above the comparison groups were 15% (95% CI = 7-22) for screening rates, 13% (95% CI = 9-18) for advice-giving rates and 4.7% (95% CI = 2.5-6.9) for biochemically verified patient quit rates. Practitioners in training programmes were effective in changing their patients' quit rates but not their own screening rates; educational interventions were more effective than practice-based interventions. For established practitioners, programmes were effective in changing their screening and advice-giving rates, but not their patients' quit rates; a combination of practice-based and educational interventions were more effective. CONCLUSIONS Primary health-care practitioners can be engaged in the treatment of tobacco dependence to increase equally their screening and advice-giving rates and their patients' quit rates with outcomes of considerable public health and clinical significance. The provision of educational interventions for practitioners in training in combination with systematic outreach practice-based support for established practitioners is likely to be an effective strategy to increase smoking quit rates throughout primary health care.
Collapse
Affiliation(s)
- Peter Anderson
- Centre for Quality of Care Research, WOK, University of Nijmegen, The Netherlands.
| | | |
Collapse
|
20
|
McMenamin SB, Schauffler HH, Shortell SM, Rundall TG, Gillies RR. Support for Smoking Cessation Interventions in Physician Organizations. Med Care 2003; 41:1396-406. [PMID: 14668672 DOI: 10.1097/01.mlr.0000100585.27288.cd] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To document the extent to which physician organizations, defined as medical groups and independent practice associations, are providing support for smoking cessation interventions and to identify external incentives and organizational characteristics associated with this support. METHODS This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California at Berkeley, to document the extent to which physician organizations provide support for smoking cessation interventions. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS Overall, 70% of physician organizations offered some support for smoking cessation interventions. Specifically, 17% require physicians to provide interventions, 15% evaluate interventions, 39% of physician organizations offer smoking health promotion programs, 25% provide nicotine replacement therapy starter kits, and materials are provided on pharmacotherapy (39%), counseling (37%), and self-help (58%). Factors positively associated with organizational support include income or public recognition for quality measures, financial incentives to promote smoking cessation interventions, requirements to report HEDIS (Health Plan Employer Data and Information Set) scores, awareness of the 1996 Clinical Practice Guideline on Smoking Cessation, being a medical group, organizational size, percentage of primary care physicians, and hospital/HMO ownership of the organization. CONCLUSION Physician organizations are providing support for smoking cessation interventions, yet the level of support might be improved with more extensive use of external incentives. Financial incentives targeted specifically at promoting smoking cessation interventions need to be explored further. Additionally, emphasis on quality measures should continue, including an expansion of HEDIS smoking cessation measures.
Collapse
Affiliation(s)
- Sara B McMenamin
- Center for Health and Public Policy Studies, University of California, Berkeley, Berkeley, California 94720-7360, USA.
| | | | | | | | | |
Collapse
|
21
|
Abstract
One of the most effective disease prevention and health promotion strategies available is the treatment of tobacco dependence. The Agency for Healthcare Research and Quality (AHRQ) clinical practice guideline for treating tobacco use and dependence provides a number of recommendations for interventions by health care systems and providers, including that treatment be reimbursed, identification of tobacco users be institutionalized, and all patients be offered brief treatment and have more intensive treatment available to them. Unfortunately, these recommended interventions have not been routinely implemented. As part of a comprehensive approach to improving implementation, provider training is needed. Three models for training healthcare providers in brief tobacco treatment intervention (medical education, professional education, and community-based education) are described, a model for training providers in intensive tobacco treatment interventions is presented, and a rationale for a national training and certification program is made.
Collapse
Affiliation(s)
- Lori Pbert
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
| |
Collapse
|
22
|
Abstract
BACKGROUND Convincing pregnant women who smoke to give up this behavior is one of the few universally agreed upon methods for improving pregnancy outcomes. An exploratory study was conducted to determine what public and quasi-public facilities serving pregnant women were doing to assist pregnant smokers in quitting, the reasons why more was not being done, and what could be done to increase smoking-cessation services. METHODS Questionnaires eliciting information about pregnancy-related smoking prevention activities were mailed to home visitation projects, federally funded Healthy Start programs, CityMatCH members, and maternal and child health units in state health departments with a subsample of local health units. Responses were obtained from 354 programs. RESULTS Only about a quarter of the respondents thought they were doing enough to help pregnant smokers stop or reduce smoking, and most thought that the inadequacy was due to insufficient funds. Only about a quarter offered smoking-cessation classes or clinics. Almost all programs had policies restricting smoking in their offices. The nationally sponsored activity that the respondents felt might be most helpful in increasing their efforts was the provision of materials. Among the 313 programs that included home visits, 86% required the home visitors to conduct a needs assessment, and 97% of those expected the woman's smoking status to be recorded. Smoking status prior to pregnancy or by other household members was required less often. Less than half of the programs provided training on smoking-cessation/reduction methods to home visitors. Only 28% said smoking-cessation/reduction had a very high priority in comparison to other home visit objectives. CONCLUSIONS; Programs for pregnant women, including those with a home visit component, do not pay sufficient attention to the problem of smoking among their clients. Programs should make greater use of the evidence-based interventions now available.
Collapse
Affiliation(s)
- Lorraine V Klerman
- Heller School for Social Policy and Management, Brandeis University, PO Box 9110/MS 035, Waltham, MA 02454-9110, USA.
| | | |
Collapse
|
23
|
Abstract
The authors review developments in understanding smoking cessation interventions over the past decade. Noteworthy is the unprecedented growth of research and knowledge that has left a deeper understanding of how best to use new and existing behavioral and pharmacologic tools and strategies to help smokers quit. The status of public-health-level interventions is evaluated, questions are raised concerning their efficacy, and suggestions are offered for further refinement of these intervention strategies. Development of cessation guidelines is reviewed, and the state of knowledge concerning behavioral and pharmacologic interventions is summarized. The authors also present agendas for behavioral and pharmacologic research related to smoking cessation and discuss individual difference factors among smokers that may prove to be important in designing new and refining existing treatments.
Collapse
Affiliation(s)
- Raymond Niaura
- Centers for Behavioral and Preventive Medicine, Brown Medical School, the Miriam Hospital, Providence, Rhode Island 02903, USA.
| | | |
Collapse
|
24
|
Abstract
The primary care setting is an important place for promoting smoking cessation. Randomized clinical trials (RCTs) testing the effect of brief smoking interventions and comprehensive programs delivered in a primary care setting present excellent evidence that such interventions significantly increase patients' smoking cessation rates and that as the dose of intervention increases, the effect increases. Unfortunately, despite widespread dissemination of preventive services guidelines and positive physician attitudes towards such services, the current level of delivery of smoking cessation intervention by physicians in real-world settings is not high, making this a major research and public health concern. Interventions to increase the rate of implementation provider-delivered brief smoking interventions can be grouped broadly into: provider education; clinical systems and procedures (e.g., screening and tracking of patients); and organizational policy (e.g., reimbursement, coverage, performance measures). Given the significant effect that primary care-based interventions can have on smoking cessation, it is important to investigate methods to increase their rate of delivery and their effect. Examples of research to motivate to intervene questions include: what are the best incentives or combination of incentives for physicians? What are the most effective strategies to remind providers to intervene? How can each of these be best implemented in different types of settings and systems? How can a stepped-care and patient-treatment matching model be used? The study of factors such as reimbursement policies and covered benefits do not lend themselves well to tightly-controlled randomized trials. Therefore, use of quasi-experimental designs, and application of qualitative strategies are needed. These designs represent a different challenge to the research community.
Collapse
Affiliation(s)
- J K Ockene
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester 01655, USA.
| |
Collapse
|
25
|
Secker-Walker RH, Gnich W, Platt S, Lancaster T. Community interventions for reducing smoking among adults. Cochrane Database Syst Rev 2002; 2002:CD001745. [PMID: 12137631 PMCID: PMC6464950 DOI: 10.1002/14651858.cd001745] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Since smoking behaviour is determined by social context, the best way to reduce the prevalence of smoking may be to use community-wide programmes which use multiple channels to provide reinforcement, support and norms for not smoking. OBJECTIVES To assess the effectiveness of community interventions for reducing the prevalence of smoking. SEARCH STRATEGY We searched the Cochrane Tobacco Addiction Group specialised register, MEDLINE (1966-August 2001) and EMBASE (1980-August 2001) and reference lists of articles. SELECTION CRITERIA Controlled trials of community interventions for reducing smoking prevalence in adult smokers. The primary outcome was smoking behaviour. DATA COLLECTION AND ANALYSIS Data were extracted by one person and checked by a second. MAIN RESULTS Thirty two studies were included, of which seventeen included only one intervention and one comparison community. Only four studies used random assignment of communities to either the intervention or comparison group. The population size of the communities ranged from a few thousand to over 100,000 people. Change in smoking prevalence was measured using cross-sectional follow-up data in 27 studies. The estimated net decline ranged from -1.0% to 3.0% for men and women combined (10 studies). For women, the decline ranged from -0.2% to + 3.5% per year (n=11), and for men the decline ranged from -0.4% to +1.6% per year (n=12). Cigarette consumption and quit rates were only reported in a small number of studies. The two most rigorous studies showed limited evidence of an effect on prevalence. In the US COMMIT study there was no differential decline in prevalence between intervention and control communities, and there was no significant difference in the quit rates of heavier smokers who were the target intervention group. In the Australian CART study there was a significantly greater quit rate for men but not women. REVIEWER'S CONCLUSIONS The failure of the largest and best conducted studies to detect an effect on prevalence of smoking is disappointing. A community approach will remain an important part of health promotion activities, but designers of future programmes will need to take account of this limited effect in determining the scale of projects and the resources devoted to them.
Collapse
Affiliation(s)
- R H Secker-Walker
- Health Promotion Research, University of Vermont, 1 South Prospect Street, Burlington, Vermont 05401-3444, USA.
| | | | | | | |
Collapse
|
26
|
O'Loughlin J, Makni H, Tremblay M, Lacroix C, Gervais A, Déry V, Meshefedjian G, Paradis G. Smoking cessation counseling practices of general practitioners in Montreal. Prev Med 2001; 33:627-38. [PMID: 11716660 DOI: 10.1006/pmed.2001.0937] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite the cost-effectiveness of physician smoking cessation counseling, many physicians do not adhere to current clinical practice guidelines. METHODS A cross-sectional mail survey was conducted in a random sample of general practitioners in Montreal to document cessation-counseling practices and identify correlates of these activities. RESULTS Of 440 eligible general practitioners, 337 (77%) completed the questionnaire. Despite favorable beliefs/attitudes about cessation counseling, only 10.5% of general practitioners provided "thorough" counseling. While high proportions of general practitioners ascertained smoking status and encouraged patients to quit, relatively few offered adjunct support (i.e., for patients preparing to quit, 49.8% offered follow-up visits; 42.5% offered educational material; 20% referred patients to community resources). Correlates of counseling completeness included high self-efficacy to provide counseling (odds ratio (OR) = 2.0, 95% confidence interval (1.1-3.6)) and favorable beliefs/attitudes about counseling (OR = 3.6 (2.0-6.4)). Correlates of ascertaining smoking status included female gender (OR = 2.3 (1.5-3.5)), high self-efficacy (OR = 3.5 (2.0-5.9)), and favorable beliefs/attitudes (OR = 2.7 (1.6-4.5)). Correlates of offering adjunct support included female gender (OR = 1.9 (1.1-3.2)), awareness of stages of change (OR = 2.4 (1.3-4.4)), and knowledge of community resources to help patients quit (OR = 2.3 (1.3-3.9)). CONCLUSION Support, training, and intervention programs to overcome lack of awareness and knowledge, unfavorable beliefs/attitudes, and low self-efficacy could increase and enhance cessation counseling practices among general practitioners.
Collapse
Affiliation(s)
- J O'Loughlin
- Direction de la santé publique, Régie régionale de la santé et des services sociaux de Montréal-Centre, 1301 Sherbrooke Est, Montréal, Québec.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Hopkins DP, Briss PA, Ricard CJ, Husten CG, Carande-Kulis VG, Fielding JE, Alao MO, McKenna JW, Sharp DJ, Harris JR, Woollery TA, Harris KW. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001; 20:16-66. [PMID: 11173215 DOI: 10.1016/s0749-3797(00)00297-x] [Citation(s) in RCA: 324] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This report presents the results of systematic reviews of effectiveness, applicability, other effects, economic evaluations, and barriers to use of selected population-based interventions intended to reduce tobacco use and exposure to environmental tobacco smoke. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (TFCPS) regarding the use of these selected interventions. The TFCPS recommendations are presented on page 67 of this supplement.
Collapse
Affiliation(s)
- D P Hopkins
- Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
|
29
|
Abstract
STUDY OBJECTIVES Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education. METHODS Experience and data from relevant randomized clinical trials within an educational framework are reviewed. OBSERVATIONS Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation. CONCLUSIONS To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.
Collapse
Affiliation(s)
- J K Ockene
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, North Worcester, MA 01655, USA.
| | | |
Collapse
|
30
|
Secker-Walker RH, Dana GS, Solomon LJ, Flynn BS, Geller BM. The role of health professionals in a community-based program to help women quit smoking. Prev Med 2000; 30:126-37. [PMID: 10656840 DOI: 10.1006/pmed.1999.0607] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Health professionals are credible sources of smoking cessation advice. This study describes changes in health professionals' reported provision of smoking cessation counseling activities for women during a community health education project that took place in two intervention counties (I) and compares these to reports from health professionals in two similar comparison counties (C). METHODS Specific smoking cessation activities reported by physicians (I n = 73, C n = 73), dentists (I n = 51, C n = 46), dental hygienists (I n = 38, C n = 44), family planning and WIC (Special Supplemental Food Program for Women, Infants and Children) counselors (I n = 14 C n = 16), and community mental health counselors (I n = 57, C n = 23) were assessed by mailed surveys at baseline, after 4 years of countywide interventions, and 2 years later. RESULTS Compared with health professionals in the comparison counties, significant increases in smoking cessation training (P < 0.01) and in reported referral of women to stop smoking groups, support groups, and one-to-one support were noted for physicians, family planning, and WIC counselors (P < 0.001); in training and referral to stop smoking groups and support groups by dentists and dental hygienists (P < 0.05); and in referral to support groups by community mental health counselors (P < 0.05). Significant increases in setting quit dates (P < 0.05) and providing self-help materials (P < 0.01) were also noted for family planning and WIC counselors. These effects were no longer demonstrable 2 years after external support for the countywide interventions was withdrawn. CONCLUSIONS We suggest that an important aspect of facilitating consistent smoking cessation advice and counseling from health professionals in the future will be the provision of a broader range of regularly available smoking cessation support systems within communities than is generally available at this time in the United States.
Collapse
Affiliation(s)
- R H Secker-Walker
- Office of Health Promotion Research, University of Vermont, Burlington,Vermont, USA.
| | | | | | | | | |
Collapse
|
31
|
Zapka JG, Pbert L, Stoddard AM, Ockene JK, Goins KV, Bonollo D. Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers. Am J Public Health 2000; 90:78-84. [PMID: 10630141 PMCID: PMC1446113 DOI: 10.2105/ajph.90.1.78] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers. METHODS WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis. RESULTS Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance. CONCLUSIONS Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.
Collapse
Affiliation(s)
- J G Zapka
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester 01655, USA.
| | | | | | | | | | | |
Collapse
|