Evaluation and costs of volunteer telephone cessation follow-up counseling for Veteran smokers discharged from inpatient units: a quasi-experimental, mixed methods study

Hospitalised Smokers' and Staff Perspectives of Inpatient Smoking Cessation Interventions and Impact on Smokers' Quality of Life: An Integrative Review of the Qualitative Literature

Aim

To identify, integrate, and appraise the evidence on hospitalised smokers' and staff perspectives of inpatient smoking cessation interventions and the impact on smokers' quality of life.

Design

The integrative review method was used to present hospitalised smokers' and staff perspectives of inpatient smoking cessation interventions. Search Method. This integrative review consisted of a comprehensive search on smoking cessation interventions that take place during an inpatient admission to hospital for adults (> age 18 years) of the following online databases: Ovid Medline, Joanna Briggs Institute, APA PsycInfo, CINAHL, Cochrane, Google Scholar, PEDro, and Scopus. The search strategy was inclusive of peer-reviewed studies limited to the English language or translated to English. A search of grey literature and manual searching of reference lists was also conducted to identify further studies not identified in the online database search. All studies that produced any qualitative data (i.e., qualitative, mixed methods, and surveys) on inpatient-initiated smoking cessation programs were included. Outcomes of interest are included but were not limited to education, counselling, and the use of pharmacotherapy. Studies undertaken in the psychiatric, adolescent, and paediatric settings were excluded.

Results

The key findings from this integrative review included positive evaluations from both patients and staff involved in inpatient smoking cessation interventions, reporting that hospitalisation was an appropriate opportunity to address smoking cessation. A number of facilitators and barriers to inpatient smoking cessation interventions included creating a supportive patient-centred environment and consideration of the cost of nicotine replacement therapy and time to deliver inpatient smoking cessation interventions. Recommendations/preferences for future inpatient smoking cessation interventions included the use of a program champion and ongoing education to demonstrate the effectiveness of the intervention, and despite the cost of nicotine replacement therapy being identified as a potential barrier, it was identified as a preference for most patients. Although quality of life was only evaluated in two studies, statistically significant improvements were identified in both.

Conclusion

This qualitative integrative review provides further insight into both clinician and patient participants' perspectives on inpatient smoking cessation interventions. Overall, they are seen to produce positive benefits, and staff training appears to be an effective means for service delivery. However, insufficient time and lack of resources or expertise appear to be consistent barriers to the delivery of these services, so they should be considered when planning the implementation of an inpatient smoking cessation intervention.

How can hospitals change practice to better implement smoking cessation interventions? A systematic review

Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.

Cost evaluation of tobacco control interventions in clinical settings: A systematic review

Elucidating the cost implications of tobacco control interventions is a prerequisite to their adoption in clinical settings. This review fills a knowledge gap in characterizing the extent to which cost is measured in tobacco control studies. A search of English literature was conducted in the following electronic databases: MEDLINE, EconLit, PsychINFO, and CINAHL using MeSH terms from 2009 to 2018. Studies were reviewed by two independent reviewers and included if they were conducted in U.S. inpatient or outpatient facilities and reported costs associated with a tobacco control intervention. They were categorized according to evaluation type, clinical setting, target population, cost measures, and stakeholder perspective. Bias risk was evaluated for RCTs. Seventeen publications were included, representing counseling interventions (n = 8) and combination (i.e., counseling and pharmacotherapy) interventions (n = 9). Studies were categorized by evaluation type: cost-effectiveness analysis (n = 10), cost utility analysis (n = 3) and cost identification (n = 4). The selected studies targeted the following populations: general adults (n = 6), hospitalized/inpatient (n = 4), military/veterans (n = 4), individuals with low socioeconomic status (n = 4), mental health or medical comorbidities (n = 2), and pregnant women (n = 2). Intervention costs included personnel, medication, education material, technology, and overhead costs. Stakeholder perspectives included: healthcare organization (n = 10), payer (n = 8), patient (n = 2), and societal (n = 1). Few studies have reported the cost of tobacco control interventions in clinical settings. Cost is a critical outcome that should be consistently measured in evaluations of tobacco control interventions to promote their uptake in clinical settings.

Evaluation of a Systems-Based Tobacco Cessation Program Using Bedside Volunteers

INTRODUCTION

Hospitalization and post-discharge provide an opportune time for tobacco cessation. This study tested the feasibility, uptake, and cessation outcomes of a hospital-based tobacco cessation program, delivered by volunteers to the bedside with post-discharge referral to Quitline services. Patient characteristics associated with Quitline uptake and cessation were assessed.

METHODS

Between February and November 2016, trained hospital volunteers approached inpatient tobacco users on six pilot units. Volunteers shared a cessation brochure and used the ASK-ADVISE-CONNECT model to connect ready to quit patients to the Delaware Quitline via fax-referral. Volunteers administered a follow-up survey to all admitted tobacco users via telephone or email at 3-months post-discharge.

RESULTS

Of the 743 admitted tobacco users, 531 (72%) were visited by a volunteer, and 97% (531/547) of those approached, accepted the visit. Over one-third (201/531; 38%) were ready to quit and fax-referred to the Quitline, and 36% of those referred accepted Quitline services. At 3 months post-discharge, 37% (135/368) reported not using tobacco in the last 30 days; intent-to-treat cessation rate was 18% (135/743). In a multivariable regression model of Quitline fax-referral completion, receiving nicotine replacement therapy (NRT) during hospitalization was the strongest predictor (odds ratios [OR] = 1.97; 95% confidence interval [CI] = 1.34 to 2.90). In a model of 3-month cessation, receiving Quitline services (OR = 3.21, 95% CI = 1.35 to 7.68) and having coronary artery disease (OR = 2.28; 95% CI = 1.11 to 4.68) were associated with tobacco cessation, but a volunteer visit was not.

CONCLUSIONS

An "opt-out" tobacco cessation service using trained volunteers is feasible for connecting patients to Quitline services.

IMPLICATIONS

This study demonstrates the feasibility of a systems-based approach to link inpatients to evidence-based treatment for tobacco use. This model used trained bedside volunteers to connect inpatients to a state-funded Quitline after discharge that offers free cessation treatment of telephone coaching and cessation medications. Receiving NRT during hospitalization positively impacted Quitline referral, and engagement with Quitline resources was critical to tobacco abstinence post-discharge. Future work is needed to evaluate the cost-effectiveness and sustainability of this volunteer model.

Nurse-Driven mHealth Implementation Using the Technology Inpatient Program for Smokers (TIPS): Mixed Methods Study

Background

Smoking is the leading cause of preventable death and disease, yet implementation of smoking cessation in inpatient settings is inconsistent. The Technology Inpatient Program for Smokers (TIPS) is an implementation program designed to reach smokers with a mobile health (mHealth) intervention using stakeholder-supported strategies.

Objective

The purpose of this study was to determine the impact of the TIPS implementation strategies on smoker-level engagement of the mHealth intervention during care transition.

Methods

We examined varying intensities (passive motivational posters only and posters + active nurse-led facilitation) of TIPS strategies on four hospital units located in two sites. Unit-level and smoker-level adoption was monitored during active implementation (30 weeks) and sustainability follow-up (30 weeks). Process measures reflecting the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework, stakeholder reported adaptations of strategies, and formative evaluation data were collected and analyzed.

Results

For our smoker-level reach, 103 smokers signed up for the mHealth intervention in-hospital, with minimal decline during sustainability follow-up. While posters + nurse facilitation did not lead to higher reach than posters alone during active implementation (27 vs 30 signed up), it did lead to higher engagement of smokers (85.2% vs 73.3% completion of the full 2-week intervention). TIPS strategy adoption and fidelity varied by unit, including adoption of motivational posters (range: weeks 1 and 5), fidelity of posters (0.4% to 16.2% of posters missing per unit weekly) and internal facilitation of nurse training sessions (average of 2 vs 7.5 by site). Variable maintenance costs of the program totaled US $6.63 (US $683.28/103) per smoker reached. Reported family-member facilitation of mHealth sign-up was an observation of unintended behavior.

Conclusions

TIPS is a feasible and low-cost implementation program that successfully engages smokers in an mHealth intervention and sustains engagement after discharge. Further testing of nurse facilitation and expanding reach to patient family and friends as an implementation strategy is needed.

Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals

Background

Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework.

Methods

This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention.

Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended).

Results

Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated; 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. Implementation: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive (“user friendly,” “streamlined,” or “saves time”), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended.

Conclusions

Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation.

Trial registration

ClinicalTrials.gov, NCT01309217

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0511-6) contains supplementary material, which is available to authorized users.

Effectiveness of the Tobacco Tactics Program in the Trinity Health System

INTRODUCTION

This study determined the effectiveness of the Tobacco Tactics intervention.

DESIGN/SETTING/PARTICIPANTS

This was a pragmatic, quasi-experimental study conducted from 2010 to 2013 and analyzed from 2014 to 2015 in five Michigan community hospitals; three received the Tobacco Tactics intervention, and two received usual care. Smokers (N=1,528) were identified during hospitalization, and sent surveys and cotinine tests after 6 months. Changes in pre- to post-intervention quit rates in the intervention sites were compared with usual care control sites.

INTERVENTION

The toolkit for nurses included: (1) 1 continuing education unit contact hour for training; (2) a PowerPoint presentation on behavioral and pharmaceutical interventions; (3) a pocket card entitled "Helping Smokers Quit: A Guide for Clinicians"; (4) behavioral and pharmaceutical protocols; and (5) a computerized template for documentation. The toolkit for patients included: (1) a brochure; (2) a cessation DVD; (3) the Tobacco Tactics manual; (4) a 1-800-QUIT-NOW card; (5) nurse behavioral counseling and pharmaceuticals; (6) physician reminders to offer brief advice to quit coupled with medication sign-off; and (7) follow-up phone calls by trained hospital volunteers.

MAIN OUTCOME MEASURES

The effectiveness of the intervention was measured by 6-month 30-day point prevalence; self-reported quit rates with NicAlert(®) urinary biochemical verification (48-hour detection period); and the use of electronic medical record data among non-responders.

RESULTS

There were significant improvements in pre- to post-intervention self-reported quit rates (5.7% vs 16.5%, p<0.001) and cotinine-verified quit rates (4.3% vs 8.0%, p<0.05) in the intervention sites compared with no change in the control sites. Propensity-adjusted multivariable analyses showed a significant improvement in self-reported 6-month quit rates from the pre- to post-intervention time periods in the intervention sites compared to the control sites (p=0.044) and a non-statistically significant improvement in the cotinine-verified 6-month quit rate.

CONCLUSIONS

The Tobacco Tactics intervention, which meets the Joint Commission standards for inpatient smoking, has the potential to significantly decrease smoking among inpatient smokers.

TRIAL REGISTRATION

This study is registered at www.clinicaltrial.gov NCT01309217.

Evaluation of physical activity interventions in children via the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework: A systematic review of randomized and non-randomized trials

CONTEXT

Existing reviews of physical activity (PA) interventions designed to increase PA behavior exclusively in children (ages 5 to 11years) focus primarily on the efficacy (e.g., internal validity) of the interventions without addressing the applicability of the results in terms of generalizability and translatability (e.g., external validity).

OBJECTIVE

This review used the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) framework to measure the degree to which randomized and non-randomized PA interventions in children report on internal and external validity factors.

METHODS AND RESULTS

A systematic search for controlled interventions conducted within the past 12years identified 78 studies that met the inclusion criteria. Based on the RE-AIM criteria, most of the studies focused on elements of internal validity (e.g., sample size, intervention location and efficacy/effectiveness) with minimal reporting of external validity indicators (e.g., representativeness of participants, start-up costs, protocol fidelity and sustainability).

CONCLUSIONS

Results of this RE-AIM review emphasize the need for future PA interventions in children to report on real-world challenges and limitations, and to highlight considerations for translating evidence-based results into health promotion practice.

Expanding the reach of the Quitline by engaging volunteers to market it in hospitals and shopping venues - a pilot study

BACKGROUND

In Canada, although there are periodic media campaigns to raise awareness of Quitlines, these services are underused. We sought to determine if a dedicated kiosk, similar to that used in the retail industry but staffed by volunteers trained in smoking cessation techniques, would be effective method to enhance Quitline reach.

METHODS

We located a kiosk in the foyer of two hospitals and in two shopping malls in Edmonton, Canada between Feb/2012 and July/2014. The cessation intervention was based on the 5 A's approach. Outcome was assessed by number of visits to the kiosk and referral rates to the Quitline. A cross sectional survey among small sample of visitors was used for evaluation. Descriptive statistics were used to summarize visitors' data.

RESULTS

Of 1091 kiosk visitors, 53.3 % were current smokers, of whom 93.3 % indicated a willingness to quit. Of these, 32.1 % requested a Quitline referral at the time of the kiosk visit. Referral requests to the Quitline were greater when the kiosk was located in the non-hospital setting 39.1 % compared to 31.1 % in hospitals (P = 0.2). Referrals from the kiosk represented 6 % of total referrals received by the provincial Quitline during the study period. Following referral the Quitline was able to reach 50 % of those referred, of those, 17 % refused to proceed. At seven month follow up 30 day abstinence rate was 3.8 % of smokers who wished quit. Visitors agreed that the kiosk design was interesting (89.3 %) and increased their knowledge about tobacco and cessation options (88.8 %) and encouraged them to take action to quit (85.7 %).

CONCLUSIONS

A "volunteer manned kiosk" can increase awareness of smoking cessation resources in the community and increase referral rates to Quitline services.