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Sustained Effects of a Systems-Based Strategy for Tobacco Cessation Assistance. Am J Prev Med 2023; 64:428-432. [PMID: 36376144 DOI: 10.1016/j.amepre.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/28/2022] [Accepted: 09/16/2022] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Primary care settings that serve lower-income patients are critical for reducing tobacco-related disparities; however, tobacco-related care in these settings remains low. This study examined whether processes for the provision of tobacco cessation care are sustained 18 and 24 months after implementing a health system-level intervention consisting of electronic health record functionality changes and expansion of rooming staff roles. METHODS This nonrandomized stepped-wedge study included electronic health record data from adults with ≥1 primary care visit to 1 of 8 community-based clinics between August 2016 and September 2019. Generalized estimating equations methods were used to compute ORs of asking about tobacco use and among those who use tobacco, providing brief advice to quit and assessing readiness to quit, contrasting 18 and 24 months after implementation to both preimplementation (baseline) and 12 months after implementation. Using a 2-level model of patients clustered in clinics, outcomes were examined over time by clinic site. Analyses were conducted in 2022. RESULTS A total of 305,665 patient visits were evaluated. Significantly higher odds of all 3 outcomes were observed at 18 and 24 months than at baseline. The odds of asking about tobacco use increased, whereas the odds of advising to quit were similar at 18 and 24 months to those at 12 months. Odds of assessing readiness to quit decreased at 18 months (OR=0.71; 95% CI=0.63, 0.80) and 24 months (OR=0.46; 95% CI=0.40, 0.52). Performance varied significantly by clinical site. CONCLUSIONS Health system changes can have a sustained impact on tobacco assessment and the provision of brief advice among lower-income patients. Strategies to sustain assessment of readiness to quit are warranted.
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Klein JD, Chamberlin ME, Kress EA, Geraci MW, Rosenblatt S, Boykan R, Jenssen B, Rosenblatt SM, Milberger S, Adams WG, Goldstein AO, Rigotti NA, Hovell MF, Holm AL, Vandivier RW, Croxton TL, Young PL, Blissard L, Jewell K, Richardson L, Ostrow J, Resnick EA. Asking the Right Questions About Secondhand Smoke. Nicotine Tob Res 2021; 23:57-62. [PMID: 31407779 DOI: 10.1093/ntr/ntz125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/25/2019] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred. METHODS A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization. RESULTS Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening. CONCLUSIONS The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening. IMPLICATIONS In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.
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Affiliation(s)
- Jonathan D Klein
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL, USA.,Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Itasca, IL, USA
| | | | | | - Mark W Geraci
- Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Susan Rosenblatt
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Rachel Boykan
- Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Brian Jenssen
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Sharon Milberger
- Michigan Developmental Disabilities Institute, Wayne State University, Detroit, MI, USA
| | - William G Adams
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
| | - Adam O Goldstein
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, MA, USA
| | - Melbourne F Hovell
- Division of Health Promotion and Behavioral Science, San Diego State University School of Public Health, San Diego, CA, USA
| | - Amanda L Holm
- Center of Health Promotion and Disease Prevention, Henry Ford Health System, Detroit, MI, USA
| | - Richard W Vandivier
- Department of Medicine, Pulmonary Sciences & Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Thomas L Croxton
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Patricia L Young
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Lani Blissard
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Kate Jewell
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Leisa Richardson
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - John Ostrow
- Flight Attendant Medical Research Institute, Coral Gables, FL, USA
| | - Elissa A Resnick
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL, USA
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Boykan R, Gorzkowski J, Wellman RJ, Jenssen BP, Klein JD, Krugman J, Pbert L, Salloum RG. Pediatric Resident Training in Tobacco Control and the Electronic Health Record. Am J Prev Med 2021; 60:446-452. [PMID: 33131991 DOI: 10.1016/j.amepre.2020.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 11/30/2022]
Abstract
Given the dangers posed by tobacco use and tobacco smoke exposure, pediatricians should address tobacco use and exposure with patients and parents at every opportunity, but this is not consistently done in practice. One reason may be that many medical residents do not receive education on how to address tobacco use and tobacco smoke exposure with patients and their parents. In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training. Respondents also reported infrequent use of electronic health record prompts regarding tobacco and the absence of prompts about critical issues (e.g., addressing tobacco smoke exposure in vehicles or other settings or offering treatment or referrals to parents who smoke). This paper provides recommendations about augmenting pediatric resident training in simple ways.
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Affiliation(s)
- Rachel Boykan
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.
| | - Julie Gorzkowski
- AAP Julius B. Richmond Center of Excellence, Itasca, Illinois; Pediatric Population Health, Department of Healthy Resilient Children Youth and Families, American Academy of Pediatrics, Itasca, Illinois
| | - Robert J Wellman
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Brian P Jenssen
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan D Klein
- AAP Julius B. Richmond Center of Excellence, Itasca, Illinois; Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | - Jessica Krugman
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Lori Pbert
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
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Amato MS, El-Toukhy S, Abroms LC, Goodfellow H, Ramsey AT, Brown T, Jopling H, Khadjesari Z. Mining Electronic Health Records to Promote the Reach of Digital Interventions for Cancer Prevention Through Proactive Electronic Outreach: Protocol for the Mixed Methods OptiMine Study. JMIR Res Protoc 2020; 9:e23669. [PMID: 33382041 PMCID: PMC7808893 DOI: 10.2196/23669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Digital behavior change interventions have demonstrated effectiveness for smoking cessation and reducing alcohol intake, which ultimately reduce cancer risk. Leveraging electronic health records (EHR) to identify at-risk patients and increasing the reach of digital interventions through proactive electronic outreach provide a novel approach that may increase the number of individuals who engage with evidence-based treatment. OBJECTIVE This study aims to increase the reach of digital behavior change interventions by implementing a proactive electronic message system for smoking cessation and alcohol reduction among a large, at-risk population identified through an acute hospital EHR. METHODS This protocol describes a 3-phase, mixed-methods implementation study to assess the acceptability, feasibility, and reach of a proactive electronic message system to digital interventions using a hospital's EHR system to identify eligible patients. In Phase 1, we will conduct focus group discussions with patients and hospital staff to assess the overall acceptability of the electronic message system. In Phase 2, we will conduct a descriptive analysis of the patient population in the hospital EHR regarding target risk behaviors and other person-level characteristics to determine the project's feasibility and potential reach. In Phase 3, we will send proactive messages to patients identified as smokers or risky drinkers. Messages will encourage and provide access to behavior change mobile apps via an embedded link; the primary outcome will be the proportion of participants who click on the link to access information about the apps. RESULTS At the time of initial protocol submission, data collection was complete, but analysis had not begun. This study was funded by Cancer Research UK from April 2019 to March 2020. Health Research Authority approval was granted in June 2019. CONCLUSIONS Increasing the reach of digital behavior change interventions can improve population health by reducing the burden of preventable death and disease. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/23669.
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Affiliation(s)
- Michael S Amato
- Truth Initiative, Washington DC, DC, United States
- College of Medicine and Science, Mayo Clinic, Rochester, MN, United States
| | - Sherine El-Toukhy
- Division of Intramural Research, The National Institute on Minority Health and Health Disparities, The National Institutes of Health, Bethesda, MD, United States
| | - Lorien C Abroms
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington DC, DC, United States
| | - Henry Goodfellow
- Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Alex T Ramsey
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, United States
| | - Tracey Brown
- Behavioural and Implementation Science research group, School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Helena Jopling
- West Suffolk NHS Foundation Trust, Bury St Edmunds, United Kingdom
| | - Zarnie Khadjesari
- Behavioural and Implementation Science research group, School of Health Sciences, University of East Anglia, Norwich, United Kingdom
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Boykan R, Walley S. Asthma to EVALI: Tobacco Use Is a Pediatric Problem. Hosp Pediatr 2020; 11:106-108. [PMID: 33386297 DOI: 10.1542/hpeds.2020-003715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Rachel Boykan
- Department of Pediatrics, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York; and
| | - Susan Walley
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Dickinson BJ, Thompson ED, Gracely EJ, Wilson KM. Smoking Cessation Counseling in the Inpatient Unit: A Survey of Pediatric Hospitalists. Hosp Pediatr 2020; 11:30-35. [PMID: 33386295 DOI: 10.1542/hpeds.2020-000414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine practices and beliefs of pediatric hospitalists regarding smoking cessation counseling for caregivers of hospitalized children. METHODS An electronic survey was distributed to 249 members of the Pediatric Research in Inpatient Settings Network over 6 weeks in 2017 (83 responses [33%]). Questions explored beliefs regarding the impact of tobacco smoke exposure (TSE) and practices in TSE screening, provision of counseling, resources, and pharmacotherapy. Nonparametric tests were used to compare groups on numeric variables, χ2 tests were used to compare groups on nominal variables, and McNemar's test was used to compare dichotomous responses within subjects. RESULTS All respondents were familiar with the term "secondhand smoke," and >75% were familiar with "thirdhand smoke" (THS). Familiarity with THS was associated with more recent completion of training (P = .04). Former smokers (7%) were less likely to agree that THS has a significant impact on a child's health (P = .04). Hospitalists ask about TSE more often than they provide counseling, resources, or pharmacotherapy to caregivers who want to quit smoking. Hospitalists are more likely to ask about TSE and provide cessation counseling when patients have asthma as opposed to other diseases. Time was identified by 41% of respondents as a barrier for providing counseling and by 26% of respondents as a barrier for providing resources. Most respondents never prescribe pharmacotherapy (72%), nor do they follow-up with caregivers after hospitalization regarding cessation (87%). CONCLUSIONS Although most respondents ask about TSE, opportunities are missed for counseling and providing support to caregivers who want to quit smoking. Providers should be educated about THS, and systems should be streamlined to facilitate brief counseling sessions.
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Affiliation(s)
- Blair J Dickinson
- Department of Pediatrics, Drexel University College of Medicine and St Christopher's Hospital for Children, Philadelphia, Pennsylvania;
| | - E Douglas Thompson
- Department of Pediatrics, Drexel University College of Medicine and St Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Edward J Gracely
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania; and
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Design and Pilot Implementation of an Electronic Health Record-Based System to Automatically Refer Cancer Patients to Tobacco Use Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17114054. [PMID: 32517176 PMCID: PMC7312526 DOI: 10.3390/ijerph17114054] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022]
Abstract
Continued tobacco use after cancer diagnosis is detrimental to treatment and survivorship. The current reach of evidence-based tobacco treatments in cancer patients is low. As a part of the National Cancer Institute Cancer Center Cessation Initiative, the Mayo Clinic Cancer Center designed an electronic health record (EHR, Epic©)-based process to automatically refer ambulatory oncology patients to tobacco use treatment, regardless of intent to cease tobacco use(“opt out”). The referral and patient scheduling, accomplished through a best practice advisory (BPA) directed to staff who room patients, does not require a co-signature from clinicians. This process was piloted for a six-week period starting in July of 2019 at the Division of Medical Oncology, Mayo Clinic, Rochester, MN. All oncology patients who were tobacco users were referred for tobacco treatment by the rooming staff (n = 210). Of these, 150 (71%) had a tobacco treatment appointment scheduled, and 25 (17%) completed their appointment. We conclude that an EHR-based “opt-out” approach to refer patients to tobacco dependence treatment that does not require active involvement by clinicians is feasible within the oncology clinical practice. Further work is needed to increase the proportion of scheduled patients who attend their appointments.
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