12-Month Evaluation of an EHR-Supported Staff Role Change for Provision of Tobacco Cessation Care in 8 Primary Care Safety-Net Clinics

SIGNIFICANCE

Guidelines urge primary care practices to routinely provide tobacco cessation care (i.e., assess tobacco use, provide brief cessation advice, and refer to cessation support). This study evaluates the impact of a systems-based strategy to provide tobacco cessation care in eight primary care clinics serving low-income patients.

METHODS

A non-randomized stepped wedge study design was used to implement an intervention consisting of (1) changes to the electronic health record (EHR) referral functionality and (2) expansion of staff roles to provide brief advice to quit; assess readiness to quit; offer a referral to tobacco cessation counseling; and sign the referral order. Outcomes assessed from the EHR include performance of tobacco cessation care tasks, referral contact, and enrollment rates for the quitline (QL) and in-house Freedom from Smoking (FFS) program. Generalized estimating equations (GEE) methods were used to compute odds ratios contrasting the pre-implementation vs. 1-, 3-, 6-, and 12-month post-implementation periods.

RESULTS

Of the 176,061 visits, 26.1% were by identified tobacco users. All indicators significantly increased at each time period evaluated post-implementation. In comparison with the pre-intervention period, assessing smoking status (26.6% vs. 55.7%; OR = 3.7, CI = 3.6-3.9), providing advice (44.8% vs. 88.7%; OR = 7.8, CI = 6.6-9.1), assessing readiness to quit (15.8% vs. 55.0%; OR = 6.2, CI = 5.4-7.0), and acceptance of a referral to tobacco cessation counseling (0.5% vs. 30.9%; OR = 81.0, CI = 11.4-575.8) remained significantly higher 12 months post-intervention. For the QL and FFS, respectively, there were 1223 and 532 referrals; 324 (31.1%) and 103 (24.7%) were contacted; 241 (74.4%) and 72 (69.6%) enrolled; and 195 (80.9%) and 14 (19.4%) received at least one counseling session.

CONCLUSIONS

This system change intervention that includes an EHR-supported role expansion substantially increased the provision of tobacco cessation care and improvements were sustained beyond 1 year. This approach has the potential to greatly increase the number of individuals referred for tobacco cessation counseling.

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

BACKGROUND

The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in order to inform strategies for improving QL engagement.

METHODS

We conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017-August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes.

RESULTS

Reasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL.

CONCLUSIONS

Participants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.

Lythrum hyssopifolia (lesser loosestrife) poisoning of sheep in Victoria

OBJECTIVE

To document an ovine disease attributed to the consumption of Lythrum hyssopifolia (lesser loosestrife).

PROCEDURES

Historical and histological review of field and experimental cases.

RESULTS

1-20% mortality occurred in sheep flocks grazing paddocks where L. hyssopifolia was the predominant green vegetation. Well-documented disease outbreaks occurred in summer on nine farms across Victoria between 1974 and 2002. Liver damage occurred in all nine outbreaks, with kidney damage in at least eight. Hepatocyte necrosis was usually zonal to midzonal (zone 2) in the liver samples from four farms and periacinar (zone 3) in those from three farms, but some livers showed only single-cell necrosis. Multinucleate hepatocytes near necrotic areas were a feature in six cases. Proximal tubular epithelium appeared to be the primary renal target and brown granules were often present in renal tubules. Biochemical and histological evidence of liver and kidney damage was obtained from two sheep experimentally pen-fed harvested L. hyssopifolia.

CONCLUSION

Chemicals in L. hyssopifolia are toxic to ovine hepatocytes and renal tubular epithelial cells.

Intranasal absorption of granulocyte-colony stimulating factor (G-CSF) from powder formulations, in sheep

Granulocyte-colony stimulating factor (G-CSF) was administered to sheep in three different nasal formulations and as a subcutaneous injection. The nasal formulations were: a solution containing L-alpha-lysophosphatidylglycerol (LPG), a powder formulation comprising small starch microspheres (SSMS) and a powder formulation comprising SSMS and LPG. Absorption of G-CSF was assessed directly by quantitation in plasma and indirectly by measurement of the pharmacodynamic response in terms of leucocyte and neutrophil counts. After the nasal delivery of the G-CSF powder formulation containing SSMS and LPG the absorption of G-CSF was significantly higher (P<0.01) than that from the simple nasal solution or the powder without the enhancer, but the resulting pharmacological response was not significantly different. The bioavailability of G-CSF from the powder formulation containing SSMS and LPG relative to the subcutaneous injection was 8.4% (+/-3.4). We also found that at the respective G-CSF doses investigated, the pharmacodynamic response of this nasal formulation, was similar to that obtained after the subcutaneous administration. The study indicates that the powder formulation containing enhancers could offer an alternative delivery route for G-CSF in the form of intranasal administration.

Management of land and livestock contaminated with polychlorinated biphenyls

Investigations were conducted on several small neighbouring beef cattle and sheep farms that were found to be contaminated with polychlorinated biphenyls (PCBs). The residues detected contained about 62% w/w chlorine and soil concentrations ranged from 0.35 to 1.9 mg/kg. Beef cattle and sheep grazing the contaminated land had PCB concentrations in their fat of 0.3 to 1.7 mg/kg and 0.19 to 0.45 mg/kg, respectively. The concentration of PCBs in the caudal fat of cattle was 0.3 to 2 times the concentration of PCBs in the land they were grazing and was positively related to stocking rates. PCBs were present in milk fat from cattle at about the same concentration as in caudal fat, and lactation appeared to contribute to decontamination. Wool grease from sheep contained about 1 to 2 times the concentration of PCBs in subcutaneous fat. Calves of contaminated cows also became contaminated. The half-life for decontamination of PCBs in a group of 8 young female beef cattle was calculated at 13 months. PCBs were detected in pasture samples at concentrations ranging from less than 0.01 mg/kg to 0.12 mg/kg. However, PCBs were not detected in any sample of hay cut from these paddocks. In 4 sheep fed a sole ration of this hay, traces of PCBs were detected in their fat following 89 days of feeding. Grazing livestock for meat production on land contaminated with PCBs is not recommended because livestock readily acquire residues, and PCBs persist in soil and livestock for long periods. Grazing sheep for wool production on land contaminated with PCBs may be an option.

A comparison of the interferon gamma assay with the absorbed ELISA for the diagnosis of Johne's disease in cattle

Two interferon gamma (IFN-gamma) assays, the IFN-gamma enzyme immunoassay (EIA) and the IFN-gamma bioassay and an absorbed ELISA were used to screen 6 cattle herds for Johne's disease. Each herd had a history of Johne's disease but the majority of infected animals did not show clinical signs. The disease status of the cattle, which were removed from the herds, was confirmed by bacteriological culture of faeces or histopathological examination and culture of tissues collected at necropsy. The sensitivities of the IFN-gamma assays and the absorbed ELISA were determined using test results from infected animals. The sensitivity of the IFN-gamma EIA in detecting subclinical (71.8 to 93.3%) and clinical animals (100%) was not significantly different. However, the IFN-gamma bioassay and the absorbed ELISA were more sensitive in detecting cattle with advanced infections (80%) than those that were subclinically affected (16.7 to 33.3%).