Training physicians about smoking cessation: a controlled trial in private practice

Strategies to improve smoking cessation rates in primary care

BACKGROUND

Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).

OBJECTIVES

To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

Multidisciplinary Teams are Essential for Developing Clinical Decision Support to Improve Pediatric Health Outcomes: An Exemplar

Clinical decision support with individualized patient education information can facilitate the translation of evidence-based guidelines into practice to improve pediatric patient outcomes. Interdisciplinary teams are required to develop and implement this technology support into practice. Engineering expertise with attention to three components is required: backend (e.g., data science, predictions), front end (e.g., user interface), and integration (e.g., workflow) must be addressed to achieve useful technology that will be adopted. An engineering framework, Technology Acceptance Model, can be used to guide the development of clinical decision support with patient education materials and includes a partnership with end users, both clinicians and patients.

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

BACKGROUND

Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

OBJECTIVES

1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

SELECTION CRITERIA

We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects.

AUTHORS' CONCLUSIONS

Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Smoking-Related Attitudes and Knowledge Among Medical Students and Recent Graduates in Argentina: A Cross-Sectional Study

BACKGROUND

Physicians in Argentina smoke at rates similar to the general population, and do not have a clear role in tobacco control strategies.

OBJECTIVE

To describe the attitudes and knowledge of medical students and recent graduates towards smoking behavior in Argentina.

DESIGN

Cross-sectional self-administered online survey conducted in 2011.

PARTICIPANTS

Medical students and recent medical graduates from the University of Buenos Aires.

MAIN MEASURES

Attitudes and knowledge were evaluated by responses to 16 statements regarding the effects of smoking cigarettes and the role of physicians in tobacco control. Rates of agreement with a full ban on indoor smoking in different public settings were assessed.

KEY RESULTS

The sample included 1659 participants (response rate: 35.1 %), 453 of whom (27.3 %) were current smokers. Only 52 % of participants agreed that doctors should set an example for their patients by not smoking, 30.9 % thought that medical advice had little effect on patients' cessation behavior, and 19.4 % believed that physicians could decline to care for smoking patients who failed to quit. In adjusted logistic regression models, current smokers had less supportive attitudes about tobacco control and were less likely than non-smokers to agree with a full indoor smoking ban in hospitals (OR: 0.30; 95 % CI 0.16-0.58), universities (OR: 0.55; 95 % CI 0.41-0.73), workplaces (OR: 0.67; 95 % CI 0.50-0.88), restaurants (OR: 0.42; 95 % CI 0.33-0.53), cafes (OR: 0.41; 95 % CI 0.33-0.51), nightclubs (OR: 0.32; 95 % CI 0.25-0.40), and bars (0.35; 95 % CI 0.28-0.45). Recent medical graduates had more accurate knowledge about cessation and were more likely to agree with a full smoking ban in recreational venues.

CONCLUSIONS

Although most participants reported a strong anti-tobacco attitude, a proportion still failed to recognize the importance of their role as physicians in tobacco control strategies. Current smokers and current students were less likely to support indoor smoking bans. Specific educational curricula could address these factors.

Tobacco brief intervention training for chiropractic, acupuncture, and massage practitioners: protocol for the CAM reach study

BACKGROUND

Tobacco use remains the leading cause of morbidity and mortality in the US. Effective tobacco cessation aids are widely available, yet underutilized. Tobacco cessation brief interventions (BIs) increase quit rates. However, BI training has focused on conventional medical providers, overlooking other health practitioners with regular contact with tobacco users. The 2007 National Health Interview Survey found that approximately 20% of those who use provider-based complementary and alternative medicine (CAM) are tobacco users. Thus, CAM practitioners potentially represent a large, untapped community resource for promoting tobacco cessation and use of effective cessation aids. Existing BI training is not well suited for CAM practitioners' background and practice patterns, because it assumes a conventional biomedical foundation of knowledge and philosophical approaches to health, healing and the patient-practitioner relationship. There is a pressing need to develop and test the effectiveness of BI training that is both grounded in Public Health Service (PHS) Guidelines for tobacco dependence treatment and that is relevant and appropriate for CAM practitioners.

METHODS/DESIGN

The CAM Reach (CAMR) intervention is a tobacco cessation BI training and office system intervention tailored specifically for chiropractors, acupuncturists and massage therapists. The CAMR study utilizes a single group one-way crossover design to examine the CAMR intervention's impact on CAM practitioners' tobacco-related practice behaviors. Primary outcomes included CAM practitioners' self-reported conduct of tobacco use screening and BIs. Secondary outcomes include tobacco using patients' readiness to quit, quit attempts, use of guideline-based treatments, and quit rates and also non-tobacco-using patients' actions to help someone else quit.

DISCUSSION

CAM practitioners provide care to significant numbers of tobacco users. Their practice patterns and philosophical approaches to health and healing are well suited for providing BIs. The CAMR study is examining the impact of the CAMR intervention on practitioners' tobacco-related practice behaviors, CAM patient behaviors, and documenting factors important to the conduct of practice-based research in real-world CAM practices.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register in January 2013 for trials of interventions involving physicians. We also searched Latin American databases through BVS (Virtual Library in Health) in February 2013.

SELECTION CRITERIA

Randomised trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomisation and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. People lost to follow-up were counted as smokers. Effects were expressed as relative risks. Where possible, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 42 trials, conducted between 1972 and 2012, including over 31,000 smokers. In some trials, participants were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics.Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow-up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register in January 2013 for trials of interventions involving physicians. We also searched Latin American databases through BVS (Virtual Library in Health) in February 2013.

SELECTION CRITERIA

Randomised trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomisation and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. People lost to follow-up were counted as smokers. Effects were expressed as relative risks. Where possible, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 42 trials, conducted between 1972 and 2012, including over 31,000 smokers. In some trials, participants were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics.Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow-up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

Training health professionals in smoking cessation

BACKGROUND

Cigarette smoking is one of the leading causes of preventable death world wide. There is good evidence that brief interventions from health professionals can increase smoking cessation attempts. A number of trials have examined whether skills training for health professionals can lead them to have greater success in helping their patients who smoke.

OBJECTIVES

To determine the effectiveness of training health care professionals in the delivery of smoking cessation interventions to their patients, and to assess the additional effects of training characteristics such as intervention content, delivery method and intensity.

SEARCH METHODS

The Cochrane Tobacco Addiction Group's Specialised Register, electronic databases and the bibliographies of identified studies were searched and raw data was requested from study authors where needed. Searches were updated in March 2012.

SELECTION CRITERIA

Randomized trials in which the intervention was training of health care professionals in smoking cessation. Trials were considered if they reported outcomes for patient smoking at least six months after the intervention. Process outcomes needed to be reported, however trials that reported effects only on process outcomes and not smoking behaviour were excluded.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics of each included study for interventions, participants, outcomes and methods were extracted by two independent reviewers. Studies were combined in a meta-analysis where possible and reported in narrative synthesis in text and table.

MAIN RESULTS

Of seventeen included studies, thirteen found no evidence of an effect for continuous smoking abstinence following the intervention. Meta-analysis of 14 studies for point prevalence of smoking produced a statistically and clinically significant effect in favour of the intervention (OR 1.36, 95% CI 1.20 to 1.55, p= 0.004). Meta-analysis of eight studies that reported continuous abstinence was also statistically significant (OR 1.60, 95% CI 1.26 to 2.03, p= 0.03).Healthcare professionals who had received training were more likely to perform tasks of smoking cessation than untrained controls, including: asking patients to set a quit date (p< 0.0001), make follow-up appointments (p< 0.00001), counselling of smokers (p< 0.00001), provision of self-help material (p< 0.0001) and prescription of a quit date (p< 0.00001). No evidence of an effect was observed for the provision of nicotine gum/replacement therapy.

AUTHORS' CONCLUSIONS

Training health professionals to provide smoking cessation interventions had a measurable effect on the point prevalence of smoking, continuous abstinence and professional performance. The one exception was the provision of nicotine gum or replacement therapy, which did not differ between groups.

Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study

BACKGROUND

Primary health care (PHC) settings offer opportunities for tobacco use screening and brief cessation advice, but data on such activities in South Africa are limited. The aim of this study was to determine the extent to which participants were screened for and advised against tobacco use during consultations.

METHODS

This cross-sectional study involved 500 participants, 18 years and older, attended by doctors or PHC nurses. Using an exit-interview questionnaire, information was obtained on participants' tobacco use status, reason(s) for seeking medical care, whether participants had been screened for and advised about their tobacco use and patients' level of comfort about being asked about and advised to quit tobacco use. Main outcome measures included patients' self-reports on having been screened and advised about tobacco use during their current clinic visit and/or any other visit within the last year. Data analysis included the use of chi-square statistics, t-tests and multiple logistic regression analysis.

RESULTS

Of the 500 participants, 14.9% were current smokers and 12.1% were smokeless tobacco users. Only 12.9% of the participants were screened for tobacco use during their current visit, indicating the vast majority were not screened. Among the 134 tobacco users, 11.9% reported being advised against tobacco use during the current visit and 35.1% during any other visit within the last year. Of the participants not screened, 88% indicated they would be 'very comfortable' with being screened. A pregnancy-related clinic visit was the single most significant predictor for being screened during the current clinic visit (OR = 4.59; 95%CI = 2.13-9.88).

CONCLUSION

Opportunities for tobacco use screening and brief cessation advice were largely missed by clinicians. Incorporating tobacco use status into the clinical vital signs as is done for pregnant patients during antenatal care visits in South Africa has the potential to improve tobacco use screening rates and subsequent cessation.

Engaging physicians and pharmacists in providing smoking cessation counseling

BACKGROUND

Health professionals have a proven, positive impact on patients' ability to quit smoking, yet few integrate cessation counseling into routine practice.The aim of this study was to evaluate the impact of continuing education training on physicians' and pharmacists' cessation counseling.

METHODS

A group-randomized trial of health care providers (87 physicians and 83 pharmacists) from 16 Texas communities compared smoking cessation training (intervention group) with skin cancer prevention training (control group). Pretraining, posttraining, and extended follow-up surveys were collected from providers. Perceived ability, confidence, and intention (ACI) to address smoking with patients were assessed with a composite ACI index. Patient exit interviews (at baseline, 1452 patients completed interviews; after 12 months, 1303 completed interviews) assessed counseling practices.

RESULTS

There was a significant increase in the percentage of physicians with a high ACI index in the intervention group from pretraining to posttraining (27% to 73%; P < .001) vs the control group (27% to 34%; P = .42) and for pharmacists (4% to 60%; P < .001) vs the control group (10% to 14%; P = .99). Similar results were seen from pretraining to extended follow-up. At baseline, fewer pharmacy patients reported being asked about smoking compared with patients seen by physicians (7% vs 33%; P = .001). There was an increase in assisting patients to quit (6% to 36%; P = .002) by physicians (baseline vs 12 months) in the intervention group, but not in the control group.

CONCLUSIONS

Training led to significant and lasting improvement in counseling among physicians. Low levels of counseling were seen among pharmacists.

Continuing medical education effect on practice performance: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines

BACKGROUND

There has been sizable debate and widespread skepticism about the effect of continuing medical education (CME) on the performance of physicians in the practice setting. This portion of the review was undertaken to examine that effect.

METHODS

The guideline panel used data from a comprehensive review of the effectiveness of CME developed by The Johns Hopkins Evidence-based Practice Center, focusing on the effect of CME on clinical performance.

RESULTS

The review found 105 studies, which evaluated the impact of CME on short- and long-term physician practice performance. Nearly 60% met objectives relative to changing clinical performance in prescribing; screening; counseling about smoking cessation, diet, and sexual practices; guideline adherence; and other topics. Single live and multiple media appeared to be generally positive in their effect, print media much less so. Multiple educational techniques were more successful at changing provider performance than single techniques. The amount or frequency of exposure to CME activities appeared to have little effect on behavior change.

CONCLUSIONS

Overall, CME, especially using live or multiple media and multiple educational techniques, is generally effective in changing physician performance. More research, however, is needed that focuses on the specific types of media and educational techniques that lead to the greatest improvements in performance.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search: September 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomization and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were counted as smokers. Effects were expressed as relative risks. Where possible, meta-analysis was performed using a Mantel-Haenszel fixed effect model.

MAIN RESULTS

We identified 41 trials, conducted between 1972 and 2007, including over 31,000 smokers. In some trials, subjects were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics. Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Prompting clinicians about preventive care measures: a systematic review of randomized controlled trials

Preventive care measures remain underutilized despite recommendations to increase their use. The objective of this review was to examine the characteristics, types, and effects of paper- and computer-based interventions for preventive care measures. The study provides an update to a previous systematic review. We included randomized controlled trials that implemented a physician reminder and measured the effects on the frequency of providing preventive care. Of the 1,535 articles identified, 28 met inclusion criteria and were combined with the 33 studies from the previous review. The studies involved 264 preventive care interventions, 4,638 clinicians and 144,605 patients. Implementation strategies included combined paper-based with computer generated reminders in 34 studies (56%), paper-based reminders in 19 studies (31%), and fully computerized reminders in 8 studies (13%). The average increase for the three strategies in delivering preventive care measures ranged between 12% and 14%. Cardiac care and smoking cessation reminders were most effective. Computer-generated prompts were the most commonly implemented reminders. Clinician reminders are a successful approach for increasing the rates of delivering preventive care; however, their effectiveness remains modest. Despite increased implementation of electronic health records, randomized controlled trials evaluating computerized reminder systems are infrequent.

The effect of a minimal intervention strategy in addition to nicotine replacement therapy to support smoking cessation in cardiovascular outpatients: a randomized clinical trial

BACKGROUND

Smoking is an important risk factor for recurrent events in cardiovascular patients. Evidence exists that nicotine replacement therapy (NRT) approximately doubles smoking cessation rates. The minimal intervention strategy (MIS) has been used successfully to assist patients to quit smoking in general practice, and was recently adapted for cardiology inpatients (C-MIS). It is hypothesized that in cardiovascular outpatients the combination of C-MIS and NRT significantly increases the number of quitters compared to NRT alone.

METHODS

A randomized clinical trial in 385 smoking patients who attended the cardiovascular outpatient departments in the Academic Medical Centre, Amsterdam for the treatment of atherosclerotic disease. Patients were allocated to either NRT + C-MIS or NRT alone. Self-reported and biochemically validated abstinence rates were measured at 12 months' follow-up.

RESULTS

Including patients with incomplete follow-up as smokers, abstinence was reported by 19% of the NRT + C-MIS group and 14% of the NRT group [absolute risk reduction (ARR) = 0.05; 95% confidence interval (CI) = -0.02; 0.12]. According to biochemical markers, abstinence rates were 28 and 24%, respectively (ARR = 0.04, 95% CI = -0.06; 0.14). Hence, no significant differences between groups were found. The number of cigarettes smoked a day decreased significantly at 12 months: from 21 to 15 a day in the experimental group, and from 21 to 14 in the control group (P<0.001), but did not differ between groups (P=0.32).

CONCLUSIONS

The effectiveness of a minimal contact intervention was investigated in order to reach as many cardiovascular patients as possible in the setting of outpatient departments. This intervention was not found to be effective.

Smoking prevention and cessation intervention delivery by pediatric providers, as assessed with patient exit interviews

OBJECTIVE

The goal was to evaluate the degree to which a smoking prevention and cessation intervention was delivered by providers to adolescents in the pediatric office setting.

METHODS

Eight pediatric clinics in central Massachusetts were assigned randomly to either a special intervention (brief pediatric provider-delivered intervention plus peer counseling) or the usual care condition. Subjects (n = 2710) were adolescents 13 to 17 years of age, both smokers (smoked in the past 30 days) and nonsmokers/former smokers. The degree to which smoking prevention and treatment interventions were delivered by providers was assessed through patient exit interviews with adolescents after their clinic visits; interviews assessed the occurrence of 10 possible intervention steps.

RESULTS

The percentage of providers engaging in the smoking interventions differed significantly between the special intervention and usual care conditions, according to adolescent reports in the patient exit interviews. For nonsmokers/former smokers, overall patient exit interview scores were 7.24 for the special intervention condition and 4.95 for the usual care condition. For current smokers, overall patient exit interview scores were 8.40 and 6.24 for the special intervention and usual care conditions, respectively. Intervention fidelity of special intervention providers was 72.2% and 84.0% for nonsmokers/former smokers and current smokers, respectively.

CONCLUSIONS

Pediatric providers who receive training and reminders to deliver a brief smoking prevention and cessation intervention to adolescents in the context of routine pediatric primary care practice can do so feasibly and with a high degree of fidelity to the intervention protocol.

General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review

OBJECTIVE

To estimate the proportion of general practitioners (GPs) and family physicians (FPs) with negative beliefs and attitudes towards discussing smoking cessation with patients.

METHODS

A systematic review.

STUDY SELECTION

All studies published in English, in peer-reviewed journals, which allowed the extraction of the proportion of GPs and FPs with negative beliefs and attitudes towards discussing smoking cessation.

DATA SYNTHESIS

Negative beliefs and attitudes were extracted and categorised. Proportions were synthesized giving greater weight to those obtained from studies with larger samples. Those assessed in two or more studies are reported.

RESULTS

Across 19 studies, eight negative beliefs and attitudes were identified. While the majority of GPs and FPs do not have negative beliefs and attitudes towards discussing smoking with their patients, a sizeable minority do. The most common negative beliefs were that such discussions were too time-consuming (weighted proportion: 42%) and were ineffective (38%). Just over a quarter (22%) of physicians reported lacking confidence in their ability to discuss smoking with their patients, 18% felt such discussions were unpleasant, 16% lacked confidence in their knowledge, and relatively few considered discussing smoking outside of their professional duty (5%), or that this intruded upon patients' privacy (5%), or that such discussion were inappropriate (3%).

CONCLUSIONS

In addition to providing skills training, interventions designed to increase the implementation of smoking cessation interventions by primary care physicians may be more effective if they address a range of commonly held negative beliefs and attitudes towards discussing smoking cessation. These include beliefs and values that influence primary care physicians' judgements about whether discussing smoking is an effective use of their time.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register and the Cochrane Central Register of Controlled Trials (CENTRAL). Date of the most recent searches: March 2004.

SELECTION CRITERIA

Randomized trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomization and completeness of follow up. The main outcome measures were abstinence from smoking after at least six months follow up and mortality. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were counted as smokers. Where possible, meta-analysis was performed using a Mantel-Haenszel fixed effect model.

MAIN RESULTS

We identified 39 trials, conducted between 1972 and 2003, including over 31,000 smokers. In some trials, subjects were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics. Pooled data from 17 trials of brief advice versus no advice (or usual care) revealed a small but significant increase in the odds of quitting (odds ratio 1.74, 95% confidence interval 1.48 to 2.05). This equates to an absolute difference in the cessation rate of about 2.5%. There was insufficient evidence, from indirect comparisons, to establish a significant difference in the effectiveness of physician advice according to the intensity of the intervention, the amount of follow up provided, and whether or not various aids were used at the time of the consultation in addition to providing advice. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (odds ratio 1.44, 95% confidence interval 1.24 to 1.67). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. It found no statistically significant differences in death rates at 20 years follow up.

REVIEWERS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Additional manoeuvres appear to have only a small effect, though more intensive interventions are marginally more effective than minimal interventions.

Smoking cessation in primary care: a clinical effectiveness trial of two simple interventions

BACKGROUND

Many primary care practices do not have systematic protocols to identify patients who smoke or to encourage clinicians to provide smoking cessation advice. We designed a study to assess the relative effectiveness of two brief interventions on screening for smoking, physician cessation advice and patient smoking cessation rates.

METHODS

We performed a nonrandomized comparison of alternative strategies for smoking cessation at a hospital-based adult primary care practice. Each intervention was implemented on a separate practice team. The "minimal" intervention consisted of a smoking status "vital sign" stamp which documented patient smoking status. The "enhanced" intervention consisted of a five-question form that assessed patient level of cessation readiness and provided cessation-counseling prompts for clinicians. Medical record documentation of screening for smoking and cessation advice and self-reported patient smoking cessation rates were collected 8-10 months after implementation.

RESULTS

Smoking status was documented at 86%, 91%, and 49%, and cessation advice at 38%, 47%, and 30% of visits on the minimal, enhanced, and control teams, respectively (P < 0.001 for smoking status and P = 0.014 for advice). Self-reported patient smoking cessation was higher on the enhanced team (12%) compared with the minimal (2%) and control (4%) teams (P < 0.001).

CONCLUSIONS

A short questionnaire that assesses readiness-to-quit and provides documentation of cessation advice improves rates of clinician cessation advice and patient smoking cessation compared with no intervention.

Support for Smoking Cessation Interventions in Physician Organizations

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.

The state of office-based interventions for youth tobacco use

Tobacco use is a serious pediatric health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Although evidence-based practice guidelines for treating nicotine dependence in youths are not yet available, professional organizations and the current clinical practice guideline for adults provide recommendations based on expert opinion. This article reports on the current tobacco treatment practices of pediatric and family practice clinicians, discusses similarities and differences between adolescent and adult tobacco use, summarizes research efforts to date and current cutting-edge research that may ultimately help to inform and guide clinicians, and presents existing recommendations regarding treating tobacco use in youths. Finally, recommendations are made for the primary care clinician, professional organizations, and health care systems and policies. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.

Effectiveness of a nationally implemented smoking cessation guideline on provider and patient practices

BACKGROUND

The Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline outlines a set of recommendations for physicians to follow in daily practice. However, the effectiveness of this guideline has not been reported. The goal of this project was to evaluate the effect of the AHCPR smoking cessation guideline on provider practices with smokers and on patient smoking rates.

METHODS

Patient survey and chart review data from 138 Veterans Administration (VA) acute care medical centers with outpatient facilities were examined. Data were available from both sources in 1996, 1997, and 1998. At the midpoint of this period (1997), the VA recommended the AHCPR smoking cessation clinical practice guideline for implementation throughout the VA healthcare system.

RESULTS

From 1996 to 1998, both the chart audit and the patient survey showed a significant increase in the percentage of patients in the VA who were counseled about smoking and a significant decrease in the percentage of patients who smoke.

CONCLUSIONS

Because the VA tied the guideline implementation to report cards and other performance-enhancing measures, guideline adherence may have been maximized in this setting. These findings suggest that healthcare systems should take an integrated approach to guideline implementation.

An academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project

BACKGROUND

Little is known about the effectiveness of interventions to disseminate smoking cessation interventions among a population of primary care physicians. This study's objective was to determine the effect of a community-based academic detailing intervention on the quit rates of a population-based sample of smokers.

METHODS

This community-based, quasi-experimental study involved representative samples of 259 primary care physicians and 4295 adult smokers. An academic detailing intervention was delivered to physicians in intervention areas over a period of 15 months. Analyses were performed on the data from the 2346 subjects who reported at least one physician visit over 24 months. Multivariate regression analyses were conducted to determine the impact of the intervention on self-reported smoking quit rates, reported by adjusted odds ratios.

RESULTS

Among smokers reporting a physician visit during the study period, there was a borderline significant effect for those residing in intervention areas versus control areas (OR = 1.35; 95% CI.99-1.83; P = 0.057). Among a subgroup of 819 smokers who reported a visit with an enrolled physician, we observed a significant effect for those residing in intervention areas (OR = 1.80; 95% CI 1.16-2.75; P = 0.008).

CONCLUSION

An academic detailing intervention to enhance physician delivered smoking cessation counseling is an effective strategy for disseminating smoking cessation interventions among community-based practices.

Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement

OBJECTIVE

To assess the frequency of clinician-reported delivery of counseling for avoidance of child environmental tobacco smoke (ETS) exposure and tobacco use at periodic well-child visits and at illness visits for asthma and otitis media (OM).

METHODS

Combined data from the National Ambulatory Medical Care Survey and the outpatient portion of the National Hospital Ambulatory Medical Care Survey from 1997 to 1999 were analyzed. The frequency of pediatric visits (<or=18 years) that included clinician-reported counseling for tobacco use/exposure prevention was assessed. Diagnosis-specific visits were determined by using International Classification of Diseases, Ninth Revision codes for asthma (493-), OM (381-, 382-), and well-child visits. Bivariate and regression analyses were performed.

RESULTS

Of 33 823 ambulatory care visits by children, 1.5% were reported to include delivery of tobacco counseling. Only 4.1% of well-child visits, 4.4% of illness visits for asthma, and 0.3% of illness visits for OM included tobacco counseling. With the use of logistic regression models, adolescent patient visits (13-18 years) were more likely to include delivery of tobacco counseling than younger child visits [OR = 15.8, 95% CI (7.5-33.5)]. Visits by children with Medicaid and those seen by a nurse practitioner or a physician's assistant were also more likely to include tobacco counseling (odds ratio: 1.6; 95% confidence interval: 1.002-2.50; and odds ratio: 3.0; 95% confidence interval: 1.5-6.0, respectively). There were no significant differences in counseling delivery by race, ethnicity, or clinician specialty.

CONCLUSIONS

Rates of tobacco counseling at well-child visits and at illness visits for diagnoses directly affected by tobacco use and ETS are extremely low. Significant opportunities exist to improve counseling rates for child ETS exposure and adolescent tobacco use in primary care.

Hospital initiatives in promoting smoking cessation: a survey of Internet and hospital-based programs targeted at consumers

STUDY OBJECTIVES

This study assesses how often local US hospitals provide smoking cessation information in the following two ways: via hospital Web sites; and via routing incoming phone calls to their hospital switchboards to an in-house smoking cessation clinic.

DESIGN

Random survey of US hospitals.

SETTING

US hospital Web pages and telephone switchboards.

PATIENTS OR PARTICIPANTS

One hundred two randomly selected US hospitals.

INTERVENTIONS

One hundred two hospital Web sites were randomly selected across the United States. The site was searched for the topic of smoking cessation. In the second phase of the survey, the main switchboard number of the same 102 hospitals was anonymously called and the "stop smoking clinic" was asked for.

MEASUREMENTS AND RESULTS

The overall results indicate that among the hospital Web sites surveyed, only 30% contained information relating to smoking cessation programs. The phone survey of hospital switchboards showed that 47% had a smoking cessation program available via phone inquiry, while 53% did not.

CONCLUSIONS

Of the US hospital Web sites visited, only 30% contained information on smoking cessation. The yield of finding the desired information was increased by the presence of an intrasite search option, which is a low-cost enhancement to any complex Web site. The relatively low cost of promoting healthy behaviors such as smoking cessation on a hospital Web site should be used more widely. Surprisingly, the phone survey of hospitals showed that the lower technology route of providing smoking cessation information to patients via a patient-initiated phone call is only available in 47% of hospitals. Both the Internet and phone-based switchboard referrals could be more widely and effectively used. Joint Commission on Accreditation of Healthcare Organizations guidelines would be one avenue of increasing the availability of smoking cessation information at hospital switchboards and Web sites.

Randomized controlled trials of continuing medical education: what makes them most effective?

INTRODUCTION

It is essential that professional standards of excellence are demonstrated in the continuing medical education (CME) curriculum and research.

METHODS

This review examines 20 randomized controlled trial (RCT) studies in CME and their effect on physician performance and/or patient health care outcomes. A systematic evaluation of the 20 RCT articles was performed. The investigators of the trials were interviewed using a standardized interview schedule. Citations from science and social science publications were compiled to obtain an unobtrusive measure of the influence of the trials.

RESULTS

Investigators were most often motivated to build on earlier research of others, their own earlier research, or a combination of others' earlier research and their own. The most effective educational strategies used multiple interventions, two-way communications, printed and graphic materials in person, and locally respected health personnel as educators. Statistically significant findings more often related to physician performance than to patient health care outcomes. The most effective studies were the ones in which the educational methods were cost effective, findings could be generalized to other physician groups, the studies were implemented elsewhere in multisite health care and health-related programs and had the most citations. Investigators interviewed about their RCTs provided advice for future directions of CME curriculum development and research.

DISCUSSION

CME program directors should determine what physicians need to learn, should reach out to nonparticipating physicians, and should focus on relevant problem areas. These problem areas should be ones in which it is possible to make changes, particularly in patient health care outcomes.

Enhancing primary care HIV prevention: a comprehensive clinical intervention

CONTEXT

Human immunodeficiency virus (HIV) and sexually transmitted disease (STD) risk assessment and counseling are recommended for a large proportion of the population, yet measured rates of such counseling remain low.

OBJECTIVE

Use a comprehensive intervention to improve and sustain rates of HIV/STD risk assessment and counseling by providers.

DESIGN

Patient telephone survey using a one-group pre- and post-intervention design with measurements over a 62-week period.

SETTING AND PARTICIPANTS

Patients (N=1042) from two outpatient clinics at a health maintenance organization (HMO) presenting for either of two types of index visit: symptomatic (n=210), or routine physical examination or birth control (n=832) visits.

MAIN OUTCOME MEASURES

Telephone survey performed within 3 weeks of the index visit. Patients' recall of a general discussion of HIV/STDs and specific discussion of sexual behaviors/risk factors.

RESULTS

The intervention was associated with increased patient recall of providers: discussing HIV/STD in general (OR 1.6; 95% CI, 1.12-2.22), asking about sexual behaviors/risk factors (OR 1.7; 95% CI, 1.2-2.6), discussing HIV prevention generally (OR 2.4; 95% CI, 1.4-4.0), and discussing personal risk reduction (OR 2.6; 95% CI, 1.6-4.3). Provision of written materials concerning HIV/STD also increased significantly (OR 2.8; 95% CI, 1.3-4.3). A clear-cut pattern of improved provider effort was seen, with the most pronounced improvements in high-risk patients. Results were stable over a 38-week follow-up period.

CONCLUSION

A sustained improvement in HIV/STD risk assessment and counseling can be achieved in an outpatient HMO setting using a relatively non-intensive systematized intervention.

Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke

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.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of health care providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care are increasingly advocated by consumers and clinicians and incorporated into training for health care providers. The effects of interventions that aim to promote patient-centred care need to be evaluated.

OBJECTIVES

To assess the effects of interventions for health care providers that aim to promote patient-centred approaches in clinical consultations.

SEARCH STRATEGY

We searched Medline (1966 - Dec 1999); Health Star (1975 - Dec 1999); PsycLit (1887- Dec 1999); Cinahl (1982 - Dec 1999); Embase (1985-Dec 1999) and the bibliographies of studies assessed for inclusion.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for health care providers that promote patient-centred care in clinical consultations. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). The participants were health care providers, including those in training.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality for each study. We extracted all outcomes other than health care providers' knowledge, attitudes and intentions.

MAIN RESULTS

17 studies met the inclusion criteria. These studies display considerable heterogeneity in terms of the interventions themselves, the health problems or health concerns on which the interventions focused, the comparisons made and the outcomes assessed. All included studies used training for health care providers as an element of the intervention. Ten studies evaluated training for providers only, while the remaining studies utilised multi-faceted interventions where training for providers was one of several components. The health care providers were mainly primary care physicians (general practitioners or family doctors) practising in community or hospital outpatient settings. In two studies, the providers also included nurses. There is fairly strong evidence to suggest that some interventions to promote patient-centred care in clinical consultations may lead to significant increases in the patient centredness of consultation processes. 12 of the 14 studies that assessed consultation processes showed improvements in some of these outcomes. There is also some evidence that training health care providers in patient-centred approaches may impact positively on patient satisfaction with care. Of the eleven studies that assessed patient satisfaction, six demonstrated significant differences in favour of the intervention group on one or more measures. Few studies examined health care behaviour or health status outcomes.

REVIEWER'S CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations may significantly increase the patient centredness of care. However, there is limited and mixed evidence on the effects of such interventions on patient health care behaviours or health status; or on whether these interventions might be applicable to providers other than physicians. Further research is needed in these areas.

Labeling smokers' charts with a "smoker" sticker: results of a randomized controlled trial among private practitioners

We randomly assigned private practitioners (n = 393) to receiving, by mail, a box of "Smoker" stickers and a recommendation to label smokers' charts with these stickers, or to no intervention. Twenty percent of the physicians reported using the stickers and applying them on 43% of their smoking patients' charts. The intervention had no impact on physician reports of the proportion of smokers advised to quit smoking, but physicians who reported using the stickers stated that they advised more smokers to quit after the intervention (89%) than before (80%, P =.02). Thus, self-reports by physicians indicated that use of the stickers was associated with an increased proportion of smokers advised to quit. However, overall, the intervention did not modify physicians' behavior.

Training health professionals in smoking cessation

BACKGROUND

There is good evidence that brief interventions from health professionals can increase rates of smoking cessation. A number of trials have examined whether specific skills training for health professionals leads them to have greater success in helping their patients who smoke.

OBJECTIVES

The aim of this review was to assess the effectiveness of training health care professionals to deliver smoking cessation interventions to their patients, and to assess the additional effects of prompts and reminders to the health professional to intervene.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for studies relating to training.

SELECTION CRITERIA

Randomised trials in which the intervention was training of health care professionals in smoking cessation. Trials were considered if they reported outcomes for patient smoking rates at least six months after the intervention. We reported on process outcomes, but we excluded trials that reported effects only on process outcomes and not smoking behaviour.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of health professionals, the nature of and duration of the training, the outcome measures, method of randomisation, and completeness of follow-up. The main outcome measures were 1. Rates of abstinence from smoking after at least six months follow-up in patients smoking at baseline. 2. Rates of performance of tasks of smoking cessation by health care professionals including offering counselling, setting quit dates, giving follow-up appointments, distributing self-help materials and recommending nicotine gum.

MAIN RESULTS

Healthcare professionals who had received training were more likely to perform tasks of smoking cessation than untrained controls. Of eight studies that compared patient smoking behaviour between trained professionals and controls, six found no effect of intervention. The effects of training on process outcomes increased if prompts and reminders were used.

REVIEWER'S CONCLUSIONS

Training health professionals to provide smoking cessation interventions had a measurable effect on professional performance. There was no strong evidence that it changed smoking behaviour.

The effectiveness of a directly mailed smoking cessation intervention to Australian discharged hospital patients

BACKGROUND

The objective was to assess the effectiveness of a directly mailed smoking cessation intervention to discharged hospital patients.

METHODS

A randomized controlled trial was used. In the 2 weeks after discharge, smokers in the intervention group were sent by mail a personally addressed letter from their medical consultant urging them to quit plus a self-help quitting manual, and smokers in the control group received usual care. Patients were surveyed about their smoking status at 6 and 12 months after discharge. A total of 1858 discharged patients responded to both questionnaires. The main outcome measures were self-reported smoking in past week at 6 and 12 months after discharge. Quitters at 12 months were biochemically tested for evidence of smoking.

RESULTS

The results failed to show that smoking cessation advice directly mailed to a broad cross-section of discharged hospital patients who smoke led to smoking cessation. However, the intervention increased cessation among smokers with medical conditions for which quitting is highly relevant. In general, patients who were more likely to quit were older, had entered the hospital as an emergency case, and had a medical diagnosis for which quitting is highly relevant.

CONCLUSIONS

This study suggests that hospital patients who smoke and are also diagnosed with conditions which call for quitting are more likely to quit if they receive from their consultant a personalized letter advising them to quit and a self-help manual.

Office system interventions supporting primary care-based health behavior change counseling

CONTENT

This article reviews the literature on the effectiveness of office system interventions to improve behavior-change counseling in primary care. These instructions consist of two principle components: tools and teamwork. Tools have been developed to assist providers with health risk assessment (questionnaires, health risk appraisals), prompting and reminding (chart stickers, checklists, flow charts, reminder letters), and education (manuals and handbooks). Teamwork entails the coordination and delegation of tasks between providers and staff.

CONCLUSIONS

A number of clinical trials, particularly in the area of smoking cessation, have demonstrated the effectiveness of tools and teamwork for increasing counseling rates and counseling effectiveness. Although no one type of tool or method of teamwork is consistently more effective than another-with effectiveness varying according to practice, provider, and patient characteristics-the use of different tools and teamwork approaches leads to additive improvements in counseling and patient behavior-change rates. More high-quality research is needed, particularly in the areas of health risk assessment and electronic reminder systems, to develop effective office interventions that can be readily implemented into a wide variety of primary care practices.

Teaching medical students alcohol intervention skills: results of a controlled trial

OBJECTIVE

To assess the relative effectiveness of videotape feedback and lecture methods for teaching alcohol brief intervention skills.

DESIGN

In a controlled trial, two student blocks received a manual, lecture and demonstration about the principles and practice of brief alcohol intervention. In addition, experimental students made a 20-min videotape and participated in a 1.5-h small group feedback session. Prior to and after training, all students completed questionnaires and videotaped interviews with simulated patients.

SETTING

Faculty of Medicine and Health Sciences of the University of Newcastle, Australia.

SUBJECTS

Final-year medical students.

RESULTS

Levels of alcohol-related knowledge, attitudes and interactional skills as well as general interactional skills were significantly improved after teaching. Alcohol-related interactional skills that were unsatisfactory at pretest reached satisfactory standards at post-test. An intergroup comparison of the improvement between pre- and post-teaching scores indicated that there was no significant difference in the effectiveness of the two methods.

CONCLUSIONS

Training can improve medical student performance in alcohol intervention. Further research is required to examine the relative effectiveness of different teaching methods.

Implementing preventive services: to what extent can we change provider performance in ambulatory care? A review of the screening, immunization, and counseling literature

Strategies to improve the delivery of preventive care often consist of office-based interventions, which are designed to modify provider behaviors or practice patterns. We report on a meta-analysis of 117 behavioral outcomes extracted from 43 studies. Meta-analytic techniques were used to express the results in a common metric, which allowed quantitative comparisons across outcomes. Studies were examined by domains of preventive care (screening, immunization, and counseling) and divided into two groups based on unit of analysis (provider or patient categories). The mean effect size reflects the difference in proportion of physicians providing the targeted behavior between the experimental and comparison groups. In the provider category, the weighted mean effect size for screening was .14, for immunization was .18, and for counseling was .28. In the patient category, the weighted means for screening and immunization were .12 and .15, respectively, but were smaller for the counseling (.08). Because tests for homogeneity of effect sizes were rejected in the patient category, caution in interpreting mean effect sizes is warranted because of variability across individual values. In summary, office-based interventions were found to have positive effects on providers' adherence to preventive recommendations. We discuss the methodological issues and needs for future work to enhance the delivery of preventive services.

A population-based survey of physician smoking cessation counseling practices

BACKGROUND

To be most effective, physicians' smoking cessation interventions must go beyond advice, to include counseling and follow-up. A full profile of physician performance on the recommended activities to promote smoking cessation has not been provided previously.

METHODS

We surveyed a representative sample of 246 community-based primary care physicians who had agreed to participate in a 3-year study to evaluate a strategy for disseminating smoking cessation interventions, based on the National Cancer Institute 4-A model and on the Transtheoretical Model of Change.

RESULTS

A majority reported they Ask (67%) and Advise (74%) their patients about smoking, while few go beyond to Assist (35%) or Arrange follow-up (8%) with patients who smoke. The criteria for "thorough" counseling was met by only 27% of physicians. More than half were not intending to increase counseling activity in the next 6 months. After controlling for other variables, physicians in private offices were more likely than physicians in HMO or other settings to be active with smoking cessation counseling. General Internal Medicine physicians were most active, and Ob/Gyn physicians were least active, with smoking cessation counseling among primary care specialty groups.

CONCLUSIONS

Innovative approaches are needed to motivate, support, and reward physicians to counsel their patients who smoke, especially when considering the movement toward managed health care.

PRECIS

A survey of primary care physicians focusing on national guidelines for smoking cessation counseling showed a majority Ask (67%) and Advise (74%) patients about smoking, but few Assist (35%) or Arrange follow-up (8%).

Tobacco cessation and youth: the feasibility of brief office interventions for adolescents

BACKGROUND

The prevalence of tobacco use among adolescents remains high and the great majority of adult smokers begin smoking prior to the age of 18. While there have been a number of primary prevention projects in communities and schools, less attention has been given to smoking cessation for adolescents. This paper reviews the literature on the theory and practice of cessation as applicable to adolescents.

METHODS

The relevant literature was culled from a MEDLINE search and supplemented with secondary searches from those articles.

RESULTS

There have been few studies on brief interventions for adolescent smoking cessation in health care settings. However, there are several models for smoking cessation that are either applicable to or designed for adolescents. Pharmacologic treatments are also beginning to be used.

CONCLUSIONS

There is a great need for the development and evaluation of models for adolescent smoking cessation in health care settings. Recent developments, however, give cause for optimism in helping adolescent smokers in tobacco cessation.

Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes

OBJECTIVE

To answer the question, "does CME work?" by reviewing the effectiveness of continuing medical education (CME) and other related educational methods on objectively-determined physician performance and/or health care outcomes. These interventions include educational materials, formal, planned CME activities or programs, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit and feedback, reminders, or a combination of these strategies.

METHODS

MEDLINE, ERIC, NTIS, the Research and Development Resource Base in CME and other relevant data sources including review articles were searched for relevant terms, from 1975 to 1994. Of those articles retrieved, randomized controlled trials of educational strategies or interventions which objectively assessed physician performance and/or health care outcomes were selected for review. Data were extracted from each article about the specialty of the physician targeted, the clinical subject of the intervention, the setting and the nature of the educational method, and the presence or degree of needs assessment or barriers to change.

RESULTS

More than two-thirds of the studies (70%) displayed a change in physician performance, while almost half (48%) of interventions produced a change in health care outcomes. Community-based strategies such as academic detailing (and to a lesser extent, opinion leaders), practice-based methods such as reminders and patient-mediated strategies, and multiple interventions appeared to be most effective activities. Mixed results and weaker outcomes were demonstrated by audit and educational materials, while formal CME conferences without enabling or practice-reinforcing strategies, had relatively little impact.

CONCLUSION

Strategies which enable and/or reinforce appear to "work" in changing physician performance or health care outcomes, a finding which has significant impact on the delivery of CME, and the need for further research into physician learning and change.