Provider feedback to improve 5A's tobacco cessation in primary care: a cluster randomized clinical trial

The implementation of ask-advise-connect in a federally qualified health center: a mixed methods evaluation using the re-aim framework

Ask-Advise-Connect (AAC) efficiently links smokers in healthcare settings with evidence-based Quitline-delivered tobacco treatment through training clinic staff to systematically ask patients about smoking status, advise smokers to quit, and connect patients with state Quitlines using the electronic health record. This study utilized a mixed-methods approach, guided by the RE-AIM framework, to evaluate the implementation of AAC in a Federally Qualified Health Center (FQHC). AAC was implemented for 18 months at a FQHC serving primarily low-socioeconomic status (SES) Latinos and Latinas. Results are presented within the RE-AIM conceptual framework which includes dimensions of reach, effectiveness, adoption, implementation, and maintenance. Quantitative patient-level outcomes of reach, effectiveness, and Impact were calculated. Post-implementation, in-depth interviews were conducted with clinic leadership and staff (N = 9) to gather perceptions and inform future implementation efforts. During the implementation period, 12.0% of GNHC patients who reported current smoking both agreed to have their information sent to the Quitline and were successfully contacted by the Quitline (Reach), 94.8% of patients who spoke with the Quitline enrolled in treatment (Effectiveness), and 11.4% of all identified smokers enrolled in Quitline treatment (Impact). In post-implementation interviews assessing RE-AIM dimensions, clinic staff and leadership identified facilitators and advantages of AAC and reported that AAC was easy to learn and implement, streamlined existing procedures, and had a positive impact on patients. Staff and leadership reported enthusiasm about AAC implementation and believed AAC fit well in the clinic. Staff were interested in AAC becoming the standard of care and made suggestions for future implementation. Clinic staff at a FQHC serving primarily low-SES Latinos and Latinas viewed the ACC implementation process positively. Findings have implications for streamlining clinical smoking cessation procedures and the potential to reduce tobacco-related disparities.

An external facilitation intervention to increase uptake of an adverse drug event reporting intervention

Background

Adverse drug events (ADEs) are a leading cause of emergency department visits and hospital admissions in Canada. ActionADE prevents repeat ADEs by enabling clinicians to document and communicate standardized ADE information across care settings. We used an external facilitation intervention to promote the uptake of ActionADE in four hospitals in British Columbia, Canada. This study examined whether, how and in what context external facilitation influenced the uptake of ActionADE.

Methods

In this convergent-parallel mixed-methods study, an external facilitator used a four-step iterative process to support site champions using context-specific implementation strategies to increase the ADE reporting rate at their sites. We extracted archival data to assess implementation determinants before and after the implementation of the external facilitation and implementation strategies. We also retrieved data on the mean monthly counts of reported ADEs for each user from the ActionADE server. Zero-inflated Poisson models were used to examine changes in mean monthly counts of reported ADEs per user between pre-intervention (June 2021 to October 2021) and intervention (November 2021 to March 2022) periods.

Results

The external facilitator and site champions co-created three functions: (1) educate pharmacists about what and how to report in ActionADE, (2) educate pharmacists about the impact of ActionADE on patient outcomes, and (3) provide social support for pharmacists to integrate ADE reporting into clinical workflows. Site champions used eight forms to address the three functions. Peer support and reporting competition were the two common strategies used by all sites. Sites' responses to external facilitation varied. The rate of mean monthly counts of reported ADEs per user significantly increased during the intervention period compared to the pre-intervention period at LGH (RR: 3.74, 95% CI 2.78 to 5.01) and RH (RR: 1.43, 95% CI 1.23 to 1.94), but did not change at SPH (RR: 0.68, 95% CI: 0.43 to 1.09) and VGH (RR: 1.17, 95% CI 0.92 to 1.49). Leave of absence of the clinical pharmacist champion and failure to address all identified functions were implementation determinants that influenced the effectiveness of external facilitation.

Conclusion

External facilitation effectively supported researchers and stakeholders to co-create context-specific implementation strategies. It increased ADE reporting at sites where clinical pharmacist champions were available, and where all functions were addressed.

Increasing clinician participation in tobacco cessation by an implementation science-based tobacco cessation champion program

BACKGROUND

We designed a process to increase tobacco cessation in an academic center and its widely distributed network community sites using clinical champions to overcome referral barriers.

METHODS

In 2020 a needs assessment was performed across the City of Hope Medical Center and its 32 community treatment sites. We reviewed information science strategies to choose elements for our expanded tobacco control plan, focusing on distributed leadership with tobacco cessation champions. We analyzed smoking patterns in patients with cancer before and following program implementation. We evaluated the champion experience and measured tobacco abstinence after 6 months of follow-up.

RESULTS

Cancer center leadership committed to expanding tobacco control. Funding was obtained through a Cancer Center Cessation Initiative (C3I) grant. Multi-disciplinary leaders developed a comprehensive plan. Disease-focused clinics and community sites named cessation champions (a clinician and nurse) supported by certified tobacco treatment specialists. Patient, staff, clinician, and champion training/education were developed. Roles and responsibilities of the champions were defined. Implementation in pilot sites showed increased tobacco assessment from 80.8 to 96.6%, increased tobacco cessation referral by 367%, and moderate smoking abstinence in both academic (27.2%) and community sites (22.5%). 73% of champions had positive attitudes toward the program.

CONCLUSION

An efficient process to expand smoking cessation in the City of Hope network was developed using implementation science strategies and cessation champions. This well-detailed implementation process may be helpful to other cancer centers, particularly those with a tertiary care cancer center and community network.

A comprehensive electronic health record-enabled smoking treatment program: Evaluating reach and effectiveness in primary care in a multiple baseline design

Effective treatments for smoking cessation exist but are underused. Proactive chronic care approaches may enhance the reach of cessation treatment and reduce the prevalence of smoking in healthcare systems. This pragmatic study evaluated a population-based Comprehensive Tobacco Intervention Program (CTIP) implemented in all (6) adult primary care clinics in a Madison, Wisconsin, USA healthcare cooperative, assessing treatment reach, reach equity, and effectiveness in promoting smoking cessation. CTIP launched in 3 waves of 2 clinics each in a multiple baseline design. Electronic health record (EHR) tools facilitated clinician-delivered pharmacotherapy and counseling; guiding tobacco care managers in phone outreach to all patients who smoke; and prompting multimethod bulk outreach to all patients on a smoking registry using an opt-out approach. EHR data were analyzed to assess CTIP reach and effectiveness among 6894 adult patients between January 2018 and February 2020. Cessation treatment reach increased significantly after CTIP launch in 5 of 6 clinics and was significantly higher when clinics were active vs. inactive in CTIP [Odds Ratio (OR) range = 2.0-3.0]. Rates of converting from current to former smoking status were also higher in active vs. inactive clinics (OR range = 2.2-10.5). Telephone treatment reach was particularly high in historically underserved groups, including African-American, Hispanic, and Medicaid-eligible patients. Implementation of a comprehensive, opt-out, chronic-care program aimed at all patients who smoke was associated with increases in the rates of pharmacotherapy and counseling delivery and quitting smoking. Proactive outreach may help reduce disparities in treatment access.

Anesthesiologists and the Other Pandemic: Tobacco Use

Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.

Implementation mapping for tobacco cessation in a federally qualified health center

Background

Implementation mapping (IM) is a promising five-step method for guiding planning, execution, and maintenance of an innovation. Case examples are valuable for implementation practitioners to understand considerations for applying IM. This pilot study aimed to determine the feasibility of using IM within a federally qualified health center (FQHC) with limited funds and a 1-year timeline.

Methods

An urban FQHC partnered with an academic team to employ IM for implementing a computerized strategy of tobacco cessation: the 5A's (Ask, Advise, Assess, Assist, Arrange). Each step of IM was supplemented with theory-driven methods and frameworks. Data collection included surveys and interviews with clinic staff, analyzed via rapid data analysis.

Results

Medical assistants and clinicians were identified as primary implementers of the 5A's intervention. Salient determinants of change included the perceived compatibility and relative priority of 5A's. Performance objectives and change objectives were derived to address these determinants, along with a suite of implementation strategies. Despite indicators of adoptability and acceptability of the 5A's, reductions in willingness to adopt the implementation package occurred over time and the intervention was not adopted by the FQHC within the study timeframe. This is likely due to the strain of the COVID-19 pandemic altering health clinic priorities.

Conclusions

Administratively, the five IM steps are feasible to conduct with FQHC staff within 1 year. However, this study did not obtain its intended outcomes. Lessons learned include the importance of re-assessing barriers over time and ensuring a longer timeframe to observe implementation outcomes.

The effectiveness of champions in implementing innovations in health care: a systematic review

Background

Champions have been documented in the literature as an important strategy for implementation, yet their effectiveness has not been well synthesized in the health care literature. The aim of this systematic review was to determine whether champions, tested in isolation from other implementation strategies, are effective at improving innovation use or outcomes in health care.

Methods

The JBI systematic review method guided this study. A peer-reviewed search strategy was applied to eight electronic databases to identify relevant articles. We included all published articles and unpublished theses and dissertations that used a quantitative study design to evaluate the effectiveness of champions in implementing innovations within health care settings. Two researchers independently completed study selection, data extraction, and quality appraisal. We used content analysis and vote counting to synthesize our data.

Results

After screening 7566 records titles and abstracts and 2090 full text articles, we included 35 studies in our review. Most of the studies (71.4%) operationalized the champion strategy by the presence or absence of a champion. In a subset of seven studies, five studies found associations between exposure to champions and increased use of best practices, programs, or technological innovations at an organizational level. In other subsets, the evidence pertaining to use of champions and innovation use by patients or providers, or at improving outcomes was either mixed or scarce.

Conclusions

We identified a small body of literature reporting an association between use of champions and increased instrumental use of innovations by organizations. However, more research is needed to determine causal relationship between champions and innovation use and outcomes. Even though there are no reported adverse effects in using champions, opportunity costs may be associated with their use. Until more evidence becomes available about the effectiveness of champions at increasing innovation use and outcomes, the decision to deploy champions should consider the needs and resources of the organization and include an evaluation plan. To further our understanding of champions’ effectiveness, future studies should (1) use experimental study designs in conjunction with process evaluations, (2) describe champions and their activities and (3) rigorously evaluate the effectiveness of champions’ activities.

Registration

Open Science Framework (https://osf.io/ba3d2). Registered on November 15, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00315-0.

Community pharmacy technicians' engagement in the delivery of brief tobacco cessation interventions: Results of a randomized trial

BACKGROUND

In recent years, the role of community pharmacy technicians has expanded to include involvement in the provision of brief tobacco cessation interventions. While technicians appear to be a key component in this service, their level of engagement and associated perceptions of this new role have not been described.

OBJECTIVE

To compare pharmacy technicians' frequency of involvement in brief tobacco cessation interventions delivered in a community pharmacy setting, as a function of training approach, and to characterize their perceptions of this expanded role, including barriers to implementation.

METHODS

Twenty California-based grocery store chain pharmacies were randomized to receive (a) written training materials-only [minimal] or (b) written training materials plus live training with coaching and active monitoring by pharmacy management [intensive]. After written materials were distributed to the sites, tobacco cessation interventions were documented prospectively for 12 weeks post-training.

RESULTS

Over the 12-week study, technicians (n = 50) documented their involvement in 524 interventions (57.7% of 908 total), with the minimal group accounting for 56.1% and the intensive group accounting for 43.9% (p < 0.001). The number of individual technicians who reported at least one intervention was 16 (of 26; 61.5%) in the minimal group and 24 (of 24; 100%) in the intensive group (p < 0.001). At the conclusion of the study, 100% of technicians in the intensive group self-rated their ability to interact with patients about quitting smoking as good, very good, or excellent compared to 73.9% in the minimal group (p = 0.10).

CONCLUSION

In both study arms, technicians documented high numbers of tobacco cessation interventions. The higher proportion of technicians providing one or more interventions in the intensive group suggests a greater overall engagement in the process, relative to those receiving minimal training. Technicians can play a key role in the delivery of tobacco cessation interventions in community pharmacies.

Understanding health disparities affecting utilization of tobacco treatment in low-income patients in an urban health center in Southern California

Tobacco use disproportionately affects low-income communities. Prevalence among patients in Federally Qualified Health Centers (FQHCs) is higher (29.3%) than the general population (20%). Little is known about the rates of referrals to cessation services and cessation pharmacotherapy practices in FQHCs. This study will examine referral and prescribing patterns based on patient characteristics at a large FQHC in Southern California. We conducted a retrospective analysis of EHR data from 2019. Patients who were ≥ 18 years old and had "tobacco use" as an active problem were included in analyses. We characterized the proportion of 1) those who were referred to California Smokers' Helpline (CSH), 2) referred to smoking cessation counseling (SCC) at the FQHC clinic, or 3) received pharmacotherapy. Associations of demographic characteristics and comorbidities with referral types and uptake of services were evaluated using mixed-effects multinomial and logistic regressions. Of the 20,119 tobacco users identified, 87% had some cessation intervention: 66% were advised to quit and given information to contact CSH, while 21% were referred to SCC. Patients were least likely to get referred to cessation services if they had more medical, psychiatric, or substance use comorbidities, were in the lowest income group, were uninsured or were Hispanic. Although EHR systems have enhanced the ease of screening, most patients do not receive more than brief advice to quit during a PCP visit. Most (70%) low-income smokers see their PCPs at least once a year, making FQHCs excellent settings to promote smoking cessation initiatives in low-income populations.

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.

Care-paradigm shift promoting smoking cessation treatment among cancer center patients via a low-burden strategy, Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment

Tobacco smoking is an important risk factor for cancer incidence, an effect modifier for cancer treatment, and a negative prognostic factor for disease outcomes. Inadequate implementation of evidence-based smoking cessation treatment in cancer centers, a consequence of numerous patient-, provider-, and system-level barriers, contributes to tobacco-related morbidity and mortality. This study provides data for a paradigm shift from a frequently used specialist referral model to a point-of-care treatment model for tobacco use assessment and cessation treatment for outpatients at a large cancer center. The point-of-care model is enabled by a low-burden strategy, the Electronic Health Record-Enabled Evidence-Based Smoking Cessation Treatment program, which was implemented in the cancer center clinics on June 2, 2018. Five-month pre- and post-implementation data from the electronic health record (EHR) were analyzed. The percentage of cancer patients assessed for tobacco use significantly increased from 48% to 90% (z = 126.57, p < .001), the percentage of smokers referred for cessation counseling increased from 0.72% to 1.91% (z = 3.81, p < .001), and the percentage of smokers with cessation medication significantly increased from 3% to 17% (z = 17.20, p < .001). EHR functionalities may significantly address barriers to point-of-care treatment delivery, improving its consistent implementation and thereby increasing access to and quality of smoking cessation care for cancer center patients.

A conceptual model to guide research on the activities and effects of innovation champions

Background

The importance of having a champion to promote implementation efforts has been discussed in the literature for more than five decades. However, the empirical literature on champions remains underdeveloped. As a result, health organizations commonly use champions in their implementation efforts without the benefit of evidence to guide decisions about how to identify, prepare, and evaluate their champions. The goal of this article is to present a model of champion impact that draws upon previous literature and is intended to inform future research on champions and serve as a guide for practitioners serving in a champion role.

Methods

The proposed model is informed by existing literature, both conceptual and empirical. Prior studies and reviews of the literature have faced challenges in terms of operationalizing and reporting on champion characteristics, activities, and impacts. The proposed model addresses this challenge by delineating these constructs, which allows for consolidation of factors previously discussed about champions as well as new hypothesized relationships between constructs.

Results

The model proposes that a combination of champion commitment and champion experience and self-efficacy influence champion performance, which influences peer engagement with the champion, which ultimately influences the champion's impact. Two additional constructs have indirect effects on champion impact. Champion beliefs about the innovation and organizational support for the champion affect champion commitment.

Conclusion

The proposed model is intended to support prospective studies of champions by hypothesizing relationships between constructs identified in the champion literature, specifically relationships between modifiable factors that influence a champion's potential impact. Over time, the model should be modified, as appropriate, based on new findings from champion-related research.

Closed-Loop Electronic Referral From Primary Care Clinics to a State Tobacco Cessation Quitline: Effects Using Real-World Implementation Training

INTRODUCTION

Patients who use tobacco are too rarely connected with tobacco use treatment during healthcare visits. Electronic health record enhancements may increase such referrals in primary care settings. This project used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the implementation of a healthcare system change carried out in an externally valid manner (executed by the healthcare system).

METHODS

The healthcare system used their standard, computer-based training approach to implement the electronic health record and clinic workflow changes for electronic referral in 30 primary care clinics that previously used faxed quitline referral. Electronic health record data captured rates of assessment of readiness to quit and quitline referral 4 months before implementation and 8 months (May-December 2017) after implementation. Data, analyzed from October 2018 to June 2019, also reflected intervention reach, adoption, and maintenance.

RESULTS

For reach and effectiveness, from before to after implementation for electronic referral, among adult patients who smoked, assessment of readiness to quit increased from 24.8% (2,126 of 8,569) to 93.2% (11,163 of 11,977), quitline referrals increased from 1.7% (143 of 8,569) to 11.3% (1,351 of 11,977), and 3.6% were connected with the quitline after implementation. For representativeness of reach, electronic referral rates were especially high for women, African Americans, and Medicaid patients. For adoption, 52.6% of staff who roomed at least 1 patient who smoked referred to the quitline. For maintenance, electronic referral rates fell by approximately 60% over 8 months but remained higher than pre-implementation rates.

CONCLUSIONS

Real-world implementation of an electronic health record-based electronic referral system markedly increased readiness to quit assessment and quitline referral rates in primary care patients. Future research should focus on implementation methods that produce more consistent implementation and better maintenance of electronic referral.

An electronic health record-based interoperable eReferral system to enhance smoking Quitline treatment in primary care

OBJECTIVE

The study sought to determine whether interoperable, electronic health record-based referral (eReferral) produces higher rates of referral and connection to a state tobacco quitline than does fax-based referral, thus addressing low rates of smoking treatment delivery in health care.

MATERIALS AND METHODS

Twenty-three primary care clinics from 2 healthcare systems (A and B) in Wisconsin were randomized, unblinded, over 2016-2017, to 2 smoking treatment referral methods: paper-based fax-to-quit (system A =6, system B = 6) or electronic (eReferral; system A = 5, system B = 6). Both methods referred adult patients who smoked to the Wisconsin Tobacco Quitline. A total of 14 636 smokers were seen in the 2 systems (system A: 54.5% women, mean age 48.2 years; system B: 53.8% women, mean age 50.2 years).

RESULTS

Clinics with eReferral, vs fax-to-quit, referred a higher percentage of adult smokers to the quitline: system A clinic referral rate = 17.9% (95% confidence interval [CI], 17.2%-18.5%) vs 3.8% (95% CI, 3.5%-4.2%) (P < .001); system B clinic referral rate = 18.9% (95% CI, 18.3%-19.6%) vs 5.2% (95% CI, 4.9%-5.6%) (P < .001). Average rates of quitline connection were higher in eReferral than F2Q clinics: system A = 5.4% (95% CI, 5.0%-5.8%) vs 1.3% (95% CI, 1.1%-1.5%) (P < .001); system B = 5.3% (95% CI, 5.0%-5.7%) vs 2.0% (95% CI, 1.8%-2.2%) (P < .001).

DISCUSSION

Electronic health record-based eReferral provided an effective, closed-loop, interoperable means of referring patients who smoke to telephone quitline services, producing referral rates 3-4 times higher than the current standard of care (fax referral), including especially high rates of referral of underserved individuals.

CONCLUSIONS

eReferral may help address the challenge of providing smokers with treatment for tobacco use during busy primary care visits.ClinicalTrials.gov; No. NCT02735382.

Tobacco Treatment Program Models in US Hospitals and Outpatient Centers on Behalf of the SRNT Treatment Network

Because tobacco use remains one of the leading causes of disease, disability, and mortality, tobacco treatment programs should be integrated into medical systems such as hospitals and outpatient centers. Medical providers have a unique, high-impact opportunity to initiate smoking cessation treatment with patients. However, there are several barriers that may hinder the development and implementation of these programs. The purpose of this review was to address such barriers by illustrating several examples of successful tobacco treatment programs in US health-care systems that were contributed by the authors. This includes describing treatment models, billing procedures, and implementation considerations. Using an illustrative review of vignettes from existing programs, various models are outlined, emphasizing commonalities and unique features, strengths and limitations, resources necessary, and other relevant considerations. In addition, clinical research and dissemination trials from each program are described to provide evidence of feasibility and efficacy from these programs. This overview of example treatment models designed for hospitals and outpatient centers provides guidelines for any emerging tobacco cessation services within these contexts. For existing treatment programs, this review provides additional insight and ideas about improving these programs within their respective medical systems.

Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis

Background

A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.

Objective

To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).

Participants

Health workers took part in the study.

Interventions

Behaviour change interventions based on social norms.

Outcome measures

Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.

Methods

Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.

Results

A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I 2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).

Limitations

The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.

Conclusions

Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.

Future work

Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.

Study registration

This study is registered as PROSPERO CRD42016045718.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.

Reducing cardiovascular risk among people living with HIV: Rationale and design of the INcreasing Statin Prescribing in HIV Behavioral Economics REsearch (INSPIRE) randomized controlled trial

Cardiovascular disease (CVD) is a major cause of morbidity among people living with HIV (PLWH). Statins can safely and effectively reduce CVD risk in PLWH, but evidence-based statin therapy is under-prescribed in PLWH. Developed using an implementation science framework, INcreasing Statin Prescribing in HIV Behavioral Economics REsearch (INSPIRE) is a stepped-wedge cluster randomized trial that addresses organization-, clinician- and patient-level barriers to statin uptake in Los Angeles community health clinics serving racially and ethnically diverse PLWH. After assessing knowledge about statins and barriers to clinician prescribing and patient uptake, we will design, implement and measure the effectiveness of (1) educational interventions targeting leadership, clinicians, and patients, followed by (2) behavioral economics-informed clinician feedback on statin uptake. In addition, we will assess implementation outcomes, including changes in clinician acceptability of statin prescribing for PLWH, clinician acceptability of the education and feedback interventions, and cost of implementation.

Efficacy of a group tobacco cessation behavioral intervention among tobacco users with concomitant mental illness in Kenya: protocol for a controlled clinical trial

BACKGROUND

The rate of tobacco use among people with mental illness is nearly twice that of the general population. Psychotropic medications for tobacco cessation are relatively expensive for most Kenyans. Behavioral counseling and group therapy are effective lower cost strategies to promote tobacco cessation, yet have not been studied in Kenya among individuals with concomitant mental illness.

METHODS/DESIGN

One hundred tobacco users with mental illness who were part of an outpatient mental health program in Nairobi, Kenya were recruited and allocated into intervention and control groups of the study (50 users in intervention group and 50 users in control group). Participants allocated to the intervention group were invited to participate in 1 of 5 tobacco cessation groups. The intervention group received the 5As (Ask, Advise, Assess, Assist and Arrange) and tobacco cessation group behavioral intervention, which included strategies to manage cravings and withdrawal, stress and anxiety, and coping with depression due to withdrawal; assertiveness training and anger management; reasons to quit, benefits of quitting and different ways of quitting. Individuals allocated to the control group received usual care. The primary outcome was tobacco cessation at 24 weeks, measured through cotinine strips. Secondary outcomes included number of quit attempts and health-related quality of life.

DISCUSSION

This study will provide evidence to evaluate the efficacy and safety of a tobacco cessation group behavioral intervention among individuals with mental illness in Kenya, and to inform national and regional practice and policy.

TRIAL REGISTRATION

Trial registration number: NCT04013724. Name of registry: ClinicalTrials.gov. URL of registry: https://register.clinicaltrials.gov Date of registration: 9 July 2019 (retrospectively registered). Date of enrolment of the first participant to the trial: 5th September 2017. Protocol version: 2.0.

Effectiveness of Village Health Worker-Delivered Smoking Cessation Counseling in Vietnam

INTRODUCTION

Smoking prevalence is high in Vietnam, yet tobacco dependence treatment (TDT) is not widely available.

METHODS

We conducted a quasiexperimental study that compared the effectiveness of health care provider advice and assistance (ARM 1) versus ARM 1 plus village health worker (VHW) counseling (ARM 2) on abstinence at 6-month follow-up. This study was embedded in a larger two-arm cluster randomized controlled trial conducted in 26 community health centers (CHCs) in Vietnam. Subjects (N = 1318) were adult patients who visited any participating CHC during the parent randomized controlled trial intervention period and were self-identified as current tobacco users (cigarettes and/or water pipe).

RESULTS

At 6-month follow-up, abstinences rates in ARM 2 were significantly higher than those in ARM 1 (25.7% vs. 10.5%; p < .001). In multivariate analyses, smokers in ARM 2 were almost three times more likely to quit compared with those in ARM 1 (adjusted odds ratio [AOR] = 2.96, 95% confidence interval [CI] = 1.78% to 4.92%). Compared to cigarette-only smokers, water pipe-only smokers (AOR = 0.4, 95% CI = 0.26% to 0.62%) and dual users (AOR = 0.62, 95% CI = 0.45% to 0.86%) were less likely to achieve abstinence; however, the addition of VHW counseling (ARM 2) was associated with higher quit rates compared with ARM 1 alone for all smoker types.

CONCLUSION

A team approach in TDT programs that offer a referral system for health care providers to refer smokers to VHW-led cessation counseling is a promising and potentially scalable model for increasing access to evidence-based TDT and increasing quit rates in low middle-income countries (LMICs). TDT programs may need to adapt interventions to improve outcomes for water pipe users.

IMPLICATIONS

The study fills literature gaps on effective models for TDT in LMICs. The addition of VHW-led cessation counseling, available through a referral from primary care providers in CHCs in Vietnam, to health care provider's brief cessation advice, increased 6-month biochemically validated abstinence rates compared to provider advice alone. The study also demonstrated the potential effectiveness of VHW counseling on reducing water pipe use. For LMICs, TDT programs in primary care settings with a referral system to VHW-led cessation counseling might be a promising and potentially scalable model for increasing access to evidence-based treatment.

Medicaid insurance status predicts postoperative mortality after total knee arthroplasty in state inpatient databases

Aim: Medicaid versus private primary insurance status may predict in-hospital mortality and morbidity after total knee arthroplasty (TKA). Materials & methods: Regression models were used to test our hypothesis in patients in the State Inpatient Database (SID) from five states who underwent primary TKA from January 2007 to December 2014. Results: Medicaid patients had greater odds of in-hospital mortality (odds ratio [OR]: 1.73; 95% CI: 1.01-2.95), greater odds of any postoperative complications (OR: 1.25; 95% CI: 1.18-1.33), experience longer lengths of stay (OR: 1.09; 95% CI: 1.08-1.10) and higher total charges (OR: 1.03; 95% CI: 1.02-1.04). Conclusion: Medicaid insurance status is associated with higher in-hospital mortality and morbidity in patients after TKA compared with private insurance.

Patients' self-reported receipt of brief smoking cessation interventions based on a decision support tool embedded in the healthcare information system of a large general hospital in China

INTRODUCTION

Healthcare information systems (HIS) are used to aid healthcare providers delivering brief smoking cessation interventions. However, evidence regarding the effectiveness of intervention models in developing countries remains limited. A smoking cessation intervention model based on a decision support tool embedded in HIS (an ‘e-information model’, including Ask, Advise, Assess, Inform, Refer and Print components) was applied in a large urban general hospital in Beijing, China. The current study was a preliminary evaluation of the implementation and effectiveness of this model.

METHODS

We conducted a retrospective investigation in the outpatient department of the hospital in the period June–July 2017. Using a paper questionnaire, patients’ self-reported receipt of the e-information model in the past 2 months and their plans to quit within 1 month were collected. Multivariate logistic regression analysis was used to examine the association between receiving the e-information model and patients’ plans to quit.

RESULTS

Among 656 currently smoking patients, the proportion of patients receiving the Ask, Advise, Assess, Refer and Print components were 73.2%, 65.4%, 49.8%, 16.0% and 10.4%, respectively. The results revealed a dose-response relationship between the number of components received and the proportion of patients planning to quit (p-trend=0.006). The likelihood of patients planning to quit within 1 month was highest among those receiving all five components (OR=2.79, 95% CI: 1.31–5.94). Moreover, a simplified model composed of two or three components also revealed a potential effect on increasing the proportion of patients planning to quit.

CONCLUSIONS

The e-information model was applied effectively in the study hospital and appeared to encourage patients to plan to quit smoking. This model could be generalized to other hospitals in China and other developing countries. However, many components of this model were less utilized, and comprehensive measures will be required to improve its application in the future.

Trends in tobacco use and tobacco cessation counselling codes among Medicare beneficiaries, 2001-2014

Background

Analysis of Medicare data is often used to determine epidemiology, healthcare utilization and effectiveness of disease treatments. We were interested in whether Medicare data could be used to estimate prevalence of tobacco use. Currently, data regarding tobacco use is derived from Behavioral Risk Factor Surveillance System (BRFSS) survey data.

We compare administrative claims data for tobacco diagnosis among Medicare beneficiaries to survey (BRFSS) estimates of tobacco use from 2001 to 2014.

Methods

Retrospective cross-sectional study comparing tobacco diagnoses using International Classification of Disease, Ninth Revision (ICD-9) codes for tobacco use in Medicare data to BRFSS data from 2001 to 2014 in adults age ≥ 65 years. Beneficiary data included age, gender, race, socioeconomic status, and comorbidities. Tobacco cessation counselling was also examined using Healthcare Common Procedure Coding System codes.

Results

The prevalence of Medicare enrollees aged ≥65 years who had a diagnosis of current tobacco use increased from 2.01% in 2001 to 4.8% in 2014, while the estimates of current tobacco use from BRFSS decreased somewhat (10.03% in 2001 vs. 8.77% in 2014). However, current tobacco use based on Medicare data remained well below the estimates from BRFSS. Use of tobacco cessation counselling increased over the study period with largest increases after 2010.

Conclusions

The use of tobacco-related diagnosis codes increased from 2001 to 2014 in Medicare but still substantially underestimated the prevalence of tobacco use compared to BRFSS data.

Closed-loop electronic referral to SmokefreeTXT for smoking cessation support: a demonstration project in outpatient care

Too few smokers who present for outpatient healthcare receive evidence-based interventions to stop smoking. Referral to nationally available smoking cessation support may enhance tobacco intervention reach during healthcare visits. This study evaluated the feasibility of outpatient electronic health record (EHR)-enabled, closed-loop referral (eReferral) to SmokefreeTXT, a National Cancer Institute text message smoking cessation program. SmokefreeTXT eReferral for adult patients who smoke was implemented in a family medicine clinic and an allergy and asthma clinic in an integrated Midwestern healthcare system. Interoperable, HIPAA-compliant eReferral returned referral outcomes to the EHR. In Phase 1 of implementation, clinicians were responsible for eReferral; in Phase 2 this responsibility shifted to Medical Assistants and/or nurses. EHR data were extracted to compute eReferral rates among adult smokers and compare demographics among those eReferred versus not referred. SmokefreeTXT data were used to compute SmokefreeTXT enrollment rates among those eReferred. Descriptive analyses of clinic staff surveys assessed implementation context and staff attitudes toward and adaptations of eReferral processes. During clinician implementation, 43 of 299 adult smokers (14.4%) were eReferred. During medical assistant (MA) implementation, 36 of 401 adult smokers (9.0%) were eReferred. Overall, among those eReferred, 25.7% completed SmokefreeTXT enrollment (3.1% of patients eligible for eReferral). Staff survey responses indicated that eReferral was efficient and easy. eReferral rates and relevant attitudes varied meaningfully by clinic. Thus, interoperable eReferral via outpatient EHR to SmokefreeTXT is feasible and acceptable to clinic staff and enrolls roughly 3.0% of smokers. Clinic context and implementation approach may influence reach.

Tobacco Use Assessment and Treatment in Cancer Patients: A Scoping Review of Oncology Care Clinician Adherence to Clinical Practice Guidelines in the U.S

BACKGROUND

Smoking after a cancer diagnosis negatively impacts health outcomes; smoking cessation improves symptoms, side effects, and overall prognosis. The Public Health Service and major oncology organizations have established guidelines for tobacco use treatment among cancer patients, including clinician assessment of tobacco use at each visit. Oncology care clinicians (OCCs) play important roles in this process (noted as the 5As: Asking about tobacco use, Advising users to quit, Assessing willingness to quit, Assisting in quit attempts, and Arranging follow-up contact). However, OCCs may not be using the "teachable moments" related to cancer diagnosis, treatment, and survivorship to provide cessation interventions.

MATERIALS AND METHODS

In this scoping literature review of articles from 2006 to 2017, we discuss (1) frequency and quality of OCCs' tobacco use assessments with cancer patients and survivors; (2) barriers to providing tobacco treatment for cancer patients; and (3) the efficacy and future of provider-level interventions to facilitate adherence to tobacco treatment guidelines.

RESULTS

OCCs are not adequately addressing smoking cessation with their patients. The reviewed studies indicate that although >75% assess tobacco use during an intake visit and >60% typically advise patients to quit, a substantially lower percentage recommend or arrange smoking cessation treatment or follow-up after a quit attempt. Less than 30% of OCCs report adequate training in cessation interventions.

CONCLUSION

Intervention trials focused on provider- and system-level change are needed to promote integration of evidence-based tobacco treatment into the oncology setting. Attention should be given to the barriers faced by OCCs when targeting interventions for the oncologic context.

IMPLICATIONS FOR PRACTICE

This article reviews the existing literature on the gap between best and current practices for tobacco use assessment and treatment in the oncologic context. It also identifies clinician- and system-level barriers that should be addressed in order to lessen this gap and provides suggestions that could be applied across different oncology practice settings to connect patients with tobacco use treatments that may improve overall survival and quality of life.

From Good to Great: The Role of Performance Coaching in Enhancing Tobacco-Dependence Treatment Rates

PURPOSE

The purpose of this study was to examine the incremental effect of performance coaching, delivered as part of a multicomponent intervention (Ottawa Model for Smoking Cessation [OMSC]), in increasing rates of tobacco-dependence treatment by primary care clinicians.

METHODS

In a cluster-randomized controlled trial, 15 primary care practices were randomly assigned to 1 of the following active-treatment conditions: OMSC or OMSC plus performance coaching (OMSC+). All practices received support to implement the OMSC. In addition, clinicians in the OMSC+ group participated in a 1.5-hour skills-based coaching session and received an individualized performance report. All clinicians and a cross-sectional sample of their patients were surveyed before and 4 months after introduction of the interventions. The primary outcome measure was rates of tobacco-dependence treatment strategy (Ask, Advise, Assist, Arrange) delivery. Secondary outcomes were patient quit attempts and smoking abstinence measured at 6 months' follow-up.

RESULTS

Primary care clinicians (166) and patients (1,990) were enrolled in the trial. Clinicians in the OMSC+ group had statistically greater rates of delivery for Ask (adjusted odds ratio [AOR] = 1.69; 95% CI, 1.05-2.72), Assist (AOR = 1.64; 95% CI, 1.08-2.49), and Arrange (AOR = 2.01; 95% CI, 1.22-3.31). Sensitivity analysis found that the rate of delivery for Advise was greater only among those clinicians who attended the coaching session (AOR = 1.65; 95% CI, 1.10-2.49; P = .02). No differences were documented between groups for cessation outcomes.

CONCLUSIONS

Performance coaching significantly increased rates of tobacco-dependence treatment by primary care clinicians when delivered as part of a multicomponent intervention.

Use of Electronic Health Record Integration for Down Syndrome Guidelines

OBJECTIVES

Established guidelines from the American Academy of Pediatrics for the care of patients with Down syndrome are often not followed. Our goal was to integrate aspects of the guidelines into the electronic health record (EHR) to improve guideline adherence throughout a child's life span.

METHODS

Two methods of EHR integration with age-based logic were created and implemented in June 2016: (1) a best-practice advisory that prompts an order for referral to genetics; and (2) a health maintenance record that tracks completion of complete blood cell count and/or hemoglobin testing, thyrotropin testing, echocardiogram, and sleep study. Retrospective chart review of patients with Down syndrome and visits to locations with EHR integration (NICUs, primary care centers, and genetics clinics) assessed adherence to the components of EHR integration; the impact was analyzed through statistical process control charts.

RESULTS

From July 2015 to October 2017, 235 patients with Down syndrome (ages 0 to 32 years) had 466 visits to the EHR integration locations. Baseline adherence for individual components ranged from 51% (sleep study and hemoglobin testing) to 94% (echocardiogram). EHR integration was associated with a shift in adherence to all select recommendations from 61.6% to 77.3% (P < .001) including: genetic counseling, complete blood cell count and/or hemoglobin testing, thyrotropin testing, echocardiogram, and sleep study.

CONCLUSIONS

Integrating specific aspects of Down syndrome care into the EHR can improve adherence to guideline recommendations that span the life of a child. Future quality improvement should be focused on older children and adults with Down syndrome.

An analysis of adaptations to multi-level intervention strategies to enhance implementation of clinical practice guidelines for treating tobacco use in dental care settings

Introduction

Our team conducted a cluster randomized controlled trial (DUET) that compared the effectiveness of three theory-driven, implementation strategies on dental provider adherence to tobacco dependence treatment guidelines (TDT). In this paper we describe the process of adapting the implementation strategies to the local context of participating dental public health clinics in New York City.

Methods

Eighteen dental clinics were randomized to one of three study arms testing several implementation strategies: Current Best Practices (CBP) (i.e. staff training, clinical reminder system and Quitline referral system); CBP + Performance Feedback (PF) (i.e. feedback reports on provider delivery of TDT); and CBP + PF + Pay-for-Performance (i.e. financial incentives for provision of TDT). Through an iterative process, we used Stirman's modification framework to classify, code and analyze modifications made to the implementation strategies.

Results

We identified examples of six of Stirman's twelve content modification categories and two of the four context modification categories. Content modifications were classified as: tailoring, tweaking or refining (49.8%), adding elements (14.1%), departing from the intervention (9.3%), loosening structure (4.4%), lengthening and extending (4.4%) and substituting elements (4.4%). Context modifications were classified as those related to personnel (7.9%) and to the format/channel (8.8%) of the intervention delivery. Common factors associated with adaptations that arose during the intervention included staff changes, time constraints, changes in leadership preferences and functional limitations of to the Electronic Dental Record.

Conclusions

This study offers guidance on how to capture intervention adaptation in the context of a multi-level intervention aimed at implementing sustainable changes to optimize TDT in varying public health dental settings.

Inside help: An integrative review of champions in healthcare-related implementation

Background/aims:

The idea that champions are crucial to effective healthcare-related implementation has gained broad acceptance; yet the champion construct has been hampered by inconsistent use across the published literature. This integrative review sought to establish the current state of the literature on champions in healthcare settings and bring greater clarity to this important construct.

Methods:

This integrative review was limited to research articles in peer-reviewed, English-language journals published from 1980 to 2016. Searches were conducted on the online MEDLINE database via OVID and PubMed using the keyword “champion.” Several additional terms often describe champions and were also included as keywords: implementation leader, opinion leader, facilitator, and change agent. Bibliographies of full-text articles that met inclusion criteria were reviewed for additional references not yet identified via the main strategy of conducting keyword searches in MEDLINE. A five-member team abstracted all full-text articles meeting inclusion criteria.

Results:

The final dataset for the integrative review consisted of 199 unique articles. Use of the term champion varied widely across the articles with respect to topic, specific job positions, or broader organizational roles. The most common method for operationalizing champion for purposes of analysis was the use of a dichotomous variable designating champion presence or absence. Four studies randomly allocated of the presence or absence of champions.

Conclusions:

The number of published champion-related articles has markedly increased: more articles were published during the last two years of this review (i.e. 2015–2016) than during its first 30 years (i.e. 1980–2009).

The number of champion-related articles has continued to increase sharply since the year 2000. Individual studies consistently found that champions were important positive influences on implementation effectiveness. Although few in number, the randomized trials of champions that have been conducted demonstrate the feasibility of using experimental design to study the effects of champions in healthcare.

Quit Outcomes and Program Utilization by Mode of Entry Among Clients Enrolling in a Quitline

PURPOSE

To investigate how mode of entry into a quitline influences program utilization and quit outcomes among clients seeking cessation services.

DESIGN

This is a retrospective analysis of clients receiving quitline services from January 2011 to June 2016.

SETTING

The study was conducted at the Arizona Smokers' Helpline.

PARTICIPANTS

Enrolled clients completed a 7-month follow-up (N = 18 650).

MEASURES

The independent variable was referral mode of entry (ie, proactive, passive, and self-referral). Outcome variables included tobacco cessation medication use, number of coaching sessions completed, and 30-day tobacco abstinence at 7 months.

ANALYSIS

Logistic regression was used to analyze tobacco abstinence after controlling for potential confounders.

RESULTS

Compared to self-referred clients, proactively referred clients were least likely (odds ratio [OR]: 0.88; 95% confidence interval [CI]: 0.81-0.97), whereas passively referred clients were most likely (OR: 1.14; 95% CI: 1.00-1.30) to report tobacco abstinence. Proactively referred (OR: 0.79; 95% CI: 0.70-0.88), but not passively referred, clients were 21% less likely to report tobacco cessation medication use than self-referred clients.

CONCLUSION

Proactive referrals are associated with lower utilization of tobacco cessation medication and less successful quit outcomes; however, provider referrals are critical to reaching tobacco users who may have more significant health risks and barriers to quitting. Examining potential barriers among both providers and provider-referred clients is needed to inform improvements in training providers on brief interventions for tobacco cessation.

An Electronic Health Record-Based Strategy to Address Child Tobacco Smoke Exposure

INTRODUCTION

A high proportion of children presenting to pediatric urgent cares are exposed to tobacco smoke. An electronic health record-based clinical decision support system for nurses to facilitate guideline-based tobacco smoke exposure screening and counseling for caregivers who smoke was designed and evaluated.

DESIGN

A mixed-methods, 3-month, prospective study that began in November 2015, data were analyzed in June 2016.

SETTING/PARTICIPANTS

Five urgent cares that were part of a large children's hospital in Cincinnati, OH. Participants were urgent care nurses.

INTERVENTION

The clinical decision support system prompted nurses to Ask, Advise, Assess, and Assist caregivers to quit smoking. Monthly feedback reports were also provided.

MAIN OUTCOME MEASURE

Clinical decision support system use rates, nurses' attitudes towards tobacco smoke exposure intervention, and percentage of children screened and caregivers counseled.

RESULTS

All nurses used the clinical decision support system. Compared with Month 1, nurses were twice as likely to advise and assess during Months 2 and 3. There was significant improvement in nurses feeling prepared to assist caregivers in quitting. Nurses reported that feedback reports motivated them to use the clinical decision support system, and that it was easy to use. Almost 65% of children were screened for tobacco smoke exposure; 19.5% screened positive. Of caregivers identified as smokers, 26% were advised to quit and 29% were assessed for readiness to quit. Of those assessed, 67% were interested in quitting, and of those, 100% were assisted.

CONCLUSIONS

A clinical decision support system increased rates of tobacco smoke exposure screening and intervention in pediatric urgent cares. Rates might further improve by incorporating all components of the clinical decision support system into the electronic health record.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02489708.

Smoking Cessation and Electronic Cigarettes in Community Mental Health Centers: Patient and Provider Perspectives

Little is known about patients' electronic cigarette use, interest in and use of smoking cessation treatments, and providers' attitude towards such treatment. We assessed patients (N = 231) and providers (45 psychiatrists, 97 case workers) in four Community Mental Health Centers. Interestingly, 50% of smokers reported interest in using electronic cigarettes to quit smoking, and 22% reported current use. While 82% of smokers reported wanting to quit or reduce smoking, 91% of psychiatrists and 84% of case workers reported that patients were not interested in quitting as the lead barrier, limiting the provision of cessation interventions. Providers' assumption of low patient interest in treatment may account for the low rate of smoking cessation treatment. In contrast, patients report interest and active use of electronic cigarettes to quit smoking. This study highlights the need for interventions targeting different phases of smoking cessation in these patients suffering disproportionately from tobacco dependence.

Smoking-Cessation Assistance: Before and After Stage 1 Meaningful Use Implementation

INTRODUCTION

Brief smoking-cessation interventions in primary care settings are effective, but delivery of these services remains low. The Centers for Medicare and Medicaid Services' Meaningful Use (MU) of Electronic Health Record (EHR) Incentive Program could increase rates of smoking assessment and cessation assistance among vulnerable populations. This study examined whether smoking status assessment, cessation assistance, and odds of being a current smoker changed after Stage 1 MU implementation.

METHODS

EHR data were extracted from 26 community health centers with an EHR in place by June 15, 2009. AORs were computed for each binary outcome (smoking status assessment, counseling given, smoking-cessation medications ordered/discussed, current smoking status), comparing 2010 (pre-MU), 2012 (MU preparation), and 2014 (MU fully implemented) for pregnant and non-pregnant patients.

RESULTS

Non-pregnant patients had decreased odds of current smoking over time; odds for all other outcomes increased except for medication orders from 2010 to 2012. Among pregnant patients, odds of assessment and counseling increased across all years. Odds of discussing or ordering of cessation medications increased from 2010 compared with the other 2 study years; however, medication orders alone did not change over time, and current smoking only decreased from 2010 to 2012. Compared with non-pregnant patients, a lower percentage of pregnant patients were provided counseling.

CONCLUSIONS

Findings suggest that incentives for MU of EHRs increase the odds of smoking assessment and cessation assistance, which could lead to decreased smoking rates among vulnerable populations. Continued efforts for provision of cessation assistance among pregnant patients is warranted.

Evaluation of a Web-Based Training in Smoking Cessation Counseling Targeting U.S. Eye-Care Professionals

Background. Smoking causes blindness-related diseases. Eye-care providers are uniquely positioned to help their patients quit smoking. Aims. Using a pre-/postevaluation design, this study evaluated a web-based training in smoking cessation counseling targeting eye-care providers. Method. The training was developed based on the 3A1R protocol: “Ask about smoking, Advise to quit, Assess willingness to quit, and Refer to tobacco quitlines,” and made available in the form of a web-based video presentation. Providers ( n = 654) at four academic centers were invited to participate. Participants completed pretraining, posttraining, and 3-month follow-up surveys. Main outcomes were self-reported improvement in their motivation, confidence, and counseling practices at 3-month follow-up. Generalized linear mixed models for two time-points (pretraining and 3-month) were conducted for these outcomes. Results. A total of 113 providers (54.0% males) participated in the study (17.7% response rate). At the 3-month evaluation, 9.8% of participants reported improvement in their motivation. With respect to the 3A1R, 8% reported improvement in their confidence for Ask, 15.5% for Advise, 28.6% for Assess, and 37.8% for Refer. Similarly, 25.5% reported improvement in their practices for Ask, 25.5% for Advise, 37.2% for Assess, and 39.4% for Refer to tobacco quitlines ( p < .001 for all except for Refer confidence p = .05). Discussion. Although participation rate was low, the program effectively improved providers’ smoking cessation counseling practices. Conclusions. Including training in smoking cessation counseling in ophthalmology curriculums, and integrating the 3A1R protocol into the electronic medical records systems in eye-care settings, might promote smoking cessation practices in these settings.

A content analysis of electronic health record (EHR) functionality to support tobacco treatment

Government regulations have created new incentives for health systems to implement changes in electronic health records (EHRs) to reduce tobacco use among patients. The purpose of this study is to conduct a content analysis of EHR modifications aimed at supporting tobacco cessation and to document these modifications using a 5 A's framework (i.e., Ask, Advise, Assess, Assist, Arrange). Fourteen trials were identified that met inclusion criteria. A content analysis of EHR functionality in these trials was conducted by two independent reviewers between February and June 2015. For "Ask," all trials provided for the documentation of smoking status in the EHR. For "Advise," 35.7 % of EHRs provided functionality related to helping a clinician provide advice to quit. For "Assess," more than half (57.1 %) of EHRs included a feature to document a patient's willingness to quit. For "Assist," EHRs offered features for medication prescribing (78.6 %), providing educational materials to patients (57.1 %), referring a patient to the quitline (50.0 %), referring a patient to a tobacco treatment specialist (42.9 %), and documenting the provision of counseling (35.7 %). Finally, for "Arrange," EHRs supported the following up of patients (35.7 %) and allowed tobacco treatment specialists to "pass back" patient notes to primary care providers (28.6 %). Studies that have modified EHRs for tobacco treatment have done so across the steps in the 5 As model, with most modifications occurring to support documenting smoking status (Ask) and assisting with medication prescribing (Assist). As health systems attempt to comply with Meaningful Use regulations, an understanding of the range of EHR modifications to support tobacco treatment is warranted.

Development of a Tobacco Cessation Clinical Decision Support System for Pediatric Emergency Nurses

Almost 50% of children who visit the pediatric emergency department are exposed to tobacco smoke. However, pediatric emergency nurses do not routinely address this issue. The incorporation of a clinical decision support system into the electronic health record may improve the rates of tobacco exposure screening and interventions. We used a mixed-methods design to develop, refine, and implement an evidence-based clinical decision support system to help nurses screen, educate, and assist caregivers to quit smoking. We included an advisory panel of emergency department experts and leaders and focus and user groups of nurses. The prompts include the following: (1) "Ask" about child smoke exposure and caregiver smoking; (2) "Advise" caregivers to reduce their child's smoke exposure by quitting smoking; (3) "Assess" interest; and (4) "Assist" caregivers to quit. The clinical decision support system was created to reflect nurses' suggestions and was implemented in five busy urgent care settings with 38 nurses. The nurses reported that the system was easy to use and helped them to address caregiver smoking. The use of this innovative tool may create a sustainable and disseminable model for prompting nurses to provide evidence-based tobacco cessation treatment.

Application of the Consolidated Framework for Implementation Research to assess factors that may influence implementation of tobacco use treatment guidelines in the Viet Nam public health care delivery system

Background

Services to treat tobacco dependence are not readily available to smokers in low-middle income countries (LMICs) where smoking prevalence remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of two strategies for implementing tobacco use treatment guidelines in 26 community health centers (CHCs) in Viet Nam. Guided by the Consolidated Framework for Implementation Research (CFIR), prior to implementing the trial, we conducted formative research to (1) identify factors that may influence guideline implementation and (2) inform further modifications to the intervention that may be necessary to translate a model of care delivery from a high-income country (HIC) to the local context of a LMIC.

Methods

We conducted semi-structured qualitative interviews with CHC medical directors, health care providers, and village health workers (VHWs) in eight CHCs (n = 40). Interviews were transcribed verbatim and translated into English. Two qualitative researchers used both deductive (CFIR theory driven) and inductive (open coding) approaches to analysis developed codes and themes relevant to the aims of this study.

Results

The interviews explored four out of five CFIR domains (i.e., intervention characteristics, outer setting, inner setting, and individual characteristics) that were relevant to the analysis. Potential facilitators of the intervention included the relative advantage of the intervention compared with current practice (intervention characteristics), awareness of the burden of tobacco use in the population (outer setting), tension for change due to a lack of training and need for skill building and leadership engagement (inner setting), and a strong sense of collective efficacy to provide tobacco cessation services (individual characteristics). Potential barriers included the perception that the intervention was more complex (intervention characteristic) and not necessarily compatible (inner setting) with current workflows and staffing historically designed to address infectious disease prevention and control rather than chronic disease prevention and competing priorities that are determined by the MOH (outer setting).

Conclusions

In this study, CFIR provided a valuable framework for evaluating factors that may influence implementation of a systems-level intervention for tobacco control in a LMIC and understand what adaptations may be needed to translate a model of care delivery from a HIC to a LMIC.

Trial registration

NCT02564653. Registered September 2015

System change interventions for smoking cessation

BACKGROUND

System change interventions for smoking cessation are policies and practices designed by organizations to integrate the identification of smokers and the subsequent offering of evidence-based nicotine dependence treatments into usual care. Such strategies have the potential to improve the provision of smoking cessation support in healthcare settings, and cessation outcomes among those who use them.

OBJECTIVES

To assess the effectiveness of system change interventions within healthcare settings, for increasing smoking cessation or the provision of smoking cessation care, or both.

SEARCH METHODS

We searched databases including the Cochrane Tobacco Addiction Group Specialized Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO in February 2016. We also searched clinical trial registries: WHO clinical trial registry, US National Institute of Health (NIH) clinical trial registry. We checked 'grey' literature, and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-RCTs, quasi-RCTs and interrupted time series studies that evaluated a system change intervention, which included identification of all smokers and subsequent offering of evidence-based nicotine dependence treatment.

DATA COLLECTION AND ANALYSIS

Using a standardized form, we extracted data from eligible studies on study settings, participants, interventions and outcomes of interest (both cessation and system-level outcomes). For cessation outcomes, we used the strictest available criteria to define abstinence. System-level outcomes included assessment and documentation of smoking status, provision of advice to quit or cessation counselling, referral and enrolment in quitline services, and prescribing of cessation medications. We assessed risks of bias according to the Cochrane Handbook and categorized each study as being at high, low or unclear risk of bias. We used a narrative synthesis to describe the effectiveness of the interventions on various outcomes, because of significant heterogeneity among studies.

MAIN RESULTS

We included seven cluster-randomized controlled studies in this review. We rated the quality of evidence as very low or low, depending on the outcome, according to the GRADE standard. Evidence of efficacy was equivocal for abstinence from smoking at the longest follow-up (four studies), and for the secondary outcome 'prescribing of smoking cessation medications' (two studies). Four studies evaluated changes in provision of smoking cessation counselling and three favoured the intervention. There were significant improvements in documentation of smoking status (one study), quitline referral (two studies) and quitline enrolment (two studies). Other secondary endpoints, such as asking about tobacco use (three studies) and advising to quit (three studies), also indicated some positive effects.

AUTHORS' CONCLUSIONS

The available evidence suggests that system change interventions for smoking cessation may not be effective in achieving increased cessation rates, but have been shown to improve process outcomes, such as documentation of smoking status, provision of cessation counselling and referral to smoking cessation services. However, as the available research is limited we are not able to draw strong conclusions. There is a need for additional high-quality research to explore the impact of system change interventions on both cessation and system-level outcomes.

Comparing Graphical Formats for Feedback of Clinical Practice Data. A Multicenter Study among Anesthesiologists in France

OBJECTIVES

Although graphical formats used to feedback clinical practice data may have an important impact, the most effective formats remain unknown. Using prevention of postoperative nausea and vomiting by anesthesiologists as an application, the objective of this study was to assess which graphical formats for feedback of clinical practice data are the most incentive to change practice.

METHODS

We conducted a multicenter cross-sectional study among anesthesiologists randomized in two groups between March and June 2014. Each anesthesiologist assessed 15 graphical formats displaying an indicator of either prescription conformity or prescription effectiveness. Graphical formats varied by: type of graph (bar charts, linear sliders, or pictographs), presence or not of a target to reach, presence or not of a contrast between a hypothetical physician and his / her team, direction of the difference between the physician and his / her team, and restitution or not of the quality indicator evolution over the previous six months. The primary outcome was a numerical scale score expressing the anesthesiologists' motivation to change his / her practice (ranging from 1 to 10 points). A linear mixed model was fitted to explain variation in motivation.

RESULTS

Sixty-six anesthesiologists assessed the conformity indicator and 67 assessed the effectiveness indicator. Factors associated with an increased motivation to change practice were: (i) presence of a clearly defined target to reach (conformity: β = 0.24 points, p = 0.0046; effectiveness: β = 1.11 points, p < 0.0001); (ii) contrast between the physician and his / her team (conformity: β = 0.38 points, p < 0.0001; effectiveness: β = 0.33 points, p = 0.0021); (iii) better results for the team than for the physician (conformity: β = 0.65 points, p < 0.0001; effectiveness β = 1.16 points, p < 0.0001). For the effectiveness indicator, anesthesiologists were more motivated to change practice with bar charts (β = 0.24 points, p = 0.0447) and pictographs (β = 0.45 points, p = 0.0001) than with linear sliders.

CONCLUSIONS

Graphs associated with a defined target to reach should be preferred to deliver feedback, especially bar graphs or pictographs for indicators which are more complex to represent such as effectiveness indicators. Anesthesiologists are also more motivated to change practice when graphs report contrasted data between the physician and his / her team and a lower conformity or effectiveness for the physician than for his / her team.

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

PURPOSE

To help clinicians and care systems determine the priority for tobacco counseling in busy clinic schedules, we assessed the lifetime health and economic value of annually counseling youth to discourage smoking initiation and of annually counseling adults to encourage cessation.

METHODS

We conducted a microsimulation analysis to estimate the health impact and cost effectiveness of both types of tobacco counseling in a US birth cohort of 4,000,000. The model used for the analysis was constructed from nationally representative data sets and structured literature reviews.

RESULTS

Compared with no tobacco counseling, the model predicts that annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by 2.0 percentage points, whereas annual counseling for adults will reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities and increase quality-adjusted life years (QALYs) by 756,601 over the lifetime of the cohort. Adult counseling would prevent 69,901 smoking-attributable fatalities and increase QALYs by 1,044,392. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided to the cohort during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. Only one-third of the potential health and economic benefits of counseling are being realized at current counseling rates.

CONCLUSIONS

Brief tobacco counseling provides substantial health benefits while producing cost savings. Both youth and adult intervention are high-priority uses of limited clinician time.

Development and Testing of a Computerized Decision Support System to Facilitate Brief Tobacco Cessation Treatment in the Pediatric Emergency Department: Proposal and Protocol

Background

Tobacco smoke exposure (TSE) is unequivocally harmful to children's health, yet up to 48% of children who visit the pediatric emergency department (PED) and urgent care setting are exposed to tobacco smoke. The incorporation of clinical decision support systems (CDSS) into the electronic health records (EHR) of PED patients may improve the rates of screening and brief TSE intervention of caregivers and result in decreased TSE in children.

Objective

We propose a study that will be the first to develop and evaluate the integration of a CDSS for Registered Nurses (RNs) into the EHR of pediatric patients to facilitate the identification of caregivers who smoke and the delivery of TSE interventions to caregivers in the urgent care setting.

Methods

We will conduct a two-phase project to develop, refine, and integrate an evidence-based CDSS into the pediatric urgent care setting. RNs will provide input on program content, function, and design. In Phase I, we will develop a CDSS with prompts to: (1) ASK about child TSE and caregiver smoking, (2) use a software program, Research Electronic Data Capture (REDCap), to ADVISE caregivers to reduce their child's TSE via total smoking home and car bans and quitting smoking, and (3) ASSESS their interest in quitting and ASSIST caregivers to quit by directly connecting them to their choice of free cessation resources (eg, Quitline, SmokefreeTXT, or SmokefreeGOV) during the urgent care visit. We will create reports to provide feedback to RNs on their TSE counseling behaviors. In Phase II, we will conduct a 3-month feasibility trial to test the results of implementing our CDSS on changes in RNs’ TSE-related behaviors, and child and caregiver outcomes.

Results

This trial is currently underway with funding support from the National Institutes of Health/National Cancer Institute. We have completed Phase I. The CDSS has been developed with input from our advisory panel and RNs, and pilot tested. We are nearing completion of Phase II, in which we are conducting the feasibility trial, analyzing data, and disseminating results.

Conclusions

This project will develop, iteratively refine, integrate, and pilot test the use of an innovative CDSS to prompt RNs to provide TSE reduction and smoking cessation counseling to caregivers who smoke. If successful, this approach will create a sustainable and disseminable model for prompting pediatric practitioners to apply tobacco-related guideline recommendations. This systems-based approach has the potential to reach at least 12 million smokers a year and significantly reduce TSE-related pediatric illnesses and related costs.

Utilization of the Electronic Health Record to Improve Provision of Smoking Cessation Resources for Vascular Surgery Inpatients

BACKGROUND AND OBJECTIVES

Identification of hospitalized patients who smoke has shown significant improvement in recent years, but provision of evidence-based tobacco cessation treatment remains a challenge. This study evaluated the utilization of an electronic health record (EHR) to facilitate implementation of evidence-based clinical practice guidelines for smoking cessation on a vascular surgery inpatient unit.

METHODS

A pre-and post-intervention cohort study was conducted over 6 months at a single academic medical center with a comprehensive EHR. All patients admitted to the vascular surgery service and documented as current smokers were included. A vascular surgery discharge order set with an evidence-based smoking cessation module was developed and implemented. The primary outcome was prescription of nicotine replacement therapy (NRT) at the time of discharge. The secondary outcome was referral for smoking cessation counseling at the time of discharge.

RESULTS

There were 52 and 42 smokers in the pre-and post-intervention cohorts, respectively. Over the 3 months following implementation of the EHR order set, prescription of NRT at the time of discharge did not change significantly (27% vs 19%, p=0.30). Referral for outpatient smoking cessation counseling increased in the post-intervention group, but did not reach significance (64% vs 72%, p=0.20).

CONCLUSIONS

Implementation of a brief tobacco dependence treatment order set in an existing EHR increased cessation counseling referrals on a vascular surgery inpatient unit. One potential limitation of the study was the modest sample size. Not being able to make smoking cessation treatment a mandatory component in discharge orders may also have contributed to the modest effect. Assessing the differential effect of EHR-based order implementation will be important in future research on this topic.

Evaluation of a primary care intervention on body mass index: the Maine Youth Overweight Collaborative

BACKGROUND

We evaluated the impact of a brief primary-care-based intervention, The Maine Youth Overweight Collaborative (MYOC), on BMI (kg/m(2)) z-score change among participants with obesity (BMI ≥95th percentile for age and sex), overweight (BMI ≥85th and <95th percentile), and healthy weight (≥50th and <85th percentile).

METHODS

A quasi-experimental field trial with nine intervention and nine control sites in urban and rural areas of Maine, MYOC focused on improvements in clinical decision support, charting BMI percentile, identifying patients with obesity, appropriate lab tests, and counseling families/patients. Retrospective longitudinal record reviews assessed BMI z-scores preintervention (from 1999 through October 2004) and one postintervention time point (between December 2006 and March 2008). Participants were youth ages 5-18 having two visits before the intervention with weight percentile greater than or equal to 95% (N=265). Secondary analyses focused on youths who are overweight (N=215) and healthy weight youth (N=506).

RESULTS

Although the MYOC intervention demonstrated significant provider and office system improvements, we found no significant changes in BMI z-scores in intervention versus control youth pre- to postintervention and significant flattening of upward trends among both intervention and control sites (p<0.001).

CONCLUSIONS

This brief office-based intervention was associated with no significant improvement in BMI z-scores, compared to control sites. An important avenue for obesity prevention and treatment as part of a multisector approach in communities, this type of primary care intervention alone may be unlikely to impact BMI improvement given the limited dosage-an estimated 4-6 minutes for one patient contact.

Cigarette Smoking, Desire to Quit, and Tobacco-Related Counseling Among Patients at Adult Health Centers

Objectives. We determined cigarette smoking prevalence, desire to quit, and tobacco-related counseling among a national sample of patients at health centers. Methods. Data came from the 2009 Health Center Patient Survey and the 2009 National Health Interview Survey. The analytic sample included 3949 adult patients at health centers and 27 731 US adults. Results. Thirty-one percent of health center patients were current smokers, compared with 21% of US adults in general. Among currently smoking health center patients, 83% desired to quit and 68% received tobacco counseling. In multivariable models, patients had higher adjusted odds of wanting to quit if they had indications of severe mental illness (adjusted odds ratio [AOR] = 3.26; 95% confidence interval [CI] = 1.19, 8.97) and lower odds if they had health insurance (AOR = 0.43; 95% CI = 0.22, 0.86). Patients had higher odds of receiving counseling if they had 2 or more chronic conditions (AOR = 2.05; 95% CI = 1.11, 3.78) and lower odds if they were Hispanic (AOR = 0.57; 95% CI = 0.34, 0.96). Conclusions. Cigarette smoking prevalence is substantially higher among patients at health centers than US adults in general. However, most smokers at health centers desire to quit. Continued efforts are warranted to reduce tobacco use in this vulnerable group.

Use of electronic health records to support smoking cessation

BACKGROUND

Health information systems such as electronic health records (EHR), computerized decision support systems, and electronic prescribing are potentially valuable components to improve the quality and efficiency of clinical interventions for tobacco use.

OBJECTIVES

To assess the effectiveness of electronic health record-facilitated interventions on smoking cessation support actions by clinicians, clinics, and healthcare delivery systems and on patient smoking cessation outcomes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, and reference lists and bibliographies of included studies. We searched for studies published between January 1990 and July 2014.

SELECTION CRITERIA

We included both randomized studies and non-randomized studies that reported interventions targeting tobacco use through an EHR in healthcare settings. The intervention could include any use of an EHR to improve smoking status documentation or cessation assistance for patients who use tobacco, either by direct action or by feedback of clinical performance measures.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of wide variation in measurement of outcomes, we were not able to conduct a meta-analysis.

MAIN RESULTS

We included six group randomized trials, one patient randomized study, and nine non-randomized observational studies of fair to good quality that tested the use of an existing EHR to improve documentation and/or treatment of tobacco use. None of the studies included a direct assessment of patient quit rates. Overall, these studies found only modest improvements in some of the recommended clinician actions on tobacco use.

AUTHORS' CONCLUSIONS

Documentation of tobacco status and referral to cessation counselling appears to increase following EHR modifications designed to prompt the recording and treating of tobacco use at healthcare visits. There is a need for additional research to enhance the potential of EHRs to prompt additional tobacco use treatment and cessation outcomes in healthcare settings.

Barriers and facilitators to expanding the role of community health workers to include smoking cessation services in Vietnam: a qualitative analysis

BACKGROUND

Despite high smoking rates, cessation services are largely unavailable in Vietnam. This study explored attitudes and beliefs of community health workers (CHWs) towards expanding their role to include delivering tobacco use treatment (TUT), and potential barriers and facilitators associated with implementing a strategy in which health centers would refer patients to CHWs for cessation services.

METHODS

We conducted four focus groups with 29 CHWs recruited from four district community health centers (CHCs) in Hanoi, Vietnam.

RESULTS

Participants supported expanding their role saying that it fit well with their current responsibilities. They further endorsed the feasibility of serving as a referral resource for providers in local CHCs expressing the belief that CHWs were "more suitable than their clinical colleagues" to offer cessation assistance. The most frequently cited barrier to routinely offering cessation services was that despite enacting a National Tobacco Control Action plan, cessation is not one of the national prevention priorities. As a result, CHWs have not been "assigned" to help smokers quit by the Ministry of Health. Additional barriers included lack of training and time constraints.

CONCLUSION

Focus groups suggest that implementing a systems-level intervention that allows providers to refer smokers to CHWs is a promising model for extending the treatment of tobacco use beyond primary care settings and increasing access to smoking cessation services in Vietnam. There is a need to test the cost-effectiveness of this and other strategies for implementing TUT guidelines to support and inform national tobacco control policies in Vietnam and other low-and middle-income countries.

Facilitators of health systems change for tobacco dependence treatment: a qualitative study of stakeholders' perceptions

Background

Health systems play key roles in identifying tobacco users and providing evidence-based care to help them quit. Health systems change – changes to health care processes, policies and financing – has potential to build capacity within these systems to address tobacco use. In 2010, ClearWay Minnesota^SM piloted a health systems change funding initiative, providing resources and technical assistance to four health care systems. This paper presents findings from a process evaluation, describing key stakeholders’ views on whether changes to how health systems treat tobacco use resulted from this initiative and what may have facilitated those changes.

Methods

A process evaluation was conducted by an independent evaluation firm. A qualitative case study approach provided understanding of systems change efforts. Interviews were conducted with key informants representing the health systems, funder and technical assistance providers. Core documents were reviewed and compared to thematic analysis from the interviews. Results were triangulated with existing literature to check for convergence or divergence. A cross-case analysis of the findings was conducted in which themes were compared and contrasted.

Results

All systems created and implemented well-defined written tobacco use screening, documentation and treatment referral protocols for every patient at every visit. Three implemented systematic follow-up procedures for patients referred to treatment, and three also implemented changes to electronic health records systems to facilitate screening, referral and reporting. Fax referral to quitline services was implemented or enhanced by two systems. Elements that facilitated successful systems changes included capitalizing on environmental changes, ensuring participation and support at all organizational levels, using technology, establishing ongoing training and continuous quality improvement mechanisms and leveraging external funding and technical assistance.

Conclusions

This evaluation demonstrates that health systems can implement substantial changes to facilitate routine treatment of tobacco dependence in a relatively short timeframe. Implementing best practices like these, including increased emphasis on the implementation and use of electronic health record systems and healthcare quality measures, is increasingly important given the changing health care environment. Lessons learned from this project can be resources for states and health systems likely to implement similar systems changes.

Dentists' self-perceived role in offering tobacco cessation services: results from a nationally representative survey, United States, 2010-2011

Introduction

Dental visits represent an opportunity to identify and help patients quit smoking, yet dental settings remain an untapped venue for treatment of tobacco dependence. The purpose of this analysis was to assess factors that may influence patterns of tobacco-use–related practice among a national sample of dental providers.

Methods

We surveyed a representative sample of general dentists practicing in the United States (N = 1,802). Multivariable analysis was used to assess correlates of adherence to tobacco use treatment guidelines and to analyze factors that influence providers’ willingness to offer tobacco cessation assistance if reimbursed for this service.

Results

More than 90% of dental providers reported that they routinely ask patients about tobacco use, 76% counsel patients, and 45% routinely offer cessation assistance, defined as referring patients for cessation counseling, providing a cessation prescription, or both. Results from multivariable analysis indicated that cessation assistance was associated with having a practice with 1 or more hygienists, having a chart system that includes a tobacco use question, having received training on treating tobacco dependence, and having positive attitudes toward treating tobacco use. Providers who did not offer assistance but who reported that they would change their practice patterns if sufficiently reimbursed were more likely to be in a group practice, treat patients insured through Medicaid, and have positive attitudes toward treating tobacco dependence.

Conclusion

Findings indicate the potential benefit of increasing training opportunities and promoting system changes to increase involvement of dental providers in conducting tobacco use treatment. Reimbursement models should be tested to assess the effect on dental provider practice patterns.