Evaluation of a Proactive Smoking Cessation Electronic Visit to Extend the Reach of Evidence-Based Cessation Treatment via Primary Care

Functional and Nonfunctional Requirements of Virtual Clinic Mobile Applications: A Systematic Review

Introduction: The Virtual Clinic Mobile Application (VCMA) is a valuable tool for managing and remotely monitoring patients with various medical conditions. It can alleviate the strain on outpatient services and offer follow-up options for patients who do not require a physical examination. A thorough understanding of recent literature can assist in identifying suitable functionalities for new development and future improvement of current applications (apps). This review study is aimed at identifying functional and nonfunctional requirements for VCMA. Methods: This study conducted a systematic search using databases such as PubMed, Scopus, ISI Web of Science, Science Direct, ProQuest, and IEEE to gather requirements of VCMA articles published in English from the inception of the databases up to April 2022. Out of a total of 1223 articles, 76 met the inclusion criteria. These articles were then analyzed using conventional content analysis to extract and categorize their requirements. Results: Two main themes and 8 subthemes in terms of VCMA requirements were extracted as follows: (1) functional requirements with 3 subthemes (demographic data documentation, health record, general features of the user interface (UI)); (2) nonfunctional requirements with 5 subthemes (usability, accessibility, compatibility, efficiency, and security). Conclusion: The findings highlight the importance of mHealth solutions for virtual care and the need for the development of apps based on the extracted functional and nonfunctional requirements for VCMA; however, controlled trials are necessary. It is recommended that transparent reporting of mHealth interventions be prioritized to enable effective interpretation of the extracted data.

Asynchronous Telemedicine: A Systematic Literature Review

Background

Asynchronous telemedicine (ATM), which describes telemedical interaction between a patient and provider where neither party communicates simultaneously, is an important telemedicine modality that is seeing increased use. In this article, we summarize the published peer-reviewed literature specifically related to ATM to (1) identify terms or phrases that are used to describe ATM, (2) ascertain how this research has thus far addressed the various aspects of the quadruple aim of medicine, and (3) assess the methodological rigor of research on ATM. We also divided the literature into pre- and post-COVID-19 onset periods to identify potential variations in the literature between these two periods.

Methods

This systematic literature review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature search, utilizing multiple databases and applying inclusion and exclusion criteria, initially produced 2624 abstracts for review. De-duplication and screening ultimately yielded 104 articles for data extraction.

Results

"Store-and-forward" and variations of "e-visit" were the most frequently used alternative terms for ATM. Care quality was the most frequently addressed aspect of the Quadruple Aim of Medicine-more than double any other category-followed by patient satisfaction. We separated cost of care into two categories: patients' cost of care and providers' cost to provide care. Patient cost of care was the third most addressed aspect of the Quadruple Aim of Medicine followed by provider well-being and provider's cost to provide care. Methodological rigor of the studies was also addressed, with only 2 quantitative studies ranked "Strong," 5 ranked "Moderate," and 97 ranked "Weak." Qualitative studies were generally acceptable but struggled methodologically with accounting for all participants and articulation of results.

Conclusions

Although "store-and-forward" is somewhat more frequently used in the studies included in this review, variants of "e-visit," are growing in recent usage. Given the relative newness of modality, it is not surprising that quality of care is the most researched aspect of the Quadruple Aim of Medicine in ATM research. We anticipate more balance between these areas as research in this field matures. Primary areas of research need currently relate to practitioners-specifically their costs of providing care and well-being. Finally, future ATM research needs to address research challenges of selection bias and blinding in quantitative studies and improved participant tracking and articulation of both study design and results in qualitative studies.

Rationale, design, and protocol for a hybrid type 1 effectiveness-implementation trial of a proactive smoking cessation electronic visit for scalable delivery via primary care: the E-STOP trial

BACKGROUND

Cigarette smoking remains the leading cause of preventable disease and death in the United States. Primary care offers an ideal setting to reach adults who smoke cigarettes and improve uptake of evidence-based cessation treatment. Although U.S. Preventive Services Task Force Guidelines recommend the 5As model (Ask, Advise, Assess, Assist, Arrange) in primary care, there are many barriers to its implementation. Automated, comprehensive, and proactive tools are needed to overcome barriers. Our team developed and preliminarily evaluated a proactive electronic visit (e-visit) delivered via the Electronic Health Record patient portal to facilitate evidence-based smoking cessation treatment uptake in primary care, with promising initial feasibility and efficacy. This paper describes the rationale, design, and protocol for an ongoing Hybrid Type I effectiveness-implementation trial that will simultaneously assess effectiveness of the e-visit intervention for smoking cessation as well as implementation potential across diverse primary care settings.

METHODS

The primary aim of this remote five-year study is to examine the effectiveness of the e-visit intervention vs. treatment as usual (TAU) for smoking cessation via a clinic-randomized clinical trial. Adults who smoke cigarettes are recruited across 18 primary care clinics. Clinics are stratified based on their number of primary care providers and randomized 2:1 to either e-visit or TAU. An initial baseline e-visit gathers information about patient smoking history and motivation to quit, and a clinical decision support algorithm determines the best evidence-based cessation treatment to prescribe. E-visit recommendations are evaluated by a patient's own provider, and a one-month follow-up e-visit assesses cessation progress. Main outcomes include: (1) cessation treatment utilization (medication, psychosocial cessation counseling), (2) reduction in cigarettes per day, and (3) biochemically verified 7-day point prevalence abstinence (PPA) at six-months. We hypothesize that patients randomized to the e-visit condition will have better cessation outcomes (vs. TAU). A secondary aim evaluates e-visit implementation potential at patient, provider, and organizational levels using a mixed-methods approach. Implementation outcomes include acceptability, adoption, fidelity, implementation cost, penetration, and sustainability.

DISCUSSION

This asynchronous, proactive e-visit intervention could provide substantial benefits for patients, providers, and primary care practices and has potential to widely improve reach of evidence-based cessation treatment.

TRIAL REGISTRATION

NCT05493254.

The Impact of Digital Health on Smoking Cessation

BACKGROUND

Smartphones have become useful tools for medicine, with the use of specific apps making it possible to bring health care closer to inaccessible areas, continuously monitor a patient's pathology at any time and place, promote healthy habits, and ultimately improve patients' quality of life and the efficiency of the health care system. Since 2020, the use of smartphones has reached unprecedented levels. There are more than 350,000 health apps, according to a 2021 IQVIA Institute report, that address, among other things, the management of patient appointments; communication among different services or professionals; the promotion of lifestyle changes related to adopting healthy habits; and the monitoring of different pathologies and chronic conditions, including smoking cessation. The number of mobile apps for quitting smoking is high. As early as 2017, a total of 177 unique smoking cessation-relevant apps were identified in the iPhone App Store, 139 were identified in Google Play, 70 were identified in the BlackBerry app store, and 55 were identified in the Windows Phone Store, but very few have adequate scientific support. It seems clear that efforts are needed to assess the quality of these apps, as well as their effectiveness in different population groups, to have tools that offer added value to standard practices.

OBJECTIVE

This viewpoint aims to highlight the benefits of mobile health (mHealth) and its potential as an adjuvant tool in health care.

METHODS

A review of literature and other data sources was performed in order to show the current status of mobile apps that can offer support for smoking cessation. For this purpose, the PubMed, Embase, and Cochrane databases were explored between May and November 2022.

RESULTS

In terms of smoking cessation, mHealth has become a powerful coadjuvant tool that allows health workers to perform exhaustive follow-ups for the process of quitting tobacco and provide support anytime and anywhere. mHealth tools are effective for different groups of smokers (eg, pregnant women, patients with chronic obstructive pulmonary disease, patients with mental illness, and the general population) and are cost-effective, generating savings for the health system. However, there are some patient characteristics that can predict the success of using mobile apps in the smoking cessation process, such as the lower age of patients, dependence on tobacco, the number of quit attempts, and the previous use of mobile apps, among others. Therefore, it is preferable to offer these tools to patients with a higher probability of quitting tobacco.

CONCLUSIONS

mHealth is a promising tool for helping smokers in the smoking cessation process. There is a need for well-designed clinical studies and economic evaluations to jointly assess the effectiveness of new interventions in different population groups, as well as their impact on health care resources.

Associations in Cigarette Smoking and Health Conditions by Race/Ethnicity Among a Diverse Sample of Patients Receiving Treatment in a Federally Qualified Health Care Setting in Chicago

Purpose

To examine the association of cigarette use and smoking-related health conditions by race/ethnicity among diverse and low-income patients at a federally qualified health center (FQHC).

Methods

Demographics, smoking status, health conditions, death, and health service use were extracted from electronic medical data for patients seen between September 1, 2018, and August 31, 2020 (n=51,670). Smoking categories included everyday/heavy smoker, someday/light smoker, former smoker, or never smoker.

Results

Current and former smoking rates were 20.1% and 15.2%, respectively. Males, Black, White, non-partnered, older, and Medicaid/Medicare patients were more likely to smoke. Compared with never smokers, former and heavy smokers had higher odds for all health conditions except respiratory failure, and light smokers had higher odds of asthma, chronic obstructive pulmonary disease, emphysema, and peripheral vascular disease. All smoking categories had more emergency department visits and hospitalizations than never smokers. The associations between smoking status and health conditions differed by race/ethnicity. White patients who smoked had a greater increase in odds of stroke and other cardiovascular diseases compared with Hispanic and Black patients. Black patients who smoked had a greater increase in odds of emphysema and respiratory failure compared with Hispanic patients. Black and Hispanic patients who smoked had a greater increase in emergency care use compared with White patients.

Conclusion

Smoking was associated with disease burden and emergency care and differed by race/ethnicity.

Health Equity Implications

Resources to document smoking status and offer cessation services should be increased in FQHCs to promote health equity for lower income populations.

An EHR-automated and theory-based population health management intervention for smoking cessation in diverse low-income patients of safety-net health centers: a pilot randomized controlled trial

This study tested the preliminary effectiveness of an electronic health record (EHR)-automated population health management (PHM) intervention for smoking cessation among adult patients of a federally qualified health center in Chicago. Participants (N = 190; 64.7% women, 82.1% African American/Black, 8.4% Hispanic/Latino) were self-identified as smokers, as documented in the EHR, who completed the baseline survey of a longitudinal "needs assessment of health behaviors to strengthen health programs and services." Four weeks later, participants were randomly assigned to the PHM intervention (N = 97) or enhanced usual care (EUC; N = 93). PHM participants were mailed a single-page self-determination theory (SDT)-informed letter that encouraged smoking cessation or reduction as an initial step. The letter also addressed low health literacy and low income. PHM participants also received automated text messages on days 1, 5, 8, 11, and 20 after the mailed letter. Two weeks after mailing, participants were called by the Illinois Tobacco Quitline. EUC participants were e-referred following a usual practice. Participants reached by the quitline were offered behavioral counseling and nicotine replacement therapy. Outcome assessments were conducted at weeks 6, 14, and 28 after the mailed letter. Primary outcomes were treatment engagement, utilization, and self-reported smoking cessation. In the PHM arm, 25.8% of participants engaged in treatment, 21.6% used treatment, and 16.3% were abstinent at 28 weeks. This contrasts with no quitline engagement among EUC participants, and a 6.4% abstinence rate. A PHM approach that can reach all patients who smoke and address unique barriers for low-income individuals may be a critical supplement to clinic-based care.

Proactive Electronic Visits for Smoking Cessation and Chronic Obstructive Pulmonary Disease Screening in Primary Care: Randomized Controlled Trial of Feasibility, Acceptability, and Efficacy

BACKGROUND

Most smokers with chronic obstructive pulmonary disease (COPD) have not yet been diagnosed, a statistic that has remained unchanged for over two decades. A dual-focused telehealth intervention that promotes smoking cessation, while also facilitating COPD screening, could help address national priorities to improve the diagnosis, prevention, treatment, and management of COPD. The purpose of this study was to preliminarily evaluate an integrated asynchronous smoking cessation and COPD screening e-visit (electronic visit) that could be delivered proactively to adult smokers at risk for COPD, who are treated within primary care.

OBJECTIVE

The aims of this study were (1) to examine e-visit feasibility and acceptability, particularly as compared to in-lab diagnostic pulmonary function testing (PFT), and (2) to examine the efficacy of smoking cessation e-visits relative to treatment as usual (TAU), all within primary care.

METHODS

In a randomized clinical trial, 125 primary care patients who smoke were randomized 2:1 to receive either proactive e-visits or TAU. Participants randomized to the e-visit condition were screened for COPD symptoms via the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE). Those with scores ≥2 were invited to complete both home spirometry and in-lab PFTs, in addition to two smoking cessation e-visits. Smoking cessation e-visits assessed smoking history and motivation to quit and included completion of an algorithm to determine the best Food and Drug Administration-approved cessation medication to prescribe. Primary outcomes included measures related to (1) e-visit acceptability, feasibility, and treatment metrics; (2) smoking cessation outcomes (cessation medication use, 24-hour quit attempts, smoking reduction ≥50%, self-reported abstinence, and biochemically confirmed abstinence); and (3) COPD screening outcomes.

RESULTS

Of 85 participants assigned to the e-visits, 64 (75.3%) were invited to complete home spirometry and in-lab PFTs based on CAPTURE. Among those eligible for spirometry, 76.6% (49/64) completed home spirometry, and 35.9% (23/64) completed in-lab PFTs. At 1 month, all cessation outcomes favored the e-visit, with a significant effect for cessation medication use (odds ratio [OR]=3.22). At 3 months, all cessation outcomes except for 24-hour quit attempts favored the e-visit, with significant effects for cessation medication use (OR=3.96) and smoking reduction (OR=3.09).

CONCLUSIONS

A proactive, asynchronous e-visit for smoking cessation and COPD screening may offer a feasible, efficacious approach for broad interventions within primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04155073; https://clinicaltrials.gov/ct2/show/NCT04155073.

Pediatrician intervention impacts parental smoking in cystic fibrosis, diabetes, and bronchiolitis

BACKGROUND

Child exposure to cigarette smoke is harmful. It should be reduced through parental smoking cessation interventions. The aim of our study was to determine the impact of simple advice provided by the pediatrician on the smoking habits of parents of children with cystic fibrosis (CF), diabetes mellitus (DM), and infants hospitalized for bronchiolitis.

METHODS

Parents were interviewed on their smoking habits. Smoking cessation advice was provided by the pediatrician. A new smoking habits assessment was done at 3 months by phone interviews.

RESULTS

A total of 260 parents were interviewed (91 in the CF group, 136 in the DM group, and 33 in the bronchiolitis group). A total of 70 parents were active smokers: 33% of parents of children with CF, 23.5% of parents of children with DM, and 24.2% for those with infants hospitalized for bronchiolitis (p = .42). In the CF group, smoking cessation had been significantly more frequently discussed with the medical team previously. A total of 67 smoking parents (95.7%) answered the 3-month assessment: 29.8% reported having started a smoking cessation process; 10.4% had quit smoking. The quitting rate was significantly higher in the groups of patients followed for a respiratory disorder (37.5% for bronchiolitis, 15% for CF vs. 0% for DM, p = .005).

CONCLUSION

This study shows the important role that information and simple advice from pediatricians can have in initiating smoking cessation in parents of patients followed in specialized clinics or who are hospitalized, with a greater efficiency in parents of patients suffering from lung disorders.