Patient recall versus physician documentation in report of smoking cessation counselling performed in the inpatient setting

Physical activity counseling during and following stem cell transplantation - patients' versus advisors' perspectives

BACKGROUND

People receiving hematopoietic stem cell transplantation (HSCT) endure long phases of therapy and immobility, which diminish their physical activity (PA) level leading to physical deconditioning. One of the reasons is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. Therefore, our study investigates reported physical activity counseling behavior of health care professionals (HCPs) and the patient perspective on this topic.

METHODS

Physicians (N = 52), nurses (N = 52) physical therapists (N = 26), and patients receiving HSCT (N = 62) participated in a nationwide cross-sectional online-survey. Patients' preferred source of information concerning PA was determined. We examined HCPs self-assessed PA counseling behavior and patients' PA recall by assessing the use of the 5As (Ask, Advice, Agree, Assist, Arrange). Analysis of survey responses was descriptive. Univariate multinomial logistic regression examined whether sociodemographic factors and patient characteristics influence the response behavior.

RESULTS

Physicians and PA specialists were patients' preferred source of information regarding PA. A large discrepancy between HCPs' perception and the degree to which HSCT patients recall advice became apparent; profound counseling steps like making referrals were less often recalled in our patient sample. Inactive patients reported to receive less basic PA counseling by physicians.

CONCLUSION

Future research should identify the requirements to increase patients' recall concerning PA counseling in the setting of HSCT. Important messages about PA need to be made more salient to those who are less active and less engaged.

Assessment of adherence to aspirin for preeclampsia prophylaxis and reasons for nonadherence

BACKGROUND

Preeclampsia is a hypertensive disease unique to pregnancy and has a significant impact on maternal and neonatal morbidity and mortality. Daily aspirin has been demonstrated to reduce the risk of preeclampsia. The American College of Obstetricians and Gynecologists recommends daily low-dose aspirin, ideally before 16 weeks' gestation, in at-risk patients for preeclampsia risk reduction. This study examined whether patients at-risk for preeclampsia by the American College of Obstetricians and Gynecologists criteria recalled aspirin recommendation and factors associated with treatment adherence.

OBJECTIVE

This study examined whether patients at-risk for preeclampsia by the American College of Obstetricians and Gynecologists criteria recalled aspirin recommendation and factors associated with treatment adherence.

STUDY DESIGN

This study used an anonymous written survey. Pregnant patients were asked to record self-reported risk factors and to recall recommendation to take aspirin for preeclampsia prophylaxis. Participants were then determined to be high-, moderate-, or low-risk on the basis of the American College of Obstetricians and Gynecologists guidelines. Self-reported adherence to recommendations and factors contributing to the patients' decisions to take or decline aspirin were assessed. Secondary outcomes included demographic characteristics of adherent patients and patients who did not recall aspirin recommendation.

RESULTS

A total of 544 surveys were distributed and 500 were returned (91.9% response rate). Of the 104 high-risk pregnancies identified, aspirin was recommended in 60 (57.7%; 95% confidence interval, 0.48-0.67). Of the 269 patients with 2 or more moderate-risk factors, aspirin was recommended for 13 (4.8%; 95% confidence interval, 0.03-0.08). Among the participants who recalled aspirin recommendation, adherence was similar between high-risk (81.7%) and moderate-risk (76.9%) groups (P=.69). Patients with chronic hypertension, a history of preeclampsia or gestational hypertension in a previous pregnancy, and pregestational diabetes mellitus were most likely to report receiving aspirin recommendation (78.8%, 76.5%, 63.8%, and 53.3%, respectively). No high-risk factor was associated with a decreased likelihood of adherence. Nonadherent patients rarely discussed their decision with their medical provider (5.9%). In the 42.3% of high-risk participants who did not recall aspirin recommendation, autoimmune disease, multiple gestation, and kidney disease were the most prevalent risk factors (42.9%, 35.7%, and 25.0%, respectively).

CONCLUSION

In the population studied, many at-risk patients, as defined by the American College of Obstetricians and Gynecologists criteria, did not recall recommendations to take aspirin for preeclampsia prophylaxis. This raises concerns for absent or ineffective counseling. Of the patients who recalled aspirin recommendation, most reported adherence, and a history of hypertensive disorders or preeclampsia, autoimmune disease, and pregestational diabetes mellitus were most often associated with adherence. There was no single factor most strongly associated with intentional nonadherence.

Quantitative and qualitative impact of One Key Question on primary care providers' contraceptive counseling at routine preventive health visits

OBJECTIVES

One Key Question (OKQ) is a clinical screening tool to assess pregnancy desire in the next year. We aimed to 1) describe the effect of OKQ implementation on contraceptive counseling rates at preventive health visits and 2) evaluate primary care providers' perception of OKQ implementation on their contraceptive counseling practices.

STUDY DESIGN

We performed a quantitative retrospective chart review of preventive health visits at eight federally qualified health centers in Utah between 2014 and 2017. Implementation of OKQ included a brief training and inclusion of OKQ in the electronic medical record. Providers received OKQ training in August 2015 and re-training in March 2017. We assessed OKQ and contraceptive counseling documentation rates using interrupted-time-series analysis. We then conducted semi-structured interviews with providers and queried them about the impact of OKQ. We identified dominant themes using modified grounded theory to create an explanatory framework.

RESULTS

Abstracting 6634 charts yielded 9840 visits with 56 unique providers (51% physician assistant, 34% physician, 14% nurse practitioner). Interrupted-time-series analysis showed a documentation increase of OKQ in late 2015 (2.6%) and again in spring 2017 (9%), however rates remained low. Contraceptive counseling rates (39.7%) did not change after OKQ implementation. Charts with evidence of a current contraceptive method were less likely to have a OKQ response documented. Interviewees reported OKQ's algorithm did not alter their contraceptive counseling.

CONCLUSIONS

OKQ did not change documented rates of contraceptive counseling and uptake was low in quantitative and qualitative analyses. Our study suggests limited usefulness of OKQ in the primary care setting.

IMPLICATIONS

Implementation of the One Key Question tool through training and optional EHR field did not increase documented rates of contraceptive counseling in a large federally qualified health center or affect provider contraceptive counseling. Our study suggests limited usefulness of OKQ as a robust screening tool in this primary care setting.

Understanding and Perception of Overlapping Surgery in an Orthopaedic Trauma Population: A Survey Study

INTRODUCTION

Recently, overlapping surgery has received attention on the national scale. This study quantifies orthopaedic trauma patients' familiarity and concern with overlapping surgery as it relates to their care.

METHODS

A 15-question survey was voluntarily completed by 200 orthopaedic trauma patients in the outpatient setting of a level I trauma center. Three domains were evaluated in the survey: demographic data, familiarity with overlapping surgery, and the degree of concern with overlapping surgery. Patients read a position statement explaining the practice of overlapping surgery, and their changes in level of concern were evaluated. Descriptive statistics were used to evaluate the data.

RESULTS

A total of 200 patients completed the survey, of which 98 (49%) were male. The age range was broadly distributed. After surgery, 124 patients (62%) were seen for follow up. The remaining 76 patients (38%) did not undergo surgery. Regarding the practice of overlapping surgery, 116 respondents (58%) had no knowledge. There were 127 patients (63%) who reported their concern level as a 1 on an ordinal scale from 1 to 5, corresponding to the lowest possible level. Overall, 182 patients (91%) reported a level of concern of 3 (the median) or less with an average score of 1.7, indicating a low average level of concern. Six patients (3%) reported the maximum level of concern. On the whole, 160 patients (80%) reported either a decreased level of concern or no change after reading our department's position statement on overlapping surgery. Of the 124 patients, 81 (65%) postoperatively reported that they perceived no effect by overlapping surgery. The most common factors cited as areas of concern by patients were the absence of attending physician in the operating room (26%), risk of error by the resident (34%), and risk of a missed step in the surgical procedure (31%).

CONCLUSION

These data indicate that most respondents had no previous knowledge of overlapping surgery and had a generally low level of concern with its use as practiced at our institution. Disclosing the use of overlapping surgery and its purpose to patients is an important component of preoperative counseling.

LEVEL OF EVIDENCE

Level V.

Are Australian smokers with mental illness receiving adequate smoking cessation and harm reduction information?

Provision of smoking cessation support in the form of advice and information is central to increasing quit rates, including among people with mental illness (MI), who have 3-5 times higher odds of smoking than those without MI. This study investigated the extent and perceived utility of quit smoking advice and information available to Australian smokers with MI through face-to-face, semi-structured, in-depth interviews with 29 current smokers with MI. Qualitative analysis identified four major sources of quit smoking advice and information: (i) mental health practitioners; (ii) Quitline; (iii) social networks; and (iv) Internet and media. All identified sources, including formal sources (mental health practitioners and Quitline), were perceived as providing inadequate information about quitting smoking, particularly regarding optimal usage of nicotine replacement therapy (NRT). Social networks emerged as a substantial source of quit smoking advice and information, especially for nontraditional methods such as vaping. Participants showed high interest in receiving support from peer-led smoking cessation groups. A minority of participants reported that they had received quit smoking information from Internet and media; this was largely restricted to negative reports about e-cigarettes and short advertisements for nicotine replacement therapy. Our findings suggest that more can be done to provide smokers with MI with practical smoking cessation advice and support. Comprehensive information resources tailored for smokers with MI should be developed and disseminated via multiple pathways. We also recommend a number of policy and practice reforms to promote smoking cessation among those with MI.

Providing routine chronic disease preventive care in community substance use services: a pilot study of a multistrategic clinical practice change intervention

OBJECTIVES

To evaluate the potential effectiveness of a practice change intervention in increasing preventive care provision in community-based substance use treatment services. In addition, client and clinician acceptability of care were examined.

DESIGN

A pre-post trial conducted from May 2012 to May 2014.

SETTING

Public community-based substance use treatment services (n=15) in one health district in New South Wales (NSW), Australia.

PARTICIPANTS

Surveys were completed by 226 clients and 54 clinicians at baseline and 189 clients and 46 clinicians at follow-up.

INTERVENTIONS

A 12-month multistrategic clinician practice change intervention that aimed to increase the provision of preventive care for smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity.

PRIMARY AND SECONDARY OUTCOME MEASURES

Client and clinician reported provision of assessment, brief advice and referral for three modifiable health risk behaviours: smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity. Clinician-reported optimal care was defined as providing care to 80% of clients or more. Client acceptability and clinician attitudes towards preventive care were assessed at follow-up.

RESULTS

Increases in client reported care were observed for insufficient fruit and/or vegetable consumption including: assessment (24% vs 54%, p<0.001), brief advice (26% vs 46%, p<0.001), and clinicians speaking about (10% vs 31%, p<0.001) and arranging a referral (1% vs 8%, p=0.006) to telephone helplines. Clinician reported optimal care delivery increased for: assessment of insufficient fruit and/or vegetable consumption (22% vs 63%, p<0.001) and speaking about telephone helplines for each of the three health risk behaviours. Overall, clients and clinicians held favourable views regarding preventive care.

CONCLUSION

This study reported increases in preventive care for insufficient fruit and/or vegetable consumption; however, minimal increases were observed for smoking or insufficient physical activity. Further investigation of the barriers to preventive care delivery in community substance use settings is needed.

TRIALREGISTRATION NUMBER

ACTRN12614000469617.

Increased Rates of Documented Alcohol Counseling in Primary Care: More Counseling or Just More Documentation?

BACKGROUND

Clinical performance measures often require documentation of patient counseling by healthcare providers. Little is known about whether such measures encourage delivery of counseling or merely its documentation.

OBJECTIVE

To assess changes in provider documentation of alcohol counseling and patient report of receiving alcohol counseling in the Veterans Administration (VA) from 2009 to 2012.

DESIGN

Retrospective time-series analysis.

PARTICIPANTS

A total of 5413 men who screened positive for unhealthy alcohol use at an outpatient visit and responded to a confidential mailed survey regarding alcohol counseling from a VA provider in the prior year.

MAIN MEASURES

Rates of provider documentation of alcohol counseling in the electronic health record and patient report of such counseling on the survey were assessed over 4 fiscal years. Annual rates were calculated overall and with patients categorized into four mutually exclusive groups based on their own reports of alcohol counseling (yes/no) and whether alcohol counseling was documented by a provider (yes/no).

KEY RESULTS

Provider documentation of alcohol counseling increased 23.6% (95% CI: 17.0, 30.2), from 59.4% to 83.0%, while patient report of alcohol counseling showed no significant change (4.0%, 95% CI: -2.3, 10.3), increasing from 66.1% to 70.1%. An 18.7% (95% CI: 11.7, 25.7) increase in the proportion of patients who reported counseling that was documented by a provider largely reflected a 14.7% decline (95% CI: 8.5, 20.8) in the proportion of patients who reported alcohol counseling that was not documented by a provider. The proportion of patients who did not report counseling but whose providers documented it did not show a significant change (4.9%, 95%CI: 0.0, 9.9).

CONCLUSIONS

If patient report is accurate, increased rates of documented alcohol counseling in the VA from 2009 to 2012 predominantly reflected improved documentation of previously undocumented counseling rather than delivery of additional counseling or increased documentation of counseling that did not meaningfully occur.

Disparities in US Healthcare Provider Screening and Advice for Cessation Across Chronic Medical Conditions and Tobacco Products

BACKGROUND

Disparities in tobacco use are worsening in the United States, disproportionately affecting those with chronic medical conditions. One possible contributor is that physicians may not screen and advise cessation uniformly across patients and/or tobacco products.

OBJECTIVE

This study examined provider communications regarding cigarette and non-cigarette tobacco products among adults with chronic conditions.

DESIGN

Cross-sectional study drawn from two waves (2013-2014) of the National Survey on Drug Use and Health (NSDUH).

PARTICIPANTS

Adults (≥ 18 years) who used tobacco in the past year.

MAIN MEASURES

Prevalence of tobacco use included past-year use of cigarettes, cigars, or smokeless tobacco among those with and without chronic conditions. Chronic conditions included asthma, anxiety, coronary heart disease, depression, diabetes, hepatitis, HIV, hypertension, lung cancer, stroke, and substance abuse. Odds ratio of receipt of screening and advice to quit across chronic condition and tobacco product type were reported. Data were analyzed using logistic regression, controlling for basic sociodemographic factors and number of provider visits.

KEY RESULTS

Adults with anxiety, depression, and substance use disorders had the highest prevalence of past-year cigarette (37.2-58.2%), cigar (9.1-28.0%), and smokeless tobacco (3.1-11.7%) use. Patients with any chronic condition were more likely to receive advice to quit than those without a condition (OR 1.21-2.37, p < 0.01), although the odds were lowest among adults with mental health and substance use disorders (OR 1.21-1.35, p < 0.01). Cigarette smokers were more likely to report being screened and advised to quit than non-cigarette tobacco users (OR 1.54-5.71, p < 0.01).

CONCLUSIONS

Results support the need for provider training to expand screening and cessation interventions to include the growing spectrum of tobacco products. Screening and referral to interventions are especially needed for those with mental health and substance use disorders to reduce the disparate burden of tobacco-related disease and death.

Smoking, Quitting, and the Provision of Smoking Cessation Support: A Survey of Orthopaedic Trauma Patients

OBJECTIVE

This study investigates orthopaedic trauma patients smoking cessation history, intentions to quit, receipt of smoking cessation care during hospital admission, and patient-related factors associated with receipt of smoking cessation care.

METHODS

An online cross-sectional survey of orthopaedic trauma patients was conducted in 2 public hospitals in New South Wales, Australia. Prevalence of smoking and associated variables were described. Logistic regressions were used to examine whether patient characteristics were associated with receipt of smoking cessation care.

RESULTS

Eight hundred nineteen patients (response rate 73%) participated. More than 1 in 5 patients (21.8%) were current smokers (n = 175). Of the current smokers, more than half (55.3%) indicated making a quit attempt in the last 12 months and the majority (77.6%) were interested in quitting. More than a third of smokers (37.4%) were not advised to quit; 44.3% did not receive any form of nicotine replacement therapy; and 24.1% reported that they did not receive any of these 3 forms of smoking cessation care during their admission. Provision of care was not related to patient characteristics.

CONCLUSIONS

The prevalence of smoking among the sample was high. Respondents were interested in quitting; however, the provision of care during admission was low. Smoking cessation interventions need to be developed to increase the provision of care and to promote quit attempts in this Australian population.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Life Years Gained From Smoking-Cessation Counseling After Myocardial Infarction

INTRODUCTION

Hospitalization for acute myocardial infarction (AMI) is an opportune time to counsel smokers to quit. Studies have demonstrated lower short-term mortality for counseled versus non-counseled smokers; yet, little is known about the long-term survival benefits of post-AMI smoking-cessation counseling (SCC).

METHODS

Data from the Cooperative Cardiovascular Project, a prospective cohort study of elderly patients with AMI between 1994 and 1996 with >17 years of follow-up, were used to evaluate the association of SCC with short- and long-term mortality in smokers with AMI. Life expectancy and years of potential life gained were used to quantify the long-term survival benefits of SCC. Cox proportional hazards models with exponential extrapolation were used to estimate life expectancy.

RESULTS

The analysis included 13,815 smokers, of whom 5,695 (41.2%) received SCC. Non-counseled smokers had higher crude mortality than counseled smokers over all 17 years of follow-up. After adjustment for patient and hospital characteristics, SCC was associated with a 22.6% lower 30-day mortality and a 7.5% lower mortality over 17 years. These survival differences produced higher life expectancy estimates for counseled smokers than non-counseled smokers at all ages, which resulted in average gains in life years of 0.13 (95% CI=-0.31, 0.56) to 0.58 (95% CI=0.25, 0.91) years, with the largest gains observed in older smokers.

CONCLUSIONS

SCC is associated with longer life expectancy and gains in life years in elderly smokers with AMI, supporting the importance of post-AMI counseling efforts.

Provision of Chronic Disease Preventive Care in Community Substance Use Services: Client and Clinician Report

INTRODUCTION

People with substance use problems have a higher prevalence of modifiable health risk behaviors. Routine clinician provision of preventive care may be effective in reducing such health behaviors. This study aimed to examine clinician provision of preventive care to clients of community substance use treatment services.

METHODS

A cross-sectional survey was undertaken with 386 clients and 54 clinicians of community substance use treatment services in one health district in New South Wales, Australia. Client- and clinician-reported provision of three elements of care (assessment, brief advice and referral) for three health risk behaviors (tobacco smoking, insufficient fruit and/or vegetable consumption and insufficient physical activity) was assessed, with associations with client characteristics examined.

RESULTS

Provision was highest for tobacco smoking assessment (90% client reported, 87% clinician reported) and brief advice (79% client reported, 80% clinician reported) and lowest for fruit and vegetable consumption (assessment 23%, brief advice 25%). Few clients reported being offered a referral (<10%). Assessment of physical activity and brief advice for all behaviors was higher for clients residing in rural/remote areas.

CONCLUSION

Assessment and brief advice were provided to the majority of clients for smoking, but sub-optimally for the other behaviors. Further investigation of barriers to the provision of preventive care within substance use treatment settings is required, particularly for referral to ongoing support.

The exit interview as a proxy measure of malaria case management practice: sensitivity and specificity relative to direct observation

BACKGROUND

This paper aims to assess the sensitivity and specificity of exit interviews as a measure of malaria case management practice as compared to direct observation.

METHODS

The malaria case management of 1654 febrile patients attending 110 health facilities from across Papua New Guinea was directly observed by a trained research officer as part of a repeat cross sectional survey. Patient recall of 5 forms of clinical advice and 5 forms of clinical action were then assessed at service exit and statistical analyses on matched observation/exit interview data conducted.

RESULTS

The sensitivity of exit interviews with respect to clinical advice ranged from 36.2% to 96.4% and specificity from 53.5% to 98.6%. With respect to clinical actions, sensitivity of the exit interviews ranged from 83.9% to 98.3% and specificity from 70.6% to 98.1%.

CONCLUSION

The exit interview appears to be a valid measure of objective malaria case management practices such as the completion of a diagnostic test or the provision of antimalarial medication, but may be a less valid measure of low frequency, subjective practices such as the provision of malaria prevention advice.

Screening and Counseling for Tobacco Use in Student Health Clinics: Reports of Health Care Providers

PURPOSE

To assess tobacco screening and counseling in student health clinics, including facilitators, barriers, and associations with campus- and state-level variables.

DESIGN

We conducted a mixed-methods study with an online survey and qualitative interviews.

SETTING

Study setting was student health clinics on college campuses.

SUBJECTS

Subjects included 71 clinic directors or designees from 10 Southeastern states (quantitative survey) and 8 directors or designees from 4 Southeastern states (qualitative interviews).

MEASURES

Quantitative measures included demographics, screening and counseling practices, clinic-level supports for such practices, perceptions of tobacco on campus, institution size, public/private status, state tobacco farming revenue, and state tobacco control funding. Qualitative measures included barriers and facilitators of tobacco screening and counseling practices.

ANALYSIS

Logistic and linear regression models assessed correlates of screening and counseling. Qualitative data were analyzed using multistage interpretive thematic analysis.

RESULTS

A total of 55% of online survey respondents reported that their clinics screen for tobacco at every visit, whereas 80% reported their clinics offer counseling and pharmacotherapy. Barriers included lack of the following: time with patients, relevance to chief complaint, student self-identification as a tobacco user, access to pharmacotherapy, and interest in quitting among smokers. In multivariable models, more efforts to reduce tobacco use, student enrollment, and state-level cash receipts for tobacco were positively associated with clinic-level supports.

CONCLUSION

This study highlights missed opportunities for screening. Although reports of counseling were higher, providers identified many barriers.

Increasing preventive care by primary care nursing and allied health clinicians: a non-randomized controlled trial

BACKGROUND

Although primary care nurse and allied health clinician consultations represent key opportunities for the provision of preventive care, it is provided suboptimally.

PURPOSE

To assess the effectiveness of a practice change intervention in increasing primary care nursing and allied health clinician provision of preventive care for four health risks.

DESIGN

Two-group (intervention versus control), non-randomized controlled study assessing the effectiveness of the intervention in increasing clinician provision of preventive care.

SETTING/PARTICIPANTS

Randomly selected clients from 17 primary healthcare facilities participated in telephone surveys that assessed their receipt of preventive care prior to (September 2009-2010, n=876) and following intervention (October 2011-2012, n=1,113).

INTERVENTION

The intervention involved local leadership and consensus processes, electronic medical record system modification, educational meetings and outreach, provision of practice change resources and support, and performance monitoring and feedback.

MAIN OUTCOME MEASURES

The primary outcome was differential change in client-reported receipt of three elements of preventive care (assessment, brief advice, referral/follow-up) for each of four behavioral risks individually (smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, physical inactivity) and combined. Logistic regression assessed intervention effectiveness.

RESULTS

Analyses conducted in 2013 indicated significant improvements in preventive care delivery in the intervention compared to the control group from baseline to follow-up for assessment of fruit and vegetable consumption (+23.8% vs -1.5%); physical activity (+11.1% vs -0.3%); all four risks combined (+16.9% vs -1.0%) and for brief advice for inadequate fruit and vegetable consumption (+19.3% vs -2.0%); alcohol overconsumption (+14.5% vs -8.9%); and all four risks combined (+14.3% vs +2.2%). The intervention was ineffective in increasing the provision of the remaining forms of preventive care.

CONCLUSIONS

The intervention's impact on the provision of preventive care varied by both care element and risk type. Further intervention is required to increase the consistent provision of preventive care, particularly referral/follow-up.

Prevalence of traditional cardiac risk factors and secondary prevention among patients hospitalized for acute myocardial infarction (AMI): variation by age, sex, and race

BACKGROUND

Modification of traditional cardiac risk factors is an important goal for patients after an acute myocardial infarction (AMI). Risk factor prevalence and secondary prevention efforts at discharge are well characterized among older patients; however, research is limited for younger and minority AMI populations, particularly among women.

METHODS

Among 2369 AMI patients enrolled in a 19-center prospective study, we compared the prevalence and cumulative number of five cardiac risk factors (hypertension, hypercholesterolemia, current smoking, diabetes, obesity) by age, sex, and race. We also compared secondary prevention strategies at discharge for these risk factors, including prescription of antihypertensive or lipid-lowering medications and counseling on preventive behaviors (smoking cessation, diabetes management, diet/weight management).

RESULTS

Approximately 93% of patients had ≥1 risk factor, 72% had ≥2 factors, and 40% had ≥3 factors. The prevalence of multiple risk factors was markedly higher for blacks than for whites within each age-sex group; black women had the greatest risk factor burden of any subgroup (60% of older black women and 54% of younger black women had ≥3 risk factors). Secondary prevention efforts for smoking cessation were less common for black compared with white patients, and younger black patients were less often prescribed antihypertensive and lipid-lowering medications compared with younger white patients.

CONCLUSIONS

Multiple cardiac risk factors are highly prevalent in AMI patients, particularly among black women. Secondary prevention efforts, however, are less common for blacks compared to whites, especially among younger patients. Our findings highlight the need for improved risk factor modification efforts in these high-risk subgroups.

The delivery of preventive care to clients of community health services

Background

Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients.

Methods

In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care.

Results

Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%).

Conclusions

Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.

Targeted versus tailored multimedia patient engagement to enhance depression recognition and treatment in primary care: randomized controlled trial protocol for the AMEP2 study

BACKGROUND

Depression in primary care is common, yet this costly and disabling condition remains underdiagnosed and undertreated. Persisting gaps in the primary care of depression are due in part to patients' reluctance to bring depressive symptoms to the attention of their primary care clinician and, when depression is diagnosed, to accept initial treatment for the condition. Both targeted and tailored communication strategies offer promise for fomenting discussion and reducing barriers to appropriate initial treatment of depression.

METHODS/DESIGN

The Activating Messages to Enhance Primary Care Practice (AMEP2) Study is a stratified randomized controlled trial comparing two computerized multimedia patient interventions -- one targeted (to patient gender and income level) and one tailored (to level of depressive symptoms, visit agenda, treatment preferences, depression causal attributions, communication self-efficacy and stigma)-- and an attention control. AMEP2 consists of two linked sub-studies, one focusing on patients with significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] scores ≥ 5), the other on patients with few or no depressive symptoms (PHQ-9 < 5). The first sub-study examined effectiveness of the interventions; key outcomes included delivery of components of initial depression care (antidepressant prescription or mental health referral). The second sub-study tracked potential hazards (clinical distraction and overtreatment). A telephone interview screening procedure assessed patients for eligibility and oversampled patients with significant depressive symptoms. Sampled, consenting patients used computers to answer survey questions, be randomized, and view assigned interventions just before scheduled primary care office visits. Patient surveys were also collected immediately post-visit and 12 weeks later. Physicians completed brief reporting forms after each patient's index visit. Additional data were obtained from medical record abstraction and visit audio recordings. Of 6,191 patients assessed, 867 were randomized and included in analysis, with 559 in the first sub-study and 308 in the second.

DISCUSSION

Based on formative research, we developed two novel multimedia programs for encouraging patients to discuss depressive symptoms with their primary care clinicians. Our computer-based enrollment and randomization procedures ensured that randomization was fully concealed and data missingness minimized. Analyses will focus on the interventions' potential benefits among depressed persons, and the potential hazards among the non-depressed.

TRIAL REGISTRATION

ClinicialTrials.gov Identifier: NCT01144104.

Patient tobacco use, quit attempts, and perceptions of healthcare provider practices in a safety-net healthcare system

BACKGROUND

Although smoking rates in the United States (US) are high, healthcare systems and clinicians can increase cessation rates through application of the US Public Health Service tobacco treatment guideline (2000, 2008). In primary care settings, however, guideline implementation remains low. This report presents the results from an assessment of patient tobacco use, quit attempts, and perceptions of provider treatment before (2004) and after (2010) guideline implementation.

METHODS

By use of a systems approach, the Louisiana Tobacco Control Initiative integrated evidence-based treatment of tobacco use into patient care practices in Louisiana's public hospital system. This prospective study, designed to collect data at 2 time points for the purpose of evaluating the effect of the 5A protocol (ask, advise, assess, assist, and arrange), included 571 and 889 adult patients selected from primary care clinics in 2004 and 2010, respectively. Chi-square analyses determined differences between survey administrations, along with direct standardization of weighted rates to control for confounding factors.

RESULTS

Patient reports indicated that provider adherence to the 5A clinical protocol increased from 2004 to 2010. Significant (P<0.001) improvements were observed for the assess (39% vs 72%), assist (24% vs 76%), and arrange (8% vs 31%) treatment variables. Patient-reported quit attempts increased, along with awareness of cessation services (from 19% to 70%, P<0.001), while use of cessation medications decreased (from 23% to 5%, P<0.002).

CONCLUSION

Following implementation of the guideline, significant improvements were noted in patient reports of provider treatment and awareness of cessation services.

A cross-sectional survey of the prevalence of environmental tobacco smoke preventive care provision by child health services in Australia

Background

Despite the need for a reduction in levels of childhood exposure to environmental tobacco smoke (ETS) being a recognised public health goal, the delivery of ETS preventive care in child health service settings remains a largely unstudied area. The purpose of this study was to determine the prevalence of ETS preventive care in child health services; differences in the provision of care by type of service; the prevalence of strategies to support such care; and the association between care support strategies and care provision.

Method

One-hundred and fifty-one (83%) child health service managers within New South Wales, Australia completed a questionnaire in 2002 regarding the: assessment of parental smoking and child ETS exposure; the provision of parental smoking cessation and ETS-exposure reduction advice; and strategies used to support the provision of such care. Child health services were categorised based on their size and case-mix, and a chi-square analysis was performed to compare the prevalence of ETS risk assessment and ETS prevention advice between service types. Logistic regression analysis was used to examine associations between the existence of care support strategies and the provision of ETS risk assessment and ETS exposure prevention advice.

Results

A significant proportion of services reported that they did not assess parental smoking status (26%), and reported that they did not assess the ETS exposure (78%) of any child. Forty four percent of services reported that they did not provide smoking cessation advice and 20% reported they did not provide ETS exposure prevention advice. Community based child and family health services reported a greater prevalence of ETS preventive care compared to other hospital based units. Less than half of the services reported having strategies to support the provision of ETS preventive care. The existence of such support strategies was associated with greater odds of care provision.

Conclusions

The existence of major gaps in recommended ETS preventive care provision suggests a need for additional initiatives to increase such care delivery. The low prevalence of strategies that support such care delivery suggests a potential avenue to achieve this outcome.

The evaluation of a Taiwanese training program in smoking cessation and the trainees' adherence to a practice guideline

Background

The Taiwanese government began reimbursement for smoking cessation in 2002. Certification from a training program was required for physicians who wanted reimbursement. The program certified 6,009 physicians till 2007. The objective of this study is to evaluate the short- and long term efficacy of the training program.

Methods

For short term evaluation, all trainees in 2007 were recruited. For long term evaluation, computer randomly selected 2,000 trainees who received training from 2002 to 2006 were recruited. Course satisfaction, knowledge, confidence in providing smoking cessation services and the adherence to a practice guideline were evaluated by questionnaires.

Results

Trainees reported high satisfaction with the training program. There was significant difference between pre- and post-test scores in knowledge. Confidence in providing services was lower in the long term evaluation compared to short term evaluation. For adherence to a practice guideline, 86% asked the status of smoking, 88% advised the smokers to quit, 76% assessed the smoker's willingness to quit, 59% assisted the smokers to quit, and 60% arranged follow-up visits for smokers. The incentive of reimbursement was the most significant factor affecting confidence and adherence.

Conclusions

The training program was satisfactory and effective. Adherence to a practice guideline in our study was better than studies without physician training in other countries.

Therapeutic intent of proton pump inhibitor prescription among elderly nonsteroidal anti-inflammatory drug users

BACKGROUND

Prescription of proton pump inhibitors (PPIs) has increased dramatically.

AIM

To assess therapeutic intent of PPI prescription among elderly veterans prescribed nonsteroidal anti-inflammatory drugs.

METHODS

Medical-record abstraction identified therapeutic intent of PPI prescription. An 'appropriate therapeutic intent' was defined as symptomatic gastro-oesophageal reflux disease or endoscopic oesophagitis, Zollinger-Ellison disease, dyspepsia, upper gastrointestinal event, Helicobacter pylori infection or nonsteroidal anti-inflammatory drug gastroprotection. Logistic regression predicted the outcome while adjusting for clinical characteristics.

RESULTS

Of 1491 patients [mean 73 years (s.d. 5.6), 73% white and 99.8% men], among those charts which did document a therapeutic indication, 88.8% were appropriate. Prior gastroscopy was predictive of an appropriate therapeutic intent (OR 2.7; 95% CI: 1.9-3.7). Prescription to patients who used VA pharmacy services only, to in-patients, or by a cardiologist or an otolaryngologist were less likely to be appropriate. Gastroprotection was poorly recognized as an indication for PPI prescription, except by rheumatologists (OR 46.7; 95% CI: 15.9-136.9), or among highly co-morbid patients (OR 1.8; 95% CI: 1.1-2.9). Among in-patients, 45% of PPI prescriptions were initiated for unknown or inappropriate reasons.

CONCLUSIONS

Type of provider predicts appropriate PPI use. In-patient prescription is associated with poor recognition of necessary gastroprotection and unknown therapeutic intent.

Clinical psychologists and smoking cessation: treatment practices and perceptions

A random sample of clinical psychologists was surveyed regarding their smoking cessation practices and perceptions. A total of 352 psychologists responded (57%) to the valid and reliable questionnaire. The majority (59.1%) of psychologists did not always identify and document the smoking status of patients. The majority reported high efficacy expectations (66.4%) and low outcome expectations (55.1%) for using the 5A's smoking cessation counseling technique. Counselors that had never smoked were almost two times more likely to have higher efficacy expectations than those that were current smokers or ex-smokers (OR = 1.94, 95% CI 1.18-3.12). The factors that predicted regular use of the 5A's included the number of identified barriers, psychologists' level of self efficacy, and the urbanicity of one's practice location.

Increasing hospital-wide delivery of smoking cessation care for nicotine-dependent in-patients: a multi-strategic intervention trial

AIMS, DESIGN AND INTERVENTION: Smoking care provision to in-patients is important in assisting smoking cessation and for management of nicotine withdrawal. Limited studies have reported the effectiveness of interventions designed to increase the hospital-wide provision of such care. A quasi-experimental matched-pair trial, involving two intervention and two control hospitals in NSW, Australia, investigated whether a multi-strategic intervention increased hospital-wide smoking care provision.

PARTICIPANTS AND MEASUREMENTS

Patient surveys (n = 274-347 per experimental condition), medical notes audits (n = 181-228) and health professional surveys (n = 229-302) were used to collect outcome data at baseline and follow-up.

FINDINGS

Significantly greater increases in intervention hospitals compared to control hospitals were found for patient-reported offer of nicotine replacement therapy (NRT) (intervention 34% versus control 12%), provision of NRT (16% versus 4%) and provision of written resources (11% versus 2%), and for the recording in medical notes of smoking management discussion (13% versus 3%), offer of NRT (24% versus 3%) and provision of NRT (21% versus 5%). Intervention group health professionals reported significantly greater increases in the mean estimate of patients who: had their smoking management discussed (30% versus 17%); were offered or provided with NRT (30% versus 18%); were asked their intention to smoke post-discharge (22% versus 10%); and were provided with discharge NRT (21% versus 4%).

CONCLUSIONS

Implementation of a multi-strategic intervention is effective in increasing hospital smoking care delivery, particularly the provision of NRT. Research is required to identify methods to increase further the delivery of this and other forms of smoking care.

Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics

OBJECTIVE

To examine the chronic care model (CCM) as a framework for improving provider delivery of 5A tobacco cessation services.

METHODS

Cross-sectional surveys were used to obtain data from 497 health care providers in 60 primary care clinics serving low-income patients in New York City. A hierarchical generalized linear modeling approach to ordinal regression was used to estimate the probability of full 5A service delivery, adjusting for provider covariates and clustering effects. We examined associations between provider delivery of 5A services, clinic implementation of CCM elements tailored for treating tobacco use, and the degree of CCM integration in clinics.

PRINCIPAL FINDINGS

Providers practicing in clinics with enhanced delivery system design, clinical information systems, and self-management support for cessation were 2.04-5.62 times more likely to perform all 5A services ( p<.05). CCM integration in clinics was also positively associated with 5As delivery. Compared with none, implementation of one to six CCM elements corresponded with a 3.69-30.9 increased odds of providers delivering the full spectrum of 5As ( p<.01).

CONCLUSIONS

Findings suggest that the CCM facilitates provider adherence to the Public Health Service 5A clinical guideline. Achieving the full benefits of systems change may require synergistic adoption of all model components.

Internet delivered support for tobacco control in dental practice: randomized controlled trial

Background

The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized.

Objective

To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings.

Methods

Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention.

Results

Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices’ mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK.

Conclusion

This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit.

Trial Registration

clinicaltrials.gov NCT00627185; http://clinicaltrials.gov/ct2/show/NCT00627185 (Archived by WebCite at http://www.webcitation.org/5c5Kugvzj)

Tobacco cessation and prevention practices reported by second and fourth year students at US medical schools

BACKGROUND

Tobacco dependence counseling is recommended to be included as core curriculum for US medical students. To date, there has been little information on students' self-reported skills and practice opportunities to provide 5A's (Ask, Advise, Assess, Assist, and Arrange) counseling for tobacco cessation.

METHODS

We conducted anonymous surveys of second year and fourth year students at multiple US medical schools between February 2004 and March 2005 (overall response rate 70%). We report on the tobacco control practices of the 860 second year and 827 fourth year students completing the survey.

MEASUREMENTS AND MAIN RESULTS

Fourth year students reported multiple opportunities to learn tobacco counseling in case-based discussions, simulated patient encounters, and clinical skills courses. They reported more instruction in family medicine (79%) and Internal Medicine (70%) than Pediatrics (54%), Obstetrics/Gynecology (41%), and Surgery clerkships (16%). Compared with asking patients about smoking, advising smokers to quit, and assessing patient willingness to quit, fourth year students were less likely to have multiple practice opportunities to assist the patient with a quit plan and arrange follow-up contact. More than half of second year students reported multiple opportunities for asking patients about smoking but far fewer opportunities for practicing the other 4 As.

CONCLUSIONS

By the beginning of their fourth year, most students in this group of medical schools reported multiple opportunities for training and practicing basic 5A counseling, although clear deficits for assisting patients with a quit plan and arranging follow-up care exist. Addressing these deficits and integrating tobacco teaching through tailored specific instruction across all clerkships, particularly in Surgery, Pediatrics, and Obstetrics/Gynecology is a challenge for medical school education.

Does delayed measurement affect patient reports of provider performance? Implications for performance measurement of medical assistance with tobacco cessation: a Dental PBRN study

Background:

We compared two methods of measuring provider performance of tobacco control activities: immediate "exit cards" versus delayed telephone follow-up surveys. Current standards, e.g. HEDIS, use delayed patient measures that may over or under-estimate overall performance.

Methods:

Patients completed exit cards in 60 dental practices immediately after a visit to measure whether the provider "asked" about tobacco use, and "advised" the patient to quit. One to six months later patients were asked the same questions by telephone survey. Using the exit cards as the standard, we quantified performance and calculated sensitivity (agreement of those responding yes on telephone surveys compared with exit cards) and specificity (agreement of those responding no) of the delayed measurement.

Results:

Among 150 patients, 21% reporting being asked about tobacco use on the exit cards and 30% reporting being asked in the delayed surveys. The sensitivity and specificity were 50% and 75%, respectively. Similarly, among 182 tobacco users, 38% reported being advised to quit on the exit cards and this increased to 51% on the delayed surveys. The sensitivity and specificity were 75% and 64%, respectively. Increasing the delay from the visit to the telephone survey resulted in increasing disagreement.

Conclusion:

Patient reports differed considerably in immediate versus delayed measures. These results have important implications because they suggest that our delayed measures may over-estimate performance. The immediate exit cards should be included in the armamentarium of tools for measuring providers' performance of tobacco control, and perhaps other service delivery.

Distributing questionnaires about smoking to patients: impact on general practitioners' recording of smoking advice

BACKGROUND

Little is known about the impact of questionnaire-based data collection methods on the consulting behaviour of general practitioners (family physicians) who participate in research. Here data collected during a research project which involved questionnaires on smoking being distributed to patients before and after appointments with general practitioners (GPs) is analyzed to investigate the impact of this data collection method on doctors' documenting of smoking advice in medical records.

METHODS

Researchers distributed questionnaires on smoking behaviour to 6775 patients who attended consultations during surgery sessions with 32 GPs based in Leicestershire, UK. We obtained the medical records for patients who had attended these surgery sessions and also for a comparator group, during which no researcher had been present. We compared the documenting of advice against smoking in patient's medical records for consultations within GPs' surgery sessions where questionnaires had been distributed with those which occurred when no questionnaires had been given out.

RESULTS

We obtained records for 77.9% (5276/6775) of all adult patients who attended GPs' surgery sessions, with 51.9% (2739) being from sessions during which researchers distributed questionnaires. Discussion of smoking was recorded in 8.0% (220/2739) of medical records when questionnaires were distributed versus 4.6% (116/2537) where these were not. After controlling for relevant potential confounders including patients' age, gender, the odds ratio for recording of information in the presence of questionnaire distribution (versus none) was 1.78 (95% CI, 1.36 to 2.34).

CONCLUSION

Distributing questionnaires about smoking to patients before and after they consult with doctors significantly increases GPs' recording of discussions about smoking medical records. This has implications for the design of some types of research into addictive behaviours and further research into how data collection methods may affect patients' and doctors' behaviours is warranted.

A comparison of patients' perceptions and an audit of health promotion practice within a UK hospital

Background

UK hospitals are required to monitor the health promotion services they provide for patients. We compared the use of audit and patient questionnaires as appropriate tools for monitoring whether patients are screened for modifiable risk factors (smoking, alcohol use, obesity, diet, and physical activity), whether staff correctly identify risk factor presence and deliver health promotion when a risk factor is identified.

Methods

We sent a questionnaire post-discharge to 322 hospitalised adult patients discharged alive between January and March 2006, and audited their hospital case notes for evidence of screening for risk factors, identification of risk factors, and delivery of health promotion to change risk factors. Agreement between the audit and questionnaire findings was assessed by Kappa statistic.

Results

There was little relationship between what was written in the case notes and what patients thought had happened. Agreement between the audit and questionnaire for screening of risk factors was at best fair. For the delivery of health promotion agreement was moderate for alcohol, poor for exercise, and no different from chance for smoking and diet. Agreement on identifying risk factors was very good for obesity, good for smoking, and moderate for alcohol misuse. The identification of diet quality and level of physical activity was too low in the audit to allow statistical comparison with self-reported diet and activity.

Conclusion

A direct comparison of data gathered in the audit and patient questionnaires provides a comprehensive picture of health promotion practice within hospitals. Poor screening agreement is likely to be due to errors in patients' recall of screening activities. Audit is therefore the preferred method for evaluating screening of risk factors, but further insight into screening practice can be gained by using the questionnaire in conjunction with audit. If a patient does not recognise that they received health promotion, then this is tantamount to not receiving it, we therefore recommend that the patient questionnaire is the preferred method for monitoring health promotion delivered. For monitoring the accuracy of risk factor identification either method is appropriate as long as the hospital uses validated screening tools for identifying alcohol misuse, diet, and physical activity.

Impact of contractual financial incentives on the ascertainment and management of smoking in primary care

BACKGROUND

The April 2004 contract for UK general practitioners (GPs) is an ambitious attempt to produce substantial changes in clinical practice. We investigated the impact of this on delivery of primary care smoking cessation interventions.

METHODS

We analysed data from patients' medical records that were held within a large database called The Health Improvement Network (THIN). We calculated for each year between 1990 and 2005 and for each quarter-year from 2003 the incidence of recording of smoking status in medical records and, in smokers, the receipt of GPs' smoking cessation advice and prescriptions for nicotine addiction treatments.

FINDINGS

Recording of smoking status increased temporarily around 1993-4 and then rose gradually from the year 2000. This rise was more marked from 2003, with an 88% increase between the first quarters of 2003 and 2004. The latter quarter was just prior to the introduction of the GP contract and higher rates of recording smoking status were sustained for the subsequent year. In smokers, there was a broadly similar pattern for the proportion recorded as having received brief cessation advice. However, while there was a sharp increase in prescriptions for nicotine addiction treatments from 2000, no comparable acceleration in this trend from 2003 was apparent.

INTERPRETATION

The 2004 GP contract increased primary care rates of smoking status ascertainment and recording of advice against smoking. The public health impact of this contract could be maximized if it also improved GPs' prescribing of nicotine addiction treatments.

Smoking cessation treatment by primary care physicians: An update and call for training

BACKGROUND

Public health and government organizations have invested considerably to increase physician adherence to smoking-cessation practice guidelines.

METHODS

A random sample of 2000 U.S. primary care physicians was ascertained from the American Medical Association (AMA) in 2002. Respondents (n = 1120, 62.3%) provided self-reported data about individual and practice characteristics and smoking-cessation practices. Data were analyzed in 2005.

RESULTS

Most primary care physicians (75%) advised cessation, 64% recommended nicotine patches, 67% recommended bupropion, 32% recommended nicotine gum, 10% referred to cessation experts, and 26% referred to cessation programs "often or always." Advising cessation was related to being older, having a faculty appointment, having trained staff for smoking counseling, and having confidence to counsel patients about smoking. Physicians who were internists, younger, and those with greater confidence to counsel patients about smoking recommended nicotine replacement more often. Prescribing bupropion was less common among older physicians, in the Northeast, with trained staff available for counseling, and with a greater proportion of minority or Medicaid patients. Prescribing bupropion was more common among AMA-member physicians and physicians with greater confidence to counsel patients about smoking. Providing a referral to an outside expert or program was more common among female physicians, and physicians in the Northeast or West, with larger clinical practices, and with trained staff for cessation counseling.

CONCLUSIONS

Current physician self-reported practices for smoking cessation suggest opportunity for improvement. Targeted efforts to educate and support subsets of primary care physicians may improve physician adherence and smoking outcomes.

Obtaining smoking histories for population-based studies on multiple primary cancers: Connecticut, 2002

Because of the absence of data on smoking history for patients in cancer registries, large population-based studies have been unable to directly assess the role of smoking in the risk of multiple primary cancers. In a random sample of 618 adults diagnosed with invasive cancer in 2002 and reported to the population-based Connecticut (CT) cancer registry, however, search of hospital records identified smoking history (current, former, never- or nonsmoker) for 83.3%. Number of cigarettes per day was known for 71.3% of 289 current or former smokers, while duration of quitting was found for 92.3% of 194 former smokers. Smoking status was strongly associated with current heavy alcohol use. Hospital records appear to be a promising resource for population-based studies on smoking histories in relation to risk of multiple primaries, although completeness of information needs to be improved in CT and assessments are needed in other cancer registries.

Measuring resident physicians' performance of preventive care. Comparing chart review with patient survey

BACKGROUND

The Accreditation Council for Graduate Medical Education has suggested various methods for evaluation of practice-based learning and improvement competency, but data on implementation of these methods are limited.

OBJECTIVE

To compare medical record review and patient surveys on evaluating physician performance in preventive services in an outpatient resident clinic.

DESIGN

Within an ongoing quality improvement project, we collected baseline performance data on preventive services provided for patients at the University of Alabama at Birmingham (UAB) Internal Medicine Residents' ambulatory clinic.

PARTICIPANTS

Seventy internal medicine and medicine-pediatrics residents from the UAB Internal Medicine Residency program.

MEASUREMENTS

Resident- and clinic-level comparisons of aggregated patient survey and chart documentation rates of (1) screening for smoking status, (2) advising smokers to quit, (3) cholesterol screening, (4) mammography screening, and (5) pneumonia vaccination.

RESULTS

Six hundred and fifty-nine patient surveys and 761 charts were abstracted. At the clinic level, rates for screening of smoking status, recommending mammogram, and for cholesterol screening were similar (difference <5%) between the 2 methods. Higher rates for pneumonia vaccination (76% vs 67%) and advice to quit smoking (66% vs 52%) were seen on medical record review versus patient surveys. However, within-resident (N=70) comparison of 2 methods of estimating screening rates contained significant variability. The cost of medical record review was substantially higher ($107 vs $17/physician).

CONCLUSIONS

Medical record review and patient surveys provided similar rates for selected preventive health measures at the clinic level, with the exception of pneumonia vaccination and advising to quit smoking. A large variation among individual resident providers was noted.

Increasing smoking cessation care in a preoperative clinic: a randomized controlled trial

BACKGROUND

Evidence suggests that preoperative clinics, like other hospital outpatient clinics and inpatient wards, fail to systematically provide smoking cessation care to patients having planned surgery.

METHODS

The aim of the study was to assess the efficacy, acceptability, and cost of a multifaceted intervention to facilitate the provision of comprehensive smoking cessation care to patients attending a preoperative clinic. Two hundred ten smoking patients attending a preoperative clinic at a major teaching hospital in Australia took part in the study. One hundred twenty-four patients were randomly assigned to an experimental group and 86 patients to a usual cessation care group. A multifaceted intervention was developed that included the use of opinion leaders, consensus processes, computer-delivered cessation care, computer-generated prompts for care provision by clinic staff, staff training, and performance feedback.

RESULTS

Ninety-six percent of experimental group patients received behavioral counseling and tailored self-help material. Experimental group patients were significantly more likely than usual care patients to report receiving brief advice by nursing (79% vs. 47%; P < 0.01) and anaesthetic (60% vs. 39%; P < 0.01) staff. Experimental group patients who were nicotine dependent were also more likely to be offered preoperative nicotine replacement therapy (NRT) (82% vs. 8%; P < 0.01) and be prescribed postoperative NRT (86% vs. 0%; P < 0.01). The multifaceted intervention was found to be acceptable by staff.

CONCLUSION

A multifaceted clinical practice change intervention may be effective in improving the delivery of smoking cessation care to preoperative surgical patients.

Measuring provider adherence to tobacco treatment guidelines: A comparison of electronic medical record review, patient survey, and provider survey

An accurate method of measuring primary care providers' tobacco counseling actions is needed for monitoring adherence to clinical practice guidelines. We compared three methods of measuring providers' tobacco counseling practices: electronic medical record (EMR) review, patient survey, and provider survey. We mailed a survey to 1,613 smokers seen by 114 Boston-area primary care providers during a 2-month period to assess what tobacco counseling actions had occurred at the visit (N = 766; 47% response rate). Smokers' reports were compared with the EMR and with their providers' self-reported usual tobacco counseling practices, derived from a provider survey (N = 110; 96% response rate). Patients reported receiving each counseling action more frequently than providers documented it in the EMR. Agreement between the patient survey and the EMR was poor for all 5A steps (kappa statistic = 0.01-0.22). Providers reported that they often or always performed each 5A action at a higher rate than indicated by EMR or patient report. However, providers who said they often or always performed individual 5A steps did not have consistently higher mean rates of EMR documentation or patient report than those who said they performed the 5A's less frequently. Little agreement was found among the three methods of measuring primary care providers' tobacco counseling actions. Implementing an EMR does not necessarily improve providers' documentation of tobacco interventions, but EMR adaptations that would standardize provider documentation of tobacco counseling might make the EMR a more reliable tool for monitoring providers' delivery of tobacco treatment services.

Impact of the Cancer Risk Intake System on patient-clinician discussions of tamoxifen, genetic counseling, and colonoscopy

The Cancer Risk Intake System (CRIS), a computerized program that "matches" objective cancer risks to appropriate risk management recommendations, was designed to facilitate patient-clinician discussion. We evaluated CRIS in primary care settings via a single-group, self-report, pretest-posttest design. Participants completed baseline telephone surveys, used CRIS during clinic visits, and completed follow-up surveys 1 to 2 months postvisit. Compared with proportions reporting having had discussions at baseline, significantly greater proportions of participants reported having discussed tamoxifen, genetic counseling, and colonoscopy, as appropriate, after using CRIS. Most (79%) reported CRIS had "caused" their discussion. CRIS is an easily used, disseminable program that showed promising results in primary care settings.

Preventing tobacco use in Norwegian dental practice

OBJECTIVES

To determine dentists' and dental hygienists' intervention activity towards patients who smoke or use snus (oral moist snuff), and to establish which factors impede interventions and cause variations in approach.

METHODS

A questionnaire was mailed to a sample of 1500 dentists (response rate: 68%) and all dental hygienists in the country (522 in all; response rate: 61%).

RESULTS

Dental hygienists conversed with patients on smoking habits on average 18 min/week, while the dentists spent 13 min doing the same. The issue of snus-use was discussed, on average, for 3 min. In eight of 10 consultations with patients suffering from tobacco-induced disorders in the oral cavity, the dentists/dental hygienists raised the subject of smoking habits with the patient. In cases without visible tobacco-induced symptoms, inquiries were made concerning smoking habits in three of 10 dentist consultations and four of 10 consultations with dental hygienists. For first-time consultations, six of 10 were queried concerning their smoking habits by their dentist, while dental hygienists enquired in seven of 10 cases. Self-reported skills, perceived barriers and attitudes explained far more of the variance in intervention impact than background variables. There were moderate differences between dentists and dental hygienists.

CONCLUSIONS

There is room for improvement in smoking and snus-use prevention efforts in the dental sector. If staff is to be rid of their misconceptions regarding the efficacy of intervention, it is important to inform them about the encouraging results at the population level.

Direct measurement of health care costs

Cost identification is fundamental to many economic analyses of health care. Health care costs are often derived from administrative databases. Unit costs may also be obtained from published studies. When these sources will not suffice (e.g., in evaluating interventions or programs), data may be gathered directly through observation and surveys. This article describes how to use direct measurement to estimate the cost of an intervention. The authors review the elements of cost determination, including study perspective, the range of elements to measure, and short-run versus long-run costs. They then discuss the advantages and drawbacks of alternative direct measurement methods such as time-and-motion studies, activity logs, and surveys of patients and managers. A parsimonious data collection effort is desirable, although study hypotheses and perspective should guide the endeavor. Special reference is made to data sources within the Department of Veterans Affairs (VA) health care system.

Smoking cessation interventions for in-patients: a selective review with recommendations for hospital-based health professionals

A selective review of the literature was conducted to provide evidence-based recommendations for the clinical management of hospitalized smokers. The Cochrane library, in particular the Cochrane review of 'Interventions for smoking cessation in hospitalised patients', was the basis for the review and was supplemented with other clinical and non-clinical literature where the review did not inform clinicians sufficiently. Evidence was reviewed on issues considered by the authors to be of importance to health professionals interested in providing a smoking cessation intervention to their patients. The review suggests that effective hospital interventions: incorporate an in-patient intervention lasting greater than 20 minutes in duration with extended post discharge follow-up; consist of at least five intervention contacts; and be delivered over at least a 3-month period. Furthermore, interventions should include in-patient advice and counselling, the provision of nicotine replacement therapy and extended proactive post discharge telephone support. The review also indicates that cessation interventions are particularly effective when delivered to patients with a cardiovascular diagnosis. All health professionals may be effective in providing cessation treatments; however, the addition of a specialist smoking cessation counsellor appears to improve interventions in this setting. Finally, without the development of supportive systems, routine intervention with smoking patients by health professionals is unlikely. Recommendations for the delivery of effective smoking cessation interventions in hospitals are provided. [Wolfenden L, Campbell E, Walsh RA, Wiggers J. Smoking cessation interventions for in-patients: a selective review with recommendations for hospital-based health professionals.

Direct observation and patient recall of health behavior advice

BACKGROUND

Patient recall of health behavior change discussions with physicians is an important intermediate outcome to adherence with recommendations and subsequent behavior change. This study reports patient recall of health behavior discussions during outpatient visits and tests patient and visit characteristics associated with recall.

METHODS

In a cross-sectional study of 2670 adult outpatients visiting 138 family physicians in 84 practices, provision of health behavior advice was measured by direct observation. Patient recall of discussion of each health behavior topic was assessed by patient survey.

RESULTS

Patient recall rates ranged from 11% for substance use assessment to 75% of smokers recalling smoking cessation advice. Patient demographics were not associated with recall. In multivariable models, the strongest predictor of patient recall of diet and exercise advice was the duration of the advice. Advice provided during well care visits was more likely to be recalled by patients than during illness visits, but presence of a health behavior-relevant diagnosis during an illness visit was associated with a 2-fold increase in patient recall.

CONCLUSIONS

Patient recall of health behavior advice is enhanced by longer duration of advice and by linking advice to visit contexts that represent teachable moments.

Inpatient smoking-cessation counseling and all-cause mortality among the elderly

BACKGROUND

Although smoking cessation is essential to the management of acute myocardial infarction (AMI), prevalence and benefits of smoking-cessation counseling in the inpatient setting are not well described among older adults. The objective of this study was to evaluate associations between inpatient smoking-cessation counseling and 5-year all-cause mortality among older adults hospitalized with AMI.

METHODS

The Cooperative Cardiovascular Project (January 1994-July 1995) included 788 Medicare beneficiaries aged >/=65 years who were current smokers, admitted to acute care facilities in North Carolina with confirmed AMI, and discharged alive. Information on smoking-cessation advice or counseling prior to discharge was abstracted from medical records. Associations of counseling with 5-year risk of death were assessed with multivariate Cox proportional hazards regression.

RESULTS

Smoking-cessation counseling was provided to 40% of AMI patients before discharge. Women (p =0.06) and blacks (p =0.02) were less likely to receive counseling. Counseling was associated with a history of chronic obstructive pulmonary disease (p =0.01). Increasing age, discharge to a skilled nursing facility, and histories of hypertension, heart failure, or stroke were associated with no counseling (p <0.05, all cause). Age-adjusted mortality rates (per 1000 enrollees) at 5 years were 488.3 for patients who were given counseling compared to 579.3 for patients without counseling. After adjustment for age, race, gender, prior histories of hypertension, cardiovascular diseases, diabetes, and chronic obstructive pulmonary disease, Killip class III or IV, and discharge to a skilled nursing facility; inpatient counseling remained associated with improved survival (relative hazard, 0.78; 95% confidence interval, 0.63-0.97).

CONCLUSIONS

Inpatient counseling on smoking cessation is suboptimal among older smokers hospitalized with AMI. Even without confirmation of actual cessation, these data suggest that provision of smoking-cessation advice or counseling has a major impact on survival of older adults.

Reported cessation advice given to African Americans by health care providers in a community health clinic

Physician smoking cessation advice has been shown to be effective in encouraging patients to attempt cessation. Few studies have examined factors associated with patient-reported physician advice in an inner city community health clinic. Smokers identified via chart review and provider referral met with a study "smoking specialist." Eligible participants self-identified as African American, smoked at least 1 cigarette per day in the prior 7 days, were 18 or older, had access to a telephone, and agreed to consider blood testing for genetic susceptibility to lung cancer. Of the 869 smokers identified, 487 were eligible and completed a brief in-person and a more extensive follow-up telephone survey within one week after their visit. Patient reports of smoking cessation advice by providers were regressed on patient demographic, smoking, health, and social support variables. Seventy percent of participants reported that they had been advised to quit smoking. Smokers who were older, did not smoke menthol cigarettes, were in poorer health, and who had a regular health care provider were most likely to report having received advice. Patients in this community health setting reported high rates of provider advice to quit smoking. Yet, even in this optimal condition, young healthy smokers did not report receiving advice, even when they were ready to quit smoking. Providers may need additional training and prompting to counsel young healthy smokers about the importance of cessation.

Factors associated with patient-recalled smoking cessation advice in a low-income clinic

It is recommended that providers advise cessation to their patients who smoke. However, patients' reports of cessation advice indicate disparities based on patients' race, gender, age, and smoking level. Providers' reports do not corroborate these disparities. We investigated whether smokers who receive their care in a community health center recalled their providers advising them to quit smoking when their providers documented such advice. We examined 219 patient-provider dyads to assess factors associated with lack of agreement between providers' documentation and patient recall. Patients were asked to recall any provider advice to quit smoking in the post 2 years. After every visit, providers completed a form to record the content of the visit. Most of the patients were African American, married, and uninsured. Sixty-eight percent of the dyads agreed in their documentation/recall. Patient race was the only factor associated with lack of agreement; African-American patients were more likely than white patients to provide discrepant reports. Although this study can not disentangle the racial difference in patient-provider recall/documentation, results may indicate an important area in which health disparities exist. Future studies should address the dynamics of patient-provider communication about smoking cessation, especially in populations that include ethnically diverse patients.

Adolescent reports of physician counseling for smoking

OBJECTIVE

Physicians can play an important role in reducing adolescent smoking by counseling their adolescent patients. The appropriate delivery of smoking prevention and cessation messages depends on adequate screening of adolescents, identification of smokers, and adolescents' willingness to disclose their smoking. The present study assessed adolescent reports of physician screening and counseling and adolescents' willingness to disclose smoking, as well as demographic and health status differences in these rates.

METHODS

Adolescents (n = 5016), ages 16 to 19, completed a survey on smoking and health. Reports of the prevalence of physician screening, counseling, and adolescents' willingness to disclose their smoking were examined, and logistic regression analyses assessed demographic and health status differences in these prevalence estimates.

RESULTS

Overall, 43.4% of the sample reported physician screening, 42.1% reported receiving counseling, and only 28.8% of adolescents reported both. Furthermore, 79.3% of smokers reported that they would admit their smoking if asked. Screening, counseling, and disclosure rates differed by gender, neighborhood income level, smoking status, and asthma status.

CONCLUSIONS

More intensive provider-delivered intervention is needed. Efforts should focus on helping providers to identify smoking correctly and to communicate appropriate prevention or cessation messages. Persistence and sensitivity with boys, experimental smokers, and youths with chronic health conditions should be a focus of provider training, because the lower willingness of these youths to disclose their smoking may be a barrier to their identification and intervention.