Patient survey examining the experience of care of a hospital-based opt-out tobacco dependency treatment service (the CURE Project)

INTRODUCTION

Treating tobacco dependency in patients admitted to hospital is a key priority in the National Health Service long-term plan. This service evaluation assessed the perception, needs and experience of care within an opt-out hospital-based tobacco dependency treatment service (the Conversation, Understand, Replace, Experts and Evidence Base (CURE) team) in North-West England.

METHODS

A survey was offered to all eligible patients between 1 July 2020 and 30 September 2020. Eligibility criteria were adult patients identified as an active smoker being approached by the CURE team as part of the standard opt-out service model, on a non-covid ward without a high suspicion of COVID-19 infection and able to read and write in English.

RESULTS

106 completed surveys were evaluated. Participants demonstrated high levels of tobacco dependency with an average of 37 years smoking history and 66% describing the onset of cravings within 30 min of hospital admission. The average number quit attempts in the previous 12 months was 1.3 but only 9% had used the most effective National Institute for Health and Care Excellence (NICE) recommended treatments. 100% felt the opt-out service model was appropriate and 96% stated the treatment and support they had received had prompted them to consider a further quit attempt. 82% of participants rated their experience of care as 9/10 or 10/10. Participants wanted a broad range of support post discharge with the most popular option being with their general practitioner. 66% and 65% of participants would have been interested in a vaping kit as stop smoking intervention and support vaping-friendly hospital grounds respectively.

CONCLUSION

These results suggest this hospital-based, opt-out tobacco dependency treatment service delivers high-quality experience of care and meets the needs of the patients it serves. It also highlights the opportunity to enhance outcomes by providing access to NICE recommended most-effective interventions (varenicline, vaping and combination nicotine replacement therapy) and providing flexible, individualised discharge pathways.

Understanding the implementation strategy of a secondary care tobacco addiction treatment pathway (the CURE project) in England: a strategic behavioural analysis

OBJECTIVES

The Conversation, Understand, Replace, Experts and evidence-based treatment (CURE) project implemented an evidence-based intervention that offers a combination of pharmacotherapy and behavioural support to tobacco-dependent inpatients. Understanding key characteristics of CURE's implementation strategy, and identifying areas for improvement, is important to support the roll-out of nationwide tobacco dependence services. This study aimed to (1) specify key characteristics of CURE's exiting implementation strategy and (2) develop theoretical-informed and stakeholder-informed recommendations to optimise wider roll-out.

DESIGN AND METHODS

Data were collected via document review and secondary analysis of interviews with 10 healthcare professionals of a UK hospital. Intervention content was specified through behaviour change techniques (BCTs) and intervention functions within the Behaviour Change Wheel. A logic model was developed to specify CURE's implementation strategy and its mechanisms of impact. We explored the extent to which BCTs and intervention functions addressed the key theoretical domains influencing implementation using prespecified matrices. The development of recommendations was conducted over a two-round Delphi exercise.

RESULTS

We identified six key theoretical domains of influences: 'environmental context and resources', 'goals', 'social professional role and identity', 'social influences', 'reinforcement' and 'skills'. The behavioural analysis identified 26 BCTs, 4 intervention functions and 4 policy categories present within the implementation strategy. The implementation strategy included half the relevant intervention functions and BCTs to target theoretical domains influencing CURE implementation, with many BCTs focusing on shaping knowledge. Recommendations to optimise content were developed following stakeholder engagement.

CONCLUSIONS

CURE offers a strong foundation from which a tobacco dependence treatment model can be developed in England. The exiting strategy could be strengthened via the inclusion of more theoretically congruent BCTs, particularly relating to 'environmental context and resources'. The recommendations provide routes to optimisation that are both theoretically grounded and stakeholder informed. Future research should assess the feasibility/acceptability of these recommendations in the wider secondary-care context.

Successes and Challenges of Implementing Tobacco Dependency Treatment in Health Care Institutions in England

There is a significant body of evidence that delivering tobacco dependency treatment within acute care hospitals can deliver high rates of tobacco abstinence and substantial benefits for both patients and the healthcare system. This evidence has driven a renewed investment in the UK healthcare service to ensure all patients admitted to hospital are provided with evidence-based interventions during admission and after discharge. An early-implementer of this new wave of hospital-based tobacco dependency treatment services is "the CURE project" in Greater Manchester, a region in the North West of England. The CURE project strives to change the culture of a hospital system, to medicalise tobacco dependency and empower front-line hospital staff to deliver an admission bundle of care, including identification of patients that smoke, provision of very brief advice (VBA), protocolised prescription of pharmacotherapy, and opt-out referral to the specialist CURE practitioners. This specialist team provides expert treatment and behaviour change support during the hospital admission and can agree a support package after discharge, with either hospital-led or community-led follow-up. The programme has shown exceptional clinical effectiveness, with 22% of all smokers admitted to hospital abstinent from tobacco at 12 weeks, and exceptional cost-effectiveness with a public value return on investment ratio of GBP 30.49 per GBP 1 invested and a cost per QALY of GBP 487. There have been many challenges in implementing this service, underpinned by the system-wide culture change and ensuring the good communication and engagement of all stakeholders across the complex networks of the tobacco control and healthcare system. The delivery of hospital-based tobacco dependency services across all NHS acute care hospitals represents a substantial step forward in the fight against the tobacco epidemic.

Understanding the enablers and barriers to implementing smoke-free NHS sites across acute care trusts in Greater Manchester: results of a hospital staff survey

Introduction

The current study aims to identify enablers and barriers to implementing smoke-free NHS hospital grounds through a hospital staff survey.

Methods

Staff members from eight acute care NHS trusts in Greater Manchester were invited to complete a 15-minute web-based questionnaire.

Results

Five-hundred and eighty-eight participants completed the questionnaire. Nineteen per cent (114/588) of respondents were current smokers and 10% (61/588) were currently vaping. Sixty per cent (68/114) smoked at work and 66% (40/61) vaped at work. Sixty-seven per cent (314/468) supported dedicated on-site tobacco addiction treatment services for hospital staff with specific support for drop-in clinics and free pharmacotherapy for staff. Sixty-one per cent (290/477) and 67% (318/477) strongly agreed / agreed that patients/visitors and staff, respectively, should not smoke on hospital grounds. Seventeen per cent (83/484) had received training in very brief advice. Thirty-five per cent (190/547) felt vaping was less harmful than smoking, 19% (92/472) felt exhaled vapour was likely to be safe to bystanders, 36% (172/475) would support vaping-friendly hospital grounds and 31% (37/120) felt confident in discussing vaping.

Discussion

Enablers to a smoke-free NHS site include dedicated tobacco addiction services for staff and empowering staff through appropriate training to support smokers on the hospital grounds. Barriers include the lack of awareness and support for the harm reduction benefits of vaping.

Health economic analysis for the 'CURE Project' pilot: a hospital-based tobacco dependency treatment service in Greater Manchester

INTRODUCTION

Treating tobacco dependency in patients admitted to acute care National Health Service (NHS) trusts is a key priority in the NHS 10-year plan. This paper sets out the results of a health economic analysis for 'The CURE Project' pilot; a new hospital-based tobacco dependency service.

METHODS

A health economic analysis to understand the costs of the intervention (both for the inpatient service and postdischarge costs), the return on investment (ROI) and the cost per quality-adjusted life year (QALY) of the CURE Project pilot in Greater Manchester. ROI and cost per QALY were calculated using the European Study on Quantifying Utility of Investment in Protection from Tobacco and Greater Manchester Cost Benefit Analysis Tools.

RESULTS

The total intervention costs for the inpatient service in the 6-month CURE pilot were £96 224 with a cost per patient who smokes of £40.21. The estimated average cost per patient who was discharged on pharmacotherapy was £97.40. The cost per quit (22% quit rate for smokers at 12 weeks post discharge) was £475. The gross financial ROI ratio was £2.12 return per £1 invested with a payback period of 4 years. The cashable financial ROI ratio was £1.06 return per £1 invested with a payback period of 10 years. The public value ROI ratio was £30.49 per £1 invested. The cost per QALY for this programme was £487.

DISCUSSION

The CURE Project pilot has been shown to be exceptionally cost-effective with highly significant ROI in this health economic analysis. This supports the NHS priority to embed high-quality tobacco addiction treatment services in acute NHS trusts, and the CURE Project provides a blueprint and framework to achieve this.

Feasibility, uptake and impact of a hospital-wide tobacco addiction treatment pathway: Results from the CURE project pilot

INTRODUCTION

Providing comprehensive tobacco addiction treatment to smokers admitted to acute care settings represents an opportunity to realise major health resource savings and population health improvements.

METHODS

The CURE project is a hospital-wide tobacco addiction treatment service piloted in Wythenshawe Hospital, Manchester, UK. The core components of the project are electronic screening of all patients to identify smokers; the provision of brief advice and pharmacotherapy by frontline staff; opt-out referral of smokers to a specialist team for inpatient behavioural interventions; and continued support after discharge.

RESULTS

From 01 October 2018 to 31 March 2019, 92% (13,515/14,690) of adult admissions were screened for smoking status, identifying 2,393 current smokers. Of these, 96% were given brief advice to quit by the admitting team. Through the automated 'opt-out' referral process, 61% patients completed inpatient behavioural interventions with a specialist cessation practitioner (69% within the first 48 hours of admission). Overall, 66% of smokers were prescribed pharmacotherapy. Over one in five of all smokers admitted during this pilot reported that they were abstinent from smoking 12 weeks after discharge (22%) at a cost £183 per quit.

DISCUSSION

National implementation of this cost-effective programme would be likely to generate substantial benefits to public health.