Impact of Adding Telephone-Based Care Coordination to Standard Telephone-Based Smoking Cessation Counseling Post-hospital Discharge: a Randomized Controlled Trial

BACKGROUND

Cessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation.

OBJECTIVE

To compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation.

DESIGN

Unblinded, randomized clinical trial PARTICIPANTS: Hospitalized smokers referred from primarily rural hospitals INTERVENTIONS: Counseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker's health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C.

MAIN MEASURES

Utilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge.

KEY RESULTS

Among 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6-12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)).

CONCLUSION

Supplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications.

TRIAL REGISTRATION

NCT01063972.

Effect of Long-term Nicotine Replacement Therapy vs Standard Smoking Cessation for Smokers With Chronic Lung Disease: A Randomized Clinical Trial

IMPORTANCE

Smokers with chronic obstructive pulmonary disease (COPD) have particular difficulty quitting. Long-term nicotine replacement therapy (LT-NRT) might offer a strategy for reducing harm from cigarettes and provide a pathway for later cessation.

OBJECTIVE

To compare the effect of LT-NRT vs standard smoking cessation (SSC) on exposure to cigarette smoke, harm related to smoking, and cessation among smokers with COPD.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded, randomized clinical trial recruited smokers who self-reported a diagnosis of COPD at any level of readiness to quit from May 23, 2014, through November 30, 2015. The 12-month follow-up was completed December 6, 2016. Patients were recruited at a clinical research unit of an academic medical center. Analysis was based on intention to treat and performed from March 8 through November 30, 2017.

INTERVENTIONS

Standard smoking cessation treatment included 10 weeks of NRT and 4 follow-up counseling sessions for those willing to make a quit attempt. Long-term NRT included 12 months of NRT and 6 follow-up counseling sessions regardless of initial willingness to quit. Overall, 198 patients were randomized to SSC, and 197 were included in the primary analysis; 200 patients were randomized to LT-NRT, and 197 were included in the primary analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was 7-day abstinence verified by carbon monoxide (CO) levels at 12 months. Secondary outcomes included cigarettes smoked per day (CPD), exposure to CO, urinary excretion of 4-methylnitrosamino-1-3-pyridyl-1-butanol (NNAL) (a smoking-related carcinogen), and adverse events.

RESULTS

Among 398 patients who were randomized (59.8% female; mean [SD] age, 56.0 [9.3] years), the mean (SD) CPD was 23.1 (12.3). Twelve-month follow-up was completed by 373 participants (93.7%), and 394 (99.0%) were included in the primary analysis. At 12 months, CO-verified abstinence occurred in 23 of 197 participants (11.7%) in the SSC arm and 24 of 197 (12.2%) in the LT-NRT arm (risk difference, 0.5%; 95% CI, -5.9% to 6.9%). Continuing smokers in the SSC and LT-NRT arms had similar, significantly reduced harms caused by smoking, including cigarette consumption by 12.4 and 14.5 CPD, respectively, exhaled CO level by 5.5 and 7.8 ppm, respectively, and mean urinary NNAL excretion by 21.7% and 23.0%, respectively. In multivariate analyses, continuing smokers with greater adherence to NRT experienced less reduction in NNAL exposure. The frequency of major adverse cardiac events was similar in both groups.

CONCLUSIONS AND RELEVANCE

Similar rates of cessation and similar reductions in exposure to tobacco smoke resulted with LT-NRT and SSC. Among continuing smokers, ongoing use of NRT was not associated with reductions in smoke exposure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02148445.

Impact of Telephone-Based Care Coordination on Use of Cessation Medications Posthospital Discharge: A Randomized Controlled Trial

INTRODUCTION

Smokers benefit from ongoing cessation support upon leaving the hospital and returning to their home environment. This study examined the impact of telephone-delivered care coordination on utilization of and adherence to cessation pharmacotherapy after hospital discharge.

METHODS

Inpatient smokers (n = 606) were randomized to receive counseling with care coordination (CCC) or counseling alone (C) for smoking cessation. Both groups received written materials and telephone-based cessation counseling during hospitalization and postdischarge. CCC recipients received help in selecting, obtaining, and refilling affordable pharmacotherapy prescriptions during and after hospitalization. Study outcomes included self-reported utilization, duration of use, and type of medication during the 3 months postdischarge.

RESULTS

Of the 487 (80%) of participants completing 3-month follow-up, 211 (43.3%) reported using cessation pharmacotherapy postdischarge; this did not differ by study arm (CCC: 44.7%, C: 42.0%, p = .55). Use of pharmacotherapy postdischarge was associated with smoking at least 20 cigarettes/day at baseline (odds ratio [OR]: 1.48; 95% confidence interval [CI]: 1.00-2.19) and receipt of pharmacotherapy during hospitalization (OR: 4.00; 95% CI: 2.39-6.89). Smokers with Medicaid (OR: 2.29; 95% CI: 1.32-4.02) or other insurance (OR: 1.69; 95% CI: 1.01-2.86) were more likely to use pharmacotherapy postdischarge than those with no health care coverage. Less than one in four (23.8% of CCC; 22.2% of C) continued pharmacotherapy beyond 4 weeks.

CONCLUSIONS

Supplemental care coordination did not improve use of postdischarge pharmacotherapy beyond that of inpatient treatment and behavioral counseling. Insurance coverage and use of medications during the hospitalization are associated with higher use of evidence-based treatment postdischarge.

IMPLICATIONS

Many hospitalized smokers do not receive the benefits of cessation pharmacotherapy postdischarge and telephone quitline programs often fail to help smokers procure pharmacotherapy. Thus, effective strategies are needed to improve utilization and adherence to evidence-based cessation therapies when smokers leave the hospital. We found that use of postdischarge pharmacotherapy was strongly associated with receipt of pharmacotherapy during the hospitalization and with the availability of insurance to cover the costs of treatment. Additional efforts to coordinate pharmacotherapy services did not improve either utilization or adherence to therapy.

Improving Quality of Care for Hospitalized Smokers with HIV: Tobacco Dependence Treatment Referral and Utilization

BACKGROUND

Most persons living with HIV smoke cigarettes and tend to be highly dependent, heavy smokers. Few such persons receive tobacco treatment, and many die from tobacco-related illness. Although advancements in antiretroviral therapy (ART) have increased the quality and quantity of life, the health harms from tobacco use diminish these gains. Without cessation assistance, thousands will benefit from costly ART, only to suffer the consequences of tobacco-related disease and death. A study was conducted to examine in detail inpatient tobacco treatment for smokers with HIV.

METHODS

Data collected at hospital admission and data collected by tobacco treatment specialists were examined retrospectively for all inpatients with HIV who were admitted to an academic medical center for a five-year period. Specifically, the prevalence of cigarette smoking, factors predictive of referral to tobacco treatment, referral for tobacco treatment, treatment participation, and abstinence at six months posttreatment were measured. Differences in referral and treatment participation between all smokers and smokers with HIV were also assessed.

RESULTS

Among the 422 admitted persons with HIV, 54.5% smoked and 21.7% were referred to inpatient tobacco treatment services. Substance abuse and tobacco-related diagnoses were predictive of referral to inpatient tobacco treatment specialists. Among the 14 treatment participants reached for follow-up, 11 (78.6%) made quit attempts and 3 (21.4%) reported abstinence. Smokers with HIV were less likely to be referred to and treated by tobacco treatment services than all smokers admitted during the same time frame.

CONCLUSIONS

Although tobacco is a major cause of mortality, few smokers with HIV are offered treatment during hospitalization. Those who are treated attempt to quit. Hospitalization offers a prime opportunity for initiating smoking cessation among those with HIV.

Creating patient and family education web sites: assuring accessibility and usability standards

This article gives details about the methods and processes used to ensure that usability and accessibility were achieved during development of the Home Parenteral Nutrition Family Caregivers Web site, an evidence-based health education Web site for the family members and caregivers of chronically ill patients. This article addresses comprehensive definitions of usability and accessibility and illustrates Web site development according to Section 508 standards and the national Health and Human Services' Research-Based Web Design and Usability Guidelines requirements.

Comparing patient and nurse specialist reports of causative factors of depression related to heart failure

PURPOSE

The purpose of this study was to compare participants' and a psychiatric nurse specialist's reports on factors precipitating depression and to validate a depression screening instrument.

DESIGN AND METHODS

Participants were screened for and asked to self-report causative factors of their depression. Participants with moderately severe and severe depressive symptoms received a psychiatric nurse specialist assessment.

FINDINGS

Participants self-reported several causative factors of depression. The psychiatric nurse specialist discovered these plus additional factors. The screening instrument was found to be reliable and valid for the measurement of depressive symptoms.

PRACTICE IMPLICATIONS

Participant self-report identifies many causative factors of depression. The psychiatric nurse specialist identifies additional factors, allowing individualized diagnoses and treatments.

Association of polychlorinated biphenyls (PCBs) with live algae and total lipids in rivers-a field-based approach

The association of PCBs and live algal cells in rivers was studied at four locations during four seasons in two Wisconsin rivers. Positive relations between particle-associated PCBs and both chlorophyll-a and algal carbon concentrations indicated that live algal cells were a significant sorption phase for dissolved PCBs. Large Pennate diatoms (Navicula, Synedra, Pinnularia, Diatoma, and Cocconeis), or more rarely, Euglenoids (Trachelomonas sp.), dominated most sample assemblages on an algal carbon basis. These assemblages made up the highest percentage of total SOC during spring (average=50%) and lowest during summer (average=15%). At the three impounded sites, most individual PCB congeners were relatively enriched in samples characterized by: (1) high concentrations of algal carbon (as a percent of SOC), (2) algal assemblages dominated (or co-dominated) by Euglenoids, and (3) high concentrations of total lipids. Despite relatively higher masses of sorbed PCBs in the most lipid-rich samples, there was no robust correlation between total lipid content and particle-associated PCBs when aggregating all samples from the study. A possible explanation is that PCBs are associated with other structural components in live algae and (or) departure from chemical equilibrium in the river due to algal growth kinetics. A kinetic uptake model was used to calculate the mass of PCBs associated with the total organic carbon content of live algae. Based on this model, PCBs were enriched in algal cells during bloom seasons (spring and fall) compared to non-bloom seasons (summer and winter). Further, although individual PCB congener partition coefficients (log) to live algal cells (range=5.3-6.4) overlapped to those for detritus (range=3.6-7.4), PCBs tended to be enriched in detrital carbon pools during non-bloom conditions. The larger range of estimated PCB partition coefficients for detritus likely reflects the more heterogeneous nature of this material compared to live algal cells.

Beryllium-7 as a tracer of short-term sediment deposition and resuspension in the Fox River, Wisconsin

Short-term (approximately monthly) sediment deposition and resuspension rates of surficial bed sediments in two PCB-laden impoundments on the Fox River, WI, were determined in the summer and fall of 1998 using 7Be, a naturally occurring radioisotope produced in the atmosphere. Decay-corrected activities and inventories of 7Be were measured in bed sediment and in suspended particles. Beryllium-7 activities generally decreased with depth in the top 5-10 cm of sediments and ranged from undetectable to approximately 0.9 pCi cm(-3). Inventories of 7Be, calculated from the sum of activities from all depths, ranged from 0.87 to 3.74 pCi cm(-2), and the values covaried between sites likely reflecting a common atmospheric input signal. Activities of 7Be did not correlate directly with rainfall. Partitioning the 7Be flux into "new" and "residual" components indicated that net deposition was occurring most of the time during the summer. Net erosion, however, was observed at the upstream site from the final collection in the fall. This erosion event was estimated to have removed 0.10 g (cm of sediment)(-2), corresponding to approximately 0.5 cm of sediment depth, and approximately 6-10 kg of polychlorinated biphenyls (PCBs) over the whole deposit. Short-term accumulation rates were up to approximately 130 times higher than the long-term rates calculated from 137Cs profiles, suggesting an extremely dynamic sediment transport environment, even within an impounded river system.

Yellow fever in the Gambia, 1978--1979: epidemiologic aspects with observations on the occurrence of orungo virus infections

An epidemic of yellow fever (YF) occurred in the Gambia between May 1978 and January 1979. Retrospective case-finding methods and active surveillance led to the identification of 271 clinically suspected cases. A confirmatory or presumptive laboratory diagnosis was established in 94 cases. The earliest serologically documented case occurred in June 1978, at the extreme east of the Gambia. Small numbers of cases occurred in August and September. The epidemic peaked in October, and cases continued to occur at a diminishing rate through January, when a mass vaccination campaign was completed. The outbreak was largely confined to the eastern half of the country (MacCarthy Island and Upper River Divisions). In nine survey villages in this area (total population 1,531) the attack rate was 2.6--4.4%, with a mortality rate of 0.8%, and a case fatality rate of 19.4%. If these villages are representative of the total affected region, there may have been as many as 8,400 cases and 1,600 deaths during the outbreak. The disease incidence was highest in the 0- to 9-year age group (6.7%) and decreased with advancing age to 1.7% in persons over 40 years. Overall, 32.6% of survey village inhabitants had YF complement-fixing (CF) antibodies. The prevalence of antibody patterns indicating primary YF infection decreased with age, in concert with disease incidence. The overall inapparent:apparent infection ratio was 12:1. In persons with serological responses indicating flaviviral superinfection, the inapparent:apparent infection ratio was 10 times higher than in persons with primary YF infection. Sylvatic vectors of YF virus, principally Aedes furcifer-taylori and Ae. luteocephalus are believed to have been responsible for transmission, at least at the beginning of the outbreak. Eighty-four percent of wild monkeys shot in January 1979 had YF neutralizing antibodies, and 32% had CF antibodies. Domestic Aedes aegypti were absent or present at very low indices in many severely affected villages (see companion paper). In January, however, aegypti-borne YF 2.5 months into the dry season was documented by isolation of YF virus from a sick man and from this vector species in the absence of sylvatic vectors. Thus, in villages where the classical urban vector was abundant, interhuman transmission by Ae. aegypti occurred and continued into the dry season. A mass vaccination campaign, begun in December, was completed on 25 January, with over 95% coverage of the Gambian population. A seroconversion rate of 93% was determined in a group of vaccinees. This outbreak emphasizes the continuing public health importance of YF in West Africa and points out the need for inclusion of 17D YF vaccination in future programs of multiple immunication.

Limitations of the complement-fixation test for distinguishing naturally acquired from vaccine-induced yellow fever infection in flavivirus-hyperendemic areas

On the basis of previous studies, it has long been stated that 17D yellow fever (YF) vaccine generally does not induce complement-fixing (CF) antibodies, and that the presence of CF antibodies could be used in epidemiological studies to distinguish individuals infected with wild YF virus from vaccinated persons. In January 1979, seroepidemiological investigations were conducted during a YF epidemic in The Gambia, West Africa. Since a mass vaccination campaign was also in progress, it was important to confirm that the CF test could be used for serodiagnosis and determination of the incidence of natural YF infections. The serological responses of 58 individuals who received 17D YF vaccine were studied. The vaccinees fell into three gorups: 1) those with prevaccination YF neutralizing (N) antibodies; 2) immunological virgins without prevaccination YF-N antibody or hemagglutination-inhibiting (HI) antibodies to heterologous flaviviruses (Zika, West Nile, dengue 1, Uganda S, Spondweni, or Ntaya; and 3) those without prevaccination YF-N antibodies but with heterologous flaviviral HI antibodies. Vaccination of persons without prior flaviviral immunological experience resulted in monotypic YF HI and/or N antibody seroconversions, but no CF antibody response. The presence of prevaccination YF N antibodies blocked serological response to the vaccine in a high proportion of the cases; however, 24% of vaccinees in this group had a marked rise in log2 YF CF antibody titer (mean increase of 3.9). Thirteen (46%) of 28 persons without prevaccination YF N, but with heterologous flaviviral HI antibodies demonstrated YF CF antibody seroconversion or increase in titer following vaccination; in this group the mean increase in log2/ YF CF antibody titer was 2.1. The CF antibody response was generally broadly cross-reactive; but in a few individuals, the YF CF antibody response was homotypic. Nine different patterns of HI and CF homologous and heterologous antibody responses were defined and are discussed. The practical significance of these studies is that they demonstrate that in a high percentage of persons with prior flavivirus exposure, anamnestic serological responses to YF vaccine result in CF antibodies similar to those induced by natural YF virus infection. In Africa and tropical America, where the background of flaviviral immunity is high, it is imperative that seroepidemiologic investigations during or after YF outbreaks be conducted prior to vaccination.