Transcript Document 7523416

QuitLink: A Leveraging Solution
to Tobacco Counseling
Tobacco Use: (circle one)
Current
Advised to quit
Former
Ready to
quit in next
30 days?
Never
1
QuitLink
3
2
Yes
No
Virginia Commonwealth University
Stephen F. Rothemich, MD, MS
Steven H. Woolf, MD, MPH
Robert E. Johnson, PhD
Kelly J. Devers, PhD
Sharon K. Flores, MS
Amy E. Burgett, RN
American Cancer Society Quitline
Pamela Villars, MEd, LPC
Vance Rabius, PhD
Group Health Cooperative
Tim McAfee, MD, MPH
Funded by AHRQ (1 R21 HS014854)
Background
• Few practices can routinely provide more
than simple cessation advice
• Numerous barriers to intensive counseling
• Lack of office support systems to conduct
cessation counseling amidst the competing
demands of busy primary care visits
• Quit lines deliver intensive counseling
Primary Objective
5As Framework for
Cessation Counseling
1°
A1
A2
A3
A4
A5
Ask
Advise
Assess
Assist
Arrange
 To test whether patientreported delivery of intensive
cessation counseling in
practices is enhanced by
QuitLink’s 3-component
approach to integrating quit
lines into primary care practice
QuitLink Components
1. An expanded vital sign intervention
(Ask, Advise, Assess done by staff)
2. Capacity to provide fax referral of
preparation-stage patients for
proactive telephone counseling
(American Cancer Society Quitline)
3. Feedback to the provider team,
including individual and aggregate
reports and prescription requests
Tobacco Use: (circle one)
Current
Advised to quit
Former
Ready to
quit in next
30 days?
Never
1
QuitLink
3
2
Yes
No
Setting
• September 2005 - June 2006
• 16 primary care practices in the
greater Richmond, VA area
– 3 inner-city, 4 rural, and 9 suburban
– 11 family medicine, 2 internal medicine,
and 3 with both specialties
– Median of 4 providers; range 2-7
Study Design
•
Cluster-randomized controlled trial
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•
•
ClinicalTrials.gov Identifier: NCT00112268
Control: Traditional tobacco-use vital sign
2 sets of cross-sectional exit surveys
1.
–
–
–
2.
3-month pre-intervention period
Block randomization of practices
Treatment arm assignment
1 hour training session at 8 intervention practices
9-month comparison period
Data Sources
• Brief exit survey distributed by research
assistants to adult patients
• Minimal data set from ACS Quitline
• Semi-structured interviews with
practice staff
Survey Participants
• Adults who had just completed a visit
with a clinician
– Physician, nurse practitioner, or physician assistant
• Exit surveys from 13,562 pre-intervention
and comparison period exit surveys
– 18% smokers
• Outcome data from 1,815 smokers in
comparison period
Intervention Elements
• Rooming staff used
Tobacco Use: (circle one)
expanded vital sign
Current
Advised to quit
• Practice offered fax
Ready to
Former
Yes
quit
in
next
referral for proactive
Never
No
30 days?
telephone counseling
• Patients contacted by ACS Quitline staff for intake
and enrollment in 4 session counseling program
• Bupropion SR fax prescription request form
• Individual patient outcomes report
• Quarterly benchmarked aggregate feedback
Data Analysis
• Intensive counseling:
– Affirmative answer to questions addressing
discussion of how to quit and/or referral
• Adjustment for temporal sampling differences
among practices and providers
• Nested, hierarchical logistic regression model
accounted for 3 sources of variation
Principal Findings (1)
Counseling
Behavior
Ask
(A1)
Advise
(A2)
Survey Question
Adjusted Affirmative Response
Control
Intervention
Difference
p value
“Did anyone ask you
today if you smoke?”
64.5%
59.6%
-4.9%
0.45
“If you smoke, did
anyone advise you
today to stop smoking?”
55.1%
57.9%
2.8%
0.40
Principal Findings (2)
Counseling
Behavior
Survey Question
Adjusted Affirmative Response
Control
Intervention
Difference
p value
Main Outcome
29.5%
41.4%
11.9%
<0.001
“If you smoke, did
Discussion anyone talk with you
today about ideas or
(A3-5)
plans to help you quit
smoking?”
28.7%
35.2%
6.5%
0.001
8.7%
21.4%
12.7%
<0.001
Intensive
Counseling
(A3-5+Referral)
Referral
“If you smoke, were you
referred today to a quit
line?”
ACS Quitline Outcomes (1)
(preliminary analysis of limited data set)
• 329 referrals over 9 months
– 237 in Q1; 66 in Q2; 26 in Q3
• Referrals volume varied by practice
– Median 39.5; range 1 – 81
• Referrals volume varied by clinician
– Median 6; range 0 – 39
– Name missing on 34
– No referral attributed to 23.5% of clinicians
ACS Quitline Outcomes (2)
(preliminary analysis of limited data set)
• Quitline reached 113 (34.3%) for intake
– Multiple call protocol; single phone number
• 88 (77.8%) elected proactive counseling
• 48 (54.5%) had at least one session
– 26 had 2+, 17 had 3+, and 6 had all 4 sessions
• 22 (45.8%) not smoking at last contact
• Additional 7 (14.6%) cut back ≥ 50%
Clinician/Staff Interviews (1)
(preliminary analysis of field notes and post-interview summaries)
• Practices liked many aspects
– Systematic process for screening and
counseling
– Concrete option to offer patients for
intensive counseling
– Relative simplicity, ease of implementation
– Not a significant burden on clinicians or staff
– Great potential value to patients
Clinician/Staff Interviews (2)
(preliminary analysis of field notes and post-interview summaries)
• Variation in how QuitLink was
implemented
– Likely led to variation in referral rates
• Practices offered suggestions for
improvement
– (e.g., brochure explaining telephone
counseling, more feedback from quit line)
Conclusions
• The intervention increased patientreported intensive counseling
• Salutatory effect on reports of in-office
discussion and quit line referrals
• Implementation and utilization varied
• Referral volumes declined over time
Limitations
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•
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•
•
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Outcome was counseling, not cessation
Relied on patient report of counseling
Hawthorne effect possible
Effect only measured for 9 months
Cannot assess individual components
Insufficient recruits for patient interviews
Impact likely reduced by several factors
Policy Implications
• Fax referral is a win-win arrangement
• Practices and quit lines can engage in
bidirectional communication
• Screening on stage of change is possible
and should be done to reduce
inappropriate referrals
Related/Future Work
•
Electronic referral in practices with EHR
1. Pilot project with Virginia state quit line
(service provider is Free & Clear)
2. RWJF Transition grant with second EHR
•
Future studies refining QuitLink model
and evaluating additional and longerterm outcomes
Tobacco Use: (circle one)
Current
Advised to quit
Former
Ready to
quit in next
30 days?
Never
1
QuitLink
3
2
Yes
No