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2023 HSR&D/QUERI National Conference Abstract

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4104 — Impact of the COVID-19 Pandemic on a Cluster-Randomized Trial of Proactive Tobacco Treatment for Veterans Undergoing Lung Cancer Screening

Lead/Presenter: Steven Zeliadt,  COIN - Seattle/Denver
All Authors: Zeliadt SB (Seattle/Denver COIN, University of Washington Department of Health Systems and Population Health, Seattle, WA), Heffner JL (Fred Hutchinson Cancer Center, Public Health Sciences, Seattle, WA) Feemster LC (Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA) Klein D (Consultant to VA Puget Sound Healthcare System, Seattle, WA) Nici L (Providence VA Medical Center, Providence, RI) Becker D (New York Harbor VA Medical Center, New York, NY) Hildie S (VA HSR&D Center of Innovation (COIN) for Veteran Centered and Value-Driven Care, Seattle, WA) Coggeshall S (VA HSR&D Center of Innovation (COIN) for Veteran Centered and Value-Driven Care, Seattle, WA)

Tobacco treatment is a critical component of lung cancer screening for current smokers. However, this component is often missed both outside and within VA. This randomized trial, building on an HSRandD pilot study where proactive intervention increased quit rates from 7% to 19%, is testing the effectiveness and cost of proactively providing tobacco medication and behavioral counseling using VA Quitline counselors to Veterans undergoing lung cancer screening. This is one of seven trials participating in the National Cancer Institute’s Smoking Cessation at Lung Examination Collaborative. Here, we report on study enrollment and receipt of tobacco treatment in the overall sample both prior to and following the start of the COVID-19 pandemic.

A total of 116 primary care providers/clusters were randomized to have their patients receive either usual care or proactive intervention, the latter of which consisted of confirming that screening results were not suspicious for malignancy, review of past tobacco treatment history, and a prompt for the PCP to order cessation medications (usually combination nicotine replacement therapy or varenicline). Patients in the proactive arm receive a mailing connected with the screening results letter alerting them that cessation medications are recommended and to expect telephone outreach by a behavioral counselor. Calls are conducted by counselors at the national VA Quitline after being trained by our study staff. Study outcomes are assessed using mailed surveys at 3 and 12 months which include self-report of cessation medication use and tobacco use, perceived susceptibility to the harmful effects of smoking, self-efficacy for quitting, and satisfaction.

A total of 825 current smokers were enrolled despite challenges associated with reduced volumes of lung cancer screening due to the COVID-19 pandemic. Study outcomes remain blinded as 12-month outcome data will not be complete until the end of 2022. Using the EMR, we identified receipt of cessation medications within 90 days of screening in 31% of the full sample. An even higher proportion of those completing the 3-month survey, 50%, reported receiving cessation medications at the time of lung cancer screening. There were no differences in self-reported receipt of medications between Veterans screened prior to COVID (51%) and during COVID (48%; p = 0.80). Over 55% of Veterans reported being very satisfied with tobacco treatment support before COVID compared to 71% during COVID (p = 0.09).

Lung cancer screening saw large drops across many healthcare systems during COVID-19, including in the VA. This trial was able to successfully enroll participants and deliver a proactive intervention including medication support and centralized telephone counseling. Early findings are promising with respect to connecting screening participants with tobacco treatment, as the overall rate of cessation medication use was much higher than previously observed (18%) using similar EMR methods for Veterans screened for lung cancer nationally outside of this study (Heffner et al 2021).

This study highlights the challenges of delivering high quality preventive services during the COVID-19 pandemic and demonstrates the potential value of proactive support and centralized telephone counseling to ensure high quality care is delivered.