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CPG 97-002 – HSR&D Study

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CPG 97-002
Implementing Guidelines for Smoking Cessation: A Randomized Trial of Evidence-Based Quality Improvement
Scott E. Sherman MD MPH
VA Greater Los Angeles Healthcare System, Sepulveda, CA
Sepulveda, CA
Funding Period: July 1998 - December 2002

BACKGROUND/RATIONALE:
Smoking is a serious and common health risk among veterans. Given the press of national initiatives and local incentives to improve smoking cessation care in response to VA performance measures, this study tests a widely applicable approach to clinical practice guidelines implementation, namely evidence-based quality improvement, which is directly relevant to the translation of efficacious treatments into enhancements in VA health care policy and practice. Evidence-Based Quality Improvement (EBQI) focuses on improved provider adherence to smoking cessation guidelines and a decrease in patient smoking rates in a manner designed to produce short- and long-term health improvements and cost benefits at the organizational level.

OBJECTIVE(S):
Adherence to smoking cessation guidelines requires practice changes at the patient, provider, and system levels to achieve optimal quit rates. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI)—an expert-designed and locally implemented clinical reorganization of smoking cessation care—on changes in smoking cessation (SC) practice among primary care providers and health outcomes among veteran smokers.

METHODS:
An evidence-based quality improvement intervention comprising provision of physician and patient educational materials, local priority setting with leadership and providers, and local adaptation of expert-designed protocols was implemented in experimental VA primary care practices (n=9). VA control sites (n=9), matched on size and academic affiliation, received smoking cessation guideline copies. We randomly sampled, consented, screened and surveyed primary care patients at all 18 sites (n=1,941 smokers) and used computer-assisted telephone interviewing to assess sociodemographics, health status, function, and smoking behavior, attitudes and treatment experience. Post-intervention 12-month follow-up interviews were completed using the same measures (n=1,080). We used multiple imputation using hotdeck techniques and applied both enrollment and attrition weights to the patient-level data. We used weighted logistic regression to evaluate intervention effects, controlling for patient-level predictors of quit attempts and quit status (e.g., level of addiction, readiness to change, age, health).

FINDINGS/RESULTS:
Primary care providers’ attitudes toward smoking cessation were the strongest predictors of counseling behavior and referral to a smoking cessation program. While primary care providers at intervention sites were more likely to counsel smokers than providers at control sites, the percent of smokers who attempted to quit and reported 1+ days of intentional quitting increased significantly among both experimental and control group patients from baseline to 12-month follow-up. Adjusting for patient socio-demographics, level of addiction and readiness-to-change, however, we found no intervention effect on quit attempts or smoking cessation and found marginally higher successes among participants at control sites (p=.094 quits, p<.05 quit attempts). Higher addiction level (OR=0.81, 95% CI 0.74-0.88) and readiness-to-change (OR=2.52, 95% CI 1.97-3.21) were the only independent predictors of smoking cessation regardless of patient age, gender, race-ethnicity, marital status, education or intervention group (p<.0001).

IMPACT:
Patient reports of increased smoking cessation counseling and treatment corroborate chart-based performance measures and provide details regarding their readiness-to-change that may facilitate provision of effective counseling by primary care providers. Performance mandates regarding smoking cessation guideline implementation have resulted not only in significant changes across facilities, but also detailed changes in the processes and outcomes of care of the population of patients seen in VA primary care practices. At the same time, in contrast to benefits demonstrated for chronic care (i.e., depression care improvement), intensive primary care-based reorganization, with locally-developed quality improvement plans supplemented by expert advice, did not lead to more quit attempts or actual smoking cessation beyond changes already underway in all sites through VA performance measurement and leadership incentives for better tobacco counseling rates. Qualitative assessment of site-specific practice changes is needed, especially where smoking cessation programs reside in behavioral health programs and primary care/mental health collaboration is needed.

PUBLICATIONS:

Journal Articles

  1. Lombardero A, Campbell DG, Harris KJ, Chaney EF, Lanto AB, Rubenstein LV. Prevalence and correlates of smoking status among veterans affairs primary care patients with probable major depressive disorder. Addictive Behaviors. 2014 Mar 1; 39(3):538-45.
  2. Yano EM, Rubenstein LV, Farmer MM, Chernof BA, Mittman BS, Lanto AB, Simon BF, Lee ML, Sherman SE. Targeting Primary Care Referrals to Smoking Cessation Clinics Does Not Improve Quit Rates: Implementing Evidence-Based Interventions into Practice. Health services research. 2008 Oct 1.
  3. Sherman SE, Yano EM, York LS, Lanto AB, Chernof BA, Mittman BS. Assessing the structure of smoking cessation care in the Veterans Health Administration. American Journal of Health Promotion : AJHP. 2006 May 1; 20(5):313-8.
  4. Sherman SE, Joseph AM, Yano EM, Simon BF, Arikian N, Rubenstein LV, Parkerton P, Mittman BS. Assessing the institutional approach to implementing smoking cessation practice guidelines in veterans health administration facilities. Military medicine. 2006 Jan 1; 171(1):80-7.
  5. Meredith LS, Yano EM, Hickey SC, Sherman SE. Primary care provider attitudes are associated with smoking cessation counseling and referral. Medical care. 2005 Sep 1; 43(9):929-34.
  6. Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2005 May 1; 15(3):126-33.
  7. Jonk YC, Sherman SE, Fu SS, Hamlett-Berry KW, Geraci MC, Joseph AM. National trends in the provision of smoking cessation aids within the Veterans Health Administration. The American journal of managed care. 2005 Feb 1; 11(2):77-85.
  8. Sherman SE, Yano EM, Lanto AB, Simon BF, Rubenstein LV. Smokers' interest in quitting and services received: using practice information to plan quality improvement and policy for smoking cessation. American journal of medical quality : the official journal of the American College of Medical Quality. 2005 Jan 1; 20(1):33-9.
  9. Mojica WA, Suttorp MJ, Sherman SE, Morton SC, Roth EA, Maglione MA, Rhodes SL, Shekelle PG. Smoking-cessation interventions by type of provider: a meta-analysis. American journal of preventive medicine. 2004 Jun 1; 26(5):391-401.
  10. Sherman SE, Lanto AB, Nield M, Yano EM. Smoking cessation care received by veterans with chronic obstructive pulmonary disease. Journal of rehabilitation research and development. 2003 Sep 1; 40(5 Suppl 2):1-12.
Reports

  1. Sherman SE, Yano EM. Implementing Smoking Cessation Guidelines: A Randomized Trial of Evidence-Based Quality Improvement: Final Report. Sepulveda, CA: VA Greater Los Angeles HSR&D Center of Excellence; 2003 May 1. Report No.: Final Report.
  2. Mittman BS, Yano EM, Sherman SE. Measurement of the structure and process of smoking cessation care: QUITS Smoking Cessation Coordinator Questionnaire (Part 1). Sepulveda, CA: VA Greater Los Angeles HSR&D Center of Excellence; 2003 Feb 1. Report No.: Techinical Report #CPG-97-002-004.
  3. Mittman BS, Yano EM, Sherman SE. Measurement of the structure and process of smoking cessation care: QUITS Smoking Cessation Coordinator Questionnaire (Part 2). Sepulveda, CA: VA Greater Los Angeles HSR&D Center of Excellence; 2003 Feb 1. Report No.: Techinical Report #CPG-97-002-005.
  4. Sherman SE, Meredith LM, Yano EM. Measurement of Primary Care Provider Smoking Cessation-Related Knowledge, Attitudes and Practice: QUITS Clinician Background Questionnaire (CBQ). Sepulveda, CA: VA Greater Los Angeles HSR&D Center of Excellence; 2003 Feb 1. Report No.: Techinical Report #CPG-97-002-003.
  5. Sherman SE, Yano EM, Mittman BS. Measurement of Smoking Cessation Guideline Adherence: Development and Application of the QUITS Site Report Card. Sepulveda, CA: VA Greater Los Angeles HSR&D Center of Excellence; 2003 Feb 1. Report No.: Techinical Report #CPG-97-002-002.
  6. Yano EM, Simon BF, Reynolds S, Lanto AB, Sherman SE. QUITS patient Health Questionnaire Baseline Survey (PHQ00): Survey Technical Monograph. Sepulveda, CA: VA Greater Los Angeles HSR&D Center of Excellence; 2002 Jul 1. Report No.: Technical Report #CPG-02-001.
Conference Presentations

  1. Yano EM, Lanto AB, Lee ML, Rubenstein LV, Sherman SE. Does Reorganization of Smoking Cessation Care Improve Patient Quit Rates? Paper presented at: VA HSR&D National Meeting; 2004 Mar 10; Washington, DC.
  2. Meredith LS, Yano EM, Hickey SC, Sherman SE. Primary Care Provider Attitudes Predict Reported Smoking Cessation Behavior. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 2; Vancouver, Canada.
  3. Sherman SE, Lanto AB, Nield M, Yano EM. Smoking Cessation Care Received by Veterans with Chronic Obstructive Pulmonary Disease (COPD). Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 2; Vancouver, Canada.
  4. Sherman SE, Yano EM, Lanto AB, Mittman BS. How Well Do Smoking Cessation Quality Measures Predict Clinical Outcomes?'. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 2; Vancouver, Canada.
  5. Yano EM, Lanto AB, Lee ML, Rubenstein LV, Sherman SE. Does Guideline-Concordant Clinical Reorganization of Smoking Cessation Care Improve Patient Quit Rates?: Results of a Group Randomized Trial. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 2; Vancouver, Canada.
  6. Fu SS, Sherman SE, Yano EM, VanRyn M, Lanto AB, Joseph AM. Racial-ethnic Variation in the Use of Pharmacotherapy for Smoking Cessation by Veteran Smokers. Paper presented at: VA HSR&D National Meeting; 2003 Feb 13; Washington, DC.
  7. Sherman SE, Yano EM, Lanto AB, Mittman BS. Development of a report card to assess organizational adherence to smoking cessation guidelines. Paper presented at: Society for Research on Nicotine and Tobacco Annual Conference; 2003 Feb 1; New Orleans, LA.
  8. Yano EM, Lanto AB, Simon BF, Sherman SE. Impact of VA Smoking Cessation Initiatives on Smoking Cessation Practices and Outcomes. Paper presented at: VA HSR&D National Meeting; 2002 Feb 1; Washington, DC.
  9. Yano EM, Sherman SE, Wang M, Lee ML, Rubenstein LV. Organizational predictors of variations in tobacco counseling rates. Paper presented at: Society of General Internal Medicine Annual Meeting; 2001 May 3; San Diego, CA.
  10. Lee ML, Rubenstein LV, Yano EM. Techniques of data weighting and missing value imputation. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC.
  11. Lee ML, Sherman SE, Yano EM. Lack of clustering in a group randomized trial of smoking cessation guideline implementation (QUITS). Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC.
  12. Mittman BS, Simon B, Sherman SE, Yano EM, Lanto AB, Lee ML, Arikian N, Joseph AM. Characteristics of VHA facility smoking cessation programs and practices. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC.
  13. Sherman SE, Yano EM, Lanto AB, Wang M, Lee ML, Mittman BS, Rubenstein LV. Health status and health care utilization of veterans who smoke. Paper presented at: Society of General Internal Medicine Annual Meeting; 2001 Feb 15; San Diego, CA.
  14. Sherman SE, Yano EM, Lanto AB, Simon B, Rubenstein LV. Veterans who smoke: Do they want to quit and are we helping them? Paper presented at: VA HSR&D National Meeting; 2001 Feb 14; Washington, DC.
  15. Sherman SE, Chapman A. Lessons learned from the initial conduct of a multi-site study. Paper presented at: VA HSR&D National Meeting; 2000 Mar 23; Washington, DC.
  16. Sherman SE, Takayesu S, West P, Chapman A. The effectiveness of bupriopion vs. bupropion plus nicotine patch in a smoking cessation clinic. Paper presented at: VA HSR&D National Meeting; 1999 Feb 25; Washington, DC.


DRA: Substance Abuse and Addiction, Health Systems
DRE: Prevention
Keywords: Clinical practice guidelines, Smoking
MeSH Terms: Smoking, Smoking Cessation, Quality, Health Promotion, Practice Guidelines

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