VA mental health patients smoke at rates almost double those found in non-mental health populations. There is an urgent need to develop cessation programs that meet the unique needs of mental health patients. This study was designed to implement and evaluate a telephone care coordination program for smokers who use VA mental health clinics.
(1) Evaluate the process of adapting, implementing, and sustaining a smoking cessation telephone care coordination program in Mental Health Clinics; (2) Determine the effectiveness of telephone counseling in promoting long-term abstinence from smoking among mental health patients; and (3) Compare the effectiveness of telephone counseling delivered by VA staff trained to work with mental health patients with that delivered by state Quitlines.
The trial used a hybrid effectiveness-implementation study design. We implemented a telephone care coordination program at six VA facilities. VA mental health providers referred patients to the program via an electronic medical record consult. Any VA mental health patient with an active telephone number and mailing address were eligible for referral. Program staff called referred patients to offer enrollment. Patients who enrolled received a self-help booklet, mailed smoking cessation medications, and proactive multi-call telephone counseling. Participants were randomized to receive this counseling from VA staff or their state Quitline (after warm-transfer to the Quitline by program staff). Participants completed telephone surveys at baseline, 2 months and 6 months to assess demographics, smoking history and status, motivation and self-efficacy toward quitting, and recent mental health functioning. Our primary outcome was 30-day point prevalence abstinence on the 6-month survey. We used Inverse probability weighting to handle missing outcomes data. We used logistic regression to test for significant differences in 6-month abstinence between the two treatment arms.
We conducted a formative evaluation throughout the study that tracked the progress of implementation at each site, tracked incoming referrals and characteristics of referring providers, and tracked patient uptake of treatment. We conducted semi-structured interviews with 16 VA mental health providers and leaders in tobacco or mental health to assess barriers and facilitators toward program implementation, and attitudes toward treating mental health patients for tobacco.
We are in the process of analyzing data. Findings thus far are as follows. We received significantly fewer referrals than anticipated, only 1206 referrals across all six sites (approximately 20% of what we expected). We received all of the referrals from a small proportion of mental health providers. Approximately 10% of providers made over 50% of all referrals. Many providers never referred anyone and almost 50% of providers who made a referral referred only one patient. We received 70% of referrals from Psychiatrists and only 9%, 8% and 7% of referrals from Psychologists, Nurse Practitioners, and Social Workers, respectively
We reached 919 (76%) patients by phone to offer enrollment. Of those, 66% enrolled in treatment, 9% enrolled in the follow-up surveys only, 9% were ineligible and 15% declined participation. 100% of participants in both treatment arms scheduled an appointment to begin counseling, and 90% were interested in using smoking cessation medications. Approximately 70% of participants in each arm completed at least one counseling session. The 6-month abstinence rate was higher in the VA counseling arm than in the Quitline arm (18% vs 12%, p=0.048).
This study demonstrated the effectiveness of a telephone smoking cessation program for VA mental health patients. The main barrier to patient access to this effective program was lack of referral from mental health providers. Future research should test strategies for increasing the screening and referral to treatment of mental health clinic patients who smoke.
- Rogers E, Fernandez S, Gillespie C, Smelson D, Hagedorn HJ, Elbel B, Kalman D, Axtmayer A, Kurowski K, Sherman SE. Telephone care coordination for smokers in VA mental health clinics: protocol for a hybrid type-2 effectiveness-implementation trial. Addiction science & clinical practice. 2013 Mar 15; 8:7.