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IIR 07-113 – HSR Study

IIR 07-113
Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans
David A. Katz, MD MSc
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: March 2009 - August 2013
Although the majority of hospitalized VA smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. VA hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Controlled trials are needed to demonstrate the effectiveness of cessation interventions that combine brief inpatient counseling with sustained relapse prevention and pharmacotherapy in hospitalized smokers.

The primary objective is to determine whether a nurse-initiated intervention, which couples brief inpatient counseling and proactive telephone counseling by a centralized tobacco quitline, improves 6-month cessation rates in hospitalized VA smokers. Co-primary aims are to determine whether the intervention improves the prescription of recommended pharmacotherapy for smoking cessation and the referral of patients for telephone counseling (or other outpatient cessation counseling). Secondary objectives include: 1) identifying barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals, and 2) determining whether the intervention changes the attitudes of ward nurses toward smoking cessation counseling.

We performed a before-after trial in hospitalized patients, aged 18 or older, who smoked at least one cigarette per day on average. The start date at each of 4 study hospitals was staggered such that the intervention was administered at a later date to the sites that initially served as concurrent control sites. After the pre-intervention period, we implemented a multi-component intervention (based on the Chronic Care Model) and enrolled a separate cohort of patients. The intervention included: 1) academic detailing of unit nurses, 2) training in the use of CPRS-based practice tools, 3) computerized referral of motivated inpatients for proactive quitline counseling, and 4) use of nursing peer leaders. Implementation was facilitated by the following: 1) face-to-face training of unit nurses in brief cessation counseling, 2) development of a modified charting tool in CPRS (for nurses to document smoking cessation counseling), 3) creation of "quick orders" to facilitate prescription of smoking cessation pharmacotherapy, 4) education and feedback meetings with internal medicine residents, 5) development of a patient education video on smoking cessation for veterans, 6) training of nurse facilitators on each study ward to provide coaching and performance feedback to ward nurses, and 7) focus groups with hospital staff to identify barriers and facilitators to implementation. Enrolled patients were contacted by telephone at 3 and 6 months to assess 7-day point prevalence abstinence (PPA) and prolonged abstinence (with biochemical confirmation of self-reported quitters at 6 months).

Performance of the 5A's by nurses and physicians was assessed by a brief patient interview just before or shortly after hospital discharge. A 5A's composite score (ranging from 0-9) was computed for each patient. Before and after the intervention, we asked staff nurses to complete a questionnaire to assess attitudes toward cessation. We also conducted semi-structured interviews in a subsample of nurses at each site to assess their perceptions of the intervention.

Four hundred and ninety eight patients (61% of eligible) enrolled and completed the baseline assessment during the pre-intervention period, and 394 patients (59% of eligible) enrolled during the post-intervention period. Two hundred and eighteen nurses (89% of those eligible) completed the pre-intervention survey, and 166 (89% of those who were still employed on a study unit) completed the post-intervention assessment.

Performance of the 5A's
Nurse performance was generally higher during the post-implementation period compared to the pre-intervention period. "Ask about smoking" increased from 84% to 91%; "Assess willingness to quit" increased from 56% to 66%; "Advise to quit" increased from 49% to 55%; "Assist in quitting" increased from 56% to 75%; and "Arrange follow-up" increased from 18% to 23%. Nurses' 5A's composite score was significantly higher during the post-implementation period (3.8 vs. 3.0, p .0001). Physicians were more likely to "Ask" and "Advise" during the post-implementation period, but the physicians' 5A's composite score did not significantly improve during the post-implementation period (2.9 vs. 2.8, p=.54).

Nurse attitudes toward cessation counseling
Pre- and post-intervention surveys of the nursing staff showed improvements in self-efficacy (47% rated themselves as moderately or very effective post-intervention, up from 31%) and role satisfaction in smoking cessation counseling (52% reported being at least somewhat satisfied post-intervention, up from 35%).

Prescription of recommended pharmacotherapy
Overall, study patients during the post-intervention period were no more likely to receive a prescription for NRT, bupropion, or varenicline than were pre-intervention study patients (38 vs. 35%, adjusted OR=1.2, 95% CI=0.9-1.6). During the post-intervention period, however, study patients with a higher readiness to quit were more likely to be prescribed cessation medication compared to patients with a lower readiness to quit.

Quitline referrals
Study patients were more likely to have received a quitline referral during the post-intervention period (9% vs. 0%, p=.0001). Of these, 23 (64%) were successfully contacted by a Quitline counselor, and 13 (36%) completed one or more counseling sessions (median=3, IQR=1-3). Referred patients had higher contemplation ladder scores (8.6 vs. 6.7, p>.001) and greater self-reported likelihood of staying off cigarettes after discharge (3.6 vs. 2.8 on a 5-point scale) at the time of the baseline interview.

Despite the increase in performance of the 5A's, 3- and 6-month cessation rates did not change significantly during the post-intervention period (assuming that those lost to follow-up were still smoking). At 3-month follow-up, intervention period patients had similar cessation outcomes to those of pre-intervention patients: 7-day PPA 12.2 vs. 14.5% (adjusted OR=0.8, 95% CI=0.5-1.2), or any quit attempt (52% vs. 52%, adjusted OR=1.0, 95% CI=0.8- 1.3). At 6-month follow-up, the same pattern was evident: 7-day PPA 13.5 vs. 13.9% (adjusted OR=.91, 95% CI=0.6-1.4 and any quit attempt 51 vs. 46% (adjusted OR=1.2, 95% CI=0.9-1.6 respectively).

Nurses generally reported that the intervention provided them with tools to use with those veterans who were ready to quit smoking. Nurses discussed several barriers to guideline implementation, however. Veterans' willingness to quit was one concern; one nurse noted the intervention "just confirmed my belief that you can't make someone stop if they don't want to unless they're really, really ready to." Logistical issues, such as rapid patient turnover and uncertainty regarding the Quitline referral process, were additional barriers. Despite these barriers, nurses noted that the intervention provided a more structured framework for delivering cessation assistance, with one nurse explaining, ".probably in the past we weren't as forthcoming on, . if someone was a smoker, we didn't go through the whole thing of trying this and that."

This study demonstrates that enhanced academic detailing of inpatient nurses can lead to significant improvements in the delivery of recommended cessation counseling. The observed improvements in cessation counseling did not lead to improved quit rates during the post-intervention period, however. More effective strategies are needed for referring motivated inpatients to outpatient cessation counseling (other than fax referral to a non-VA quitline). Further improvements in cessation counseling may be realized by providing more hands-on training to nurses and physicians in motivational interviewing and interprofessional collaboration.

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Journal Articles

  1. Katz DA, Stewart K, Paez M, Holman J, Adams SL, Vander Weg MW, Battaglia CT, Joseph AM, Titler MG, Ono S. "Let Me Get You a Nicotine Patch": Nurses' Perceptions of Implementing Smoking Cessation Guidelines for Hospitalized Veterans. Military medicine. 2016 Apr 1; 181(4):373-82. [view]
  2. Katz D, Vander Weg M, Fu S, Prochazka A, Grant K, Buchanan L, Tinkelman D, Reisinger HS, Brooks J, Hillis SL, Joseph A, Titler M. A before-after implementation trial of smoking cessation guidelines in hospitalized veterans. Implementation science : IS. 2009 Sep 10; 4:58. [view]
  3. Kamath AS, Vaughan Sarrazin M, Vander Weg MW, Cai X, Cullen J, Katz DA. Hospital costs associated with smoking in veterans undergoing general surgery. Journal of the American College of Surgeons. 2012 Jun 1; 214(6):901-8.e1. [view]
  4. Katz DA, Holman JE, Johnson SR, Hillis SL, Adams SL, Fu SS, Grant KM, Buchanan LM, Prochazka A, Battaglia CT, Titler MG, Joseph AM, Weg MV. Implementing Best Evidence in Smoking Cessation Treatment for Hospitalized Veterans: Results from the VA-BEST Trial. Joint Commission Journal on Quality and Patient Safety. 2014 Nov 1; 40(11):493-1. [view]
  5. Vander Weg MW, Holman JE, Rahman H, Sarrazin MV, Hillis SL, Fu SS, Grant KM, Prochazka AV, Adams SL, Battaglia CT, Buchanan LM, Tinkelman D, Katz DA. Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial. Journal of substance abuse treatment. 2017 Jun 1; 77:79-88. [view]
  6. Katz DA, Holman J, Johnson S, Hillis SL, Ono S, Stewart K, Paez M, Fu S, Grant K, Buchanan L, Prochazka A, Battaglia C, Titler M, Vander Weg MW. Implementing smoking cessation guidelines for hospitalized veterans: effects on nurse attitudes and performance. Journal of general internal medicine. 2013 Nov 1; 28(11):1420-9. [view]
  7. Kuperman EF, Chapin J, Grant KM, Vander Weg MW, Katz DA. The Association between the Electronic Health Record and Patient-Reported Receipt of Tobacco Cessation Care in Hospitalized Veterans. Joint Commission Journal on Quality and Patient Safety. 2018 May 1; 44(5):304-306. [view]
Conference Presentations

  1. Katz DA, Vander Weg MW, Holman JE, Nugent A, Baker L, Gillette M, Ono SS, Reisinger HS, Johnson SR, Titler M. Attitudes of Emergency Clinicians Toward the Delivery of Smoking Cessation Counseling. Poster session presented at: Society for Medical Decision Making Annual Meeting; 2010 Oct 24; Toronto, Canada. [view]
  2. Katz DA, Fu S, Grant K, Prochazka A, Battaglia C, Johnson SR, Hillis SL, Titler M, Vander Weg MW, Buchannan L. Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans: Nurse Attitudes and Performance. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD. [view]
  3. Kamath AS, Vander Weg MW, Fu S, Grant K, Prochazka A, Katz DA. Nicotine Withdrawal and Smoking Status in Hospitalized Veterans. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ. [view]
  4. Katz DA, Stewart K, Paez MB, Holman JE, Adams SL, Vander Weg MW, Battaglia C, Joseph A, Titler M, Ono S. Nurses’ Perceptions in Implementing Smoking Cessation Guidelines for Hospitalized Veterans. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 12; Hollywood, FL. [view]
  5. Cirillo DJ, Li Y, Smolderson KG, Buchanan DM, Horwitz PA, Vander Weg MW, Faseru B, Jones PG, Spertus J, Katz DA. Outpatient Cardiac Rehabilitation and Smoking Cessation in Patients with Acute Myocardial Infarction. Poster session presented at: American Heart Association Annual Scientific Sessions; 2012 Nov 3; Los Angeles, CA. [view]
  6. Stewart K, Ono SS, Paez MB, Cunningham CL, Holman JE, Katz DA. Smoke Shack(les): Cultural Barriers to Smoking Cessation in VA Hospitals. Poster session presented at: American Anthropological Association Annual Meeting; 2013 Nov 21; Chicago, IL. [view]
  7. Kamath AS, Vaughan-Sarrazin MS, Vander Weg MW, Cullen J, Katz DA. Surgical Costs Associated with Smoking in Veterans Undergoing General Surgery. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Substance Use Disorders, Health Systems
DRE: Prevention, Treatment - Observational
Keywords: Management, Quality assurance, improvement, Smoking
MeSH Terms: none

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