Tobacco use is a serious health problem for veterans, as 19% of VHA patients currently use tobacco. Tobacco cessation quality improvement efforts by the Substance Use Disorders QUERI and the VA Public Health Strategic Healthcare Group could be evaluated using data in the VA electronic medical record. Responses to clinical reminders about tobacco use are saved in site-specific health factor datasets. In late 2010, these facility-level datasets were consolidated in the VA Corporate Data Warehouse. Entries are not standardized and their value for quality improvement efforts was uncertain.
This project had the following specific objectives:
1. Describe VA health factors data. Standardize health factor data and characterize information on tobacco use and cessation services by facility, by setting, and by provider type.
2. Evaluate completeness of follow-up. Identify cohorts of current tobacco users and recent quitters and the proportion with one year and two year follow-up data.
3. Identify quit and relapse rates. Determine rates of quitting among those identified as current tobacco users and rates of relapse among recent quitters.
4. Evaluate counseling and referral activities. Evaluate health factors data as a source of information on tobacco cessation services conducted by VHA.
Health factors data in the Corporate Data Warehouses for the three-year period ending September 30, 2011 (the 2009-2011 federal fiscal years) on tobacco use was extracted. The 40 characters of text of the field "Health Factor Type" was assigned a standardized interpretation. Records pertaining to tobacco use were assigned to mutually exclusive categories for tobacco use status: current user, former user quit within last year, former user quit one to seven years previously, former user quit more than seven years previously, or life-time non-user of tobacco. Additional categories were created for records that could not be assigned to one of these five categories. The number of unique individuals who had a tobacco status assessment was compared to the number of unique patients at each facility. A cohort of patients with a tobacco use assessment in the year ending September 30, 2009 was defined and followed to determine the proportion that had a follow-up assessment within one year and within two years. Tobacco use status at the follow-up assessment was determined.
Project activities and findings were reviewed by advisory group that includes the leader of VHA tobacco cessation programs, five leading researchers in tobacco cessation efforts, and tobacco cessation practitioners.
Over the three fiscal years 2009-2011, health factors data included tobacco use assessments of 5.0 million patients in 14.4 million encounters. Assessments occurred in in primary care clinics (70.7%), outpatient mental health clinics (9.4%), inpatient settings (6.1%), and other outpatient clinics (11.8%). Among 5.7 million users of VA care in fiscal year 2011, 4.0 million (70.3%) had tobacco use status assessed within an appropriate timeframe and recorded in the health factors dataset. Facility level rates of timely assessment recorded in these data source ranged from a low of 26.4% to a high of 90.6%.
During the three year period, 24.0% of patients reported their status as current user at all assessments, 25.4% were lifetime never users, and 26.7% were former users. The remainder reported a change in status during the three years.
Most persons identified as currently using tobacco had follow-up tobacco status assessments. Among 1.0 million persons determined to be a current user of tobacco in their first assessment recorded in fiscal year 2009, 62.5% had another assessment recorded in these data within 12 months, and 88.2% had another record within 24 months. More than 10% were no longer using tobacco according to the first follow-up assessment record.
Follow-up data was also available for most recent quitters. There were 73 thousand persons identified as a former user of tobacco who had quit in fiscal year 2009. It was determined that 56.5% were assessed again in 12 months, and 86.4% were assessed again within 24 months. More than one-third of these individuals had started using tobacco again at their follow-up assessment.
Few tobacco status assessments indicated the type of tobacco used. Health factors data on smoking cessation services were tabulated, but it was difficult to distinguish exactly what services were provided based on the health factors entry. Uncertainty about the completeness of cessation services entries was a further limitation.
Health factors data had longitudinal information on tobacco use status. A follow-up tobacco use assessment was recorded within 2 years for 88% of current users of tobacco and for 86% of recent quitters identified in 2009. These data represent a low cost way of evaluating quality improvement of smoking cessation services.
Health factors data included the tobacco use status of 4.0 million (70%) of users of VHA health services during 2011. These data will be useful for studies that require information on this important predictor of disease risk.
None at this time.
Substance Abuse and Addiction