People living with HIV/AIDS smoke at nearly three times the rate of the general population. These extraordinary smoking rates are associated with greater AIDS related morbidity, greater non-AIDS related morbidity, and greater mortality.The VHA Handbook on Uniform Mental Health Services (UMHS) specifically mandates that smoking cessation counseling and evidenced based pharmacotherapy be provided for all adult patients using tobacco products who wish to quit smoking. Although the majority of people living with HIV/AIDS are interested in receiving smoking cessation treatment, smoking cessation interventions may not be routinely offered in the HIV treatment setting. Recognizing these challenges, the VHA office of HIV, Hepatitis, and Public Health Pathogens Programs and the Tobacco & Health: Policy and Program developed and recently distributed the HIV Provider Smoking Cessation Handbook and the accompanying patient workbook entitled: My Smoking Cessation Workbook: A Resource for Patients to VA HIV clinics. Whether or not these materials have reached their intended audience or altered perceptions of utilizing tobacco cessation interventions in the HIV treatment setting or have successfully led to implementation efforts on the facility level is not known. Clearly, a critical opportunity exists to evaluate whether these materials have had an impact or are even known by providers. Moreover, there is a need to evaluate, more broadly speaking, the extent to which-and what types of-smoking cessation therapies are offered to HIV/AIDS patients. We contend that addressing these topics in a mixed-methods evaluation is achievable within the framework of a rapid response project.
Responding to the HIV/Hepatitis C QUERI's major goal to provide Better Chronic Disease Management for people living with HIV/AIDS as well as the SUD QUERI's major goal of addressing substance use as a complicating factor in the treatment of HIV, the goal of this proposal is to use an explanatory mixed-method approach that is informed by the revised PARIHS framework to evaluate clinician-, facility-, and system-level barriers and facilitators associated with implementation of smoking cessation treatment within the HIV treatment setting in VA. This goal is consistent with the Annotated Six-Step QUERI Process Model's steps 3A-B which specifically recommends "measuring quality, outcome and performance gaps as well as to identify barriers and facilitators of improvement."
The goal of this project was to use an explanatory mixed-method approach that is informed by the revised PARIHS framework to evaluate clinician-, facility-, and system-level barriers and facilitators associated with implementation of smoking cessation treatment within the HIV treatment setting.
VA Clinicians from across the country completed the ORCA (Organizational Readiness to Change Assessment) survey, a demographic questionnaire, and a semi-structured interview. The ORCA assesses organizational readiness to adopt evidence based interventions and organizational capacity to successfully implement tobacco cessation interventions. The ORCA is based on the PARIHS framework and utilizes a 5-point Likert scale rating system. It has 3 scales that correspond to the key elements of the PARIHS model: Context (alpha=0.74), Evidence (alpha=0.85), and Facilitation (alpha=0.9).The demographic questionnaire included standardized items regarding age, gender, education, length of employment in the VA, and whether participants smoke. The in-depth interview was used to elicit from clinicians their own perceptions of, and, if relevant, their experiences with, smoking cessation within the context of HIV treatment in VA. Questions were asked about participants' perceptions of the barriers and facilitators-both present and anticipated in the future-to implementing smoking cessation treatments among veterans receiving HIV care, any personal experiences of offering smoking cessation care to HIV infected veterans, any observations of smoking cessation initiatives conducted by other clinicians, and, among others, how the shifting structural and organizational landscape of VA healthcare (at the facility and national levels) might facilitate or impede smoking cessation efforts including the receipt of the HIV Provider Smoking Cessation Handbook.
Study Sample Characteristics
Nineteen clinicians working at 8 different facilities across the VA participated in the study (Range: 1 clinician-3 clinicians per facility). About half of the participants (52.6%), were from facilities representing the Northeast and Mid-Atlantic region of continental United States while the other half (48.4%) were from facilities representing the South and South West region of the continental United States. The vast majority of clinicians were physicians (73.7%) who worked at the VA for an average of 12 years. Most clinicians self-identified as being white (78.9%), non-Hispanic (89.5%), men (52.6%) who were former or never smokers (100%).
Smoking Cessation Services Available at Each Site
Based on qualitative interviews, participants reported considerable variability in terms of the smoking cessation (SC) interventions they (or their clinic) offer. Most clinicians reported using the clinical reminder about smoking status in the electronic medical record as the jumping off point for further smoking cessation discussions. However, some noted that the reminders were unhelpful or ignored. Some clinicians reported having a facility level smoking cessation group or counselor to refer patients. From a pharmacological perspective, nicotine replacement therapy was frequently mentioned as being readily available and easy to prescribe. Some clinicians reported reluctance to prescribe varenacline or bupropion due to comorbid mental health problems in the patient population. Longer-term employees tended to have a better handle on what smoking cessation services were offered or available at their clinic.
With respect to the ORCA's Evidence Scale, on average, participants reported agreeing to strongly agreeing (4.5 (0.4)) that smoking cessation interventions will improve health outcomes for patients with HIV who smoke; they also reported agreeing to strongly agreeing (4.2 (0.4)) that evidence supports the implementation of smoking cessation interventions within the HIV clinical setting. In accord with the ORCA findings, clinicians reported in interviews that smoking cessation (SC) interventions were extremely important and potentially beneficial to their patients that smoke given the evidence that smoking is associated with high rates of morbidity and mortality among people living with HIV who smoke. Clinicians noted that their own lack of SC education, knowledge, and skills were a major barrier to implementing SC efforts.
With respect to the ORCA's Context Scale, on average participants reported neither agreeing nor disagreeing (3.8 (0.6)) that the VA supports the implementation of smoking cessation interventions within the HIV clinical setting. Additional concern was noted regarding having enough resources in terms of staff, training, space and funding to implement smoking cessation interventions (ORCA score: 3.1(0.9)). These findings were supported by the qualitative interviews. Most clinicians reported that lack of time, a lack of dedicated space and funding to commit to SC efforts were major barriers to implementation efforts. They also noted that a lack of clear and consistent communication between specialty and primary care clinicians about SC efforts prevents care coordination. In addition, a lack of on-site integrated SC behavioral treatment made it difficult for clinicians to gauge the success or failure of SC among patients.
With respect to the ORCA's Facilitation Scale, on average participants reported neither agreeing nor disagreeing to agreeing (3.8 (0.4)) that there was adequate facilitation to implement smoking cessation interventions within the HIV clinical setting. It is important to note that several participants chose not answer questions from the ORCA about Facilitation as they did not believe it applied to their site. The qualitative interviews added to the findings from the ORCA. The vast majority of clinicians interviewed had neither used nor heard of the VA Quitlines, nor had they received or used the HIV Provider Smoking Cessation Handbook. None of the clinicians interviewed had on-site facilitation for smoking cessation counseling. Clinicians largely agreed that an on-site SC champion would be effective. Such a person would ameliorate many of the barriers to SC.
Overall, VA Clinicians in this study identified that the lack of education, time, dedicated space, funding to commit to SC, and clear and consistent communication between clinicians, all as being major barriers to implementing smoking cessation interventions. VA clinicians largely agreed that that an on-site Smoking Cessation champion would be effective in overcoming these barriers. We believe that these findings may inform and guide the VA on ways to improve delivery of smoking cessation treatment in the HIV maintenance setting.
None at this time.