Nicotine dependence is three to four times more common among individuals with a substance use disorder (SUD) than among individuals without an SUD. Up to half of long-term smokers will die from smoking-related illness, making tobacco dependence (TD) the most lethal form of addiction. VHA policy and VA/DoD clinical practice guidelines specify provision of tobacco dependence treatment for all tobacco dependent Veterans in SUD and other mental health treatment programs. Despite extensive evidence and clear guideline recommendations, however, SUD providers have historically failed to consider tobacco dependence a primary focus of treatment. Seventy-nine percent of patients in substance abuse residential rehabilitation treatment programs and domiciliaries (SARRTPs) are identified tobacco users. Yet tobacco treatment implementation within SARRTPs has been low and variable, i.e., only 10% of tobacco-using patients receive both documented tobacco treatment and an ICD-9 tobacco dependence diagnosis, and facility level pharmacotherapy receipt among these patients ranges from 0% to 100%. The goal of this project is to implement and evaluate a multifaceted facilitation intervention program to increase tobacco treatment implementation in SARRTP programs. The project builds on previous collaborations between SUD QUERI and the Office of Clinical Public Health Tobacco & Health: Policy and Programs, the Office of Mental Health Operations, and VHA Mental Health Services.
The primary aim of this project is to increase implementation of TD pharmacotherapy for tobacco-dependent patients in three SARRTPs using a multifaceted facilitation model. Secondary aims include: 1) evaluating the impact of the implementation intervention on tobacco use status, 2) evaluating the impact of the implementation intervention on continuity of care for tobacco-dependent patients, and 3) tracking implementation program costs to conduct economic analyses.
In three SARRTPs, we will refine and test a facilitation intervention with documented success in other VHA mental health implementation efforts. The project will be conducted in two phases. First, we will incorporate staff surveys, interviews, and stakeholder engagement meetings in a developmental formative evaluation to tailor and refine the intervention. Second, we will conduct a summative evaluation of the implementation program using an interrupted time series design to evaluate implementation outcomes.
Pre-implementation (baseline) results for all three sites revealed many similarities including: high knowledge of tobacco treatment and health effects but lower confidence in the efficacy of tobacco treatment and providers' ability to deliver treatment. All sites were also less likely to use any tobacco treatment practices despite knowing what to do. Sites 1 and 2 had less confidence in the efficacy of tobacco treatment and the abilities of providers to provide treatment than Site 3. Also, Site 1 and 2 were less likely to use any tobacco treatment practices compared to Site 3. Contextual factors were also extremely variable at each site. Site 1 had extremely limited leadership support and resources, while Site 2 had involved program leaders but with significant staff turnover slowing adoption of tobacco practices. Site 3 has the support of program leaders, but structural facility organization and staff attitudes towards tobacco treatment have slowed adoption of tobacco practices.
Sites 1 and 2 have completed their intervention periods as of April and July 2016. Preliminary post-implementation results from the national tobacco dashboard revealed appreciable gains in evidence-based tobacco practices at Site 1, including an increase in diagnosis, pharmacotherapy, and counseling rates. Preliminary post-implementation results from telephone interviews revealed that Site 1 had extensive penetration of tobacco practices to a variety of staff roles and an overall culture shift in the way staff addressed tobacco. These results were mirrored in the preliminary survey results, where Site 1 showed significant improvement across all five survey scales (beliefs, knowledge, efficacy, practices, and barriers) with the most dramatic increase in the practices scale.
Preliminary post-implementation results from the national tobacco dashboard revealed modest gains in evidence-based tobacco practices at Site 2, including small increases in diagnosis and pharmacotherapy, with a large increase in counseling rates. The increase in counseling was likely due to a new requirement for Veteran attendance in the tobacco counseling class. Despite these gains, Site 2 interview results revealed that there was far less penetration to other program staff beyond the champion staff team, and fewer staff had made changes to their roles in order to accommodate tobacco practices. Site 2 survey results showed modest increases in four of the survey scales (beliefs, knowledge, efficacy, and barriers); however, for the practices scale, Site 2 scores decreased. This decrease in the survey practices scale despite increases seen on the tobacco dashboard may reflect how the dashboard measures were influenced by only a few staff making changes to their clinical practice, while broader practice changes across a wider staff audience was lacking.
These findings reflect preliminary results for secondary measures; we will continue to analyze survey and interview post-implementation data for Sites 1 and 2 in more detail as we wait for post-implementation data for Site 3. In addition, six-month post-implementation data for all three sites will be collected and analyzed on a staggered schedule starting in FY2017. The primary outcome measure, which is the proportion of tobacco-using patients receiving pharmacotherapy during their residential stay, will be analyzed after all sites have completed their intervention periods.
SUD residential treatment program staff from Sites 1 and 2 have increased their knowledge of evidence-based tobacco treatment practices through the tobacco clinical trainings and the consultations with External Facilitators over the course of the intervention period. The tobacco treatment dashboard data indicate a corresponding increase in these tobacco treatment practices. As Site 3's intervention period will not end until October 2016, the impact at this site is yet to be determined. We also plan to continue monitoring tobacco practices at all three sites for an extended time period after the end of each intervention period to understand whether the changes in tobacco treatment practices are sustainable beyond the lifetime of the project.
The tobacco treatment dashboard which was developed to provide audit and feedback to each site during the project will ultimately be disseminated as a VA operations resource in collaboration with the Deputy Director of Mental Health Residential Rehabilitation Services in Mental Health Services. As part of the dashboard development process, feedback from each project site was used to improve the accuracy of data capture so that other VA facilities can utilize the dashboard data to make improvements to tobacco treatment in their MHRRTP programs. National rollout of the tobacco dashboard will likely occur in Quarter 1 or 2 of FY17.
- Patel YA, Gifford EJ, Glass LM, McNeil R, Turner MJ, Han B, Provenzale D, Choi SS, Moylan CA, Hunt CM. Risk factors for biopsy-proven advanced non-alcoholic fatty liver disease in the Veterans Health Administration. Alimentary pharmacology & therapeutics. 2018 Jan 1; 47(2):268-278.
- Gifford E, Tavakoli S, Wisdom J, Hamlett-Berry K. Implementation of smoking cessation treatment in VHA substance use disorder residential treatment programs. Psychiatric services (Washington, D.C.). 2015 Mar 1; 66(3):295-302.
- Patel YA, Gifford EJ, Glass LM, Turner MJ, Han B, Moylan CA, Choi S, Suzuki A, Provenzale D, Hunt CM. Identifying Nonalcoholic Fatty Liver Disease Advanced Fibrosis in the Veterans Health Administration. Digestive diseases and sciences. 2018 Sep 1; 63(9):2259-2266.