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TRX 01-080 – HSR&D Study

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TRX 01-080
Facilitating Implementation of the PHS Smoking Cessation Guidelines - RESET
Melissa R. Partin PhD
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: October 2001 - September 2003

BACKGROUND/RATIONALE:
The adverse impact of tobacco use on disease prevalence and health care costs is well documented. Hence, finding effective ways to reduce tobacco dependence is an essential component of improving the outcomes, quality and efficiency of VHA care. The U.S. Public Health Service (PHS) Smoking Cessation Clinical Practice Guideline provides specific recommendations for treating tobacco dependence. Despite their strong evidence base, however, these recommendations have not been fully integrated into clinical practice within the VHA. Recent data suggest that logistical difficulties associated with identifying and linking smokers with appropriate treatments may explain why the PHS Smoking Cessation Guideline has not been more broadly implemented.

OBJECTIVE(S):
The primary objective of this study is to assess the effectiveness of an intervention for increasing the rate of tobacco dependence treatment in a population of smokers identified through the VA Pharmacy Benefits Management database. Secondary objectives of this study include (1) assessing the effect of the intervention on smoking cessation rates, and (2) developing options for overcoming potential barriers to broad implementation of the strategies.

METHODS:
The effectiveness of the intervention will be evaluated using a multi-center, randomized, controlled trial. Veterans receiving a prescription for transdermal nicotine, nicotine gum, or bupropion for smoking cessation in the past year at one of the participating VHA facilities (as determined from Pharmacy Benefits Management records) will be eligible for the study. A total of 1,900 eligible veterans selected from five test sites will be randomly assigned to one of two groups: (1) patient phone call and tailored, computerized prompt to providers (intervention), or (2) usual care (control). The primary outcome is the proportion of patients receiving pharmacological or other smoking cessation treatment in the six month follow-up period, as assessed from VA pharmacy and outpatient data files. All patients will be recruited to a brief phone interview six months post-intervention to gather secondary outcome measure data related to smoking status, quit history, and use of smoking cessation assistance.

FINDINGS/RESULTS:
The intervention phase of the study started in September 2002 and was completed in February 2003. 951 subjects were randomized to the intervention group and 949 to the control group. 62% of subjects in the intervention group who consented to be interviewed were still smoking and were not receiving pharmacological treatment for smoking cessation at the time of the intervention. 91% of these subjects were interested in quitting (65% within 30 days, 26% within six months). 91% of the subjects who wanted to quit within either 30 days or six months were interested in receiving pharmacological treatment for smoking cessation and 83% were interested in participating in an individual or group behavioral intervention.

For all patients in the intervention group that reported they were currently smoking, not currently receiving treatment for smoking cessation, and interested in quitting smoking within the next six months, a progress note was delivered via CPRS to their primary care provider (and in some locations, also a designated representative from the smoking cessation clinic). The progress note communicated the patient's smoking status and characteristics, interest in quitting, and treatment preferences. A total of 431 progress notes were added to patient's computerized charts. 84% of progress notes delivered were signed.

IMPACT:
The U.S. Public Health Service (PHS) Smoking Cessation Clinical Practice Guideline provides specific recommendations for reducing tobacco dependence. Despite their strong evidence base, however, these recommendations have not been fully integrated into clinical practice within the VHA. The proposed project will help identify efficient and effective methods for implementing the PHS Smoking Cessation Clinical Practice Guideline, and will facilitate the broad integration of these methods into VA primary care practice.

PUBLICATIONS:

Journal Articles

  1. Nelson DB, Partin MR, Fu SS, Joseph AM, An LC. Why assigning ongoing tobacco use is not necessarily a conservative approach to handling missing tobacco cessation outcomes. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2009 Jan 1; 11(1):77-83.
  2. Fu SS, Okuyemi KS, Partin MR, Ahluwalia JS, Nelson DB, Clothier BA, Joseph AM. Menthol cigarettes and smoking cessation during an aided quit attempt. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2008 Mar 1; 10(3):457-62.
  3. Baines AD, Partin MR, Davern M, Rockwood TH. Mixed-mode administration reduced bias and enhanced poststratification adjustments in a health behavior survey. Journal of clinical epidemiology. 2007 Dec 1; 60(12):1246-55.
  4. Partin MR, An LC, Nelson DB, Nugent S, Snyder A, Fu SS, Willenbring ML, Joseph AM. Randomized trial of an intervention to facilitate recycling for relapsed smokers. American journal of preventive medicine. 2006 Oct 1; 31(4):293-9.
  5. Fu SS, Partin MR, Snyder A, An LC, Nelson DB, Clothier B, Nugent S, Willenbring ML, Joseph AM. Promoting repeat tobacco dependence treatment: are relapsed smokers interested? The American journal of managed care. 2006 Apr 1; 12(4):235-43.
Conference Presentations

  1. Partin MR. Promoting repeat treatment among relapsed smokers: results from a randomized controlled trial. Paper presented at: VA HSR&D National Meeting; 2006 Feb 17; Arlington, VA.
  2. Fu SS, Partin MR, Snyder A, An L, Nelson DB, Nugent S, Willenbring ML, Joseph AM. Interest in Recycling Among Relapsed Smokers. Paper presented at: Minnesota Health Services Research Annual Conference; 2004 Jan 26; Minneapolis, MN.


DRA: Substance Abuse and Addiction, Health Systems
DRE: Treatment - Observational
Keywords: Clinical practice guidelines, Screening, Smoking
MeSH Terms: Pharmaceutical Services, Treatment, Smoking Cessation, Substance-Related Disorders, Abbreviated Injury Scale

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