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Unintended consequences of evidence-based QI: Smoking cessation clinic referral doesn't improve Quits

Yano EM, Rubenstein LV, Chernof BA, Mittman BS, Lanto AB, Sherman SE. Unintended consequences of evidence-based QI: Smoking cessation clinic referral doesn't improve Quits. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.


Objectives:We evaluated the impact of locally-tailored smoking cessation guideline implementation on quit attempts and smoking cessation. Methods:In a prospective, multi-center, group-randomized trial among 18 VA facilities, matched on size and academic affiliation, smokers (n = 1,941) were identified through random sampling and screening of all primary care patients with 3 or more visits in the previous 12 months, enrolled, and interviewed at baseline and 12-months follow-up (n = 1,080). Using an evidence-based quality improvement (EBQI) approach to local evidence review, priority setting and tailoring, intervention sites were provided with guideline-based physician and patient educational materials and helped to local quality improvement plans with iterative expert consultation. We evaluated intervention impact as self-reported quit attempts and smoking cessation rates at 12-months, weighted for enrollment and attrition, and controlling for patient sociodemographics, health status, smoking behavior, nicotine dependence, and readiness-to-change.Results:Intervention practices uniformly chose strategies focused on smoking cessation clinic referral. Adjusting for patient-level predictors, quit attempts and cessation increased significantly in all practices. Predictors of unsuccessful quit attempts included a history of smoking cessation clinic attendance, history of nicotine patch use, lower nicotine dependence, and reliance on care outside of primary care. Nonwhite smokers were more likely to attempt to quit but no more successful than whites, when adjusting for patient and practice factors. Patients who quit were more likely to see primary care providers for their usual care (OR = 2.68, 95%CI 1.41-5.68) and less likely to be everyday smokers (OR = 0.47, 95%CI 0.28-0.79). Implications:Local tailoring of evidence-based quality improvement strategies led to physician adoption of smoking cessation clinic referral as the standard of care in primary care practices, which, while substantiated by the published literature on its efficacy, fails to consider the impact of the flow of patients to a scarce resource and patients' preferences. Impacts:This study reveals an important paradox in efforts to translate evidence into practice, specifically in aligning the evidence (in this case, referral to smoking cessation clinics) to the goal (improvements in practice-level smoking cessation behavior). Quality improvement interventions must more explicitly lay out the tradeoffs associated with different types of evidence, and help managers and providers take contextual factors into account.

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