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Does Guideline-Concordant Clinical Reorganization of Smoking Cessation Care Improve Patient Quit Rates?: Results of a Group Randomized Trial
Yano EM, Lanto AB, Lee ML, Rubenstein LV, Sherman SE. Does Guideline-Concordant Clinical Reorganization of Smoking Cessation Care Improve Patient Quit Rates?: Results of a Group Randomized Trial. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 2; Vancouver, Canada.
Background Adherence to smoking cessation guidelines requires practice changes at the patient, provider and system levels to achieve optimal quit rates. The objective of this study was to evaluate the effectiveness of an expert-designed, locally implemented clinical reorganization of smoking cessation care on quit rates. Methods An evidence-based quality improvement intervention comprising provision of physician and patient educational materials, local priority setting with leadership and providers, and local adaptation of expert-designed protocols was implemented in experimental VA primary care practices (n = 9). VA control sites (n = 9), matched on size and academic affiliation, received smoking cessation guideline copies. We randomly sampled, consented, screened and surveyed primary care patients at all 18 sites (n = 1,941 smokers) and used computer-assisted telephone interviewing to assess sociodemographics, health status, function, and smoking behavior, attitudes and treatment experience. Post-intervention 12-month follow-up interviews were completed using the same measures (n = 1,080). We used multiple imputation using hotdeck techniques and applied both enrollment and attrition weights to the patient-level data. We used weighted logistic regression to evaluate intervention effects, controlling for patient-level predictors of quit attempts and quit status (e.g., level of addiction, readiness-to-change, age, health). Results The percent of smokers who attempted to quit and reported 1+ days of intentional quitting increased significantly among both experimental and control groups patients from baseline to 12-months follow-up. Adjusting for patient sociodemographics, level of addiction and readiness-to-change, we found no intervention effect on quit attempts or smoking cessation and found marginally higher successes among participants at control sites (p < .05 quit attempts, p = .094 cessation). Higher addiction level (OR = 0.81, 95% CI 0.74-0.88) and readiness-to-change (OR = 2.52, 95% CI 1.97-3.21) were the only independent predictors of smoking cessation regardless of patient age, gender, race-ethnicity, marital status, education or intervention group (p < .0001). Conclusion Intensive primary care-based reorganization with locally-developed quality improvement plans supplemented by expert advice did not lead to more quit attempts or actual smoking cessation beyond changes already underway in all sites through VA performance measurement and leadership incentives for better tobacco counseling rates. Qualitative assessment of site-specific practice changes is needed to ascertain intervention features or other quality improvement actions that fostered more guideline-concordant care and promoted cessation.