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Translating preoperative smoking cessation interventions into routine clinical care of veterans, provider beliefs

Vick CC, Graham LA, Henderson WG, Houston TK, Hawn MT. Translating preoperative smoking cessation interventions into routine clinical care of veterans, provider beliefs. Translational behavioral medicine. 2011 Nov 24; 1(doi: 10.1007/s13142-001-0096-1):604-608.

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Smoking among veterans undergoing surgery is estimated to be 36%. Smoking has been linked to postoperative surgical complications including ischemia and cardiac arrhythmias, pneumonia, deep venous thrombosis, pulmonary embolism, and surgical site infection. Preoperative smoking cessation interventions, in which smokers quit at least 6weeks prior to surgery, have been shown to be effective both in smoking cessation and reduction of postoperative complications; however, little is known about physician beliefs regarding the optimal location and the responsible provider for intervention, or whether surgery should be postponed or delayed based on smoking status. Within the routine coordination from medical to surgical care, how should cessation interventions best be implemented? To better inform the translation of preoperative best practices for smoking cessation into clinical care in VA, a survey regarding preoperative smoking cessation beliefs and practices was administered to primary care physicians, surgeons, and anesthesia providers. Chi square tests were used to examine differences in proportions by provider type. Most providers agreed that the primary care clinic is the best location for intervention, with preoperative and surgical clinics ranked by few as the optimal location (13% and 11%, respectively); most respondents (82%) reported that they would refuse or delay surgery in some cases based on smoking status. There were no differences in either beliefs on location or delay based on provider type. Primary care providers were most likely to advise (86.7%) and assess (80.0%) while anesthesia providers were least likely (59.1% and 22.7%, respectively). Taking time to counsel and the belief that dedicated resources would improve quit rates were associated with advising patients to quit smoking, while being uncomfortable with counseling, the belief that acute health takes precedence and the belief that there is not always time to counsel were identified as barriers to assessing patients for smoking cessation intervention. Primary care providers were more optimistic (100%) that patients would quit if counseled, more often (73.3%) reported having time to counsel, and were less likely to report that acute health takes precedence. Most providers believe that smoking cessation would reduce postoperative complications, with the ideal location for the intervention being the primary care clinic, and that some surgical cases should be delayed for this intervention. 8]. Preoperative smoking cessation interventions, when patients quit at least 6 weeks prior to surgery, have been shown to be effective at increasing the likelihood that smokers will quit as well as reducing postoperative outcomes [8-13]. Implementation of smoking cessation interventions in the preoperative period is challenging. Little is known about the optimal location for preoperative smoking cessation, especially in regard to physician knowledge, attitudes, and beliefs about smoking cessation interventions across specialties. In our clinical setting, Veterans' Affairs hospitals, implementation of consistent preoperative cessation intervention might require considerable re-engineering of preoperative care. Within the routine coordination from medical to surgical care, how should cessation interventions best be implemented? In order to better examine the best location and specialty for implementation of preoperative smoking cessation interventions in VA, more information on provider adherence to the recommended "5 A's" (ask, advise, assess, assist, and arrange) guidelines, as well as specific information on barriers and facilitators is needed. We examined healthcare provider beliefs about the optimal location for preoperative smoking cessation intervention, knowledge, attitudes, and beliefs on delay and refusal of elective surgery based on smoking status, aswell as practice patterns in regard to smoking cessation intervention.

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