Characteristics of VHA facility smoking cessation programs and practices

Mittman BS, Simon B, Sherman SE, Yano EM, Lanto AB, Lee ML, Arikian N, Joseph AM. Characteristics of VHA facility smoking cessation programs and practices. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC.

Related HSR&D Project(s)

• CPG 97-002 – Implementing Guidelines for Smoking Cessation: A Randomized Trial of Evidence-Based Quality Improvement

Objectives: VHA national performance monitoring policies provide strong incentives for VHA facilities to identify patients who smoke and to provide effective smoking cessation services. We surveyed 40 VHA facilities to assess their smoking cessation programs and practices and adherence to the AHCPR smoking cessation practice guideline. Methods: Two key-informant mailed questionnaires were fielded to 40 VHA facilities participating in two VA HSRandD-funded smoking cessation guideline implementation studies, including a national sample of 20 facilities and a regional (southwestern US) sample of 20 facilities. One questionnaire collected information from primary care managers regarding primary/ambulatory care-based smoking cessation practices, including smoking status assessment and primary care-based counseling, referral and treatment. The second questionnaire collected information from each facility's smoking cessation coordinator regarding specialized smoking cessation programs/clinics. Additional data on facility characteristics were obtained from the VHA Primary Care Practices Survey (1999). Questionnaire responses were used to create scales assessing intensity of primary/ambulatory care-based assessment, counseling, referral and pharmacologic treatment activities. Descriptive statistics and bivariate analyses were conducted to assess smoking cessation program characteristics and relationships with facility characteristics. Results: Completed surveys were received from all 40 sites. Smoking behavior assessment and treatment/referral practices varied widely across all 40 sites: over 90% of all sites reported that primary care providers (PCPs) and nurses assess patient smoking status at 'most' or 'all/almost all' outpatient visits; fewer sites reported use of other assessment methods as well, including clerk or pharmacist assessment or written questionnaire completed at the time of visit. Assessment techniques are used in widely varying combinations, with PCP and nurse assessments used in an apparently redundant manner, rather than as substitutes. 70% of the 40 facilities appear to be in compliance with AHCPR guideline recommendations specifying identification of smoking status at all visits, while 95% follow recommended use of explicit assessment approaches as part of a pre-visit vital sign process or involving reminders. Fewer than half of the facilities follow guideline recommendations to intervene with every patient who smokes. Assessment activity, measured by the assessment intensity scale, was unrelated to referral and pharmacologic treatment intensity but moderately related to counseling (r = .45; p = .002). Counseling and pharmacologic treatment (comprising two approaches to primary/ambulatory care-based smoking cessation) were also moderately correlated (r = .42; p = .007) and, therefore, apparently used as complementary techniques. Referral to a specialized smoking cessation program, which can serve as a substitute for primary care-based counseling and treatment, was not significantly correlated with counseling or treatment intensity (p > .6). Conclusions: VHA facilities use a broad range of methods for achieving VHA smoking cessation performance goals. Overlapping methods may represent beneficial reinforcement or may represent opportunities to better coordinate practices, involving a more carefully coordinated package of techniques that meet smoking behavior assessment, referral and treatment goals efficiently and effectively. Impact: These results provide research, policy, and management relevant insights into current smoking cessation related practices. They help identify areas where further information and policy improvement are needed to increase guideline adherence and efficient use of clinical resources.