Provider feedback to improve 5A's tobacco cessation in primary care: a cluster randomized clinical trial. Results of a randomized controlled trial of intervention to implement smoking guidelines in Veterans Affairs medical centers: increased use of medications without cessation benefit. An electronic health record-based intervention to improve tobacco treatment in primary care: a cluster-randomized controlled trial. A demonstration project for using the electronic health record to identify and treat tobacco users. A computerized aid to support smoking cessation treatment for hospital patients. Tools to improve documentation of smoking status. Continuous quality improvement and electronic medical records. Do faxed quitline referrals add value to dental office-based tobacco-use cessation interventions? Effects of physician counseling on the smoking behavior of asbestos-exposed workers. Care coordination to increase referrals to smoking cessation telephone counseling: a demonstration project. The feasibility of paper-based Tracking Codes and electronic medical record systems to monitor tobacco-use assessment and intervention in an Individual Practice Association (IPA) Model health maintenance organization (HMO). [The effect of smoking cessation counseling at health checkup].
The electronic health record (EHR) may be an effective tool to help clinicians address tobacco use more consistently. To evaluate the impact of EHR-generated practice feedback on rates of referral to a state-level tobacco quitline, we conducted a cluster randomized clinical trial (feedback versus no feedback) within 19 primary care clinics in Oregon. Intervention clinics received provider-specific monthly feedback reports generated from EHR data. The reports rated provider performance in asking, advising, assessing, and assisting with tobacco cessation compared with a clinic average and an achievable benchmark of care. During 12 months of follow-up, EHR-documented rates of advising, assessing, and assisting were significantly improved in the intervention clinics compared with the control clinics (p<.001). A higher case-mix index and presence of a clinic champion were associated with higher rates of referral to a state-level quitline. EHR-generated provider feedback improved documentation of assistance with tobacco cessation. Connecting physician offices to a state-level quitline was feasible and well accepted. The AHRQ Clinical Practice Guideline for Treating Tobacco Use and Dependence recommends screening and treatment of all tobacco users. Effective methods to implement recommendations are needed because simple guideline dissemination does not necessarily result in changes in practice.
                The Guideline Implementation for Tobacco (GIFT) study tested an organizational intervention to improve Guideline implementation.
                GIFT randomized 20 Veterans Affairs medical centers to intervention or control conditions. We trained prime movers at each site to improve identification of smoking status, promote primary care interventions and increase availability of smoking cessation medications. Sites and patients were evaluated before and after intervention.
                GIFT included 20 Veterans Affairs medical centers and 5678 subjects.
                Data regarding smoking status, delivery of treatment, medication use, and smoking cessation were collected from participant surveys, medical record review, survey of site leaders, and Pharmacy Benefits Management.
                The intervention did not increase participant report of being asked about smoking status or receipt of counseling. It did increase the rate of identification of smoking status in the medical record (P = 0.0001) but did not increase the rate of counseling to stop smoking. Site level data showed no increase in the number of patients receiving smoking cessation medications or dollars spent on medications. Individual smoker data showed a significant increase in the use of medications for smoking cessation in intervention sites (odds ratio = 6.89, P < 0.0001); however, only a small minority of smokers received medication even after the intervention. There was no difference in smoking cessation rates between participants at the intervention and treatment sites.
                We conclude that improvements in smoking cessation rates are likely to require more intensive intervention in this population. To improve the documentation and treatment of tobacco use in primary care, we developed and implemented a 3-part electronic health record enhancement: (1)smoking status icons, (2) tobacco treatment reminders, and (3) a Tobacco Smart Form that facilitated the ordering of medication and fax and e-mail counseling referrals.
                We performed a cluster-randomized controlled trial of the enhancement in 26 primary care practices between December 19, 2006, and September 30, 2007. The primary outcome was the proportion of documented smokers who made contact with a smoking cessation counselor. Secondary outcomes included coded smoking status documentation and medication prescribing.
                During the 9-month study period, 132 630 patients made 315 962 visits to study practices. Coded documentation of smoking status increased from 37% of patients to 54% (+17%) in intervention practices and from 35% of patients to 46% (+11%) in control practices (P < .001 for the difference in differences). Among the 9589 patients who were documented smokers at the start of the study, more patients in the intervention practices were recorded as nonsmokers by the end of the study (5.3% vs 1.9% in control practices; P < .001). Among 12 207 documented smokers, more patients in the intervention practices made contact with a cessation counselor (3.9% vs 0.3% in control practices; P < .001). Smokers in the intervention practices were no more likely to be prescribed smoking cessation medication (2% vs 2% in control practices; P = .40).
                This electronic health record-based intervention improved smoking status documentation and increased counseling assistance to smokers but not the prescription of cessation medication. While the majority of smokers visit a primary care physician each year, only a small proportion of them receive evidence-based tobacco dependence treatment. The electronic health record (EHR) provides an opportunity to prompt clinicians to deliver tobacco dependence treatment in primary care.
                Over 1 year, Dean Health Systems worked with the University of Wisconsin School of Medicine and Public Health to modify the existing Dean EHR system (Epic Systems Corp, Verona, Wisconsin) to improve identification and treatment of adult smokers visiting primary care clinics. Modifications included evidence-based prompts that helped guide medical assistants to identify smokers and clinicians to deliver a brief tobacco cessation intervention (medication and Wisconsin Tobacco Quit Line referral). Eighteen primary care clinics provided data 1 year before and 1 year after implementing the EHR modifications.
                A higher percentage of adult patients had their tobacco use status identified after EHR modification compared to pre-implementation (71.6% versus 78.4%, P < .001). During the post-implementation year, 6.3% of adult smokers were prescribed tobacco cessation medication, 2.5% of adult smokers had documentation of counseling, and 1.5% of adult smokers had counseling billed (pre-implementation data not available).
                This demonstration project showed that a large health care system can increase the delivery of tobacco dependence treatment interventions (increased identification of smokers and relatively high rates of delivering specific tobacco dependence clinical interventions) building on an existing EHR platform. The project demonstrated that brief, evidence-based tobacco dependence interventions can be incorporated into primary care, especially when the EHR is used to improve clinic workflow. Hospital-based interventions promote smoking cessation after discharge. Strategies to deliver these interventions are needed, especially now that providing smoking cessation advice or treatment, or both, to inpatient smokers is a publicly reported quality-of-care measure for US hospitals.
                To assess the effect of adding a tobacco order set to an existing computerized order-entry system used to admit Medicine patients to 1 hospital.
                Pre-post study.
                Proportion of admitted patients who had smoking status identified, a smoking counselor consulted, or nicotine replacement therapy (NRT) ordered during 4 months before and after the change. In 4 months after implementation, the order set was used with 76% of Medicine admissions, and a known smoking status was recorded for 81% of these patients. The intervention increased the proportion of admitted patients who were referred for smoking counseling (0.8 to 2.1%) and had NRT ordered (1.6 to 2.5%) (p < .0001 for both). Concomitantly, the hospital's performance on the smoking cessation quality measure improved.
                Adding a brief tobacco order set to an existing computerized order-entry system increased a hospital's provision of evidence-based tobacco treatment and helped to improve its performance on a publicly reported quality measure. It provides a model for US hospitals seeking to improve their quality of care for inpatients. Despite the deleterious effects of smoking on the nation's health and evidence that smoking cessation advice by family practice physicians is cost-effective, self-sustaining office systems to identify smokers in primary care clinics have been difficult to establish. We worked on a continuous quality improvement project group, aided by an electronic medical record, to design a system to document and periodically update smoking status in a consistent place in the medical record.
                Using the continuous quality improvement plan-do-study-act cycle, a 7-member group worked with nursing staff to define roles, routines and responsibilities for medical assistants to screen for and document 1 of 4 categories of smoking status in the major problem list of the electronic medical record for at least 80% of patient appointments. Screening rate was tracked monthly by means of the electronic medical record and feedback was given to staff.
                The screening rate rose from 18.4% to 80.3% within 2 weeks after the system was implemented and was maintained for 19 months. An additional benefit was an increased rate of smoking cessation counseling documented by providers, from a baseline rate of 17.1% to 48.3%.
                A continuous quality improvement group process aided by an electronic medical record is useful to develop a self-sustaining office system to screen, document, and periodically update smoking status in a consistent place in the medical record. Although screening for and documenting smoking status are only the first step toward helping patients stop smoking, it is an important one. The Ask, Advise, Refer (AAR) model of intervening with patients who use tobacco promotes a brief office-based intervention plus referral to a tobacco quitline. However, there is little evidence that this model is effective. The primary aim of this study was to evaluate the effects on patients' tobacco use of two levels of a dental office-based intervention compared with usual care.
                The authors randomly assigned 68 private dental clinics to one of three conditions: 5 As (Ask, Advise, Assess, Assist, Arrange); 3 As (AAR model); or usual care, and they enrolled 2,160 participants.
                At the 12-month assessment, compared with those in usual care, participants in the two intervention conditions combined were more likely to report cessation of tobacco use, as measured by nine-month prolonged abstinence (3 percent versus 2 percent; F(1,66) = 3.97, P < .10) and 12-month point prevalence (12 percent versus 8 percent; F(1,66) = 7.32, P < .01). There were no significant differences between participants in the clinics using the 5 As and 3 As strategies.
                The results of this study are inconclusive as to whether referrals to a quitline add value to brief dental office-based interventions. Patients receiving telephone counseling quit tobacco use at higher rates, but only a small percentage of those proactively referred actually received counseling.
                The results confirm those of previous research: that training dental practitioners to provide brief tobacco-use cessation advice and assistance results in a change in their behavior, and that these practitioners are effective in helping their patients to quit using tobacco. Physician antismoking advice has been shown to increase smoking cessation, particularly among patients who have medical problems or perceive themselves to be at risk. The present study tested three hypotheses: (a) providing 3 to 5 min of behavioral counseling regarding a cessation strategy would be more effective than simply warning the smoker to quit smoking; (b) smokers with abnormal pulmonary function would be more likely to comply with medical advice than would smokers with normal pulmonary function; and (c) that smokers with abnormal pulmonary function who receive behavioral counseling would be the group most likely to achieve prolonged abstinence. Asbestos-exposed smoking men undergoing screening in a mandated program for naval shipyard workers were categorized as having normal or abnormal pulmonary status on the basis of chest X ray and pulmonary function tests (PFT). They were then randomly assigned within PFT categories to receive either a simple warning or 3 to 5 min of behavioral cessation counseling from the physician who gave them the results of their pulmonary tests. Subjects' smoking status was evaluated at 3- and 11-month intervals following the physician intervention. Smokers who received behavioral counseling were more likely to quit and remain abstinent over the 11-month period (8.4% abstinent) than were smokers given a minimal warning (3.6% abstinent). Prolonged abstinence rates among abnormal PFT subjects (3.7%) did not differ from those of normals (5.9%). The group with normal PFT who received behavioral counseling achieved the highest level of abstinence (9.5%). Maintaining adequate physician compliance with the counseling protocol proved difficult; implications of this for future efforts are discussed. To test the effectiveness of a care coordination program for telephone counseling in raising referral and treatment rates for smoking cessation.
                A demonstration project implementing a smoking cessation care coordination program offering telephone counseling and medication management to patients referred from primary care.
                The study was performed at 18 Veterans Health Administration (VA) sites in California. Participants were VA patients receiving primary care. We randomly allocated 10 of 18 sites to receive the Telephone Care Coordination Program, which included simple 2-click referral, proactive care coordination, medication management, and 5 follow-up telephone calls. Each patient received a 30- to 45-minute counseling session from the California Smokers' Helpline. Patients at control sites received usual care.
                During 10 months, we received 2965 referrals. We were unable to reach 1156 patients (39%), despite at least 3 attempts. We excluded 73 patients (3%), and 391 patients (13%) were not interested. We connected the remaining 1345 patients (45%) to the Helpline. At 6-month followup, 335 patients (11% of all referrals and 25% of participating patients) were abstinent. Providers at intervention sites reported referring many more patients to telephone counseling than providers at control sites (15.6 vs 0.7 in the prior month).
                The program generated a large number of referrals; almost half of the patients referred were connected with the Helpline. Long-term abstinence was excellent. These results suggest that managed care organizations may be able to improve tobacco control by implementing a similar system of care coordination. Despite evidence of its effectiveness, tobacco cessation is not systematically addressed in routine healthcare settings. Its measurement is part of the problem. A pilot study was designed to develop and implement two different tobacco tracking systems in two independent primary care offices that participated in an IPA Model health maintenance organization in Portland, Oregon. The first clinic, which utilized a paper-based charting system, implemented CPT-like tracking codes to measure and report tobacco-cessation activities, which were eventually included in the managed-care organization's (MCO) claims database. The second clinic implemented an electronic tracking system based on its computerized electronic medical record (EMR) charting system. This paper describes the pilot study, including the processes involved in building provider acceptance for the new tracking systems in these two clinics, the barriers and successes encountered during implementation, and the resources expended by the clinics and by the MCO during the pilot. The findings from the 3-month implementation period were that documentation of tobacco-use status remained stable at 42-45% in the paper-based clinic and increased from 79% to 88% in the EMR clinic. This pilot study demonstrated that Tracking Codes are a feasible preventive-care tracking system in paper-based medical offices. However, high levels of effort and support are needed, and a critical mass of insurers and health plans would need to adopt Tracking Codes before widespread use could be expected. Results of the EMR-based tracking system are also reviewed and discussed. Smoking cessation counseling is an important element of tobacco control in the workplace, but it is not easy to persuade workers to stop smoking. We performed a controlled intervention trial to evaluate the effectiveness of a new cessation program developed by Nakamura et al., which consisted of one brief individual counseling session and 4 follow-up telephone calls. Two hundred and twenty-eight smokers who visited our center for an annual health checkup were randomly divided into two group: 117 were assigned to the intervention group, and 111 were controls. Smoking status questionnaires were administered to assess the smoking habit of each subject and to evaluate their stages of change toward smoking cessation before the counseling session. Stage-matched cessation counseling was then provided to the intervention group by nurses who had completed training courses for this program. During the counseling session, carbon monoxide in expired air and nicotine metabolites in urine were measured to enhance self-perception of smoking. Only those clients who set a quit date during their counseling sessions received follow-up telephone calls. It was easy to implement this program (15 to 20 minutes long) during a health checkup. No significant differences were observed in the baseline characteristics of the two groups. The cross-sectional smoking cessation rates at 6 months and 1 year of follow-up were 6.2 times higher in the intervention group than in the control group. The continuous smoking cessation rate at 1 year of follow-up was 7.6 times higher in the intervention group than in the control group. In the intervention group, the lower level of nicotine metabolites in urine and higher smoking stage were related to cessation success, but other baseline characteristics were similar in those who quit smoking and those who did not. The effectiveness and easy applicability of this cessation program was proved in the present study. Further examinations in various settings are expected to clarify the effectiveness of this program.
At least in the short term, documentation of tobacco status and increased referral to cessation counseling do appear to increase following the introduction of an expectation to use the EHR to record and treat patient tobacco use at medical visits. There is a need for additional research to further understand the effect of EHRs on smoking treatment in healthcare settings.