BACKGROUND/RATIONALE:
Despite 40 years of progress, smoking remains the leading preventable cause of death in the United States, responsible for 435,000 deaths per year. Smoking is a particular problem within the VA, as VA users smoke substantially more than the general population across all categories of sex, age, and race. When adjusted for age and gender, the rate of smoking among VA users is 10% higher than the general US population - 33% vs. 23%. The prevalence of heavy tobacco users (defined as >20 cigarettes per day) in the VA is more than double that of the non-VA U.S. population (7.4% vs. 3.5%).

Current VA policy and new VA/DoD guidelines both mandate that patients be offered treatment (medications and counseling), regardless of whether they attend a smoking cessation program. Thus it is essential to treat patients within primary care, since most smokers interested in quitting cannot or will not attend a cessation program.

OBJECTIVE(S):
This project sought to make smoking cessation an area of excellence for two VA networks by adapting and expanding the primary care-based Telephone Care Coordination Program (TCCP) throughout Sierra Pacific Healthcare Network (VISN 21) and Greater Los Angeles Healthcare System (VISN 22).

This regional expansion built on the TCCP, a very successful VA Substance Use Disorder QUERI demonstration project implemented at two facilities. In the demonstration project, across the 10 intervention sites, there were 2,900 referrals for smoking cessation in 10 months. VA care coordinators proactively contacted patients and connected them with the California Smokers' Helpline. About 45% of patients starting treatment were abstinent six months later--equal to or better than smoking cessation clinics. A cost analysis showed substantial savings per quitter compared to provider-based and clinic-based programs.

METHODS:
We developed a telephone-based smoking cessation program that was integrated as a routine clinical care option at five VISN 21 and VISN 22 facilities (38 clinic sites). Referrals to the program were generated by a provider during a visit through a brief consult in CPRS. Program staff then recruited patients and, after obtaining consent, enrolled the patients into treatment. Data were collected at the site level (quantity of referrals, service origins, etc.) and at the patient level (demographics, enrollment rates, abstinence rates at six months, etc.).

This project was a group randomized trial testing of whether telephone care coordination increases the rate of smoking cessation treatment. At the patient level, two questions are addressed:

1) Is proactive care coordination (counselor initiates the call to the patient) more effective than reactive coordination (coordinator waits for the patient to call)?

2) Is multi-session counseling more effective than brief primary care-based counseling plus self-help materials?

We randomly allocated all participating sites within VISNs 21 and 22 to either self-help or intensive counseling treatment arms. We randomly allocated each week of program referrals to either proactive or reactive care coordination. All patients received brief smoking cessation counseling from their primary care physician, smoking cessation medications (after study enrollment by the VA care coordinator), and a follow-up call at 6 months. Care coordination was provided by VA clinical staff (donated as in-kind support from the participating facilities). Intensive counseling was provided by the California Smokers' Helpline.

FINDINGS/RESULTS:
Over 18 months, we received 4580 referrals. Proactive contact patients were more likely to enroll in the program (1239/2237 = 55%) than reactive contact patients (702/2343 = 30%) (OR 2.9, 95% CI 2.5-3.3). Self-help patients were equally likely to enroll (773/1842 = 42%) as quitline patients (1168/2738 = 43%) (OR 0.97, 95% CI 0.9-1.1). We attempted to contact all 4580 patients for 6-month follow-up. Of those, 377 had moved and 39 died prior to evaluation. Of the remaining 4164 subjects, we were able to evaluate 2775 subjects (67%), of whom 560 were abstinent (20%).

Comparing abstinence rates across treatment groups shows that proactive contact patients were more likely to quit (291/1313=22%) than reactive contact patients (269/1462=18%) (OR 1.3, 95% CI 1.05-1.5). Quitline patients were more likely to be abstinent (358/1638=22%) than self-help patients (202/1137=18%) (OR 1.3, 95% CI 1.07-1.6).

IMPACT:
There has been considerable discussion nationally on how to increase access to and use of telephone quitlines for smoking cessation. The study gives crucial information to help inform this national discussion. Preliminary analyses strongly support proactive recruitment of patients into treatment and suggest that telephone care coordination is about as effective as referral to a smoking cessation clinic, with likely lower costs and less inconvenience for patients than conventional smoking clinic care.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Sherman SE, Takahashi N, Kalra P, Gifford E, Finney JW, Canfield J, Kelly JF, Joseph GJ, Kuschner W. Care coordination to increase referrals to smoking cessation telephone counseling: a demonstration project. The American journal of managed care. 2008 Mar 1; 14(3):141-8. [view]
2. Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic disparities in the use of nicotine replacement therapy for smoking cessation in an equal access health care system. American Journal of Health Promotion : AJHP. 2005 Nov 1; 20(2):108-16. [view]

Conference Presentations

1. Sherman SE, Cummins S, Finney J, Kalra P, Kuschner W, York LS, Zhu SH. Engaging VA Patients in Telephone Counseling for Smoking Cessation: Results of a Telephone Care Coordination Program. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
2. Katzburg J, Yano EM, Sherman SE. Research informing policy: Designing a tailored, patient-centered smoking cessation program. Presented at: American Public Health Association Annual Meeting and Exposition; 2007 Nov 4; Washington, DC. [view]
3. Sherman SE, Cummins S, York LS, Finney J, Kalra P, Kuschner W, Guvenc-Tuncturk S, Zhu SH. Results from a Study of Telephone Care Coordination for Smoking Cessation. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
4. Sherman SE, Estrada M. Should I use a patient survey or provider survey?: Assessing outcome in smoking cessation studies. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 1; Los Angeles, CA. [view]
5. Sherman SE, Cummins S, Finney J, Kalra P, Kuschner W, York LS, Zhu SH. Telephone Care Coordination For Smoking Cessation: A Randomized Trial. Paper presented at: Society for Research on Nicotine and Tobacco / Society for Research Nicotine and Tobacco - Europe Joint Conference; 2009 Apr 28; Dublin, Ireland. [view]
6. 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. [view]

DRA: Substance Use Disorders, Health Systems Science
DRE: Prevention
Keywords: Implementation, Smoking, Telemedicine
MeSH Terms: none