Smoking is the leading preventable cause of death and disease in the United States, and veterans experience an unequal burden of tobacco use compared to the general population. Despite an array of regional and national efforts to improve guideline adherence, delivery of smoking cessation treatment for veteran smokers is lower than almost all other rates of preventive care delivery.
This project evaluated the influence of discrete organizational characteristics and approaches on the quality of care received by veteran smokers with three aims: (1) determine the organizational and contextual factors that contribute to delivery of guideline adherent smoking cessation treatment, (2) identify the factors associated with successful approaches to smoking cessation treatment, and (3) examine how change in organizational and practice structure over a seven year period impacted smoking cessation treatment rates.
This project utilized patient-level data from the Survey of Healthcare Experiences of Patients (SHEP), the External Peer Review Program (EPRP) and administrative data from 2002 and 2007, organizational-level data from the 1999-2000 VHA Survey of Primary Care Practices (n=235) and the 2007 VHA Clinical Practice Organization Survey Primary Care Director Module (n=225), and area level data from the Area Resource File. Measures included facility characteristics, primary care practice structure, delivery care components and practice arrangements specific to smoking cessation, and environmental features. The primary outcome included patient reported treatment, referral and medications (SHEP) and documented counseling/referral and offer of medication (EPRP). We utilized random-intercept logistic regression, adjusting for patient clustering within facility.
In 2002, 14% of smokers reported smoking cessation treatment and 29% reported being referred for treatment. In 2007, 83% of smokers reported they were advised to quit one or more times, 60% reported counseling, and 62% reported medications (SHEP). Fifty-four percent of smokers had documentation of brief counseling/referral and 64% had medications (EPRP). Patients at VA medical centers had increased odds of having treatment offered compared to those at community based outpatient clinics. In 2002, patients seen in primary care practices with planned or implemented service lines had increased odds of treatment or medications. By 2007, over 90% of sites reported on-site specialty smoking cessation treatment and a primary care focus for smoking cessation significantly increased the odds of being offered medications. Only 19% of sites reported that their capacity to meet patients' needs for smoking cessation treatment services was always sufficient. Virtually all VA facilities reported employing one or more methods to promote guideline adherence for smoking cessation counseling, but none of the methods were significantly linked with smoking cessation treatment. Significant regional differences existed at both years. Overall, simple changes in primary care authority and resources over time were not sufficient to influence 2007 smoking cessation treatment rates.
The VA has made significant advances in smoking cessation treatment but still falls shy of optimal care. To continue to improve treatment rates, general organizational factors need to be augmented by more specific smoking cessation measures to further understand the mutable factors that impact treatment.
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