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Implementation of Smoking Cessation Treatment Guidelines: Do Strategies Around Counseling Translate to Treatment?
Farmer Coste MM, Yano EM, Sherman SE, Lanto AB, Riopelle DD. Implementation of Smoking Cessation Treatment Guidelines: Do Strategies Around Counseling Translate to Treatment? Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
Among the first VA performance measures, both tobacco use detection and counseling rates achieved a ceiling effect early in VA's quality transformation. However, smoking cessation (SC) treatment rates are lower than almost all other preventive care delivery. We examined whether organizational characteristics shown to impact counseling rates and other preventive services influenced SC treatment/referral rates.
We used organizational measures from the VHA Survey of Primary Care Practices (1999-2000; n = 235 VA facilities) on local methods used to promote SC guideline adherence, sufficiency of practice resources, and authority over clinical arrangements. We used patient self-reported SC treatment or referral from the 2002 Survey of Healthcare Experiences of Patients to create facility scores, and used facility-level linear regression to evaluate the effectiveness of different guideline implementation methods.
On average, 42% of smokers reported being treated or referred for SC treatment, with substantial facility-level variation (range 16%-60%). Rates were even lower for specific treatments: 20% for self-help (5%-37%), 27% for counseling (7%-48%), and 32% for medications (3%-55%). Virtually all VA facilities (98%) reported employing one or more methods to promote guideline adherence for SC counseling, using computer reminders (66%), chart reminders (55%) and provider education (82%), but these methods did not predict SC treatment rates. Primary care structural features, such as resource sufficiency and practice autonomy, also failed to predict treatment rates.
In 2002, prior to VA's implementation of a treatment-related performance measure, patient-reported SC treatment/referral rates were low. None of the methods that have supported routine care tobacco counseling significantly impacted subsequent treatment rates. VA practices with better resources and those with the autonomy to redesign their care arrangements, both of which have predicted better prevention performance, had no significant influence on SC treatment rates.
Common quality improvement implementation strategies that have worked for detection and counseling of smokers and other VA performance measures do not translate into benefits for SC treatment. While there are no "magic bullets" that apply to all components of SC guidelines, this work suggests that system-wide improvement of SC treatment will likely require organizational strategies that eliminate barriers to treatment not currently addressed by these particular methods.