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Implementing Smoking Cessation Guidelines: A Randomized Trial of Evidence-Based Quality Improvement: Final Report
Sherman SE, Yano EM. Implementing Smoking Cessation Guidelines: A Randomized Trial of Evidence-Based Quality Improvement: Final Report. Sepulveda, CA: VA Greater Los Angeles HSR&D Center of Excellence; 2003 May 1. Report No.: Final Report.
BACKGROUND/RATIONALE: Smoking is a serious and common health risk among veterans. Given the press of national initiatives and local incentives to improve smoking cessation care in response to VA performance measures, this study tests a widely applicable approach to clinical practice guidelines implementation, namely evidence-based quality improvement, which is directly relevant to the translation of efficacious treatments into enhancements in VA health care policy and practice. EBQI focuses on improved provider adherence to smoking cessation guidelines and a decrease in patient smoking rates in a manner designed to produce short- and long-term health improvements and cost benefits at the organizational level.OBJECTIVES: Adherence to smoking cessation guidelines requires practice changes at the patient, provider, and system levels to achieve optimal quit rates. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI)-an expert-designed and locally implemented clinical reorganization of smoking cessation care-on changes in smoking cessation (SC) practice among primary care providers and health outcomes among veteran smokers.METHODS: An evidence-based quality improvement intervention comprising provision of physician and patient educational materials, local priority setting with leadership and providers, and local adaptation of expert-designed protocols was implemented in experimental VA primary care practices (n = 9). VA control sites (n = 9), matched on size and academic affiliation, received smoking cessation guideline copies. We randomly sampled, consented, screened and surveyed primary care patients at all 18 sites (n = 1,941 smokers) and used computer-assisted telephone interviewing to assess sociodemographics, health status, function, and smoking behavior, attitudes and treatment experience. Post-intervention 12-month follow-up interviews were completed using the same measures (n = 1,080). We used multiple imputation using hotdeck techniques and applied both enrollment and attrition weights to the patient-level data. We used weighted logistic regression to evaluate intervention effects, controlling for patient-level predictors of quit attempts and quit status (e.g., level of addiction, readiness to change, age, health).FINDINGS/RESULTS: Primary care providers' attitudes toward smoking cessation were the strongest predictors of counseling behavior and referral to a smoking cessation program. While primary care providers at intervention sites were more likely to counsel smokers than providers at control sites, the percent of smokers who attempted to quit and reported 1+ days of intentional quitting increased significantly among both experimental and control groups patients from baseline to 12-months follow-up. Adjusting for patient socio-demographics, level of addiction and readiness-to-change, however, we found no intervention effect on quit attempts or smoking cessation and found marginally higher successes among participants at control sites (p = .094 quits, p < .05 quit attempts). Higher addiction level (OR = 0.81, 95% CI 0.74-0.88) and readiness-to-change (OR = 2.52, 95% CI 1.97-3.21) were the only independent predictors of smoking cessation regardless of patient age, gender, race-ethnicity, marital status, education or intervention group (p < .0001). CONCLUSION: Our intervention of locally-determined, expert-assisted evidence-based quality improvement had an effect on providers' attitudes and reported practices with respect to smoking cessation but had no effect on the actual rate of smoking cessation. The rate of smoking cessation increased significantly from baseline to follow-up in both experimental and control sites, suggesting any intervention effect was overshadowed by ongoing secular trends within the VA. Most intervention sites opted for incremental changes in practice that were ultimately insufficient to have an effect on the primary care population of users. Sites were generally very resistant to shifting from a smoking cessation clinic-based referral approach to a population-based approach to smoking cessation, which may explain the lack of population effect. Future smoking cessation efforts should consider alternate approaches to restructuring care that address these barriers.STATUS: Complete.IMPACT: Patient reports of increased smoking cessation counseling and treatment corroborate chart-based performance measures and provide details regarding their readiness-to-change that may facilitate provision of effective counseling by primary care providers. Performance mandates regarding smoking cessation guideline implementation have resulted not only in significant changes across facilities, but also detailed changes in the processes and outcomes of care of the population of patients seen in VA primary care practices. At the same time, in contrast to benefits demonstrated for chronic care (i.e., depression care improvement), intensive primary care-based reorganization with locally-developed quality improvement plans supplemented by expert advice did not lead to more quit attempts or actual smoking cessation beyond changes already underway in all sites through VA performance measurement and leadership incentives for better tobacco counseling rates. Qualitative assessment of site-specific practice changes is needed, especially where smoking cessation programs reside in behavioral health programs and primary care/mental health collaboration is needed.