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Keywords:

  • tobacco screening;
  • tobacco cessation quality initiatives;
  • maintaining tobacco screening;
  • tobacco control for public health

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Objectives:  Due to the addictive nature of the disease and interrelated societal influences on the behavior of tobacco use, repeated interventions are often required before people successfully stop using tobacco. Our objective was to implement a multicomponent clinical intervention initiative enabling health care providers to effectively screen for tobacco use. We also sought to describe changes in emergency medicine providers’ documentation of cessation advice to tobacco users.

Methods:  The intervention was conducted at three emergency departments (EDs) and four clinics at a community-based teaching hospital and health network. Health care providers with the opportunity to identify and counsel tobacco-using patients in ambulatory health care settings were the study population. The authors initiated a quality improvement initiative for tobacco screening that employed a multicomponent strategy to facilitate systemic changes that support 100% tobacco use identification, documentation, and counseling. Baseline, posteducation, and post–wrap-around documented screening rates were compared within each site across the intervention. Cumulative ED baseline, posteducation, and post–wrap-around rates of provider advice to tobacco users were compared across the intervention. Percentage of possible available gain was calculated in consideration of a 100% ceiling effect. Statistical analysis was performed using SPSS and MetStat. Descriptive statistics and Pearson’s chi-square cell frequency were used to analyze and compare sites. Fisher’s exact test was used to compare those tests with a chi-square cell frequency of five or less. The statistical tests used for pre-/postintervention percentage comparisons by site had power between 80% and 90%, detecting differences of 10% and 20% or more at a 0.05 level of significance.

Results:  Significant increases in posteducation screening rates for all ED sites complemented significant increases in ED post–wrap-around intervention screening rates. Significant increases in ED provider documented cessation advice were also noted.

Conclusions:  This initiative successfully changed tobacco screening behavior of health care providers at all sites. It was particularly successful in the ED, typically an environment less likely to be conducive to preventive health interventions.

Nicotine dependence is a chronic condition affecting all countries, and cigarette smoking is the most prevalent type of tobacco consumption.1 Data from the 2007 Behavioral Risk Factor Surveillance System indicate a national prevalence of 19.8%, with a range from 11.7% (Utah) to 28.2% (Kentucky).2 A World Bank report projects tobacco use to be the leading cause of death worldwide by 2030, with an estimated 10 million people worldwide dying of tobacco-related causes.3 The Food and Agriculture Organization claims that applying aggressive antismoking and antitobacco interventions could drop the projected 1.4 kg per year adult consumption by 20%.1 In an effort to reduce tobacco-related disease and death, the World Health Organization adopted a Framework Convention on Tobacco Control Public Health Treaty in 2003.4

Due to the addictive nature of the disease and interrelated societal influences on the behavior of tobacco use, repeated interventions are often required before people successfully stop using tobacco.5,6 Provision of educational materials, tobacco cessation tools, addiction treatments, counseling, and simply reminding or consistently urging people to abstain increases the likelihood of effecting a change in patient behavior.3,7 Repetitive reminders and provision of education materials from a respected member of society, such as one’s health care provider, increases the likelihood of effecting a change in tobacco use behavior.8 Health care providers are uniquely positioned to identify, counsel, and motivate tobacco-using patients, especially in the context of a medical condition exacerbated by smoking. However, especially in the emergency department (ED), patient visits are often limited by time constraints as well as a primary focus on medical care of the reason for the visit. How best to screen, educate, and manage the tobacco-using patient is complex for most health care professionals.

Providers have multiple opportunities to make a difference in the health of their tobacco-using patients, so treating nicotine dependence should be an integral component of a quality health care delivery system.5,6 Quality improvement (QI) interventions are one way to effectively institutionalize nicotine dependence identification and treatment. One such method for assisting patients in achieving tobacco abstinence is the systematic screening, identification, and education of tobacco users.6 However, in the past decade there has only been a small increase in ambulatory care physicians’ rates of patient smoking status identification (most recently at 68%) and a small decrease in rates of counseling smokers (most recently 20%).9 Encouraging the provider to consistently screen, educate, and manage treatment of tobacco users on a regular basis remains a challenge for health care institutions, especially in their acute care (e.g., ED) divisions. For effective implementation of QI interventions, it is essential that providers learn new behaviors and skills. Most importantly, they must apply learned skills to create new behavior patterns. Education and one-time prompting alone typically will not produce behavior change into one of consistent tobacco use identification and treatment. The successful QI intervention, therefore, must facilitate systemic alterations that produce an environment conducive to change.10–12 The Task Force on Community Preventive Services recommends a multicomponent intervention to increase provider tobacco use screening and advice rates.13 Possible barriers to implementation should also be considered and addressed.11,12 Nemeth8 identifies four major barriers to changing the efforts behavior of health care providers: difficulty and expense in changing, lack of return on investment, lack of demand for improvement, and the nature of health care. The objective of this article is to describe our network initiative and success in health care provider tobacco screening.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

The Tobacco Screening Initiative

The tobacco screening initiative is supported by the network’s Department of Community Health and Health Studies (DCHHS), in consultation with a local tobacco control coalition (Coalition for a Smoke-Free Valley). DCHHS led the development of the initiative and provides ongoing program evaluation; the Coalition lends its expertise for best practice advice in tobacco screening and cessation efforts, tobacco control advocacy, and best practice reduction strategies. The initiative culminates in transfer of program responsibility from the DCHHS to each site. It employs a multicomponent strategy to facilitate systemic changes that support 100% tobacco use identification, documentation, and counseling for 100% of eligible patients. This initiative was presented to the institutional review board and waived because it was primarily a QI process evaluation. Written informed consent from subjects was waived.

Strategic Flow

The initial step for a site implementing the initiative is identification of champions and their immersion into the tobacco screening initiative work group. Baseline data are then obtained for each site. The remaining components are designed to be phased in, wrapping around the provider to form an environment conducive to patient screening and referral as part of the patient–provider relationship. Ongoing support for sites implementing or having had implemented the screening initiative is provided through a dedicated work group and continuous education sessions. The work group promotes the initial educational session. The first education sessions are accomplished over an approximate 6-month time period after the baseline data collection. Subsequently, approximately 1 year from baseline, data collection (hereafter referred to as posteducation) chart abstractions at each site are performed again.

There is an ongoing interrelationship between the work group and educational efforts. After project initiation, the work group gets feedback from the session (via participants and educators). The feedback is digested by the work group and further revisions and additions to the educational training occur. Posteducation data results are factored into the choices of the next educational approaches at each site. Repeat chart audits (hereafter referred to as post–wrap-around) occurs at approximately 2 years from baseline. During the continuous QI intervention, this back and forth fashion exchange persists (Figure 1).

image

Figure 1.  Tobacco use screening and counseling initiative. Components of the tobacco use screening and counseling initiative patient educational materials are network-specific; the remaining activities that proximally encircle the health care provider are site-specific.

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The program end point is determined when the site is independently performing its evaluation and goal setting with minimal assistance from DCHHS. Champions remain members of the work group and provide a liaison service to the site, as well as convey expert experience to other sites. Adoption and maintenance of the effort by each site results in a program steeped in ownership and a sense of responsibility, cushioned by the ongoing foundation of support.

Key Strategic Components

Tobacco Screening Work Group.  A tobacco screening work group was developed to spearhead the program and provide ongoing support to sites. The work group fostered sites throughout the initiative and supported them following implementation. The work group was chaired by the DCHHS manager and was composed of representatives from the Coalition, institution, and participating site champions. The work group met monthly during the initiative for 1½-hour sessions. Additionally, for the extent of the program, one full-time equivalent program manager was devoted across the network to conducting the project, arranging and providing education, and providing data results biannually to departments.

Site-specific Champions.  Providers with a keen interest in tobacco cessation and who are respected by their coworkers were recruited from each participating site. These champions devoted approximately 1½ hours every 6 months to review data measurements with the work group chair. There was variability between champions as to additional time and effort devoted to their site activities. The ED site champion devoted an additional 1 hour a month to other activities associated with the process. Each champion served as a change agent within his or her site, advocated the program, and acted as a liaison between the site and the work group. Champions also served on the work group, offering support to sister sites. This component served to address the lack of demand for improvement barrier identified by Nemeth.8

Education and Follow-up.  Tobacco screening and cessation training was given to all providers at each implementing site. Follow-up and new employee sessions were offered periodically, dependent on site-specific needs. These programs were framed after the Clinical Practice Guidelines for Treating Tobacco Use and Dependence6 and occurred at least twice a year. Through these programs, all site providers became uniformly aware of best practice tobacco cessation interventions recommended by the U.S. Public Health Service. Sessions were facilitated by the Coalition and presented by local experts and trained network staff.

Standardized, Easy-access Patient Education Materials.  The work group reviewed patient-centered tobacco use educational materials commonly used by U.S.-based health care institutions. Selection criteria for educational materials were determined by a combination of the panel of experts from the network’s inpatient cessation consultants, the health care providers, and the Coalition for a Smoke-Free Valley. In partnership with the network’s patient education unit, appropriate patient education materials were chosen (sixth to eighth grade reading level) and categorized based on cultural orientation and readiness-to-quit stage. These materials were placed on the network’s intranet site for easy access by providers. Like education and follow-up, this component served to address the difficulty and expense in changing and nature of health care barriers identified by Nemeth.8

Customized Screening Instruments and Procedures.  The work group used information from clinical and administrative staff members at each site to assess tobacco use screening techniques. The appropriateness of tobacco use screening questions and ease of use was highlighted. Provider and support staff members were involved in goal setting and consistency of their assessment tools. Barriers to screening were identified and addressed in site policy and procedure updates. This component also addressed the difficulty in changing barriers identified by Nemeth.8

Evaluation, Feedback, and Goal Setting.  Tobacco use screening and cessation advice performance is evaluated twice annually for each participating site. Performance reports were shared with all health care and support staff. Performance reports that were generated every 6 months took approximately 80 hours of chart abstraction time per site. Discussions were led to reinforce successful interventions, set screening goals, and when necessary, consider root causes of performance level drop-off. A team approach was encouraged by providing site-based, rather than provider-specific, rates. Repeated measurements and discussion served to promote tobacco use screening as an essential component in the provision of quality care. This component served to address lack of return on the investment barrier identified by Nemeth.8 Measures for screening and advice that are presented as post–wrap-around in this article occurred approximately 2 years postbaseline.

Participating Site Characteristics

The tobacco screening initiative has been successfully implemented in seven of the network’s ambulatory clinical sites. The sites are an office obstetrics/gynecology setting, a family practice clinic, an internal medicine clinic, a dental clinic, and three separate EDs. The network has over 100,000 annual patient visits distributed over these EDs. Each ED is attached to an individual hospital site. The sites represent three distinct subpopulations: 1) inner city, 2) suburban trauma center, and 3) suburban with behavioral health unit. The tobacco use rate of patients (whose charts were audited for this study) in the ED sites was 33% and cumulatively across all sites and all time periods represented in this initiative was also 33%.

Continuous Evaluation Methods

Quantitative evaluation is based on a pre-/postintervention research design with repeated measures. Data were collected at baseline and every 6 months throughout the study. Data were retrospectively collected from no fewer than 50 randomly selected medical records of unique patients seen during a randomly selected 1-week period. Those presenting with trauma, or under age 16 years, were excluded from review. Trained reviewers were used to collect predetermined information using standardized protocol and collection forms. Chart review training occurred to systematize the process for research assistants doing reviews. Each reviewer abstracted data from 10 charts, and then one of the authors reviewed the same set to ensure consensus. If at any time a reviewer had a specific finding that needed interpretation, he or she had specific lead research staff available for clarification before data entry. Thereafter, the trained reviewers thoroughly perused the medical records for documentation.

The information gathered at each site included demographics such as patient date of birth, encounter date, presenting complaint, discharge diagnosis, and whether any portion of the chart included advice to quit smoking or referral for cessation assistance. Additionally recorded for the ED sites was whether the patient was admitted, severity of illness by triage assessment, and whether discharge instructions had recorded advice to quit or referral for cessation assistance. A successful screening was determined if the chart indicated the patient had been screened (yes or no) for tobacco use by a provider. If the patient responded positive to tobacco use, the ED chart was evaluated for provision of cessation advice. Cessation advice/management was considered provided if any part of a tobacco user’s written record (including discharge instruction) had any component of advice to quit, counseling, or referral for further cessation treatment.

At least one tobacco use screening within the past 12 months was considered a positive screen for those patients presenting on multiple occasions to one of the nonemergency sites within that time period. Protocol, data collection sheets, and information gathered were intentionally kept relatively straightforward in anticipation of transferring evaluation responsibility to the site. Site-specific findings were shared with each site. Clinical staff members were encouraged to participate in discussions of need and scope of additional interventions to achieve desired screening rates. Timelines and informational logs were maintained by the DCHHS facilitator. Data were analyzed using a qualitative analysis technique of keywords-in-context to identify recurring themes.14

Pre- and postintervention documented screening rates were compared within each site across the intervention and are cited within this report to solely evaluate the strength and effectiveness of the overall initiative. Percentage of possible available gain statistical evaluation (compared to baseline data points) for purposes of this report was performed posteducation at approximately 12 months and at post–wrap-around (24 months). The tobacco screening work group considered an increase between 10 and 20% to be significant based on the anticipated investment of time and effort for the project. Percentage of possible available gain (improvement/available gain) was calculated in consideration of a 100% ceiling effect. Statistical analysis was performed using SPSS (2001, SPSS Inc., Chicago, IL) and MetStat (1990, MetroHealth, Cleveland, OH). Descriptive statistics and Pearson’s chi-square tests were used to describe and compare screening at sites and to compare cumulative ED pre- and postcessation advice. Fisher’s exact test was used to compare those tests with a chi-square cell frequency of five or less. The statistical tests used for pre- and postintervention percentage comparisons by site had power between 80 and 90%, detecting differences of 10% to 20% or more at a 0.05 level of significance.15

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Table 1 displays screening rates, screening improvement, and percentage of available gain for each site. It also shows the cumulative ED site documented health care provider cessation advice improvements in tobacco users. Figure 2 shows continuous improvement in the rates across the intervention for sites with demonstrative improvement. It should be noted that, as reflected in Table 1, the dental clinic had begun and was near completion of the wrap-around before posteducation screening rates were performed and chart review was not performed posteducation intervention. In summary, each ED site had a progressive, significant increase in screening rates from baseline through post–wrap-around intervention (p < 0.001). Cumulative ED documented cessation advice for tobacco users also had a progressive significant (p < 0.001) increase from baseline through post–wrap-around intervention.

Table 1.    Screening and Advice to Quit Improvement Rates (%) with Confidence Intervals (CIs) by Site
Location of screeningBaseline Total RateTotal Rate Posteducation% of Possible Available Gain Posteducation from Baseline Improvement (95% CI)Total Rate Post– wraparound% of Possible Available GainPost–wrap-around Improvement from Posteducation Rate (95% CI)
  1. OB/GYN = obstetrics/gynecology.

  2. *Differences statistically significant at p < 0.001.

Inner-city ED0.460.94890.48* (0.42–0.53)0.99760.44* (0.03–0.05)
Suburban trauma ED0.630.89710.26* (0.20–0.32)0.99880.10* (0.08–0.12)
Suburban community ED0.260.72620.46* (0.44–0.48)0.95800.23* (0.20–0.26)
ED advice to quit to tobacco users0.060.32280.26* (0.23–0.29)0.58380.26* (0.24–0.28)
OB/GYN office0.540.81600.27* (0.22–0.32)0.92560.10 (0.09–0.11)
Internal medicine office0.800.86240.05 (0.045–0.055)0.92470.07 (0.06–0.08)
Dental office0.020.94950.92* (0.91–1.00)
Family practice clinic0.890.34–0.55* (–0.50 to –0.60)0.67500.33% (0.30–0.36)
image

Figure 2.  Model of continuous rate incremental improvement. The family practice clinic did not yield continuous improvement and is not included in this figure. Dental = dental clinic; LVPP = internal medicine clinic; CWM = obstetrics/gynecology clinic; EDSC = suburban community ED; EDSA = suburban trauma ED; EDI = inner city ED.

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Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

It has been suggested that systematic screening and identification of tobacco users be considered like a vital sign of primary intervention for smoking cessation.16 Provider education about nicotine addiction and office-based interventions have shown effectiveness in increasing tobacco screening rates.17,18 Evaluation of the network’s tobacco screening initiative supports this finding. Five of six intervention sites (83%) evaluated after the education sessions demonstrated screening rate increases ranging from 5% to 48%. This represents 24% to 89% of available gain. Three of these sites were EDs that inherently do not foster ongoing doctor–patient relationships and in which post–wrap-around results revealed higher than previously reported averages for ambulatory patients in screening and cessation.9 These results suggest that, although education is a significantly valuable component in the effort to institutionalize tobacco use identification and screening, as a stand-alone initiative it is not enough. Other suggested factors that would have a positive influence in changing provider behavior are reduction of system barriers and facilitation of provider buy-in. The network tobacco screening initiative invokes provider participation and program buy-in through involvement of site-specific champions and through biannual site-specific screening review and performance feedback. Two components of the overall strategy (the site-specific champion and the performance feedback) are felt to have had the most impact on our desired outcomes. Carefully selected standardized patient education materials readily available to the provider through the network’s intranet and site-specific customized screening assessment forms have helped remove some of the expense and time barriers. Involvement of a local tobacco control expert and an active work group lends credibility and peer support to the initiative. This multicomponent strategy wraps itself around the caregiver to form an environment conducive to tobacco user identification and referral. Evaluation of screening rates after implementation of the wrap-around initiative revealed that six of the seven sites (86%) attained screening rates of 92% to 99%. This represents additional 47% to 88% of available gain.

To advance tobacco cessation within an ambulatory patient population, tobacco use screening must be linked with the provision of brief clinical interventions and, as appropriate, counseling and behavioral therapies with or without pharmacotherapy. While the work described here focuses on tobacco use screening, our treatment initiative includes interventions to support providers in these subsequent strategies. Both brief and intensive tobacco cessation counseling services are now available to the network’s ambulatory and in-house patients. These patients may receive ongoing support through the tobacco treatment program in conjunction with the patient’s primary provider. Similar performance measurements will be implemented to assess the proportion of patients receiving these services and the effectiveness of system-based tobacco cessation interventions to improve counseling rates, as necessary.

Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

This effort was designed as a QI initiative, so there will be points that will not hold up to the same scrutiny as a formal research study. For example, an interobserver reliability of the methods used by the research assistants who performed the chart reviews is lacking. However, the data abstractors were trained research associates from our health studies unit, and there was a systematic method to their education and evaluation of their work. Questions for clarification from abstractors were most common at the start-up of the process or upon reentering a practice for a specific collection period (for example, the center that converted to an electronic medical record during the study). Errors found in each of their first 10 charts reviewed were nearly nonexistent, as were their questions after data abstraction began. Because data points were objective and uncomplicated, interrater reliability was not felt to be necessary by the work group.

The tobacco work group’s choice to consider significant an increase of 10% to 20% in tobacco screening could be challenged. In fact, it is somewhat arbitrary and was settled on by a majority of member consideration of what would be worthwhile when offset by the value of the time and effort they anticipated putting into the program.

The reported measurement of health care provider documented cessation advice to tobacco users at the ED sites deserves discussion. While the data are reported herein, they are not compared to other sites because the range of site variability in data point collection precluded accuracy of the comparison. There were few charting technique differences across sites in screening documentation, but in advice to quit messages there were marked differences. One clear example is that ED patients (in contrast to clinic patients) receive computer generated written discharge instructions, another opportunity for cessation advice that gives them an unfair advantage. Also, ED discharge instructions were modified postbaseline and preeducation, to reflect automated cessation messages for tobacco using patients. Notably, even if this would discredit the significance of the ED posteducational cessation advice improvement, without any further charting changes, the post–wrap-around improvement was still significant.

Evaluation of the site (family practice clinic) that decreased screening rates posteducation and that did not attain a post–wrap-around screening rate within the 90th percentile deserves discussion. The work group struggled with the data outcomes at this site. Initial qualitative feedback from the site champion revealed other influential factors acting as barriers, such as the implementation (at this site only) of a computerized medical record system. Simultaneous implementation of these two initiatives temporarily negated customized patient screening forms that facilitate documentation, especially when the patient screened negative for tobacco use. It is plausible that screening occurred, but was not documented within the newly computerized medical record. Clinical interview and observation revealed that tobacco use screening is a customary part of the patient’s annual examination for this site. Even through a lengthy study period, it is unclear what affected the data. Without a systematic approach, and in response to the data reported to them, the site self-audited by direct observation a sample of their patient assessments. They self-reported that under direct observation, some patients were advised to quit, but did not have this documented in their medical records. No comparison of direct observation in any of the EDs was undertaken. We acknowledge that the difficulties at this site seriously impair the possibility of generalizing this approach to other family practice settings, but feel strongly that the impact of the intervention at the ED sites is clear.

Although this multicomponent wrap-around tobacco screening initiative was implemented in seven separate sites, the authors recognize that the evaluation reflects success of an initiative offered at a network of hospitals in Pennsylvania, with a smoking prevalence of 33%. It is not clear that similar multicomponent strategies offered at other health care institutions would have similar results.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Continuous quality improvement interventions with performance feedback may be effective in achieving tobacco use screening rates in ambulatory care practices. However, not all initiatives are adapted to such levels to maximize desired results. In particular, one of the barriers to ED tobacco cessation screening and advice is the inability of the providers to see themselves as successful in this endeavor (perhaps they believe it is out of their scope of practice). This study clearly shows that using this wrap-around strategy, emergency medicine providers cannot only accomplish tobacco cessation activities, but also do it with the same or greater consistency than providers in more traditionally accepted venues for this service. A multicomponent initiative that goes beyond education to incorporate continued improvement strategies and ongoing measurement is essential to meeting expectations and providing quality health care.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

The authors acknowledge that support, in part, for this project came from a grant from the Dorothy Rider Pool HealthCare Trust.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. Acknowledgments
  9. References
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