BACKGROUND/RATIONALE:
Smoking is the leading preventable cause of death in the U.S., and veterans experience a particularly heavy burden with smoking rates 43% higher than the civilian population. Current practice guidelines recommend that providers assist all smokers in quitting through detection, counseling and treatment. While VA performance measures have demonstrated significant gains in tobacco use screening (around 95%), delivery of smoking cessation interventions among identified smokers is lower than almost all other rates of preventive care delivery despite an array of regional and national efforts to improve guideline adherence. This project evaluates the influence of discrete organizational characteristics and approaches-specifically, structural features of primary care practice and smoking cessation-related processes of care-on the quality of care received by veteran smokers.
OBJECTIVE(S):
The study has three specific 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, controlling for the organizational and contextual factors identified in Aim #1, and (3) examine how change in organizational and practice structure over a six year period impact smoking cessation treatment rates.
METHODS:
The study capitalizes on established VA secondary data sources including organizational surveys, administrative data, patient surveys, and chart review. Organizational-level measures of interest including environmental features, facility characteristics, and primary care practice structure, are available from the 2000 VHA Survey of Primary Care Practices (n=235) and the VHA Clinical Practice Organization Survey - 2006 Chief of Staff Module (n=111) and 2007 Primary Care Director Module (n=225). The primary outcome measure of smoking cessation treatment recommendation for individual counseling, group counseling, smoking cessation programs, and medication prescriptions are available from the Survey of Healthcare Experiences of Patients (SHEP), a yearly survey mailed to approximately 300,000 veterans with at least one VA visit, of which approximately 20% are smokers; and the External Peer Review Program (EPRP), a chart review completed on a SHEP subset (N =24,000). Data from SHEP/EPRP years 2002, 03, 05, 06, and 07 will be used in the analyses. SHEP and EPRP as well as the VA Outpatient Care (OPC) datasets will provide patient level demographic data.
In addition to bi-variate analyses, this research will utilize two-level hierarchical analysis of the organizational and quality improvement approaches (level 2) and patient-level (level 1) predictors of smoking cessation treatment to evaluate the relationship of organizational and patient-level factors to smoking cessation treatment practices, adjusting for patient clustering within facility. A longitudinal analysis will be conducted to examine the impact of change in organizational predictors on smoking cessation treatment rates over the six year period.
FINDINGS/RESULTS:
In preliminary analyses of 2002 calendar year SHEP patient data (n=368,242), 84% of the sample is White, 96% male, and ages range from 19 - 90+ years with a mean age of 58. Twenty percent of the overall sample was identified as smokers, with smoking rates highest among American Indians (34%) and Blacks (32%); and slightly higher among females (26%) than males (20%). Among the sub-sample of smokers (n=73,418), 39% reported either being treated for smoking or referred for quitting tobacco use by their VA provider in the past 12 months.
IMPACT:
To date, implementation researchers lack an understanding of the care veterans receive for smoking cessation that is needed to design and implement effective system-wide interventions capable of demonstrable gains in VA performance at the facility and VISN levels. By identifying the organizational strategies and approaches that are linked to high rates of smoking cessation treatment in the VA nationally, this research will provide a valuable portrait of the fixed and mutable characteristics at the organizational-level that foster effective smoking cessation care to ultimately improve the quality of VA smoking cessation care.
PUBLICATIONS:
Journal Articles
- Farmer MM, Bastani R, Kwan L, Belman M, Ganz PA. Predictors of colorectal cancer screening from patients enrolled in a managed care health plan. Cancer. 2008; 112(6): 1230-8.
