Implementing Guidelines for Smoking Cessation: A Randomized Trial of Evidence-Based Quality Improvement
Scott E. Sherman MD MPH
New York, NY
New York, NY
Funding Period: July 1998 - December 2002

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. Evidence-Based Quality Improvement (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.

OBJECTIVE(S):
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 group patients from baseline to 12-month 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).

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.

PUBLICATIONS:

Journal Articles

1. Sherman SE, Yano EM, York LS, Lanto AB, Chernof BA, Mittman BS. Assessing the structure of smoking cessation care in the Veterans Health Administration. American Journal of Health Promotion : AJHP. 2006; 20(5): 313-8.
2. Sherman SE, Joseph AM, Yano EM, Simon BF, Arikian N, Rubenstein LV, Parkerton P, Mittman BS. Assessing the institutional approach to implementing smoking cessation practice guidelines in veterans health administration facilities. Military Medicine. 2006; 171(1): 80-7.
3. Meredith LS, Yano EM, Hickey SC, Sherman SE. Primary care provider attitudes are associated with smoking cessation counseling and referral. Medical Care. 2005; 43(9): 929-34.
4. Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Women's Health Issues. 2005; 15(3): 126-33.
5. Jonk YC, Sherman SE, Fu SS, Hamlett-Berry KW, Geraci MC, Joseph AM. National trends in the provision of smoking cessation aids within the Veterans Health Administration. American Journal of Managed Care. 2005; 11(2): 77-85.
6. Sherman SE, Yano EM, Lanto AB, Simon BF, Rubenstein LV. Smokers' interest in quitting and services received: using practice information to plan quality improvement and policy for smoking cessation. American Journal of Medical Quality. 2005; 20(1): 33-9.
7. Mojica WA, Suttorp MJ, Sherman SE, Morton SC, Roth EA, Maglione MA, Rhodes SL, Shekelle PG. Smoking-cessation interventions by type of provider: a meta-analysis. American Journal of Preventive Medicine. 2004; 26(5): 391-401.
8. Sherman SE, Lanto AB, Nield M, Yano EM. Smoking cessation care received by veterans with chronic obstructive pulmonary disease. Journal of Rehabilitation Research and Development. 2003; 40(5 Suppl 2): 1-12.

DRA: Health Services and Systems, Substance Abuse, Addictive Disorders
DRE: Prevention, Quality of Care
Keywords: Clinical practice guidelines, Smoking
MeSH Terms: Health Promotion, Practice Guidelines, Smoking, Smoking Cessation, Quality