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BACKGROUND/RATIONALE:
Smoking is the most preventable cause of death. The VA has made great strides towards implementation of systematic outpatient tobacco control, including pharmacotherapy. Our proposal addresses another important service area in need of implementation of smoking cessation interventions - surgery. Over 375,000 surgical procedures are performed yearly in the VA. Based on VA National Surgical Quality Improvement Program (NSQIP), smoking prevalence among Veterans undergoing surgery (36%) is even higher than the overall smoking prevalence in Veterans using the VA (30%).
Because considerable prior research suggests that smokers are at increased risk for postoperative complications, randomized trials of preoperative smoking cessation have been conducted. Unfortunately, the most successful interventions studied in these trials are often complex, and costly, and would be difficult to implement for all patients receiving surgery.
In addition, the well known smoking-related risk of postoperative complications may not be uniform across procedures. Notably, two recent studies of Veterans attempting to describe the independent association of smoking and postoperative complications had opposing results. These two studies conducted a similar analysis of 30-day surgical site infections using the VA NSQIP database, but differed in the specific subset of surgical procedures, suggesting that more detailed analyses are needed.
If detailed information on smoking-attributable risk were available for specific procedures, procedure characteristics and specific patients with other comorbidites, then the intensity of smoking cessation interventions could better be matched to the level of risk. However, the interaction of procedure characteristics and smoking has not been previously assessed; nor has the potential of this more detailed information to influence the implementation of smoking cessation interventions.
OBJECTIVE(S):
In this two-year project, our three Specific Aims are to:
1. Refine knowledge about the impact of smoking on surgical complications. Further detail the association of smoking and 30-day risk of surgical complications by analyzing variations by procedure and patient characteristics using a cohort of 502,647 patients (185,085 smokers) receiving surgery in the VA from 2000-2004, using NSQIP data.
2. Describe barriers, facilitators, and current pre-operative smoking cessation practices across VA. Conduct a comparative case-study using a mix of quantitative and qualitative approaches to characterize effective care processes for preoperative smoking cessation interventions currently in use by VA Medical Centers (VAMCs).
3. Combine knowledge gained in Aims 1 and 2 with current knowledge on efficacy of smoking cessation interventions to develop an implementation study that tailors preoperative cessation interventions to the local environment and to the patient. Informed by an expert panel, we will develop and pilot patient education materials and practice level tools, and begin planning an implementation study focused on preoperative interventions in surgeries where risk is greatest, and tailored to patient and local system characteristics.
METHODS:
For Aim 1, we will conduct a national retrospective cohort study assessing 30-day patient outcomes for patients undergoing surgery within the VA during the years 2000-2004. We will use the National Surgical Quality Improvement Program database for these analyses. For Aim 2, we will develop and refine a brief survey to assess barriers and the availability and intensity of pre-operative smoking cessation interventions. We will then conduct key informant interviews by conference call. We have chosen to interview 10 facilities with higher intensity programs to achieve high levels of theme saturation among the top performers. For comparison, we will interview five low-intensity facilities. Thus, we will be able to qualitatively compare the processes, but will use the majority of resources to explore the top performers. To accomplish Aim 3, we plan to use the expert panel as a general sounding board for our formative research. We will collapse data from Aim 1, Aim 2, and literature reviews, to provide potential scenarios for implementing more intensive, but targeted, preoperative cessation interventions. To formalize this process, we will use a combination of techniques, including nominal group technique and cross-impact analysis.
FINDINGS/RESULTS:
No results at this time.
IMPACT:
As discussed above, of the 375,000 veterans undergoing surgery yearly in the VA, over one-third are smokers. Smoking causes significant increase in postoperative morbidity in this large segment of the Veteran population, and increase in costs to the VA. Preoperative smoking cessation interventions, especially those that are more intense, have promise in reducing morbidity, but are costly and under-utilized. The actual frequency and intensity of preoperative smoking cessation efforts by VA clinicians and facilities is unknown. In discussions with Dr. Kamal Itani, Chief of Surgery at the Boston VA, and Dr. Michael Bishop, Director of the VA Headquarters Anesthesia Service, their impression is that preoperative smoking efforts are underway, but are of low intensity and not systematically implemented.
Our analysis will compare the smoking-attributable risk across the most frequent procedures in the VA. Results of this analysis will allow facilities to best match intensity of smoking cessation procedures to level of risk due to smoking. By evaluating current effective care processes in Specific Aim 2, we will be able to develop a menu of strategies that can be incorporated into implementation strategies for preoperative smoking cessation interventions.
Our project is in response to the Implementation solicitation (Solicitation B) of the current HSR&D Priorities For Investigator-Initiated Research. This project will result in data (differences in smoking attributable risk), characterize effective care processes (ongoing preoperative care), and develop tools (with the help of our national advisory board) that are necessary intermediates needed for designing and planning implementation research for preoperative smoking cessation interventions that will improve Veteran's Healthcare. Specifically, our results will be leveraged to provide:
1. Veterans who smoke with detailed evidence about their postoperative risks.
2. Clinicians and Facilities with
A. Procedure-specific data about the risks of smoking to their patients and
thus, a rationale to provide more intensive counseling.
B. Data on how hospitals who are early adopters of preoperative smoking
cessation interventions have successfully integrated these services into
preoperative care.
3. Policy Makers at all levels with evidence to consider system level approaches
to target policies and incentives for preoperative smoking cessation.
One additional rationale supports the relevance of this proposal. Smoking rates are higher among African-American patients (35.9%) compared with Whites (29.4%). In addition, Dr. Houston's and others' previous research projects have documented disparities in tobacco control. Finally, recent research using NSQIP data has noted that African-American and Hispanic Veterans have a higher rate of postoperative infectious and non-infections complications, compared with white Veterans. Arguably, some of this disparity in surgical outcomes may be related to differences in smoking rates, and lower receipt of smoking cessation advice among ethnic minorities resulting in higher rates of postoperative complications. Thus, preoperative smoking cessation interventions may reduce this disparity.
Finally, our project was planned for a high level of "veteran centricity" (will lead to improvement in Veteran's healthcare). Each of the Specific Aims will contribute to planning policy and health services implementation changes for preoperative smoking cessation.
PUBLICATIONS:
None at this time.
DRA:
Substance Abuse, Addictive Disorders
DRE:
Prevention, Treatment
Keywords:
Smoking, Surgery, Nicotine
MeSH Terms:
none
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