TE Vaughn, Department of Health Management and Policy, University of Iowa College of Public Health; MM Ward, Department of Health Management and Policy, University of Iowa College of Public Health; BN Doebbeling, Program in Health Services Research, Iowa City VAMC, Department of Internal Medicine, The University of Iowa College of Medicine and Department of Epidemiology, University of Iowa College of Public Health; WR Clarke, Department of Biostatistics, University of Iowa College of Public Health; T Uden-Holman, Department of Health Management and Policy, University of Iowa College of Public Health; E Letuchy, Department of Internal Medicine, The University of Iowa College of Medicine

Objectives: Smoking is the chief avoidable cause of illness and death in the United States. Practice guidelines have been developed and implemented within VA, that recommend appropriate smoking cessation interventions for outpatient clinic settings. The purpose of this study is to identify rates of compliance with VA clinical practice guidelines (CPGs) for smoking cessation and identify organizational factors associated with better compliance.

Methods: A national random sample of 844 physicians at 127 VAMC ambulatory care clinics completed a survey of their self-reported knowledge, attitudes, and practice patterns regarding VA smoking cessation CPGs. The analysis consisted of principal components factor analysis of survey items to create scales and step-wise multivariate regression. Generalized estimating equations and SUDAAN were employed to address the complex sampling approach (physicians at different facilities with different selection probabilities) and multiple respondents at facilities. The dependent variable, Interventions, averages items that asked physicians how often seven specific interventions were provided to smoking patients, using a Likert-type scale: explain the risks of smoking, suggest stopping smoking, provide written material about smoking cessation, refer to smoking cessation programs, write prescriptions for nicotine replacement and/or Zyban and follow up on the patient's progress (Cronbach's alpha = .75). Independent variables included survey data regarding micro-organizational factors (management support, policies and procedures), physician knowledge and attitudes about guidelines, physician characteristics and American Hospital Association (AHA) data on organizational characteristics (bedsize, teaching status, services).

Results: Most common interventions (providers indicated "always" or "usually") were: "explaining the health risks of smoking" (86%), "suggesting stopping" (95%), "referring to a smoking cessation program" (57%) and "following up on the patient's progress" (71%). Least common were: "providing written materials about smoking cessation" (22%) and "writing prescriptions for nicotine replacement" (16%) or Zyban (12%). Most (71%) physicians indicated that their facility had a policy limiting prescriptions for nicotine replacement therapy and Zyban to patients who enroll in smoking cessation programs (prescription policy); 12% were unaware whether their facility had such a policy.

The regression model explained 29% of the variation in Interventions. Significant positive correlates included: greater teamwork in implementing the guideline (B=.06, p<.0001), reported knowledge of other VA CPGs (B=.17, p<.0001), belief that smokers are receptive to stopping (B=.22, p<.0001), and physician gender (female; B=.17, p<.01). Negative correlates were: belief that implementing changes takes too long (B=-.05, p<.05), being unaware of whether a facility has a prescription policy (B=-.35, p<.0001), the existence of such a policy (B=-.25, p<.001), and physician specialty (non-primary care specialties, e.g., surgery, dermatology, psychiatry, emergency medicine); B=-.71, p<.001).

Conclusions: Adherence to VA smoking cessation guidelines is associated with organizational policies and implementation processes as well as physician knowledge and attitudes. Fortunately, all of these are potentially malleable.

Impact: VA quality improvement efforts would benefit from studies that identify effective ways to address implementation processes and organizational policies that improve provider knowledge of CPGs, support change in provider practice patterns consistent with CPGs and demonstrate the effectiveness of the new practices.