EM Yano, VA Greater Los Angeles HSR&D Center of Excellence; SE Sherman, VA Greater Los Angeles HSR&D Center of Excellence; AB Lanto, VA Greater Los Angeles HSR&D Center of Excellence; ML Lee, VA Greater Los Angeles HSR&D Center of Excellence; LV Rubenstein, VA Greater Los Angeles HSR&D Center of Excellence

Objectives: Tobacco use is the leading preventable cause of death and disease in the U.S., despite the availability of a wide range of effective smoking cessation treatments. While veterans' smoking prevalence varies as a national performance measure, VA medical centers (VAMC's) have been working to improve smoking cessation counseling rates among the veterans they serve, with variable success. We evaluated the determinants of tobacco counseling rates among VAMC's to assess the extent to which the organization of care may account for some of the variation.

Methods: We conducted a facility-level analysis linking tobacco counseling rates and primary care features among 140 VAMC's. VAMC-specific tobacco counseling rates were derived from the VA External Peer Review Program (EPRP), based on chart abstractions performed on random samples of veteran outpatients at each VAMC with at least 1 primary care and at least 1 subspecialty visit in FY97. Measures of the organization of primary care were derived from the VHA Primary Care Delivery Model Survey (1996) and organizational culture scores from the first wave of the National VA Quality Improvement Survey (Management Decision and Research Center). Bivariate analyses were performed to examine the relationship between individual organizational features and tobacco counseling rates. We conducted multiple linear regression among those features at p<.25 using a forward stepwise algorithm.

Results: Counseling rates varied by region (p<.01), with lowest rates in the East (.73) and highest in the Western states (.83). More complex VAMC's had lower tobacco counseling rates (p<.0001), consistent with lower rates among urban (p<.0001), academic (p<.01) VA's, with more internal medicine houseofficers (p<.01) and larger patient caseloads (p<.001). VA's with higher self-reported levels of primary care implementation and those with higher proportions of veteran users receiving most or all of their care in primary care had higher tobacco counseling rates (p<.05). We found no difference between VA's with and without firm systems (0.80 vs. 0.77), although VA's where physicians were responsible for their patient panels as inpatients had higher rates (p<.05). Higher tobacco counseling rates occurred in VA's with higher leadership (p<.001) and quality improvement orientation scores (p<.05), as well as among VA's with more primary care-based process action teams (p<.05). Rates were marginally higher among those with higher group (p=.054) and risk taking cultures (p=.055).

Conclusions: Achieving more guideline-adherent smoking cessation practices in large, academic VA's may pose significant challenges for VA providers and planners. Improving veterans' quit rates may require additional intervention at the primary care program level, as conventional features that foster overall primary care performance may not uniformly succeed for smoking cessation care. At the same time, more research is needed on the provider behavior interventions that are most likely to overcome system barriers to screening, counseling and referral.

Impact: These results provide important information about the influence of primary care organizational features on performance, specifically tobacco counseling rates. System-level changes in primary care-based screening, counseling and referral may be needed to foster more guideline-adherent smoking cessation care and, ultimately, improved population quit rates.