Clinical inquiries. What predicts a successful smoking cessation attempt?

Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results). Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).

Pre-precepting Residents on Matters of Importance for Today - The PROMPT Study.

CONTEXT: Achieving the goals proposed in national screening guidelines for colon cancer is difficult, especially in a primary care residency. The major vehicle for teaching outpatient medicine is the precepting process. Preceptors use their influence to teach guideline principles. Unfortunately, most precepting occurs after the visit and lost opportunities occur frequently. OBJECTIVE: To test whether having preceptors discuss screening guidelines with residents prior to patient encounters (pre-precepting) could improve adherence to colon cancer prevention guidelines. DESIGN: Intervention trial: An historical control group of 100 randomly chosen patient charts were studied to see if United States Preventative Services Task Force (USPSTF) guidelines for colon cancer screening were achieved. Faculty then pre-precepted 100 randomly chosen eligible patients with residents. Discussion with the patient and/or orders for screening tests were calculated from the residents' notes. A survey of all participants was also done to gauge acceptance. SETTING: A community health center for the medically underserved with approximately 13,000 patients. We limited our intervention to active patients over the age of 50. INTERVENTION: Preceptors selected eligible patients from resident appointment lists. USPSTF colon cancer screening guidelines were discussed prior to resident-patient encounters. OUTCOME MEASURES: A review of the pre-precepted charts determined the documented rate of discussion and /or screening. A satisfaction survey of residents and faculty was used to determine acceptance. RESULTS: A statistically significant improvement was noted in the pre-precepted group as compared to the historical controls (p˂0.05, X2 testing). Surveys of participants showed they accepted the new intervention. CONCLUSIONS: Screening for colon cancer can be improved by pre-precepting. A pilot study for quality improvement via pre-precepting was well accepted by both faculty and residents. A multi-center blinded trial should be considered to further test this technique.

Quality improvement in family practice: a recipe for change.

A new recipe is presented, splitting quality improvement into 4 levels. The Q1 level corresponds to the everyday processes that guide our daily work flow. Q2 corresponds to commonly thought of outcome measures such as HEDIS criteria. Q3 relates to the executive functions that permit seasoned clinicians to draw generalizations about care for individual patients by synthesizing large amounts of data from both psychosocial as well as classical history/physical sources. Finally Q4 reflects more population-based quality improvement activities. Examples are given for each. Each of these levels requires a different approach for improvement activities. Each must be seen in the context of an expanded "quality compass" and in the paradigm of the PLAN-DO-CHECK-ACT cycle of quality improvement. Finally, a practical application of how this could be instituted at a Family Practice residency is given.