ABSTRACT
INTRODUCTION: Tobacco use remains pervasive amongst veterans. Unfortunately, the negative impact on postoperative outcomes may preclude surgeons from offering operative intervention to veterans who smoke. As such, a major health event may provide added incentive to quit. We sought to describe the role of acute illness and interventional specialist involvement in Veterans Affairs Smoking Cessation Program referrals compared to primary care wellness initiatives. METHODS: We retrospectively reviewed consultations to the pharmacy-led Smoking Cessation Program (SCP) at the Middleton Memorial VA Hospital from 2017 to 2019. Consultations placed during the last three months were categorized based on the source of referral: primary care, acute care, and interventional specialties. Descriptive statistics were used to assess rates of veteran engagement based on referral source. Consultation completion was used as a proxy for veteran engagement. RESULTS: A total of 2993 new SCP consultations were placed during the study period. Overall, veteran engagement rose from 43% in 2017 to 53% in 2019. In recent months, there were 282 SCP referrals. While only 19 (7%) of these referrals were placed by interventional specialties - primarily cardiology and thoracic surgery - the rate of veteran engagement was 63%. The majority of referrals (65%) were placed by primary care providers with an engagement rate of 68%. In contrast, only 42% of consultations placed in the context of an acute illness were completed. CONCLUSIONS: In our study, primary care directed smoking cessation referrals were most prevalent and resulted in the highest completion rates. The presence of an acute illness in isolation failed to impact program success. However, while surgeon-initiated referrals were meager in number, the engagement rate approached that of primary care. This finding suggests that surgeons play a powerful role in influencing patient behavior that may be harnessed to augment success of existing smoking cessation programs.
ABSTRACT
Background: Access to specialty health care in the Veterans Affairs (VA) system continues to be problematic. Given the potential temporal and fiscal benefits of telehealth, the Madison VA developed a virtual consultation (VC) mechanism to expedite diagnostic and therapeutic interventions for Veterans with incidentally discovered pulmonary nodules. Materials and. Methods: VC, a remote encounter between referring provider and thoracic surgeon for incidentally discovered pulmonary nodules, was implemented at the Madison VA between 2009 and 2011. Time from request to completion of consultation, hospital cost, and travel costs were determined for 157 veterans. These endpoints were then compared with in-person consultations over a concurrent 6-mo period. Results: For the entire study cohort, the mean time to completion of VC was 3.2 d (SD ± 4.4 d). For the 6-mo period of first VC availability, the mean time to VC completion versus in-person consultation was 2.8 d (SD ± 2.8 d) and 20.5 d (SD ± 15.6 d), respectively (p < 0.05). Following initial VC, 84 (53%) veterans were scheduled for virtual follow-up alone; no veteran required an additional office visit before further diagnostic or therapeutic intervention. VA hospital cost was $228 per in-person consultation versus $120 per episode for VC - a 47.4% decrease. The average distance form veteran home to center was 86 miles, with an average travel reimbursement of $112 per in-person consultation, versus no travel cost associated with VC. Conclusions: VC for incidentally discovered pulmonary nodules significantly decreases time to consultation completion, hospital cost, and veteran travel cost. These data suggest that a significant opportunity exists for expansion of telehealth into additional practice settings within the VA system.
