A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support.

INTRODUCTION: This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach. METHODS: A stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts. RESULTS: Forty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2-33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7). CONCLUSIONS: Despite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased. IMPLICATIONS: Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach. TRIAL REGISTRATION: clinicaltrials.gov #NCT02764385 , registration date 06/05/2016.

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines.

BACKGROUND: The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in order to inform strategies for improving QL engagement. METHODS: We conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017-August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes. RESULTS: Reasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL. CONCLUSIONS: Participants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.

12-Month Evaluation of an EHR-Supported Staff Role Change for Provision of Tobacco Cessation Care in 8 Primary Care Safety-Net Clinics.

SIGNIFICANCE: Guidelines urge primary care practices to routinely provide tobacco cessation care (i.e., assess tobacco use, provide brief cessation advice, and refer to cessation support). This study evaluates the impact of a systems-based strategy to provide tobacco cessation care in eight primary care clinics serving low-income patients. METHODS: A non-randomized stepped wedge study design was used to implement an intervention consisting of (1) changes to the electronic health record (EHR) referral functionality and (2) expansion of staff roles to provide brief advice to quit; assess readiness to quit; offer a referral to tobacco cessation counseling; and sign the referral order. Outcomes assessed from the EHR include performance of tobacco cessation care tasks, referral contact, and enrollment rates for the quitline (QL) and in-house Freedom from Smoking (FFS) program. Generalized estimating equations (GEE) methods were used to compute odds ratios contrasting the pre-implementation vs. 1-, 3-, 6-, and 12-month post-implementation periods. RESULTS: Of the 176,061 visits, 26.1% were by identified tobacco users. All indicators significantly increased at each time period evaluated post-implementation. In comparison with the pre-intervention period, assessing smoking status (26.6% vs. 55.7%; OR = 3.7, CI = 3.6-3.9), providing advice (44.8% vs. 88.7%; OR = 7.8, CI = 6.6-9.1), assessing readiness to quit (15.8% vs. 55.0%; OR = 6.2, CI = 5.4-7.0), and acceptance of a referral to tobacco cessation counseling (0.5% vs. 30.9%; OR = 81.0, CI = 11.4-575.8) remained significantly higher 12 months post-intervention. For the QL and FFS, respectively, there were 1223 and 532 referrals; 324 (31.1%) and 103 (24.7%) were contacted; 241 (74.4%) and 72 (69.6%) enrolled; and 195 (80.9%) and 14 (19.4%) received at least one counseling session. CONCLUSIONS: This system change intervention that includes an EHR-supported role expansion substantially increased the provision of tobacco cessation care and improvements were sustained beyond 1 year. This approach has the potential to greatly increase the number of individuals referred for tobacco cessation counseling.

Designing for Sustainability: An Approach to Integrating Staff Role Changes and Electronic Health Record Functionality Within Safety-Net Clinics to Address Provision of Tobacco Cessation Care.

BACKGROUND: Guidelines urge primary care practices to routinely provide tobacco cessation care, but quality indicators for the provision of advice and assistance to quit smoking lag. This study evaluated the implementation of a systems-based strategy to improve performance of tobacco cessation care in primary care clinics. METHODS: Changes to the electronic health record (EHR) facilitated staff to document when they ask about tobacco use, advise the patient to quit, offer to connect the patient to a quitline (QL) counselor, and refer interested patients to receive a call from a QL. Medical assistants (MAs) were trained to use the new sections of the EHR, and their roles were expanded to include the provision of brief cessation advice and activation of the QL referral. Primary outcomes were change in tobacco cessation processes preimplementation vs. one, three, and six months postimplementation of the strategy. RESULTS: The increase in performance of tobacco cessation care was significant and sustained at six months postimplementation for assessing smoking status (50.9% vs. 76.3%; odds ratio [OR] = 3.04; 95% confidence interval [CI] = 2.80-3.31), providing advice (15.1% vs. 92.7%; OR = 69.3; 95% CI = 51.88-92.60), assessing readiness to quit (22.8% vs. 76.6%; OR = 10.80; 95% CI = 8.92-13.08), and accepting a referral to the QL (1.3% vs. 21.7%; OR = 20.31; 95% CI = 4.91-84.05). CONCLUSION: Key stakeholder engagement informed a system change intervention that includes an EHR-supported role expansion of MAs for QL referrals; these changes substantially increased the provision of tobacco cessation care.

Medical Provider Recommendations to Massage Therapy: a Card Study.

BACKGROUND: Communication between massage therapy patients and their medical providers has not been widely described, especially with respect to health care in the United States. PURPOSE: To examine which type of medical providers recommend massage therapy (MT), and how often massage therapy patients tell their providers about their treatment. SETTING: Independent massage therapy practices in a Practice-based Research Network (PBRN) in Northeast Ohio. PARTICIPANTS: 21 licensed massage therapists (LMT). RESEARCH DESIGN: A cross-sectional descriptive study. For consecutive, nonrepeating visits to their practices, each LMT completed up to 20 cards with information on the patient and visit. Analysis compared visits for patients based on whether they reported telling their health provider about their use of MT or being recommended for massage by a health provider. RESULTS: Among 403 visits to 21 LMTs, 51% of patients had told their primary care clinician about seeing an LMT, and for 23%, a health-care provider had recommended visiting an LMT for that visit. Patients who told their primary care provider that they use massage therapy were more likely to be established patients, or to be seen for chronic pain complaints. Visits recommended by a physician were more likely to be for chronic conditions. CONCLUSION: Patients who are established in the massage practice and those receiving massage for a specific condition are more likely to tell their primary care provider that they use massage and are also more likely to have been recommended for massage by a health-care provider. This information will help LMTs target and inform patients about the importance of talking with their health-care providers about their use of massage, and provide LMTs with a starting point of which types of health-care providers already recommend massage. This information will further open the dialogue about the integration of massage therapy in conventional health care.

Electronic medical record documentation of tobacco cessation support at eight community safety-net clinics with a high prevalence of tobacco use.

OBJECTIVES: The high prevalence of tobacco use at primary care safety-net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting agencies to demonstrate care quality. This study examines tobacco cessation support rates and patient characteristics using electronic medical record (EMR) data. METHODS: This cross-sectional study engaged eight community health centers affiliated with a county hospital system in NE Ohio where adult tobacco use rates exceed 30%. EMR data from June 2014 through May 2016 were analysed to assess rates of tobacco cessation counselling, order of cessation medications, or both. The association of tobacco cessation support with patient characteristics and quit attempts was assessed using multivariable logistic regression models. RESULTS: Among 21 702 current tobacco users, 74% had no intervention documented; 15.4% had counselling documented, 6.4% were prescribed tobacco cessation medication, and 4.2% had both documented. Males, those aged 18 to 34, and African Americans were more likely to have no documented intervention. Of current tobacco users with at least two visits, 5.6% had a quit attempt. Medication alone was associated with a greater likelihood of a quit attempt (AOR: 1.72 [95% CI: 1.36-2.17]) as well as counselling and medication combined (AOR: 1.95 [95% CI: 1.48-2.56]). CONCLUSIONS: Tobacco cessation support was lacking for 74% of current smokers and was less likely in subgroups including males, younger adults, and African Americans. Ordering tobacco cessation medication combined with counselling nearly doubled the likelihood of a quit attempt.

Parental Vaccine Acceptance: A Logistic Regression Model Using Previsit Decisions.

This study explores how parents' intentions regarding vaccination prior to their children's visit were associated with actual vaccine acceptance. A convenience sample of parents accompanying 6-week-old to 17-year-old children completed a written survey at 2 pediatric practices. Using hierarchical logistic regression, for hospital-based participants (n = 216), vaccine refusal history ( P < .01) and vaccine decision made before the visit ( P < .05) explained 87% of vaccine refusals. In community-based participants (n = 100), vaccine refusal history ( P < .01) explained 81% of refusals. Over 1 in 5 parents changed their minds about vaccination during the visit. Thirty parents who were previous vaccine refusers accepted current vaccines, and 37 who had intended not to vaccinate choose vaccination. Twenty-nine parents without a refusal history declined vaccines, and 32 who did not intend to refuse before the visit declined vaccination. Future research should identify key factors to nudge parent decision making in favor of vaccination.