Depressive symptoms and smoking cessation after hospitalization for cardiovascular disease.

BACKGROUND: Although smoking cessation is essential for prevention of secondary cardiovascular disease (CVD), many smokers do not stop smoking after hospitalization. Mild depressive symptoms are common during hospitalization for CVD. We hypothesized that depressive symptoms measured during hospitalization for acute CVD would predict return to smoking after discharge from the hospital. METHODS: This was a planned secondary analysis of data from a placebo-controlled, double-blind, randomized trial of bupropion hydrochloride therapy in 245 smokers hospitalized for acute CVD. All subjects received smoking counseling in the hospital and for 12 weeks after discharge. Depressive symptoms were measured during hospitalization with the Beck Depression Inventory (BDI), and smoking cessation was biochemically validated at 2-week, 12-week, and 1-year follow-up. The effect of depressive symptoms on smoking cessation was assessed using multiple logistic regression and survival analyses. RESULTS: Twenty-two percent of smokers had moderate to severe depressive symptoms (BDI >or= 16) during hospitalization. These smokers were more likely to resume smoking by 4 weeks after discharge (P= .007; incidence rate ratio, 2.40; 95% confidence interval, 1.48-3.78) than were smokers with lower BDI scores. Smokers with low BDI scores were more likely to remain abstinent than were those with high BDI scores at 3-month follow-up (37% vs 15%; adjusted odds ratio, 3.02; 95% confidence interval, 1.28-7.09) and 1-year follow-up (27% vs 10%; adjusted odds ratio, 3.77; 95% confidence interval, 1.31-10.82). We estimate that 27% of the effect of the BDI score on smoking cessation was mediated by nicotine withdrawal symptoms. CONCLUSIONS: Moderate to severe depressive symptoms during hospitalization for acute CVD are independently associated with rapid relapse to smoking after discharge and lower rates of smoking cessation at long-term follow-up. The relationship was mediated in part by the stronger nicotine withdrawal symptoms experienced by smokers with higher depressive symptoms.

Bupropion for smokers hospitalized with acute cardiovascular disease.

PURPOSE: Smoking cessation after myocardial infarction reduces cardiovascular mortality, but many smokers cannot quit despite state-of-the-art counseling intervention. Bupropion is effective for smoking cessation, but its safety and efficacy in hospitalized smokers with acute cardiovascular disease is unknown. METHODS: A five-hospital randomized double-blind placebo-controlled trial assessed the safety and efficacy of 12 weeks of sustained-release bupropion (300 mg) or placebo in 248 smokers admitted for acute cardiovascular disease, primarily myocardial infarction and unstable angina. All subjects had smoking counseling in the hospital and for 12 weeks after discharge. Cotinine-validated 7-day tobacco abstinence, cardiovascular mortality, and new cardiovascular events were assessed at 3 months (end-of-treatment) and 1 year. RESULTS: Validated tobacco abstinence rates in bupropion and placebo groups were 37.1% vs 26.8% (OR 1.61, 95% CI, 0.94-2.76; P=.08) at 3 months and 25.0% vs 21.3% (OR, 1.23, 95% CI, 0.68-2.23, P=.49) at 1 year. The adjusted odds ratio, after controlling for cigarettes per day, depression symptoms, prior bupropion use, hypertension, and length of stay, was 1.91 (95% CI, 1.06-3.40, P=.03) at 3 months and 1.51 (95% CI, 0.81-2.83) at 1 year. Bupropion and placebo groups did not differ in cardiovascular mortality at 1 year (0% vs 2%), in blood pressure at follow-up, or in cardiovascular events at end-of-treatment (16% vs 14%, incidence rate ratio [IRR]1.22 (95% CI: 0.64-2.33) or 1 year (26% vs 18%, IRR 1.56, 95% CI 0.91-2.69). CONCLUSIONS: Bupropion improved short-term but not long-term smoking cessation rates over intensive counseling and appeared to be safe in hospitalized smokers with acute cardiovascular disease.

Rural communities improving quality through collaboration: the MaineHealth story.

Small and rural communities face unique challenges in improving healthcare quality. To address these challenges, MaineHealth, an integrated health system serving small and rural communities, leveraged knowledge, resources, and data through collaboration to help providers improve care and outcomes for asthma, heart failure, diabetes, and depression. The programs emphasized patient self-care, used uniform clinical standards, and supported population-based data collection. This collaborative approach provided an effective way to achieve improved outcomes across a geographically and structurally diverse system, and it can help influence improvement efforts in other small and medium-sized rural communities.

Use and effectiveness of tobacco telephone counseling and nicotine therapy in Maine.

BACKGROUND: Since 2001, the Maine Bureau of Health has offered free evidence-based treatment for tobacco dependence, including telephonic counseling and nicotine replacement therapy (NRT). This study examined the utilization of treatment services, evaluated quit outcomes, and estimated the population impact of treatment. METHODS: This is a descriptive study of tobacco users receiving treatment services from the Maine Tobacco HelpLine from January 2003 to December 2004. Demographics of callers were compared to adult smokers statewide, and NRT utilization was examined among callers eligible for therapy. Quit outcomes were assessed by telephone interview among a sample of callers registered November 15, 2003 to January 31, 2004 (n=535), 6 months after assistance. The population impact of treatment was estimated by applying intent-to-treat (30-day point prevalence) quit rates to services delivered in 2003 and 2004. Analyses were conducted in 2005. RESULTS: A total of 12,479 adult smokers (3% of smokers annually) utilized Maine's tobacco services during 2003 and 2004. Compared to smokers statewide, callers were more likely to be aged 45 to 64, female, or uninsured. A total of 82.3% of callers who were eligible for NRT and received counseling obtained free NRT. Intent-to-treat quit rates at 6 months were 12.3% (95% confidence interval [CI]=8.1-17.6) for counseling, and 22.5% (95% CI=19.1-26.3) for counseling plus NRT. An estimated 1864 smokers calling in 2003-2004 had successfully quit. CONCLUSIONS: The Maine Tobacco HelpLine and NRT programs have demonstrated effectiveness and population outreach, particularly to uninsured smokers. This study suggests that for quit lines to maximize their impact, tobacco medication access may be important.

Office-based intervention for tobacco dependence.

A successful office approach for any behavior change, including for tobacco, makes the intervention part of the everyday work of the medical practice. This article recommends how to integrate tobacco treatments efficiently into clinical practice. Specific ways to think systematically about smoking cessation and intervene with patients are discussed. Strategies to implement office-based changes to improve tobacco intervention are then presented.

Using claims data to examine patients using practice-based Internet communication: is there a clinical digital divide?

BACKGROUND: Practice-based Internet communication allows patients to obtain health information, ask questions, and submit requests through a personalized Web site. While such online tools also bring great promise for educating patients with the goal of fostering behavior change, it is important to examine how individuals currently using such services differ from those who do not. OBJECTIVE: The study used administrative information to characterize a population of patients communicating with a medical practice through the Internet during the end of 1999 and through 2000. METHODS: Patient claims data generated during clinical encounters from January 1999 through May 2000 were examined to measure the relationship between patient demographics, frequency of visits, specific acute diagnoses, and specific chronic diagnoses and the use of online communication with the practice. RESULTS: Ten percent of patients, and 13.2% of patients 18 years or older, used the practice Web site. There were differences in use of the practice Web site by age and insurance status, but not by gender. Use of the practice Web site was similar or higher among patients having a diagnosis for a variety of acute and chronic conditions compared to those not having such a diagnosis. Patients with more clinic visits were more likely to use the Web-based service. CONCLUSIONS: Patients using practice-based Internet communication and having significant health risks can be identified through the use of administrative data, presenting an opportunity to test online educational efforts to improve health.

Academic profiling of tobacco-related performance measures in primary care.

Academic detailing and data feedback are two methods that have been used to change provider behavior. Academic profiling is proposed as an intervention that combines provider educational outreach and peer-comparison feedback of data generated from chart reviews and health plans. This project assessed the feasibility of academic profiling, using baseline measures to assess provider performance in identifying and treating patients who smoke. The pilot study was undertaken with four primary care practices in Maine. Two health plans shared administrative claims data on adult patients of participating providers. Two educational sessions were conducted: one including feedback of tobacco-related chart documentation and claims for nicotine replacement and bupropion (Zyban), and the other, coding for tobacco use (ICD-9 305.1) in adults enrolled in two health plans during 1998. A mailed survey assessed provider attitudes following the intervention. Among 24 providers, 80% attended the first session and 70% attended the second session. Provider documentation of tobacco status in the medical records varied from 68% to 100%. The frequency of tobacco pharmacotherapy claims for adult health plan enrollees having a provider visit in 1998 varied from 0% to 4.6% (mean 1.5%) by provider. The frequency of tobacco use diagnosis claims (ICD-9 305.1) varied from 0% to 19.8% by provider. More than 90% of the providers who reviewed the profiling graphs found the data were understandable, and 66% reported that the sessions helped them improve the ways they interact with patients who smoke. Practices vary in tobacco-related documentation, the prescribing of tobacco pharmacotherapy, and the coding for tobacco use. Providers are willing to participate in educational outreach using peer-comparison feedback, presenting opportunities to improve performance in the treatment of tobacco dependence.