Interest in Recycling Among Relapsed Smokers

1
Interest in Recycling Among Relapsed Smokers

• Steven S. Fu, MD, MS
• Melissa R. Partin, PhD
• Annamay Snyder, BA
• Lawrence C. An, MD
• David Nelson, PhD
• Sean Nugent, BA
• Mark Willenbring, MD
• Anne M Joseph, MD, MPH

2
Background

• 20 million smokers try to quit each year
• Most attempts dont ? long-term abstinence
• Multiple attempts necessary

3
Background DHHS Clinical Practice Guideline

• Systematize identification of smokers
• Offer treatment to all identified smokers
• Use pharmacological and behavioral tx
• Treat tobacco dependence as chronic condition
• Repeat intervention often necessary

4
BackgroundVA Compliance with Guideline

• Substantial improvement in
• Identification
• Advise
• Sub-optimal treatment rates
• 15 pharmacological tx
• 1/3rd behavioral tx
• Systematic follow-up rare

5
BackgroundVA Barriers to Implementation

• Providers aware of guideline
• Favorably predisposed
• Remaining barriers include
• Staff time
• Technical support (system for id smokers)
• Patient attitudes (? provider skepticism /
  discouragement)

6
BackgroundSolutions

• Focus on enabling and reinforcing factors
• Minimize individual provider burden
• Systematize identification of smokers
• Address provider skepticism
• Target motivated patients

7
REcycling Smokers through Effective Treatment
(RESET) Study

• Uses administrative databases to identify
  motivated smokers
• Encourages and facilitates recycling
• Addresses provider skepticism by
• Pointing out successes
• Highlighting recycling interest
• Reduces primary care provider burden

8
RESET Objectives

• Assess effectiveness of patient phone call,
  computerized progress note intervention for
  increasing
• Tobacco dependence treatment
• Cessation
• Satisfaction

9
RESET Target Population(Eligibility Criteria)

• Veterans
• Age 19
• Primary care appointment at participating
  facility in 2001 or 2002
• Received NRT or bupropion rx between February and
  October 2002

10
RESET Study Design

• Randomized, controlled trial
• 1900 eligible veterans randomized to
• Patient phone call / computerized provider prompt
  (intervention)
• Usual care (control)
• Stratified by facility (Denver, Providence, New
  Orleans, Salt Lake City, Seattle)

11
RESET InterventionPatient Phone Call

• Contact 4-9 months after last rx fill
• Assess
• Smoking status and characteristics
• Experience with last quit attempt
• Motivation (quit within 30 days, 6 months)
• Treatment preferences, contraindications
• Follow-up letter

12
RESET Intervention Provider Prompt

• Computerized progress note
• Currently abstinent (reinforcement)
• Quit next 0-6 months with NRT
• Quit next 0-6 months with bupropion, no
  contraindications
• Quit next 0-6 with bupropion, contraindications
• Information on
• Patient contact date
• Smoking status and characteristics
• Quit challenges, side effects
• Motivation (quit within 30 days, 6 months)
• Treatment preferences, contraindications

13
RESET InterventionProvider Prompt

• Delivered to
• Primary care provider
• One additional signer
• Request for
• Signature
• Amendment with course of action

14
SAMPLE PROMPT We spoke to patient's name by
phone on date. Mr./Ms. patients name WANTS
TO ATTEMPT TO QUIT SMOKING IN THE NEXT 30 DAYS/6
months using drug1 choice, drug2 choice and
individual/group counseling. Please consider
arranging drug therapy and/or counseling to
help patient meet his/her quit goal.
  CURRENT PATIENT INFORMATION Tried to quit
smoking using drug in last fill month/year.
Did/Did not receive counseling with this
quit attempt (name of cessation clinic if
appropriate). Relapsed to smoking after
days abstinence. Currently smoking current
cigs/day/day. Main problems remaining
abstinent include challenge1challenge2cha
llenge3. Reported no/some side effects with
drug (list of any side effects
reported).   Please sign to acknowledge receipt
and, if possible, make addendum with plan of
action. You can share this information with
another staff member by writing an addendum to
this note and adding an additional signer.   It
takes most patients several attempts to
successfully quit smoking. For information on how
to help a patient who is ready to quit smoking,
see the Quick Reference Guide for Clinicians at
http//www.surgeongeneral.gov/tobacco/tobaqrg.htm

15
RESET Process Analysis

• Patient intervention response (from phone call)
• Prevalence and predictors of relapse
• Distribution and determinants of quit motivation
• Treatment preferences
• Intervention exposure
• Provider intervention response
• Proportion of notes signed
• Distribution of notes across provider types
• Average waiting time to note signature
• Feedback from qualitative interviews

16
RESET Process Analysis Sample

• 1900 randomized

951 Intervention
949 Control
Completed intervention call 599 (63)
136 Not eligible (23)
357 Relapsed (60)
106 Abstinent (18)
17
Results Sample Characteristics by smoking
status
18
Results Sample Characteristics by smoking
status
19
ResultsInterest in quitting among relapsed
smokers
20
Results Sample characteristics by quit interest
21
Results Sample characteristics by quit interest
22
Treatment preferences

• Interested in pharmacological tx 90
• NRT 65
• Bupropion 48
• Interested in behavioral tx 65
• Individual 41
• Group 28

23
Summary and Conclusions

• Relapsed smokers very receptive to recycling
• Majority want repeat treatment within month
• Significant interest in pharmacological tx
• Receptivity to behavioral tx
• Recent pharmacological tx users in action phase
  of quitting ? potentially fruitful intervention
  target
• Loss to follow-up barrier to success of proactive
  recycling strategies