QuitLink: A Leveraging Solution to Tobacco Counseling

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QuitLink A Leveraging Solution to Tobacco
Counseling

• Virginia Commonwealth University
• Stephen F. Rothemich, MD, MS
• Steven H. Woolf, MD, MPH
• Robert E. Johnson, PhD
• Kelly J. Devers, PhD
• Sharon K. Flores, MS
• Amy E. Burgett, RN
• American Cancer Society Quitline
• Pamela Villars, MEd, LPC
• Vance Rabius, PhD
• Group Health Cooperative
• Tim McAfee, MD, MPH
• Funded by AHRQ (1 R21 HS014854)

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Background

• Few practices can routinely provide more than
  simple cessation advice
• Numerous barriers to intensive counseling
• Lack of office support systems to conduct
  cessation counseling amidst the competing demands
  of busy primary care visits
• Quit lines deliver intensive counseling

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Primary Objective

• To test whether patient-reported delivery of
  intensive cessation counseling in practices is
  enhanced by QuitLinks 3-component approach to
  integrating quit lines into primary care practice

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QuitLink Components

1. An expanded vital sign intervention (Ask, Advise,
   Assess done by staff)
2. Capacity to provide fax referral of
   preparation-stage patients for proactive
   telephone counseling (American Cancer Society
   Quitline)
3. Feedback to the provider team, including
   individual and aggregate reports and prescription
   requests

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Setting

• September 2005 - June 2006
• 16 primary care practices in the greater
  Richmond, VA area
• 3 inner-city, 4 rural, and 9 suburban
• 11 family medicine, 2 internal medicine,
  and 3 with both specialties
• Median of 4 providers range 2-7

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Study Design

• Cluster-randomized controlled trial
• ClinicalTrials.gov Identifier NCT00112268
• Control Traditional tobacco-use vital sign
• 2 sets of cross-sectional exit surveys
• 3-month pre-intervention period
• Block randomization of practices
• Treatment arm assignment
• 1 hour training session at 8 intervention
  practices
• 9-month comparison period

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Data Sources

• Brief exit survey distributed by research
  assistants to adult patients
• Minimal data set from ACS Quitline
• Semi-structured interviews with practice staff

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Survey Participants

• Adults who had just completed a visit with a
  clinician
• Physician, nurse practitioner, or physician
  assistant
• Exit surveys from 13,562 pre-intervention and
  comparison period exit surveys
• 18 smokers
• Outcome data from 1,815 smokers in comparison
  period

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Intervention Elements

• Rooming staff used expanded vital sign
• Practice offered fax referral for proactive
  telephone counseling
• Patients contacted by ACS Quitline staff for
  intake and enrollment in 4 session counseling
  program
• Bupropion SR fax prescription request form
• Individual patient outcomes report
• Quarterly benchmarked aggregate feedback

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Data Analysis

• Intensive counseling
• Affirmative answer to questions addressing
  discussion of how to quit and/or referral
• Adjustment for temporal sampling differences
  among practices and providers
• Nested, hierarchical logistic regression model
  accounted for 3 sources of variation

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Principal Findings (1)
Counseling Behavior Survey Question Adjusted Affirmative Response Adjusted Affirmative Response Adjusted Affirmative Response Adjusted Affirmative Response
Counseling Behavior Survey Question Control Intervention Difference p value
Ask (A1) Did anyone ask you today if you smoke? 64.5 59.6 -4.9 0.45
Advise (A2) If you smoke, did anyone advise you today to stop smoking? 55.1 57.9 2.8 0.40

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Principal Findings (2)
Counseling Behavior Survey Question Adjusted Affirmative Response Adjusted Affirmative Response Adjusted Affirmative Response Adjusted Affirmative Response
Counseling Behavior Survey Question Control Intervention Difference p value
Intensive Counseling (A3-5Referral) Main Outcome 29.5 41.4 11.9 lt0.001
Discussion (A3-5) If you smoke, did anyone talk with you today about ideas or plans to help you quit smoking? 28.7 35.2 6.5 0.001
Referral If you smoke, were you referred today to a quit line? 8.7 21.4 12.7 lt0.001

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ACS Quitline Outcomes (1)(preliminary analysis
of limited data set)

• 329 referrals over 9 months
• 237 in Q1 66 in Q2 26 in Q3
• Referrals volume varied by practice
• Median 39.5 range 1 81
• Referrals volume varied by clinician
• Median 6 range 0 39
• Name missing on 34
• No referral attributed to 23.5 of clinicians

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ACS Quitline Outcomes (2)(preliminary analysis
of limited data set)

• Quitline reached 113 (34.3) for intake
• Multiple call protocol single phone number
• 88 (77.8) elected proactive counseling
• 48 (54.5) had at least one session
• 26 had 2, 17 had 3, and 6 had all 4 sessions
• 22 (45.8) not smoking at last contact
• Additional 7 (14.6) cut back 50

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Clinician/Staff Interviews (1)(preliminary
analysis of field notes and post-interview
summaries)

• Practices liked many aspects
• Systematic process for screening and counseling
• Concrete option to offer patients for intensive
  counseling
• Relative simplicity, ease of implementation
• Not a significant burden on clinicians or staff
• Great potential value to patients

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Clinician/Staff Interviews (2)(preliminary
analysis of field notes and post-interview
summaries)

• Variation in how QuitLink was implemented
• Likely led to variation in referral rates
• Practices offered suggestions for improvement
• (e.g., brochure explaining telephone counseling,
  more feedback from quit line)

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Conclusions

• The intervention increased patient-reported
  intensive counseling
• Salutatory effect on reports of in-office
  discussion and quit line referrals
• Implementation and utilization varied
• Referral volumes declined over time

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Limitations

• Outcome was counseling, not cessation
• Relied on patient report of counseling
• Hawthorne effect possible
• Effect only measured for 9 months
• Cannot assess individual components
• Insufficient recruits for patient interviews
• Impact likely reduced by several factors

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Policy Implications

• Fax referral is a win-win arrangement
• Practices and quit lines can engage in
  bidirectional communication
• Screening on stage of change is possible and
  should be done to reduce inappropriate referrals

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Related/Future Work

• Electronic referral in practices with EHR
• Pilot project with Virginia state quit line
  (service provider is Free Clear)
• RWJF Transition grant with second EHR
• Future studies refining QuitLink model and
  evaluating additional and longer-term outcomes

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