Targeting Primary Care Referrals to Smoking Cessation Clinics Does Not Improve Quit Rates

VA Greater Los Angeles HSR&D Center of Excellence, Sepulveda VA Ambulatory Care Center (152), 16111 Plummer Street, Sepulveda, CA 91343, USA.
Health Services Research (Impact Factor: 2.78). 06/2008; 43(5 Pt 1):1637-61. DOI: 10.1111/j.1475-6773.2008.00865.x
Source: PubMed


To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.
We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.
In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.
To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.
Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.
EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

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    • "Both sets of researchers attempted to evaluate ''real-world'' settings where the leadership and resources and actions emanated from the organizations themselves rather than being undergirded or provided totally by the researchers. Elizabeth Yano, Lisa Rubenstein, Melissa Farmer, Bruce Chernof, Brian Mittman, Andrew Lanto, Barbara Simon, Martin Lee, and Scott Sherman evaluated a quality-improvement based effort to help Veterans quit smoking (Yano et al. 2008). Eighteen VA facilities were randomized to receive quality improvement assistance (structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback and monitoring) or mailed guidelines and VA audit-feedback reports. "

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    • "For example, in the Substance Use Disorders (SUD) QUERI, a process evaluation of organizational barriers in a multi-state group randomized trial of evidence-based quality improvement strategies for implementing smoking cessation guidelines led to a redesign of key intervention components (Table 4). During the trial, qualitative evaluation of organizational processes identified patient reluctance to attend smoking cessation clinics, inconsistent provider readiness to counsel in primary care, and variable ease in referral and capacity in behavioural health sessions [91]. Quantitative surveys and analysis of the organizational factors (e.g., formulary changes, smoking cessation clinic availability) influencing smoking cessation clinic referral practices across the 18 participating sites also were conducted [92,93]. "
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