Adding a teachable moment approach to a team-based primary care ask-advise-connect approach for tobacco cessation
BACKGROUND: Guidelines urge primary care practices to provide routine tobacco-cessation care. Implementation of effective and sustainable strategies is lacking, especially for socially and economically disadvantaged populations. We tested a systems-based approach that engages the medical assistant (...
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| Format: | eBook |
| Language: | English |
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[Washington, D.C.]
Patient-Centered Outcomes Research Institute (PCORI)
2021, [2021]
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| Online Access: | |
| Collection: | National Center for Biotechnology Information - Collection details see MPG.ReNa |
| Summary: | BACKGROUND: Guidelines urge primary care practices to provide routine tobacco-cessation care. Implementation of effective and sustainable strategies is lacking, especially for socially and economically disadvantaged populations. We tested a systems-based approach that engages the medical assistant (MA) who records the patient's vital signs at the beginning of a routine visit and the added effect of a clinician-based approach that draws on a relationship-centered communication strategy. In-depth interviews were conducted with 55 patients referred to the QL to explore their experiences and identify opportunities to improve the referral process. RESULTS: Of the 224 079 visits to 1 of the 8 clinical sites during the study period, 37 909 (25.9%) were made by identified tobacco users.EFFECT OF AAC: All indicators of AAC use significantly increased post implementation. Compared with the pre-AAC period, the following process measures increased and remained significant 12 months post-AAC: assessing smoking status (26.6% vs 55.7%; odds ratio [OR], 3.7; 95% CI, 3.6-3.9); providing advice (44.8% vs 88.7%; OR, 7.8; 95% CI, 6.6-9.1); assessing readiness to quit (15.8% vs 55.0%; OR, 6.2; 95% CI, 5.4-7.0); and acceptance of referral to tobacco-cessation counseling (0.5% vs 30.9%; OR, 81.0; 95% CI, 11.4-575.8). OBJECTIVES: This project aimed to (1) improve delivery and documentation of tobacco-cessation care to disadvantaged patients using an Ask-Advise-Connect (AAC) systems-based approach; (2) test the effect of combining the clinician-based Teachable Moment Communication Process (TMCP) intervention with AAC on advice to quit, referrals to cessation counseling, and provision of tobacco-cessation medications; and (3) examine the narratives of patient subgroups to understand and improve the referral experience. METHODS: This study engaged a health care system and 8 primary care clinical sites with 2 interventions. The 3-month period before the AAC intervention represented a pre-AAC control period (baseline). All sites received the AAC strategy throughout the study, and its use was evaluated for a minimum of 6 months (AAC only). Next, using a group-randomized, stepped-wedge design, sites received the TMCP intervention (AAC+TMCP). Among a subsample of approximately 125 patients per time period, there were no adverse effects on visit satisfaction for either the AAC-only or the AAC+TMCP intervention time periods compared with the pre-AAC time period. Analysis of in-depth interviews with participants initially agreeing to QL contact found that the major barriers preventing patients from completing the QL program included lack of clear expectations for the QL, life stressors preventing enrollment, and difficulty making time for the counseling sessions. Regardless of level of engagement with the QL program, patients encouraged primary care teams to continue asking them about their smoking status and offering tobacco-cessation support. CONCLUSIONS: The AAC system change intervention substantially increased the provision of tobacco-cessation care, with improvements sustained beyond 1 year. Adding TMCP training for clinicians improved ordering of tobacco-cessation medications, but other outcomes did not improve. Future work requires more complete integration of the AAC and TMCP approaches and tools into EHR systems for the combined process to be fully tested. LIMITATIONS: The study was conducted in 1 health care system with a single EHR system. The modest uptake of the TMCP approach after training (8% of smokers' clinic visits) limited the ability to assess the intervention's impact This process generated 1223 QL referrals; 324 (31.1%) patients were contacted by the QL, 241 (74.4%) were enrolled, and 195 (80.9% of enrollees) completed at least 1 counseling session. EFFECT OF TMCP: In total, 44 of 60 eligible clinicians received the TMCP training. During the 6-month post-TMCP intervention period, 68% of TMCP-trained clinicians used a TMCP approach (documented by flow sheet use) ≥1 times, with the median number of uses being 15 (interquartile range, 2-33). Overall, the TMCP was used in 661 of 8198 visits by smokers (8%). There was no improvement in any of the outcomes for the AAC+TMCP group vs the AAC-only group. Among visits when clinicians used the TMCP approach, there was a significant increase in the ordering of tobacco-cessation medications (OR, 2.6; 95% CI, 1.9-3.5). Provision of brief advice, assessment of readiness to quit, contact by and enrollment in the QL program, and quit attempts did not improve. The patient population consisted of 40% Medicaid, 23.9% Medicare, 6.1% uninsured, and 30% commercially insured individuals. The AAC strategy involved changes to the electronic health record (EHR), a new role for MAs, and a new capacity to send electronic referrals to the quitline (QL) to enroll patients in tobacco-cessation counseling. Next, in accord with their practice's place in the stepped-wedge design, 44 of the 60 eligible clinicians attended training on the TMCP, an approach to counseling patients to quit tobacco that is aligned with patient readiness. Generalized linear models tested the effect of interventions on immediate outcome measures of process, including delivery of advice, offers of assistance and referrals accepted, and QL contact and enrollment rates. Receipt of tobacco-cessation medications and quit attempts were also assessed. The primary outcome was QL contact. |
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| Physical Description: | 1 PDF file (96 pages) illustrations |