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)

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

Primary Objective  To test whether patient- reported delivery of intensive cessation counseling in practices is enhanced by QuitLink’s 3-component approach to integrating quit lines into primary care practice 1°1°

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

Setting September June 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

Study Design Cluster-randomized controlled trial – ClinicalTrials.gov Identifier: NCT Control: Traditional tobacco-use vital sign 2 sets of cross-sectional exit surveys 1.3-month pre-intervention period – Block randomization of practices – Treatment arm assignment – 1 hour training session at 8 intervention practices 2.9-month comparison period

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

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

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

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

Principal Findings (1) Counseling Behavior Survey Question Adjusted Affirmative Response ControlInterventionDifferencep 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

Principal Findings (2) Counseling Behavior Survey Question Adjusted Affirmative Response ControlInterventionDifferencep value Intensive Counseling (A3-5+Referral) Main Outcome 29.5%41.4%11.9% <0.001 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% Referral “If you smoke, were you referred today to a quit line?” 8.7%21.4%12.7% <0.001

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

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%

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

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)

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

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

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

Related/Future Work Electronic referral in practices with EHR 1.Pilot project with Virginia state quit line (service provider is Free & Clear) 2.RWJF Transition grant with second EHR Future studies refining QuitLink model and evaluating additional and longer- term outcomes