Implementation of HIT-Enhanced Tobacco Treatment for Hospitalized Smokers
| Status: | Completed |
|---|---|
| Conditions: | Smoking Cessation, Tobacco Consumers |
| Therapuetic Areas: | Pulmonary / Respiratory Diseases |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 11/24/2018 |
| Start Date: | August 2013 |
| End Date: | September 2016 |
This study will implement and test the effectiveness and cost-effectiveness of a tobacco
cessation intervention (Academic Detailing + Integrated Tobacco Order Set - AD + ITOS) for
adults admitted to the hospital. The intervention will begin during the hospital stay and
continue after discharge. The intervention will use resources easily available to most acute
care hospitals: computerized physician order entry, physician and nurse education, staff
meetings for physicians, nurses and allied health professionals, online learning
capabilities, faxing to primary care providers (PCPs), and the telephone counseling and
support available from a state smokers' quitline (QL).
The investigators hypothesize that the subjects in the intervention arm (AD + ITOS) will be
more likely to achieve tobacco abstinence at 12 months post hospital stay than subjects in
the control arm (Academic Detailing - AD). Tobacco abstinence will be assessed by self report
and biochemical verification (exhaled carbon monoxide reading).
cessation intervention (Academic Detailing + Integrated Tobacco Order Set - AD + ITOS) for
adults admitted to the hospital. The intervention will begin during the hospital stay and
continue after discharge. The intervention will use resources easily available to most acute
care hospitals: computerized physician order entry, physician and nurse education, staff
meetings for physicians, nurses and allied health professionals, online learning
capabilities, faxing to primary care providers (PCPs), and the telephone counseling and
support available from a state smokers' quitline (QL).
The investigators hypothesize that the subjects in the intervention arm (AD + ITOS) will be
more likely to achieve tobacco abstinence at 12 months post hospital stay than subjects in
the control arm (Academic Detailing - AD). Tobacco abstinence will be assessed by self report
and biochemical verification (exhaled carbon monoxide reading).
Cigarette smoking remains the leading cause of preventable death and illness in the United
States. In 2008, 20.6% of all American adults smoked, and 435,000 died from smoking-related
illnesses. Economic costs of smoking dependence are estimated at $193 billion/year and have
far-reaching implications for the individual, workplace, society and the healthcare system.
However, treatment is associated with significant individual and society benefits, and both
counseling and pharmacotherapy have been demonstrated to be effective treatments. Along with
poverty and low education, smoking causes a greater loss of quality-adjusted life years than
race, uninsurance, overweight, or binge drinking.
Smokers are admitted to acute care hospital more than nonsmokers. Using estimates from a
number of sources, we estimate that approximately 6.1-12.5 million hospitalizations occur
annually among adult smokers. This represents 20-41% of the 29.8 million annual inpatient
stays in US acute care hospitals among adults age 18 and older unrelated to pregnancy or
childbirth. Put another way, the nation's 46 million smokers represent 20% of the adult
population, but account for 20-40% of all hospitalizations unrelated to pregnancy. Given that
US hospitals are now smoke-free (per Joint Commission regulations), and many of these
admissions are for tobacco-related conditions, the hospital admission represents a profound
opportunity—a "teachable moment"—for tobacco control.
Recent "core measure" regulations by the Joint Commission and the Centers for Medicare and
Medicaid Services require hospitals to report publicly their tobacco screening for patients
admitted with acute myocardial infarction, congestive heart failure, and pneumonia. Although
many hospitals have improved their performance considerably on these smoking measures,
sometimes this has resulted from "gaming," e.g. giving all discharged patients a preprinted
instruction sheet that includes boilerplate text about smoking cessation. Thus, although most
hospitals assess inpatients for tobacco use (either through a nursing assessment or the
physician's initial history and physical examination), there are often no systems in place to
initiate or sustain tobacco treatment for smokers. This gap in service delivery prevents
millions of smokers from accessing the many effective, evidence-based treatments for tobacco
dependence during a period in which they may be particularly receptive to an intervention.
Hence, the overarching goal of this project is to implement and study the effectiveness and
cost-effectiveness of a tobacco intervention for hospitalized adults that begins during
inpatient treatment and continues after discharge. To enhance dissemination, we will use
resources currently available to most acute care hospitals: computerized physician order
entry, physician and nurse education, staff meetings for physicians, nurses, and allied
health professionals, online learning capabilities, faxing to primary care providers (PCPs),
and the telephone counseling and support available from a state smokers' quitline (QL). In
the final year, a toolkit will be disseminated by professional societies. We hypothesize that
the proposed intervention is clinically effective, cost effective, sustainable, and
generalizable. All interventions are evidence-based and consistent with the 2008 Public
Health Service clinical practice guideline for tobacco dependence treatment.
The Specific Aims of the proposed project are to:
Primary Aims:
1. Determine whether Academic Detailing (AD) and an Integrated Tobacco Order Set (ITOS)
compared to AD alone improves biologically verified smoking cessation at 12 months
post-quit in a cohort of 960 smokers age > 18 years admitted to Yale New Haven Hospital
(YNHH).
Secondary Aims:
2. Study ITOS's ability to encourage smokers to use treatment services and reduce
consumption.
3. Study ITOS's ability to enhance provider delivery of tobacco screening and treatment.
4. Conduct an incremental cost-effectiveness analysis of the intervention.
Our associated hypotheses are:
1. Subjects treated by physicians in the AD+ITOS arm will have a higher rate of
biochemically verified 7-day point prevalence smoking abstinence at 12 months post-quit
than subjects treated by physicians in the AD arm, in a cohort of adult smokers admitted
to the inpatient units of Yale-New Haven Hospital.
2. Subjects treated by AD+ITOS physicians will have made more quit attempts, and
experienced greater reduction in daily cigarette consumption, than smokers treated by AD
physicians.
3. A higher proportion of patients treated by AD+ITOS physicians will have tobacco
treatment initiated in hospital than patients treated by AD physicians.
4. Societal costs of AD+ITOS, per abstinent smoker, will be cost-effective relative to AD.
States. In 2008, 20.6% of all American adults smoked, and 435,000 died from smoking-related
illnesses. Economic costs of smoking dependence are estimated at $193 billion/year and have
far-reaching implications for the individual, workplace, society and the healthcare system.
However, treatment is associated with significant individual and society benefits, and both
counseling and pharmacotherapy have been demonstrated to be effective treatments. Along with
poverty and low education, smoking causes a greater loss of quality-adjusted life years than
race, uninsurance, overweight, or binge drinking.
Smokers are admitted to acute care hospital more than nonsmokers. Using estimates from a
number of sources, we estimate that approximately 6.1-12.5 million hospitalizations occur
annually among adult smokers. This represents 20-41% of the 29.8 million annual inpatient
stays in US acute care hospitals among adults age 18 and older unrelated to pregnancy or
childbirth. Put another way, the nation's 46 million smokers represent 20% of the adult
population, but account for 20-40% of all hospitalizations unrelated to pregnancy. Given that
US hospitals are now smoke-free (per Joint Commission regulations), and many of these
admissions are for tobacco-related conditions, the hospital admission represents a profound
opportunity—a "teachable moment"—for tobacco control.
Recent "core measure" regulations by the Joint Commission and the Centers for Medicare and
Medicaid Services require hospitals to report publicly their tobacco screening for patients
admitted with acute myocardial infarction, congestive heart failure, and pneumonia. Although
many hospitals have improved their performance considerably on these smoking measures,
sometimes this has resulted from "gaming," e.g. giving all discharged patients a preprinted
instruction sheet that includes boilerplate text about smoking cessation. Thus, although most
hospitals assess inpatients for tobacco use (either through a nursing assessment or the
physician's initial history and physical examination), there are often no systems in place to
initiate or sustain tobacco treatment for smokers. This gap in service delivery prevents
millions of smokers from accessing the many effective, evidence-based treatments for tobacco
dependence during a period in which they may be particularly receptive to an intervention.
Hence, the overarching goal of this project is to implement and study the effectiveness and
cost-effectiveness of a tobacco intervention for hospitalized adults that begins during
inpatient treatment and continues after discharge. To enhance dissemination, we will use
resources currently available to most acute care hospitals: computerized physician order
entry, physician and nurse education, staff meetings for physicians, nurses, and allied
health professionals, online learning capabilities, faxing to primary care providers (PCPs),
and the telephone counseling and support available from a state smokers' quitline (QL). In
the final year, a toolkit will be disseminated by professional societies. We hypothesize that
the proposed intervention is clinically effective, cost effective, sustainable, and
generalizable. All interventions are evidence-based and consistent with the 2008 Public
Health Service clinical practice guideline for tobacco dependence treatment.
The Specific Aims of the proposed project are to:
Primary Aims:
1. Determine whether Academic Detailing (AD) and an Integrated Tobacco Order Set (ITOS)
compared to AD alone improves biologically verified smoking cessation at 12 months
post-quit in a cohort of 960 smokers age > 18 years admitted to Yale New Haven Hospital
(YNHH).
Secondary Aims:
2. Study ITOS's ability to encourage smokers to use treatment services and reduce
consumption.
3. Study ITOS's ability to enhance provider delivery of tobacco screening and treatment.
4. Conduct an incremental cost-effectiveness analysis of the intervention.
Our associated hypotheses are:
1. Subjects treated by physicians in the AD+ITOS arm will have a higher rate of
biochemically verified 7-day point prevalence smoking abstinence at 12 months post-quit
than subjects treated by physicians in the AD arm, in a cohort of adult smokers admitted
to the inpatient units of Yale-New Haven Hospital.
2. Subjects treated by AD+ITOS physicians will have made more quit attempts, and
experienced greater reduction in daily cigarette consumption, than smokers treated by AD
physicians.
3. A higher proportion of patients treated by AD+ITOS physicians will have tobacco
treatment initiated in hospital than patients treated by AD physicians.
4. Societal costs of AD+ITOS, per abstinent smoker, will be cost-effective relative to AD.
Inclusion Criteria:
- 18 years or older
- admitted to any medical ward, telemetry or cardiac care unit
- identified as a smoker by the nurse or physician in the admitting EMR
- treated by a study physician
- able to give written informed consent
Exclusion Criteria:
- inability to read or understand English or Spanish
- lacks capacity to give informed consent
- currently receiving formal tobacco dependence treatment
- current suicide or homicide risk
- current psychotic disorder or life-threatening or unstable medical or psychiatric
condition within past 6 months
- unable to provide 2 telephone contact numbers
- unwilling to follow up per study protocol, including release of information to assess
treatment engagement at 30-days
- live outside of New Haven County
- leaving the hospital against medical advice
- history of clinically significant allergic reaction to nicotine replacement therapies,
varenicline or bupropion
- use of an investigational drug within 30 days
- use of tobacco products other than cigarettes
- women of childbearing potential who are pregnant, nursing, or sexually active and not
practicing effective contraception (oral injectable, or implantable contraceptives,
intrauterine device, or barrier method with spermicide)
- do not have access to a phone with a CT area code (required to use the CT Tobacco
Quitline)
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