System Based Tracking and Treatment for Emergency Patients Who Smoke: STTEPS

Emergency Departments (EDs) are a critical component of the U.S. healthcare system, treating
over 119 million patients each year. While EDs have historically neglected tobacco control
efforts, several recent studies have examined the feasibility and efficacy of implementing
tobacco cessation in the ED. Work by our research team and others, has shown that tobacco
treatment is both feasible and effective in the ED setting.

Effective, evidence-based interventions for treating tobacco dependence have also been
codified in the United States Public Health Service guidelines. Even brief interventions
delivered by physicians and other healthcare providers can produce significant increases in
cessation across diverse clinical settings (e.g., outpatient clinics, surgery units, EDs),
and patient groups (cardiac, respiratory, general admissions). However, in clinical
practice, delivery of tobacco interventions is inconsistent at best, particularly in
non-primary care settings.

This translational study uses an existing Emergency Department Information System (EDIS), to
facilitate the identification of smokers and to enhance the provision of smoking cessation
intervention materials and pharmacological adjuncts for patients receiving treatment in the
ED. The EDIS tracks the geographic and chronologic progression of patients through the ED
and contains triage and nursing notes, lab values, radiology reports and links to images,
vital signs, embedded printable discharge instructions, and fax links to primary care
provider (PCP) offices.

Following recruitment of a baseline (care-as-usual) cohort (Step 1), the investigators will
provide training to ED physicians and staff to improve the identification and treatment of
smokers. Following Step 1, the investigators will make adaptations to the EDIS system that
include smoking status tracking, tobacco treatment prompts and medication information panels
for the emergency treating physician, and links to printable discharge instructions,
quit-smoking medication information and referral to a pro-active phone follow-up counseling
for enrolled smokers. A second cohort of participants (Step 2) will be enrolled after
implementation is complete. Contemporaneous with Steps 1 and 2, participant cohorts will be
recruited at a control site (UMass Medical) to control for potential effects of historical
trends. This study represents a comprehensive systems-based translation of empirically
supported tobacco treatment built into a widely used patient tracking platform (MedHost)
maximizing the probability of developing a sustainable tobacco intervention that can be
readily disseminated.

Specific Aims A.1. To test the incremental efficacy of a modified Emergency Department
Information System (EDIS) "MedHost", using a multiple-cohort design implemented in 2 steps.
Two recruitment phases (baseline/care as usual and full implementation) will be used to
assess the impact of EDIS enhancements on rates of identification and treatment of ED
patients who smoke. The primary outcome is the difference in six-month abstinence between
those recruited prior to program implementation (Baseline) versus those recruited when the
program is fully implemented (Step 2). H1) Smokers enrolled during Step 2 at RIH will show
significantly greater cessation at month 6 compared Step 1 and control site participants.

A.2. To compare rates of smoker identification, physician intervention and follow up care
for smoking cessation and use of quit-smoking medications among ED patients recruited before
and after EDIS modification. H2) Compared to Step 1 and the control site, Step 2 will show
significantly higher rates of smoker identification, physician intervention and follow-up
for smoking, and use of quit-smoking medications.

A.3. To investigate the effects of the EDIS enhancement on relevant behavioral and
psychological constructs that may act as mediators of smoking behavior change ("Mechanisms
of Action"), and the relationships of these potential mediators to smoking cessation (e.g.,
perceived risk, nicotine dependence; in Measures section). H3) Participants enrolled during
Step 2 at RIH will show greater changes in posited mediational constructs than those
enrolled in Step 1 and at the control site.

A.4. To examine the incremental costs of implementation of the intervention and to conduct
analyses of marginal cost effectiveness using cost-per-smoker-quit. (This aim is not
hypothesis driven) Exploratory Aim: A.5. To examine ED physician and other health care
providers (HCP) attitudes regarding the utility of the EDIS system for tobacco intervention.
The investigators will conduct interviews with ED physicians and nurses to elicit their
perceptions of the usefulness and helpfulness of the modified EDIS, and its effects on their
perceived self-efficacy and motivation to provide tobacco intervention. The investigators
will also solicit direct feedback on the modified platform and user interface.