Warm Handoff Versus Fax Referral for Linking Hospitalized Smokers to Quitlines
Introduction
Hospitals are important but untapped venues for reaching and treating smokers. An estimated 1.1 million smokers in the United Kingdom and 6.5 million smokers in the U.S. are hospitalized each year.1, 2 Few hospitals provide assistance in quitting,3 even though effective interventions exist.4 Guidelines in many countries, however, recommend that hospitals integrate smoking-cessation interventions into routine care,5 and there are increasing regulatory pressures on hospitals to do so.6, 7, 8 In the U.S., healthcare reform recently placed new resources in the hands of patients and providers by mandating coverage of evidence-based cessation services and expanding public and private insurance coverage.9
To help smokers quit, hospitals must provide at least 1 month of supportive contact post-discharge.4 Referral to tobacco quitlines is in many ways an ideal method for hospitals to provide that follow-up. Quitlines are available—free of charge—in a number of countries throughout the world.10, 11 Quitlines are effective and cost effective for smoking cessation,12, 13, 14 accessible for smokers with telephones, and are undersubscribed and eager to increase their reach.15, 16
A number of U.S. hospitals have begun referring smokers to quitlines via fax referral.17, 18, 19 This process typically involves identifying smokers, assessing for willingness to quit, completing a fax referral form, and faxing the form to the quitline. The quitline then proactively calls to register the patient and provide counseling. Observational studies, however, have found that only 16%–53% of smokers who are fax referred actually register for services.20, 21, 22, 23 No studies have yet reported cessation rates among fax-referred smokers.
“Warm handoff” is another promising strategy for effecting transitions in health care. In a warm handoff, patients who screen positive for health issues are immediately introduced to a specialty care provider for on-the-spot enrollment and treatment. At present, no clinical trials of the effectiveness and cost effectiveness of warm handoffs for treating tobacco dependence have been published. One study that focused on the treatment of substance use disorders reported that warm handoff achieved 80%–90% enrollment rates.24, 25 Preliminary results from one hospital-based smoking-cessation trial examining warm handoff versus provision of a quitline phone number reported biochemically verified abstinence rates of 7.5%, with no differences across groups.26 These findings were disappointing, but the results were very preliminary—reported in 2015 conference proceedings—and the effects on enrollment, treatment adherence, and costs of care remain unknown.
The objective of this study was to determine the relative effectiveness, and cost effectiveness, of warm handoff versus fax referral for transitioning inpatient smokers to post-discharge care. This study is one of six studies in the U.S. Consortium of Hospitals Advancing Research on Tobacco,27 which were designed to test methods for implementing cessation guidelines in real-world hospital settings.
Section snippets
Methods
The trial employed a two-arm, individually randomized design to examine the impact of warm handoff on enrollment in quitline services and biochemically verified cessation at 6 months post-enrollment. Participants were smokers admitted to two large hospitals in Kansas with dedicated tobacco treatment interventionists on staff. The study protocol28 provides an in-depth description of the study design and methods. The IRBs at both hospitals approved study protocols, and all participants provided
Results
Of 3,719 individuals identified as smokers, 2,060 were ineligible, 605 declined to participate, and 1,054 provided consent and were enrolled in the trial (Figure 1). The top reason for ineligibility was planning to continue smoking after leaving the hospital (n=892; 42% of ineligibles). The proportion of participants reached for follow-up was 89% at Month 1 and 85% at Month 6. Randomization resulted in groups with similar baseline characteristics (Table 1) except for alcohol use (p=0.04);
Discussion
Warm handoff was more effective than fax referral at enrolling hospitalized smokers in quitline services. This, however, did not translate into any advantage in quitting. Both study arms, but especially fax referral, yielded much higher quit rates than projected, resulting in similar outcomes across the study arms. The costs for both interventions were the same; hospitals, however, bore less of the costs for the warm handoff. Both interventions meet Joint Commission and Centers for Medicare and
Conclusions
Warm handoff is an excellent tool for linking patients to phone-based treatment, but the conditions under which this tool might be most effective remain unclear. Because warm handoff provided a “try it, you’ll like it” opportunity to sample quitline services, it could be especially effective among treatment-naïve or -resistant smokers.
Low- and middle-income countries could readily adopt these interventions. The use of mobile communications is prevalent globally.57 Integrating quitlines into
Acknowledgments
The authors gratefully acknowledge the efforts of Brian Hernandez, Genevieve Casey, Lisa Silverman, Terri Tapp, Andrea Elyachar, Sharon Fitzgerald, and Hope Krebill for conducting the trial. The authors thank the State of Kansas Tobacco Use Prevention Program of the Kansas Department of Health and Environment for their advice in designing the study and administration of the Kansas tobacco quitline, KanQuit. The authors also thank the care providers and electronic health record data managers of
References (57)
- et al.
Quitlines in North America: evidence base and applications
Am J Med Sci
(2003) - et al.
Use and effectiveness of tobacco telephone counseling and nicotine therapy in Maine
Am J Prev Med
(2005) - et al.
The feasibility of connecting physician offices to a state-level tobacco quit line
Am J Prev Med
(2006) - et al.
Clinical faxed referrals to a tobacco quitline: reach, enrollment, and participant characteristics
Am J Prev Med
(2009) - et al.
Increased evidence-based tobacco treatment through Oklahoma hospital system changes
Am J Prev Med
(2015) - et al.
Exploring brief measures of nicotine dependence for epidemiological surveys
Addict Behav
(2003) - et al.
Telephone counseling as adjuvant treatment for nicotine replacement therapy in a “real-world” setting
Prev Med
(2000) - et al.
A randomized trial of Text2Quit: a text messaging program for smoking cessation
Am J Prev Med
(2014) - et al.
Prevalence of smoking among patients treated in NHS hospitals in England in 2010/2011: a national audit
Thorax
(2015) - et al.
Helping hospitalized smokers quit: new directions for treatment and research
J Consult Clin Psychol
(1993)
Smoking care provision in hospitals: a review of prevalence
Nicotine Tob Res
Interventions for smoking cessation in hospitalised patients
Cochrane Database Syst Rev
The Joint Commission’s new tobacco-cessation measures—will hospitals do the right thing?
N Engl J Med
Helping smokers quit—opportunities created by the Affordable Care Act
N Engl J Med
Tobacco quitlines: looking back and looking ahead
Tob Control
Treating Tobacco Use and Dependence: 2008 Update
Telephone counselling for smoking cessation
Cochrane Database Syst Rev
The potential of quitlines to increase smoking cessation
Drug Alcohol Rev
North American Quitline Consortium. Quitline Operations: A Practical Guide to Promising Approaches
Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents
WMJ
Rapid implementation of a smokers’ quitline fax referral service in an urban area
J Health Care Poor Underserved
Practice-based referrals to a tobacco cessation quit line: assessing the impact of comparative feedback vs general reminders
Ann Fam Med
Ravenswood: bringing behavioralists into an FQHC
National Council Magazine
The financial dimension of integrated behavioral/primary care
J Clin Psychol Med Settings
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Closed-Loop Electronic Referral From Primary Care Clinics to a State Tobacco Cessation Quitline: Effects Using Real-World Implementation Training
2021, American Journal of Preventive MedicineCitation Excerpt :About half of roomers never eReferred a smoker to quitline treatment. Absolute eReferral and WTQL service reach rates remained low, suggesting the need to explore more intensive implementation strategies (e.g., in-person training) or motivational strategies to increase smoker willingness to accept treatment, such as incentives42–44 and warm hand-offs (e.g., a clinician handing the patient the phone to receive quitline treatment).44,45 This research identified factors that are associated with relatively poor eReferral implementation: (1) patients who use other forms of tobacco in addition to cigarettes, (2) staff or clinicians who do not regularly perform rooming duties or who see relatively few patients who smoke, and (3) the passage of time after implementation.
Ten Million Calls and Counting: Progress and Promise of Tobacco Quitlines in the U.S.
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This article is part of a theme section titled Implementing Tobacco Cessation Interventions for Hospitalized Smokers