Warm Handoff Versus Fax Referral for Linking Hospitalized Smokers to Quitlines

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Introduction

Few hospitals treat patients’ tobacco dependence. To be effective, hospital-initiated cessation interventions must provide at least 1 month of supportive contact post-discharge.

Study design

Individually randomized clinical trial. Recruitment commenced July 2011; analyses were conducted October 2014–June 2015.

Setting/participants

The study was conducted in two large Midwestern hospitals. Participants included smokers who were aged ≥18 years, planned to stay quit after discharge, and spoke English or Spanish.

Intervention

Hospital-based cessation counselors delivered the intervention. For patients randomized to warm handoff, staff immediately called the quitline from the bedside and handed the phone to participants for enrollment and counseling. Participants randomized to fax were referred on the day of hospital discharge.

Main outcome measures

Outcomes at 6 months included quitline enrollment/adherence, medication use, biochemically verified cessation, and cost effectiveness.

Results

Significantly more warm handoff than fax participants enrolled in quitline (99.6% vs 59.6%; relative risk, 1.67; 95% CI=1.65, 1.68). One in four (25.4% warm handoff, 25.3% fax) were verified to be abstinent at 6-month follow-up; this did not differ significantly between groups (relative risk, 1.02; 95% CI=0.82, 1.24). Cessation medication use in the hospital and receipt of a prescription for medication at discharge did not differ between groups; however, significantly more fax participants reported using cessation medication post-discharge (32% vs 25%, p=0.01). The average incremental cost-effectiveness ratio of enrolling participants into warm handoff was $0.14. Hospital-borne costs were significantly lower in warm handoff than in fax ($5.77 vs $9.41, p<0.001).

Conclusions

One in four inpatient smokers referred to quitline by either method were abstinent at 6 months post-discharge. Among motivated smokers, fax referral and warm handoff are efficient and comparatively effective ways to link smokers with evidence-based care. For hospitals, warm handoff is a less expensive and more effective method for enrolling smokers in quitline services.

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

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