Referring Hospitalized Smokers to Outpatient Quit Services: A Randomized Trial

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Introduction

Linking outpatient cessation services to bedside counseling for hospitalized smokers can improve long-run quit rates. Adding an assisted referral (AR) offer to a tobacco treatment specialist consult service fits the team approach to care in U.S. hospitals.

Design

A two-arm patient-randomized trial tested the effectiveness of adding an AR offer to outpatient smoking-cessation services and interactive voice recognition (AR+IVR) follow-up to a usual care (UC) tobacco-cessation consult for hospitalized smokers.

Setting/participants

Over 24 months (November 2011–November 2013), 898 hospitalized adult smokers interested in quitting smoking were recruited from three large hospitals in the Portland, Oregon, area: an integrated group model HMO (n=622), a community hospital (n=195), and an academic health center (n=81).

Intervention

Tobacco treatment specialists identified smokers and provided an intensive bedside tobacco use assessment and cessation consultation (UC). AR+IVR recipients also received proactive ARs to available outpatient counseling programs and medications, and linked patients to a tailored IVR telephone follow-up system.

Main outcome measures

The primary outcome was self-reported 30-day abstinence at 6-month follow-up. Secondary outcomes included self-reported and continuous abstinence and biochemically confirmed 7-day abstinence at 6 months. Follow-up was completed in September 2014; data were analyzed in 2015.

Results

A total of 597 and 301 hospitalized smokers were randomized to AR+IVR and UC, respectively. AR+IVR and UC recipients received 19.3 and 17.0 minutes of bedside counseling (p=0.372), respectively. Most (58%) AR+IVR patients accepted referrals for counseling, 43% accepted medications, and 28% accepted both. Self-reported 30-day abstinence for AR+IVR (17.9%) and UC (17.3%) were not statistically significant (p=0.569). Differences in 7-day, continuous, and biochemically confirmed abstinence by treatment group also were insignificant, overall and adjusting for site.

Conclusions

Adding an AR to outpatient counseling and medications did not increase cigarette abstinence at 6 months compared to UC alone.

Introduction

Cigarette smoking is the leading cause of preventable death and disease in the U.S., resulting in 480,000 deaths and more than $170 billion in excess medical care expenditures per year.1, 2 Although smoking rates have declined substantially since the late 1990s,1, 3 more needs to be done. Counseling programs to help smokers quit are effective and highly cost effective, particularly when combined with cessation medications.3, 4, 5

The forced abstinence associated with a hospital stay, particularly in smoke-free facilities, represents an opportunity to initiate professional treatment and link patients with multiple intervention contacts after discharge. This approach can lead to significant increases in quit rates.3, 6, 7, 8, 9, 10, 11, 12 In 2012, the Joint Commission recognized the importance of treating tobacco dependence for all hospitalized smokers by broadening the requirements for effective treatment to include referral to outpatient services and follow-up.13, 14

Creating an integrated clinical pathway—from inpatient assistance to outpatient cessation services—is challenging for any healthcare delivery system, even integrated organizations that also provide outpatient and behavioral health services. An effective model includes in-hospital treatment by trained professionals whose primary responsibility is tobacco cessation15 and a hospital-managed follow-up program for continuity of care.16 Integrating inpatient and outpatient cessation services is much more daunting for free-standing community and academic hospitals that serve patients who are potentially covered by dozens of health insurance plans. Typically, insurance plans cover inpatient services, but prior authorization is needed for outpatient coverage.

In 2010, NIH funded seven clinical trials to evaluate the effectiveness and cost effectiveness of hospital-based smoking-cessation programs that linked smokers to post-discharge outpatient interventions.16 Investigators from each study and NIH formed the Consortium of Hospitals Advancing Research on Tobacco to create common data elements that would enable data pooling and analyses across studies. This study presents data from the Inpatient Technology-Supported Assisted Referral study (U01 HL105231; clinical trials registration, NCT01236079), a patient-randomized clinical effectiveness trial. Each participant received a comprehensive bedside tobacco-cessation consult as part of usual care (UC), delivered by a trained tobacco treatment specialist (TTS): a physician assistant, research registered nurse, or health educator, depending on the study site. Patients also received information about outpatient cessation programs and medications. Patients randomized to the study treatment also received ARs for post-discharge tobacco-cessation services (counseling and medications) plus interactive voice recognition support (AR+IVR). IVR was used to provide efficient post-discharge follow-up for treatment plans initiated during hospitalization.17, 18, 19

The Inpatient Technology-Supported Assisted Referral study tested the hypothesis that adding an AR to outpatient quit services and IVR follow-up to a bedside smoking-cessation consultation would significantly increase self-reported 30-day abstinence at 6-month follow-up compared to the bedside consult service only. The overall goal of the study was to demonstrate that combining tobacco treatment expertise with electronic health systems technology could effectively link in-hospital tobacco dependence treatment to cost-effective outpatient follow-up care, thus increasing patient’s use of outpatient quit programs and medications compared to UC. A detailed description of the study protocol is available elsewhere.20

Section snippets

Methods

A randomized controlled clinical effectiveness trial was conducted with 900 patients who had been admitted to one of three large hospitals. All study participants received bedside tobacco-cessation consults as part of UC, and 597 patients were randomly selected to receive a TTS-delivered AR+IVR. Participants completed baseline and 6-month follow-up assessments, with a $50 incentive for completing follow-up. Blinded study staff arranged and conducted the assessments. Intervention fidelity was

Results

Study participants were recruited over 24 months (November 2011–November 2013). Follow-up assessments were completed in August 2014, and data analysis was completed in 2015. TTSs conducted initial electronic medical record prescreening for 3,828 hospitalized adult smokers who met study eligibility criteria (Figure 1). Prescreening identified 2,908 (76%) patients who were eligible for a bedside quit consult and study recruitment visit. TTSs identified 986 (34%) patients who were screened

Discussion

This trial demonstrated that dedicated TTSs can provide intensive cessation counseling lasting nearly 20 minutes as part of an integrated hospital care delivery team, and that most smokers will accept an AR offer as part of this service. The bedside intervention was delivered as planned. The additional 2–3 minutes spent with patients in the AR+IVR group suggest that adding an AR is not burdensome. Unfortunately, the referral did not increase the use of outpatient counseling programs compared to

Conclusions

Post-hospitalization cessation counseling and medications have proven to increase abstinence, decrease hospitalizations, and improve mortality.6, 9 Despite being accepted by patients, the AR program had little effect on patient-reported counseling and a small effect on medication use compared to usual care. Thus, more needs to be done to ensure that the linkage to outpatient services is robust.

Acknowledgments

The authors wish to thank Dr. William Riley at the Office of Behavioral and Social Sciences Research, NIH; Consortium of Hospitals Advancing Research on Tobacco members; staff at Kaiser Sunnyside Medical Center, Legacy Emanuel Hospital, and Oregon Health and Science University Hospital; and tobacco treatment specialists Christina Carlson, Deborah Conn, and Anya Hill.

Funding was provided by the National Heart, Lung, and Blood Institute (U01 HL105231; clinical trials registration, NCT01236079).

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    This article is part of a theme section titled Implementing Tobacco Cessation Interventions for Hospitalized Smokers

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