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Abstract
IntroductionThis study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach.MethodsA stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts.ResultsForty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2–33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7).ConclusionsDespite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased.ImplicationsTobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach.Trial Registrationclinicaltrials.gov #NCT02764385, registration date 06/05/2016.
Highlights
This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support
Implications: Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient
The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach
Summary
This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. One systems change approach is Ask-AdviseConnect, (AAC) [9, 10] In a manner consistent with the Clinical Practice Guidelines for Treating Tobacco Use and Dependence, AAC engages the medical assistant or nurse that rooms the patient to: Ask about tobacco use; for current tobacco users, briefly Advise the patient to quit using tobacco; and offer to Connect patients interested in taking action to quit smoking to cessation counseling support through a quitline referral For this system, the direct connection to the quitline (QL) is made by clicking a link in the electronic health record (EHR) that securely sends the patient’s name and phone number to the QL staff who contact the patient within 24 h. Augmenting the AAC strategy with other personalized approaches may improve patient enrollment in tobacco cessation services and quitting
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