Evaluating the QUIT-PRIMO clinical practice ePortal to increase smoker engagement with online cessation interventions: a national hybrid type 2 implementation study.

Thomas K Houston,Midge N Ray,Thomas M English,Daniel E Ford,Arlene S Ash,Jeroan J Allison,Timothy P Hogan,Rajani S Sadasivam

doi:10.1186/s13012-015-0336-8

Abstract

BackgroundEffective web-assisted tobacco interventions (WATIs) have been underutilized by smokers; moreover, despite practice guideline recommendations, clinical teams do not routinely refer smokers to WATIs. Our goal was to test a clinical practice innovation, an ePortal designed to change practice and patient behavior. Our hypotheses were that the integrated system would result in increased smoker referrals, with an automated follow-up system resulting in more smoker registrations and finally augmentations of the WATI would result in more smokers quitting at 6 months.MethodsPractice ePortal Implementation Trial: Practices (n = 174) were randomized to an online practice ePortal with an “e-referral tool” to the WATI (e-referred smokers received automated email reminders from the practice) and with practice feedback reports with patient tracking and practice-to-patient secure messaging versus comparison (a paper “referral prescription”). Implementation success was measured by the number of smokers referred and smokers registering.Clinical Effectiveness Trial: To estimate the effectiveness of the WATI components on 6-month smoking cessation, registered smokers were randomized into three groups: a state-of-the-art tailored WATI control [control], the WATI enhanced with proactive, pushed tailored email motivational messaging (messaging), and the WATI with messaging further enhanced with personal secure messaging with a tobacco treatment specialist and an online support group (personalized).ResultsPractice ePortal Trial results: A total of 4789 smokers were referred. The mean smokers referred per practice was not statistically different by group (ePortal 24.89 (SD 22.29) versus comparison 30.15 (SD 25.45), p = 0.15). The e-referral portal implementation program resulted in nearly triple the rate of smoker registration (31 % of all smokers referred registered online) versus comparison (11 %, p < 0.001).Clinical Effectiveness Trial results: Active smokers randomized to the personalized group had a 6-month cessation rate of 25.2 %, compared with the messaging group (26.7 %) and the control (17 %). Next, when using an inverse probability weighted selection model to account for attrition, those randomized to the two groups that received motivational messaging (messaging or personalized) were more likely to quit than those in the control (p = 0.04).ConclusionsAmong all smokers referred, the e-referral resulted in nearly threefold greater registrants (31 %) than paper (11 %). The practice ePortal smokers received multiple reminders (increasing registration opportunities), and the practices could track patient progress. The result was more smokers registering and, thus, more cessation opportunities. Combining the proactive referral and the WATI resulted in higher rates of smoking cessation.Trial RegistrationWeb-delivered Provider Intervention for Tobacco Control (QUIT-PRIMO) - a randomized controlled trial: NCT00797628.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0336-8) contains supplementary material, which is available to authorized users.

Highlights

Clinical practices have embraced routine screening for tobacco use, [1, 2] brief advice to quit is becoming universal, [3, 4] and pharmaceutical treatments are increasing
Among all smokers referred, the e-referral resulted in nearly threefold greater registrants (31 %) than paper (11 %)
Combining the proactive referral and the web-assisted tobacco interventions (WATI) resulted in higher rates of smoking cessation

Summary

Introduction

Clinical practices have embraced routine screening for tobacco use, [1, 2] brief advice to quit is becoming universal, [3, 4] and pharmaceutical treatments are increasing. As defined by Curran et al, hybrid type 2 trials include dual testing of the implementation (practice ePortal intervention) and the clinical intervention (the WATI in this study) [11]. These hybrid implementation-effectiveness studies are appropriate (1) when there has been gathering evidence for clinical efficacy (creating “implementation momentum”), but further detailed effectiveness evidence is needed, and (2) when an implementation strategy addressing barriers to implementing the clinical intervention (the WATI) has not been fully tested in a real-world practice setting. Effective web-assisted tobacco interventions (WATIs) have been underutilized by smokers; despite practice guideline recommendations, clinical teams do not routinely refer smokers to WATIs. Our goal was to test a clinical practice innovation, an ePortal designed to change practice and patient behavior. Our hypotheses were that the integrated system would result in increased smoker referrals, with an automated follow-up system resulting in more smoker registrations and augmentations of the WATI would result in more smokers quitting at 6 months

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