Abstract
Tobacco cessation after cancer diagnosis leads to better patient outcomes. However, tobacco treatment services are frequently unavailable in cancer care settings, and multilevel implementation challenges can impede uptake of new programs. The National Cancer Institute (NCI) dedicated Cancer Moonshot funding through the Cancer Center Cessation Initiative (C3I) for NCI-Designated Cancer Centers to implement or enhance the implementation of tobacco treatment services. We examined a pragmatic application of the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) to evaluate tobacco treatment programs implemented within Cancer Centers funded through C3I. Using three C3I-funded Centers as examples, we describe how each RE-AIM construct was operationalized to evaluate the implementation of a wide range of cessation services (e.g., tobacco use screening, counseling, Quitline referral, pharmacotherapy) in this heterogeneous group of cancer care settings. We discuss the practical challenges encountered in assessing RE-AIM constructs in real world situations, including using the electronic health record (EHR) to aid in assessment. Reach and effectiveness evaluation required that Centers define the setting(s) where cessation services were implemented (to determine the “denominator”), enumerate the patient population, report current patient tobacco use, patient engagement in tobacco treatment, and 6-month cessation outcomes. To reduce site heterogeneity, increase data accuracy, and reduce burden, reach was frequently captured via standardized EHR enhancements that improved the identification of current smokers and tobacco treatment referrals. Effectiveness was determined by cessation outcomes (30-day point prevalence abstinence at 6-months post-engagement) assessed through a variety of data collection approaches. Adoption was measured by the characteristics and proportion of targeted cancer care settings and clinicians engaged in cessation service delivery. Implementation was assessed by examining the delivery of tobacco screening assessments and intervention components across sites, and provider-level implementation consistency. Maintenance assessments identified whether tobacco treatment services continued in the setting after implementation and documented the sustainability plan and organizational commitment to continued delivery. In sum, this paper demonstrates a pragmatic approach to using RE-AIM as an evaluation framework that yields relevant outcomes on common implementation metrics across widely differing tobacco treatment approaches and settings.
Highlights
Continued smoking after a cancer diagnosis has been associated with adverse outcomes, including overall and cancer specific mortality, and increased risk of developing a second primary cancer
This paper provides examples of a pragmatic application of the RE-AIM framework to evaluate the implementation of real-world tobacco treatment programs in cancer care settings using simple, low burden measures gathered across clinical settings using electronic health records (EHRs) to aid in measurement [12, 17]
Using case studies from three funded C3I Cancer Centers, this report describes the application of the RE-AIM framework and the operationalization of each construct to evaluate the implementation of a range of cessation services in cancer care settings
Summary
Continued smoking after a cancer diagnosis has been associated with adverse outcomes, including overall and cancer specific mortality, and increased risk of developing a second primary cancer. 1. Define the setting where patients are assessed for tobacco use and identified as current smokers during their medical visit (e.g., the whole cancer center, or certain clinics). Adoption At the setting level, all 21 outpatient oncology clinics in the Siteman Cancer Center adopted ELEVATE and initiated tobacco assessment and treatment services with the new pointof-care EHR module. At 1-year postimplementation, EHR data revealed that 99% of providers/clinic staff had initiated use of the new smoking status assessment, 79% initiated medication documentation, and 85% initiated the counseling referral components of ELEVATE, indicating high levels of adoption. Implementation Implementation was assessed for the following elements key to delivering the TIPS program: tobacco use screening, provider referrals, and intervention delivery to smokers referred. The sustainability goals are to identify 100% of current tobacco smokers (and recent quitters), maintain an overall program reach of at least 50% of eligible patients, and demonstrate abstinence rates that are at least comparable to published estimates
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