Provider and clinical setting characteristics associated with tobacco pharmacotherapy dispensed in the Veterans Health Administration.

Amanda C Blok,Hyungjin Myra Kim,Sonia A Duffy,Mark C Geraci,Paul G Barnett,Rosalinda V Ignacio

doi:10.18332/tid/140091

Abstract

INTRODUCTIONWhile initiation rates of tobacco cessation pharmacotherapy have improved both inside and outside the Department of Veteran Affairs (VA), prescribing rates remain low. The objective of this study was to examine correlation of the characteristics of providers, clinics, and facilities with initiation of tobacco cessation pharmacotherapy.METHODSThis retrospective, observational study used VA outpatient electronic medical record data from federal fiscal year 2011. Logistic regression models estimated the adjusted odds ratio associated with provider characteristics for pharmacotherapy initiation.RESULTSFor the 639507 veterans who used tobacco, there were 30388 providers caring for them. Younger (p<0.001) and female (p<0.001) providers were more likely to initiate tobacco cessation pharmacotherapy. Compared to physicians, pharmacists were 74% more likely to initiate pharmacotherapy, while all groups of nurses were 5–8% and physicians’ assistants were 12% less likely (p<0.001). Compared to those seen in primary care clinics, patients assessed in substance use treatment clinics were 16% more likely to have pharmacotherapy initiated (p<0.001), while those in psychiatry were 10% less likely (p<0.001), and those in outpatient surgery were 39% less likely to initiate pharmacotherapy (p<0.001). Compared to almost all other classes of VA facilities, patients seen in primary care community-based outpatient clinics (CBOCs) were 7–28% more likely to initiate pharmacotherapy (p<0.0001).CONCLUSIONSWhile the VA is at the leading edge of providing tobacco cessation pharmacotherapy, targeting quality improvement efforts towards providers, clinics, and facilities with low prescribing rates will be essential to continue the declining rates of tobacco use among VA patients.

Highlights

While initiation rates of tobacco cessation pharmacotherapy have improved both inside and outside the Department of Veteran Affairs (VA), prescribing rates remain low
The majority (80%) of the patients were assessed in outpatient primary care clinics, 10% in outpatient psychiatry clinics, 6% in outpatient specialty clinics, and the remainder in outpatient substance use disorder treatment, outpatient surgery and other outpatient settings (4%)
52% of providers who made the index use assessment in VA medical centers (VAMCs) and Health Factor (HF) assessment had one or more patients who initiated the majority (83%) in VA facilities located in urban tobacco cessation pharmacotherapy

Summary

Introduction

The Veterans Administration (VA) implemented the National Smoking and Tobacco Use Cessation Program in 2004, mandating the availability of tobacco cessation pharmacotherapy to veterans who are interested in quitting, regardless of their interest in tobacco treatment programs[3] This initiative included the implementation of tobacco treatment policy, increased provider training, increased availability of tobacco treatment pharmacotherapy and counseling, and increased the rate and quality of tobacco cessation interventions using clinical reminders in the electronic medical record system. While there was substantial initial improvement, determining practices and providers that remain low-prescribers of pharmacotherapy is needed to break through the plateau effect on prescribing behavior change. This is crucial for tobacco cessation in veterans, as three quarters of those who use tobacco remain untreated. This is unfortunate, as the use of FDA-approved medications increases the quit rate by 50–60%, regardless of setting[6]

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