# Presentation: 790473

## Measuring QI Intervention Implementation:  Helping the Blind Men See?QUITS Trial (Smoking Cessation)

- QUERI National Meeting
- Working Group
- December 12, 2008

## QUITS (Quality Improvement Trial for Smoking cessation)
Evidence-based quality improvement approach to implementing smoking cessation guidelines 
Actually Pre-QUERI then part of Substance Use Disorders (SUD) QUERI
Scott Sherman, MD & Becky Yano, PhD (Co-PIs)

- QUITS (Quality Improvement Trial for Smoking cessation)
- Evidence-based quality improvement approach to implementing smoking cessation guidelines
- Actually Pre-QUERI then part of Substance Use Disorders (SUD) QUERI
- Scott Sherman, MD & Becky Yano, PhD (Co-PIs)

## QUITS Smoking Cessation Trial

**EBQI**

- Education “toolkit”

- Local QI plan development

- Expert review/feedback

- Performance feedback

- Leadership support

- “local buy-in”
- “priority-setting”

- _Evidence base:_
-  SC clinic referrals
-  Tobacco quitlines
-  PC-based intn’s

## QUITS
Regional concentration in southwest (3 networks)
Matched on size/academic affiliation within network
Included VAMCs and CBOCs
Excluded COE’s VAMC
We chose participating sites and randomized within pairs within network

- QUITS
- Regional concentration in southwest (3 networks)
- Matched on size/academic affiliation within network
- Included VAMCs and CBOCs
- Excluded COE’s VAMC
- We chose participating sites and randomized within pairs within network

## Multiple Data Sources:  Measuring Implementation

|  | QUITS | Examples |
| --- | --- | --- |
| Semi-structured interviews: leaders, providers, mgrs | -- | Participation, level of implementation |
| Organizational site surveys:
PC/MH leaders, SC mgrs |  | Clinic structure, processes, change |
| Administrative data |  | Visits, Rxs, costs |
| Patient surveys |  | PHQ9, quits |
| Provider surveys |  | Knowledge, attitudes, behaviors |
| Practice checklists (experts) |  | QII components |

## QUITS Organizational Site Surveys

| Pre-Implementation Structures | Intervention practices | Control Practices |
| --- | --- | --- |
| Pre-visit smoking assessment | 56% | 38% |
| Smoking status reminders | 100% | 75% |
| Local screening perf tracked | 33% | 13% |
| PCPs prescribe cessation Rxs | 38% | 50% |
| Provider feedback on SC perf | 38% | 62% |
| Smokers referred to SC clinics | 33% | 38% |

*Source*:  Yano, Rubenstein, Farmer, et al., HSR, 2008;43(5), Part 1:1637-1661.

## QUITS Administrative Data

| EBQI
Period | INTERVENTION
PRACTICES |  |  | CONTROL PRACTICES |  |  |
| --- | --- | --- | --- | --- | --- | --- |
|  | SC | PC | Attend
Rate | SC | PC | Attend Rate |
| Pre | 1214
(4.2) | 91,741
(3.0) | 55.6 | 1,582
(3.5) | 80,775
(2.6) | 76.8 |
| Base-line | 1,137
(4.4) | 85,274
(3.2) | 56.0 | 1,979
(3.2) | 100,830
(3.0) | 77.0 |
| Post | 1,926
(3.9) | 111,536
(3.4) | 72.6 | 1,993
(3.5) | 114,357
(2.9) | 68.3 |

*Source*:  Yano, Rubenstein, Farmer, et al., HSR, 2008;43(5), Part 1:1637-1661.

## QUITS Patient Surveys

|  | Intervention Smokers | Control Smokers |
| --- | --- | --- |
| MD talked about quitting | 68% | 66% |
| If yes, prescribed patches | 35% | 41%* |
| MD referred to SC program | 37% | 45%* |
| Of referrals, recall attending
Of attendees, Rx’d NRT | 35%
33% | 50%***
63%*** |
| Smoking cessation (>30d) | 9% | 9% |

- * Screened >36,000 primary care patients to identify, enroll >2,000 current smokers.

*Source*:  Yano, Rubenstein, Farmer, et al., HSR, 2008;43(5), Part 1:1637-1661.

## Smoking cessation expert review of:
Local QI plans (with feedback to practices)
Implementation activities
Completed practice checklist of intervention components
Evidence-based vs. non-evidenced based
Changes from QI plan to implementation

- Smoking cessation expert review of:
- Local QI plans (with feedback to practices)
- Implementation activities
- Completed practice checklist of intervention components
- Evidence-based vs. non-evidenced based
- Changes from QI plan to implementation

*Source*:  Yano, Rubenstein, Farmer, et al., HSR, 2008;43(5), Part 1:1637-1661.

## QUITS Post-Implementation Survey

|  | Planned | Implemented |
| --- | --- | --- |
| Provider education (eg CME) | 67% | 44% |
| Patient education/activation | 56% | 44% |
| Provider profiling/feedback | 56% | 11% |
| PC-based org changes* | 33% | 22% |
| Smoking cessation clinic chg | 22% | 22% |
| Provider incentives | 11% | 11% |

- * Brief counseling program, computerized referral in PC or counselor/nurse hired in SC clinic

*Source*:  Yano, Rubenstein, Farmer, et al., HSR, 2008;43(5), Part 1:1637-1661.

## QUITS Post-Implementation Survey

|  | # planned EBPs | # planned EBPs implem’d | # new elements | # new elements implem’d |
| --- | --- | --- | --- | --- |
| Site 1 | 4 | 1 | 2 | 1 |
| Site 2 | 8 | 6 | 8 | 4 |
| Site 3 | 5 | 0 | 0 | 0 |
| Site 4 | 7 | 2 | 4 | 2 |
| Site 5 | 3 | 1 | 1 | 0 |
| Site 6 | 4 | 2 | 2 | 0 |
| Site 7 | 4 | 0 | 0 | 0 |

*Source*:  Yano, Rubenstein, Farmer, et al., HSR, 2008;43(5), Part 1:1637-1661.