Implementing National Tobacco Cessation Guidelines in Primary Care: A Practice Improvement Project

Background and Purpose: National guidelines recommend tobacco cessation counseling at every clinic visit using the 5 A’s, defined as asking about status, advising to quit, assessing readiness to quit, assisting in quitting, and arranging for follow-up after quitting. However, providers cite barriers such as lack of time and personal discomfort with the subject as reasons conversations are not held. This practice improvement focuses on overcoming these barriers through an evidence-based intervention in a small, urban, primary care clinic. Methods: A onetime staff education session about guidelines paired with a protocol algorithm and enhanced patient resources was trialed to determine its effect on the frequency of charted cessation conversations. An electronic health record documentation template, or dot phrase, measured the frequency of 5 A use in clinic visits for identified tobacco users. Providers received performance feedback twice during eight weeks of data collection. An attitude survey, administered before implementation and upon completion of data collection, determined the effect of the intervention on provider attitudes toward discussing tobacco use. Conclusions: The average frequency of use of the dot phrase was above the goal of 50% during the data collection period. Frequency of charting of all 5 A’s was higher during the data collection period than at baseline. Provider attitudes about discussing cessation demonstrated no significant changes, based on baseline and post-implementation survey responses. Implications for Practice: Education and enhanced resources to facilitate tobacco cessation conversations have a positive impact on the frequency that clinic providers document tobacco cessation conversations with identified tobacco users. TOBACCO CESSATION IN PRIMARY CARE 3 Introduction Problem Description Tobacco use is the largest preventable cause of death and disease in the United States (Office of Disease Prevention and Health Promotion, 2014). In addition to contributing to multiple cancers, tobacco use also plays a role in the development of heart and lung disease and affects existing conditions, such as Type-2 diabetes (Office of Disease Prevention and Health Promotion, 2014). National guidelines advise providers to query all adult patients about their current level of tobacco use, recommend cessation, and provide behavioral and pharmacological interventions at every clinic visit (U.S. Preventive Services Task Force, 2015). The Agency for Healthcare Research and Quality (AHRQ) provides evidence based guidelines that recommend utilizing the first three of the “5A’s” on all tobacco users; defined as asking about smoking status, advising to quit smoking and assessing the patient’s willingness to quit (AHRQ, 2008). If the patient is ready to quit, the additional two A’s of assisting the patient in quitting and arranging for follow-up within a week of the patient’s determined quit date are required (AHRQ, 2008). Unfortunately, despite these guidelines providers frequently fail to assess and intervene consistently with tobacco users (U.S. Department of Health and Human Services, 2008). Enhancing the ability of staff to deliver effective tobacco cessation counseling is a goal among providers at a small, primary care clinic in the Northwest region of the United States serving Medicaid and uninsured adult African American patients. Prior to implementation of the intervention, the clinic’s standard practice was to ask all patients about current tobacco use on intake with further cessation conversations left up to the discretion of the provider. Barriers to providing quality tobacco cessation identified by clinic staff include lack of time, reduced prioritization and low level of patient readiness to quit. Additionally, staff identified inadequate TOBACCO CESSATION IN PRIMARY CARE 4 clinical cessation intervention skills as a barrier, defined by the staff as an inability to know how to effectively direct cessation conversations. Available Knowledge The barriers identified by staff are not isolated to this clinic, but are echoed in a qualitative study by Blumenthal (2007) among providers caring for underserved communities. Additionally, Meredith, Yano, Hickey, and Sherman (2005) found that providers with more favorable attitudes towards smoking cessation have higher rates of patient-reported smoking cessation behaviors. Therefore, working through barriers faced by providers may improve their attitude towards discussing tobacco use with patients and, in turn, increase quit rates by patients. While evidence-based guidelines for tobacco cessation exist, many patients are not screened to determine tobacco use or provided with assistance quitting (Linder, Rigotti, Schneider, Kelley, Brawarsky, & Haas, 2009). Previous studies have demonstrated that less than 30% of smokers seen for primary care visits are offered evidence-based assistance in quitting (Bentz et al., 2007). When tobacco dependence is understood as a chronic disease requiring multiple interventions and quit attempts (US Department of Health, 2008), the importance of provider identification and documentation of tobacco use, and subsequent counseling, is underscored. Further support of this is the frequency with which smokers cite a provider’s advice to quit as an important motivator for cessation (US Department of Health, 2008). In a review of 42 studies conducted between 1972 and 2012, Stead et al. (2013) concluded that a brief cessation discussion by providers significantly increases the likelihood that someone who uses tobacco will quit and be free of use for at least 12 months. More intensive discussions, advice, and follow-up support further increase the likelihood that someone will quit tobacco products (Stead et al., 2013). This highlights the importance of ensuring providers are adequately trained to TOBACCO CESSATION IN PRIMARY CARE 5 identify tobacco use among their patients, start and continue the dialogue surrounding cessation, and support patients through the challenges of quitting. Previous studies demonstrate the efficacy of provider education about the 5 A’s on the rates of documented cessation conversations. Caplan, Stout and Blumenthal (2010) utilized an intervention at a clinic serving predominately African American patients in the state of Georgia that consisted of provider education and patient provision of Pathways to Freedom, a culturally sensitive educational brochure. Comparing the frequency of 5 A’s use preand post-intervention, with 308 identified tobacco users in each group, Caplan, Stout and Blumenthal (2010) found statistically significant increases (p < 0.0001) in the frequency of provider charted advising (89 post v. 37 pre), assessing (73 post v. 16 pre), assisting (65 post v. 19 pre) and arranging (53 post v. 18 pre). Gordon, Andrews, Crews, Payne and Severson (2007) compared a control group to a group of providers educated on using the 3 A’s (ask, advise, and assess) to a group using 5 A’s (ask, advise, assess, assist, and arrange) among dental office staff and found significant data for higher levels of quit rates among those receiving 3 or 5 A’s compared to the control who received neither (χ2 (1, n = 1381) = 3.37, p<0.05). The data from this study indicates that even partial completion of the 5 A’s produces significant results for quit rates compared to usual care. In addition to the effect of provider education on behavior change, other studies demonstrate the impact that enhanced resources can provide on the frequency of appropriately utilizing the 5 A’s. Katz, Muchlenbruch, Brown, Fiore and Baker (2002) added a real-time alert in the electronic health record (EHR), performance feedback reports, and an algorithm guideline for clinic staff in addition to AHRQ guidelines about tobacco cessation. Compared to a group who only received AHRQ guidelines with no additional prompts or resources, Katz et al. (2002) found that the intervention group had significantly greater (p ≤ 0.05) rates of providers asking TOBACCO CESSATION IN PRIMARY CARE 6 about smoking status (71% intervention v. 58% control), advising to quit (50% intervention v. 19% control), asking about willingness to quit (66% intervention v. 14% control), providing quit literature (30% intervention v. 0.01% control), setting a quit date (28% intervention v. 0.001% control) and discussing pharmacotherapy (36% intervention v. 0.02% control). The effect of provider feedback on performance was also demonstrated by Bentz et al. (2006) who report significantly (p < 0.001) higher rates of advising (71.6% intervention v. 52.7% control), assessing (65.5% intervention v. 40.1% control) and assisting (20.1% intervention v. 10.5% control) implementation among providers receiving individual performance feedback. Rationale The primary theory guiding the practice improvement is the Theory of Reasoned Action. Using this theory, behavior is believed to be influenced by an individual’s attitude about the behavior and by his or her subjective norms, defined as the individual’s perception of other’s opinion of the behavior (White, 2012b). This theory assumes that individuals are rational beings and that to successfully change behaviors, the individual must have a positive attitude towards the change, feel they have control over the change, and perceive the change as positive by their social group (White, 2012b). An individual’s attitude towards a behavior is influenced by his or her beliefs about the outcome of the behavior and his or her evaluation of the expected outcomes (White, 2012b). For this practice improvement, addressing the common barriers to provider provision of smoking cessation can help the individual providers at the clinic develop a more favorable attitude towards performing the intervention. Furthermore, informing the providers of the evidence-based nature of the intervention, and its success in similar practice environments, can help to foster positive