Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics.

Tobacco use remains the leading cause of preventable death and disability in the United States (McGinnis and Foege 1993; Mokdad et al. 2004). Recent studies rank smoking cessation treatment as the most cost-effective preventive service due to its potential impact on public health and economic savings (Maciosek et al. 2006; Solberg et al. 2006). However, while health services such as tobacco screening and counseling have been thoroughly supported by evidence reviews and are highly recommended by the U.S. Preventive Services Task Force (USPSTF), significant gaps persist between recommended and usual care (Fiore et al. 2000; Hopkins et al. 2001; USPSTF 2005). Best practices as outlined in the Public Health Service (PHS) Clinical Practice Guideline: Treating Tobacco Use and Dependence (Fiore et al. 2000) recommends the following “5As” approach: (1) ask about tobacco use at every visit, (2) advise smokers to quit, (3) assess smokers’ readiness to quit, (4) assist quit attempts through counseling and pharmacotherapy, and (5) arrange follow-up to prevent relapse. The guideline provides strong evidence that brief advice combined with additional assistance such as counseling and pharmacotherapy can double quit rates (Fiore et al. 2000). Despite this evidence, there is inconsistent adherence to the guideline. Rates for cessation advice range from 30 to 75 percent, with actual treatment ranging from 2 to 38 percent for pharmacotherapy to <10 percent for referral and follow-up (Denny et al. 2003; Quinn et al. 2005; Schroeder 2005; Ferketich, Kahn, and Wewers 2006). The 5As are targeted to audiences such as primary care providers who are uniquely positioned to interact with smokers. More than 70 percent of smokers are seen by a primary care clinician at least once a year with an average of over three visits annually (Centers for Disease Control and Prevention 1993). Furthermore, many smokers report wanting their physician to discuss cessation with them and report greater satisfaction with the visit when their tobacco use is addressed (Fiore et al. 2000; Quinn et al. 2005). While primary care clinics are strategic venues for delivering cessation services, guideline awareness and dissemination alone are insufficient for routine application in busy care settings (Solberg et al. 2000). This research examines the potential for the chronic care model (CCM), a systems-level quality improvement framework, to enhance 5As delivery by primary care providers. Studies of the CCM to date have typically focused on improving the care of patients with chronic illnesses including diabetes, hypertension, congestive heart failure, asthma, and depression (Wagner et al. 2001a, b; Bodenheimer, Wagner, and Grumbach 2002a, b; Bonomi et al. 2002; Kilbourne et al. 2004; Sperl-Hillen et al. 2004; Mangione-Smith et al. 2005; Pearson et al. 2005; Stroebel et al. 2005; Parchman et al. 2007). Beyond this, the model has also been preliminarily explored as a template for primary prevention and for delivery of services that address health risk behaviors (Glasgow et al. 2001; Hung et al. 2007). The current research builds on this work in prevention by specifically targeting tobacco use and examining how implementation of the CCM might improve provider adherence to treatment guidelines. Methodologically, this study also builds on the existing CCM literature by using multilevel modeling techniques to estimate both organizational- and individual-level effects on provider delivery of health services. This approach indicates the extent to which provider delivery of the 5As may be attributed to clinic implementation of the CCM, adjusting for provider covariates and clustering. Thus, this study will: (1) describe the prevalence of CCM features tailored for treating tobacco use in urban primary care clinics; (2) examine relationships between provider 5As delivery and clinic implementation of each CCM element; and (3) examine associations between the degree of CCM integration in clinics and provider delivery of 5A services.