Health Services Research. 2008 Jun 3. [Epub ahead of print]
Targeting Primary Care Referrals to Smoking Cessation Clinics Does Not Improve Quit Rates: Implementing Evidence-Based Interventions into Practice.
Yano EM, Rubenstein LV, Farmer MM, Chernof BA, Mittman BS, Lanto AB, Simon BF, Lee ML, Sherman SE.
Significance:
Quality improvement is often used to improve performance in health care systems, but there is as yet little evidence of its effectiveness. This study used evidence-based quality improvement in an 18-site group randomized trial of implementing smoking cessation guidelines.
Despite warnings from smoking cessation experts, sites chose to focus on the approach with which they were most familiar – referrals to an on-site smoking cessation clinic. Since most smokers will not or do not attend these programs, the increase in referrals that the sites achieved did not improve population cessation rates. This suggests two things: 1) to improve the health of a population, a broad reach is often more important than a large effect size, and 2) allowing sites to choose quality improvement goals – even with considerable expert-based guidance – may not be the best approach to quality improvement.
Abstract:
Objective. To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.
Data Sources/Study Setting. We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.
Study Design. In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.
Data Collection. To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.
Principal Findings. Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.
Conclusions. EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.
PMID: 18522670
