BackgroundAccurate smoking status is key for research purposes, but can be costly and difficult to measure. Within the Veteran’s Health Administration (VA), smoking status is recorded as part of routine care as “health factors” (HF)—fields that researchers can query through the electronic health record (EHR). Many researchers are interested in using these fields to track changes in smoking status over time, however the validity of this measure for assessing change is unknown. The primary goal of this project was to examine whether HFs can be used to accurately measure change in tobacco status over time, with secondary goals of assessing the optimum timeframe for assessment and variation in accuracy by site.MethodsSecondary analysis of the Veterans VICTORY study, a pragmatic smoking cessation randomized controlled trial conducted from 2009 to 2011. Eligible subjects were identified via the EHR using a past 90-day HF indicating current tobacco use (for example: “CURRENT SMOKER”, “CURRENTLY USES TOBACCO”). Participants were surveyed at 1 year to determine prolonged smoking abstinence. We identified HFs for tobacco status within +/− 120 days of the follow-up survey mailing date and recorded the temporally closest HF. Among subjects with both measures, we compared the two for agreement using kappa statistics and concordance.Results1713 subjects (33%) had both follow-up survey and HF data, 1594 (31%) had only a survey response, 790 (15%) had only HF and 1026 (20%) had neither. For subjects with both measures, there was 90% concordance and moderate agreement (Kappa 0.48, 95%CI 0.41–0.55, Sensitivity 54.4, 95%CI 41.1–67.7, Specificity 94.3, 95%CI 87.5–100.0).ConclusionsWe found high concordance but only moderate agreement by kappa statistics between HFs and survey data. The difference is likely accounted for by the natural history of quit attempts, in which patients cycle in and out of quit attempts. HFs appear to provide an accurate measure of population level quit behavior utilizing data collected in the course of clinical care.Electronic supplementary materialThe online version of this article (10.1186/s12874-018-0501-2) contains supplementary material, which is available to authorized users.

BackgroundCurrent guidelines advise providers to assess smokers’ readiness to quit, then offer cessation therapies to smokers planning to quit and motivational interventions to smokers not planning to quit.ObjectivesWe examined the relationship between baseline stage of change (SOC), treatment utilization, and smoking cessation to determine whether the effect of a proactive smoking cessation intervention was dependent on smokers’ level of motivation to quit.DesignSecondary analysis of a multicenter randomized controlled trial.ParticipantsA total of 3006 current smokers, aged 18–80 years, at four Veterans Affairs (VA) medical centers.Interventions: Proactive care included proactive outreach (mailed invitation followed by telephone outreach), offer of smoking cessation services (telephone or face-to-face), and access to pharmacotherapy. Usual care participants had access to VA smoking cessation services and state telephone quitlines.Main MeasuresBaseline SOC measured with Readiness to Quit Ladder, and 6-month prolonged abstinence self-reported at 1 year.Key ResultsAt baseline, 35.8 % of smokers were in preparation, 38.2 % in contemplation, and 26.0 % in precontemplation. The overall interaction between SOC and treatment arm was not statistically significant (p = 0.30). Among smokers in preparation, 21.1 % of proactive care participants achieved 6-month prolonged abstinence, compared to 13.1 % of usual care participants (OR, 1.8 [95 % CI, 1.2–2.6]). Similarly, proactive care increased abstinence among smokers in contemplation (11.0 % vs. 6.5 %; OR, 1.8 [95 % CI, 1.1–2.8]). Smokers in precontemplation quit smoking at similar rates (5.3 % vs. 5.6 %; OR, 0.9 [95 % CI, 0.5–1.9]). Within each stage, uptake of smoking cessation treatments increased with higher SOC and with proactive care as compared with usual care.LimitationsMostly male participants limits generalizability. Randomization was not stratified by SOC.ConclusionsProactive care increased treatment uptake compared to usual care across all SOC. Proactive care increased smoking cessation among smokers in preparation and contemplation but not in precontemplation. Proactively offering cessation therapies to smokers at all SOC will increase treatment utilization and population-level smoking cessation.

Objective: Most veterans with posttraumatic stress disorder (PTSD) who receive care from the Veterans Health Administration (VHA) do not receive individual psychotherapy. The purpose of this study was to explore gender differences in initiation and completion of a sufficient course (defined as attending 8 or more sessions) of individual psychotherapy among male and female VHA users recently diagnosed with PTSD. Method: Participants (N ϭ 7,218) were veterans in a prospective national cohort survey of VHA users diagnosed with PTSD; oversampling was used to increase representation of women and minority veterans. Results: Forty-two percent of the sample (40.1% of men, 52.3% of women) initiated individual psychotherapy within 6 months of their index PTSD diagnosis. Of those who initiated, 12.1% (10.8% of men, 17.7% of women) completed a sufficient course of individual psychotherapy. Women were generally more likely than men to initiate individual psychotherapy. However, we found an interaction between gender and age, such that younger men were more likely to initiate psychotherapy than older men; age was not significantly associated with initiation among women. Regarding completion of individual psychotherapy, an interaction between gender and beliefs about psychotherapy was found, such that men were less likely to complete individual psychotherapy when they held more negative beliefs about psychotherapy; these beliefs did not significantly impact female veterans' likelihood of completing psychotherapy. Conclusions: Overall, while female veterans are more likely than male veterans with PTSD to initiate individual psychotherapy, rates of initiation and completion of individual psychotherapy for both genders remain relatively low. Interventions are needed to increase engagement in individual psychotherapy, particularly for male veterans with PTSD.

This study is registered at www.clinicaltrials.gov NCT00608426.