Using a multilevel implementation strategy to facilitate the screening and treatment of tobacco use in the outpatient urology clinic: A prospective hybrid type I study

Abstract

BACKGROUND: Urologists frequently treat patients for tobacco-related conditions but infrequently engage in evidence-based practices (EBPs) that screen for and treat tobacco use. Improving the use of EBPs will help to identify smokers, promote cessation, and improve patients' health outcomes. METHODS: A prospective type I hybrid effectiveness-implementation study was performed to test the feasibility and effectiveness of using a multilevel implementation strategy to improve the use of tobacco EBPs. All urology providers at outpatient urology clinics within the Veterans Health Administration Greater Los Angeles and all patients presenting for a new urology consultation were included. The primary outcome was whether a patient was screened for tobacco use at the time of consultation. Secondary outcomes included a patient's willingness to quit, chosen quit strategy, and subsequent engagement in quit attempts. RESULTS: In total, 5706 consecutive veterans were seen for a new consultation during the 30-month study period. Thirty-six percent of all visits were for a tobacco-related urologic diagnosis. The percentage of visits that included tobacco use screening increased from 18% (before implementation) to 57% in the implementation phase and to 60% during the maintenance phase. There was significant provider-level variation in adherence to screening. Of all screened patients, 38% were willing to quit, and most patients chose a "cold turkey" method; 22% of the patients elected referral to a formal smoking cessation clinic, and 24% chose telephone counseling. Among those willing to quit, 39% and 49% made a formal quit attempt by 3 and 6 months, respectively. CONCLUSIONS: A strategy that includes provider education and a customized clinical decision support tool can facilitate provider use of tobacco EBPs in a surgery subspecialty clinic.

Smoking status among cancer patients by medical specialty: A U.S. nationwide representative analysis

“…While our results are consistent with previously reported findings between younger age and lower education associated with smoking in tobacco‐related cancer patients, 12,13,16,20,21 we interestingly found that the rate of individuals continuing to smoke varied according to the specialty involved in cancer care thus highlighting the likely important role of the healthcare professional with respect to tobacco cessation. It is feasible that these findings are due to a difference in tobacco cessation counseling by the treating physician 22 . Specifically, we identified that having urological or gynecological cancer was significantly associated with continuation of smoking after a cancer diagnosis.…”

“…It is feasible that these findings are due to a difference in tobacco cessation counseling by the treating physician. 22 Specifically, we identified that having urological or gynecological cancer was significantly associated with continuation of smoking after a cancer diagnosis. These findings suggested that urologists and gynecologists might not offer adequate counseling about tobacco cessation to patients compared to other specialists.…”

Improving Tobacco Cessation Rates Using Inline Clinical Decision Support

“…[22] One study promoted counseling within the clinician workflow, but did not report follow up tobacco cessation rates. [18] This study evaluates tobacco cessation patient outcomes associated with the implementation of a widely-used, user-centered, workflowintegrated, non-interruptive CDS tool designed to increase clinician awareness of patient tobacco use.…”

“…Existing CDS literature regarding tobacco cessation has largely focused on alerts which automatically generate electronic consults to tobacco cessation services, [11][12][13][14][15][16][17][18] print information…”

“…Existing CDS literature regarding tobacco cessation has largely focused on alerts which automatically generate electronic consults to tobacco cessation services, [11][12][13][14][15][16][17][18] print information for patients, 13,19 automatically add tobacco use to the patient problem list, 14,15 or facilitate ordering of medication therapy. [13][14][15]18,20 Some studies, which explored clinical prompting of tobacco cessation counseling, were intended to be usability-focused or prototypes. 17,21 Others have implemented brief counseling training but were unable to integrate into the provider workflow.…”