Top

Published in:

Open Access 01-12-2021 | Research Article

A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support

Authors: Susan A. Flocke, Elizabeth L. Albert, Steven A. Lewis, Thomas E. Love, Jeanmarie C. Rose, David C. Kaelber, Eileen L. Seeholzer

Published in: BMC Primary Care | Issue 1/2021

Abstract

Introduction

This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach.

Methods

A stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts.

Results

Forty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2–33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7).

Conclusions

Despite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased.

Implications

Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach.

Trial Registration

clinicaltrials.gov #NCT02764385, registration date 06/05/2016.

U.S. Department of Health and Human Services. The Health Consequences of Smoking - 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA; 2014. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. Accessed 25 Nov 2020.

Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults — United States, 2019. MMWR. 2020;69(46):1736–1742. https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm.

Yoon PW, Bastian B, Anderson RN, Collins JL, Jaffe HW. Potentially preventable deaths from the five leading causes of death–United States, 2008–2010. MMWR Morb Mortal Wkly Rep. 2014;63(17):369–74.PubMedPubMedCentral

Piper ME, Baker TB, Mermelstein R, et al. Recruiting and engaging smokers in treatment in a primary care setting: developing a chronic care model implemented through a modified electronic health record. Transl Behav Med. 2012. https://doi.org/10.1007/s13142-012-0178-8.CrossRefPubMedCentral

Levy DE, Klinger E V., Linder JA, et al. Cost-Effectiveness of a Health System-Based Smoking Cessation Program. Nicotine Tob Res. 2016:ntw243. doi:https://doi.org/10.1093/ntr/ntw243

McCarthy DE, Adsit RT, Zehner ME, et al. Closed-loop electronic referral to SmokefreeTXT for smoking cessation support: a demonstration project in outpatient care. Transl Behav Med. 2019. doi:https://doi.org/10.1093/tbm/ibz072

Hood-Medland EA, Stewart SL, Nguyen H, et al. Health System Implementation of a Tobacco Quitline eReferral. Appl Clin Inform. 2019;10(04):735–42. https://doi.org/10.1055/s-0039-1697593.CrossRefPubMedPubMedCentral

Adsit RT, Fox BM, Tsiolis T, et al. Using the electronic health record to connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop demonstration project. Transl Behav Med. 2014;4(3):324–32. https://doi.org/10.1007/s13142-014-0259-y.CrossRefPubMedPubMedCentral

Vidrine JI, Shete S, Li Y, et al. The ask-advise-connect approach for smokers in a safety net healthcare system: A group-randomized trial. Am J Prev Med. 2013;45(6):737–41. https://doi.org/10.1016/j.amepre.2013.07.011.CrossRefPubMedPubMedCentral

10.

Piñeiro B, Vidrine DJ, Wetter DW, et al. Implementation of Ask-Advise-Connect in a safety net healthcare system: quitline treatment engagement and smoking cessation outcomes. Transl Behav Med. 2018:1–5. doi:https://doi.org/10.1093/tbm/iby108

11.

Bui TC, Piñeiro B, Vidrine DJ, Wetter DW, Frank-pearce SG, Vidrine JI. Quitline Treatment Enrollment and Cessation Outcomes Among Smokers Linked With Treatment via Ask-Advise-Connect : Comparisons Among Smokers With and Without HIV. Nicotine Tob Res. 2019:1–4. doi:https://doi.org/10.1093/ntr/ntz227

12.

Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2013;(5):CD000165. https://doi.org/10.1002/14651858.

13.

Tong EK, Strouse R, Hall J, Kovac M, Schroeder SA. National survey of U.S. health professionals’ smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res. 2010;12(7):724–733. doi:https://doi.org/10.1093/ntr/ntq071

14.

Flocke SA, Antognoli E, Step MM, Marsh S, Parran T, Mason MJ. A teachable moment communication process for smoking cessation talk: description of a group randomized clinician-focused intervention. BMC Health Serv Res. 2012;12(1):109. https://doi.org/10.1186/1472-6963-12-109.CrossRefPubMedPubMedCentral

15.

Flocke SA, Clark E, Antognoli E, et al. Teachable moments for health behavior change and intermediate patient outcomes. Patient Educ Couns. 2014;96:43–9. https://doi.org/10.1016/j.pec.2014.03.014.CrossRefPubMedPubMedCentral

16.

Flocke SA, Seeholzer E, Lewis SA, et al. 12-Month Evaluation of an EHR-Supported Staff Role Change for Provision of Tobacco Cessation Care in 8 Primary Care Safety-Net Clinics. J Gen Intern Med. 2020;35(11):3234–42. https://doi.org/10.1007/s11606-020-06030-7.CrossRefPubMed

17.

Makoul G, Krupat E, Chang C-H. Measuring patient views of physician communication skills: development and testing of the Communication Assessment Tool. Patient Educ Couns. 2007;67(3):333–42. https://doi.org/10.1016/j.pec.2007.05.005.CrossRefPubMed

18.

Flocke SA, Step MM, Antognoli E, et al. A randomized trial to evaluate primary care clinician training to use the Teachable Moment Communication Process for smoking cessation counseling. Prev Med (Baltim). 2014;69:267–73. https://doi.org/10.1016/j.ypmed.2014.10.020.CrossRef

19.

Karn S, Fernandez A, Grossberg LA, et al. Systematically Improving Tobacco Cessation Patient Services Through Electronic Medical Record Integration. Health Promot Pract. 2016;17(4):482–9. https://doi.org/10.1177/1524839916643910.CrossRefPubMed

20.

Silfen SL, Cha J, Wang JJ, Land TG, Shih SC. Patient characteristics associated with smoking cessation interventions and quit attempt rates across 10 community health centers with electronic health records. Am J Public Health. 2015;105(10):2143–9. https://doi.org/10.2105/AJPH.2014.302444.CrossRefPubMedPubMedCentral

21.

Stead LF, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane database Syst Rev. 2012;10:CD008286. doi:https://doi.org/10.1002/14651858.CD008286.pub2

22.

Jaén CR, McIlvain H, Pol L, Flocke SA, Crabtree BF, Phillips RL. Tailoring tobacco counseling to the competing demands in the clinical encounter. J Fam Pract. 2001;50(10):859–63.PubMed

23.

Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;2012(6). doi:https://doi.org/10.1002/14651858.CD000259.pub3

24.

Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open. 2016;6(6). doi:https://doi.org/10.1136/bmjopen-2016-011045

25.

Albert E, Rose J, Gill I, Flocke S. Quitting the quitline : a qualitative study of patient experience of electronic referrals to quitlines. BMC Public Health. 2020:1–22. doi:https://doi.org/10.21203/rs.2.22186/v2

Title: A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support
Authors: Susan A. Flocke
Elizabeth L. Albert
Steven A. Lewis
Thomas E. Love
Jeanmarie C. Rose
David C. Kaelber
Eileen L. Seeholzer
Publication date: 01-12-2021
Publisher: BioMed Central
Published in: BMC Primary Care / Issue 1/2021
Electronic ISSN: 2731-4553
DOI: https://doi.org/10.1186/s12875-021-01423-x

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support

Abstract

Introduction

Methods

Results

Conclusions

Implications

Trial Registration

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

Implications

Trial Registration

Please log in to get access to this content

Other articles of this Issue 1/2021

Making sense of symptoms, clinicians and systems: a qualitative evaluation of a facilitated support group for patients with medically unexplained symptoms

Prepared and highly committed despite the risk of COVID-19 infection: a cross-sectional survey of primary care physicians’ concerns and coping strategies in Singapore

Mastery of type 2 diabetes prevention and treatment knowledge by general practitioners in Shanghai: a cross-sectional study

Use of alternative consultation forms in Danish general practice in the initial phase of the COVID-19 pandemic – a qualitative study

First contact of care for persons with spinal cord injury: a general practitioner or a spinal cord injury specialist?

Prerequisites for providing effective support to family caregivers within the primary care setting – results of a study series in Germany