Interactive voice response telephony to promote smoking cessation in patients with heart disease: A pilot study
Introduction
Cigarette smoking is a principal causative factor in the development of coronary heart disease (CHD), the leading cause of death in North America [1]. Quitting smoking is the most effective intervention to reduce morbidity and mortality in CHD patients who smoke. Patients who quit smoking reduce their relative risk of death by 36% and non-fatal re-infarction by 32% [2]. The risk reduction achieved through quitting smoking is as great as or superior to that observed with: statins for lowering cholesterol (a 29% reduction); aspirin (15%); beta-blockers (23%); or ACE inhibitors (23%) [2].
Hospitalization for CHD provides an excellent opportunity to initiate smoking cessation treatment. Hospitalization often provides an enhanced motivation to quit smoking. It has been reported that 65% of smokers hospitalized with myocardial infarction (MI) intend to quit smoking in the next 30 days [3], compared with only 20% of non-hospitalized smokers [4]. Secondly, hospitals provide a smoke-free environment thereby reducing the triggers to smoke and supporting non-smoking behaviour. Finally, patients have access, in-hospital, to health professionals who can provide distinct assistance with nicotine withdrawal (e.g. through the provision of nicotine replacement therapy [NRT]) and deliver the specific, relevant smoking-cessation advice and support that will help patients remain smoke-free after discharge [5]. Unfortunately, while many patients may use the in-hospital smoke-free period as the stimulus for a quit attempt, many relapse to smoking after returning home. In a previous investigation conducted at our institution (the University of Ottawa Heart Institute), we found that despite an initial smoking cessation intervention, almost two-thirds of smokers resumed smoking within a year of hospitalization for CHD; half of those resumed smoking within 1 month [3].
Effective treatments for smoking cessation in patients with CHD have been previously described [6], [7], but they are frequently misperceived as intensive and/or expensive and institutional resources applied to smoking cessation have typically been limited or non-existent. Interventional day procedures for the treatment of CHD (e.g. percutaneous coronary intervention [PCI]) and shorter hospital stays are becoming more common, seemingly making it difficult to initiate treatment for tobacco addiction in-hospital. Consistent and ongoing patient follow-up is important to maximize smoking cessation success. Interventions in the hospital setting with less than 1-month post-discharge follow-up do not appear to significantly increase cessation [8], [9]. To date, follow-up support for smoking cessation in patients with CHD has usually consisted of proactive (counselor initiated) telephone counseling, or in-person contacts. When in-hospital contact is combined with follow-up lasting more that 1-month after discharge, the odds of quitting increase substantially (OR = 1.98, 95% CI: 1.49–2.65) [8]. Most in-hospital programs fail to provide such follow-up. A survey of 12 hospitals in our region revealed that none had follow-up systems in place to assist smokers after their discharge from hospital. Innovative, cost-efficient solutions are required to address these challenges.
Interactive voice response technology is a sophisticated application of speech recognition software which when combined with automatic dialing capabilities allows calls to be made to willing patients to inquire about smoking cessation status, assess motivation and evaluate perceived competency relevant to a particular cessation attempt. The technology recognizes patient's verbal responses, documents them and thereby distinctly assists in guiding further patient follow-up. Interactive voice response (IVR) technology, therefore, has the potential to significantly improve follow-up of new non-smokers following hospitalization and to enhance the provision of clinical support during a particular, ongoing smoking cessation attempt. An IVR system can easily be programmed to generate automated telephone calls to hundreds of patients. The resulting interactions are personalized and conversational. The IVR system will record responses and store them in a database. It provides a low cost method of maintaining contact with a large number of patients, monitoring their quit progress and when necessary, transferring them to a live counselor for additional help. The counselor is able to link with the database to obtain information about the patient's smoking cessation needs and provide appropriate ongoing support.
Previous studies have investigated IVR's role in the diagnosis, assessment and clinical follow-up of other conditions and have shown that information obtained by IVR is reliable and valid [10], [11], [12]. One apparent advantage of IVR is that patients may be willing to disclose more sensitive information than when speaking with a live interviewer [13]. However, IVR appears to be most successful when used in combination with human intervention [14]. IVR has been used in other smoking cessation studies, with promising results [15], [16], It has not been used previously, however, in a setting involving hospitalized smokers with CHD.
The purpose of this pilot study was to determine the feasibility and potential efficacy of an IVR monitoring and follow-up system to support smoking cessation in smokers hospitalized with CHD. The pilot was conducted in the context of a busy tertiary care hospital setting. Information derived from this feasibility study will be used to refine the nature, content, and timing of the IVR intervention. Information regarding subject retention and effect size obtained from the present trial will aid in the determination of the sample size required for a definitive clinical trial to evaluate the intervention.
Section snippets
Setting
The project was completed at the University of Ottawa Heart Institute (UOHI), a tertiary care cardiac facility serving a population of 1.0 million people. Approval of the study protocol was obtained from the Research Ethics Committee at the UOHI.
Participants
Participants were current smokers (≥5 cigarettes per day) over the age of 18 years, hospitalized at UOHI for acute coronary syndrome (ACS), elective PCI or diagnostic catheterization related to CHD. Patients living too far away to be available for
Recruitment
Between November 2004 and May 2005, 186 patient charts were reviewed for eligibility. Seventy-seven patients were excluded because they did not meet the eligibility criteria (i.e. hospitalization for something other than ACS, elective PCI, or diagnostic catheterization related to CHD; smoking fewer than five cigarettes per day; or living too far away). The remaining 111 patients were invited to participate and 100 agreed (90.1% participation rate of eligible patients). The main reasons for
Discussion
Smoking cessation is by far the most effective intervention to reduce morbidity and mortality among patients with CHD who smoke. Quitting is a difficult process, which is substantially aided by effective follow-up care. The purpose of this pilot study was to determine the feasibility and potential efficacy of an IVR monitoring and follow-up system to support smoking cessation in smokers hospitalized with CHD. Our data suggest the IVR system is feasible for use in this population and when
Acknowledgements
This research was funded by a partnership coordinated by the Canadian Tobacco Control Research Initiative (Grant number 15735). Robert D. Reid is supported by a New Investigator Award from the Heart and Stroke Foundation of Canada. The authors also acknowledge the ongoing support of the Ontario Ministry of Health Promotion.
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