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Physicians have frequent opportunities to intervene with their smoking patients as approximately 70% of smokers see a physician each year.1 Even brief counselling by a physician significantly improves the rate of smoking cessation according to meta-analyses performed by the Tobacco Use and Dependence Guideline Panel and summarised as “ask, advise, assist, and arrange follow-up” in the Agency for Health Care Policy and Research (AHCPR) guidelines.2 Despite these evidence based recommendations, physicians identify only about half of current smokers, advise less than half, and assist and arrange follow up with a small minority.3 There are several explanations for this disparity between physicians' knowledge and their actual behaviour including inadequate training, resource and time constraints, and lack of information on community cessation resources.
Office systems that screen patients for smoking status increase the rate of smoking cessation interventions by health care providers.4 We hypothesised that providers would be more likely to adhere to the AHCPR guidelines if they could delegate the time consuming steps of assistance and follow up to a telephone cessation resource.
This pilot study assessed the feasibility of a central telephone smoking cessation resource that would proactively call smokers who gave their provider consent for referral. We also evaluated whether providers would be then more likely to adhere to the smoking cessation guidelines. In a quasi-experimental pre-test, post-test design, a sample of patients seen for any type of visit with a provider in three participating primary care clinics in Vermont were interviewed at exit from the clinic. Only current smokers were asked about their providers' adherence to guidelines. The primary outcome measure was the proportion of current smokers who reported being asked, advised, assisted, and having follow up arranged at baseline and four months after implementation of the resource.
Two hundred and nine patients were referred to the resource from the three clinics over the four month duration of resource availability. We estimated that this represented 20% of the total number of smokers seen at the clinics during this time period. We interviewed 54 smokers at baseline and 111 smokers four months after implementation. After the intervention, rates of asking and advising about smoking were not significantly changed from baseline (table 1). The increase in the proportion of smokers who were offered assistance did not reach significance (p = 0.052). There was a significant increase in those who had follow-up arranged (table 1).
Our study demonstrates that a smoking cessation proactive telephone resource is feasible and that providers will refer patients to such a resource. The resource had a contact rate of only 52% of referred current smokers, which we attribute to the resource not having evening calling hours, a significant limitation. Implementation of this proactive smoking cessation telephone resource was associated with improved arrangement of follow up. These preliminary data suggest that further studies of the effect of referral resources on adherence of physicians to guidelines are warranted. Because of the non-randomised design of this pilot study, we cannot attribute improvements in provider adherence solely to the availability of the telephone resource, as provider focus groups, surveys, and training also may have increased adherence to the guidelines. Only a randomised study can address this issue.
Financial support: Robert Wood Johnson Foundation, Princeton, New Jersey (Award 035850), University of Vermont Patient Oriented Research (Award 6-28529).
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