Transcript TOBACCO TACTICS - University of Michigan Health System

Tobacco Tactics Manuals Used by Month during Intervention Period in the
Ann Arbor VA, July 2007-May 2008
TOBACCO TACTICS: BRINGING THE PROGRAM TO THE SMOKER
1,2
RN ;
2
MPH ;
2
MPH ;
1,2
PhD ; and
Sonia A. Duffy, PhD,
Lee A. Ewing,
Carrie A. Karvonen-Gutierrez,
David L. Ronis,
the Tobacco Tactics Team
1University of Michigan; 2VA Ann Arbor Healthcare System, Center for Clinical Management Research
BACKGROUND
SUMMATIVE (OUTCOME) EVALUATION
•Smokers have an increased risk of morbidity and mortality resulting in
twice as many hospital stays, longer hospital stays, and greater expenses
per admission than nonsmokers.
•In the Ann Arbor intervention site, smoking rates did not increase
significantly largely because pre-intervention rates were unusually high.
Sub-analyses show that the pre-intervention sample had significantly more
heart patients than the post-intervention sample and heart patients are
highly motivated to quit.
•Inpatient smoking programs are efficacious and have a high reach as
they capitalize on a teachable moment, take advantage of cessation
induced by hospital smoking bans, enroll a higher percentage of patients
who smoke, and result in higher cessation rates.
•The majority of smoking services in the Department of Veterans Affairs
(VA) are provided by outpatient programs. Although efficacious,
outpatient smoking cessation programs are poorly attended and few
smokers are reached. Inpatient cessation programs have not been widely
implemented.
OBJECTIVE
•The objective of this study is to implement and evaluate the nurseadministered Tobacco Tactics program in the VA.
FORMATIVE (PROCESS) EVALUATION
•About 96% (210/219) of inpatient nurses in Ann Arbor, 57% (159/279) in
Detroit, and an additional 282 non-targeted personnel attended training.
•The intervention has disseminated to units initially not targeted including
psychiatric, substance abuse, and outpatient clinics.
•Nurses’ self-reported administration of cessation services increased from
57% pre-training to 86% post-training (p=0.0002).
•Preliminary data analysis (N=1170) shows that those in the intervention
group are reporting an increase in receiving and satisfaction with the
selected cessation services, particularly in regards to medications compared
to the Indianapolis control site (P=0.06).
•Residents were given a brief overview of the program along with the
medication algorithm during orientation. Physician advice to quit smoking
(as reported by patients on their 6-month surveys) was high in both the preintervention and post-intervention period in both the experimental and
control group, ranging between 74-82%.
METHODS
•In this quasi-experimental implementation study, Ann Arbor and Detroit
were the intervention sites and Indianapolis was the control site.
•At the intervention sites, research nurses taught the intervention to staff
nurses using the Tobacco Tactics nurse toolkit which includes: 1) one
contact hour for training; 2) PowerPoint presentation on behavioral and
pharmaceutical interventions; 3) pocket card “Helping Smokers Quit: A
Guide for Clinicians”; 4) pharmaceutical and behavioral protocols; and 5)
computerized template for documentation.
•The patient toolkit includes: 1) brochure; 2) videotape; 3) Tobacco Tactics
manual; 4) pharmaceuticals; 5) 1-800-QUIT-NOW help line; and 6)
volunteer follow-up phone counseling.
•At the Indianapolis control site, patients were referred to usual care
outpatient groups.
•Smokers in all facilities were surveyed at baseline and 6 months after
discharge.
•Volunteers were trained to provide telephone follow-up counseling and peer
support to patients 2, 14, 21, and 60 days post-discharge. In the Ann Arbor
site only, during the intervention period, two volunteers made 1,776 attempts
(no more than 3 attempts per time point) to reach 270 patients of which 85%
were reached at least once. An average of 2 follow-up calls per patient
were made to 230 patients for a total of 552 patient contacts.
•In the Detroit intervention site, 6-month cotinine verified quit rates went
from 7.8% pre-intervention to 17.4% post-intervention compared to 8.9%
quit rates during these periods in the Indianapolis control site.
•Further sub-analyses show that the intervention seems to have the most
benefit for motivated patients, i.e. those thinking of quitting smoking in the
next 30 days.
Able to quit for 24 hours
Not nicotine dependent and
thinking of quitting in next 30 days
Pre-Intv.
During
Post-Intv.
% (n)
% (n)
% (n)
30.6 (15)
50.0 (10) 53.9 (14)
Nicotine dependent and thinking
of quitting in next 30 days
Pre-Intv. During Post-Intv.
% (n)
% (n)
% (n)
53.9 (14) 47.1 (8) 48.3 (14)
Not used tobacco last 7 days
20.8 (15)
15.8 (3)
20.0 (5)
13.8 (8)
13.3 (2)
17.2 (5)
Negative cotinine strip
12.9 (8)
13.3 (2)
21.7 (5)
P=0.047
13.5 (7)
6.7 (1)
48.3 (14)
Cotinine verified quit selfreport
6.7 (8)
10.5 (2)
16 (4)
P=0.099
12.1 (7)
0.0 (0)
14.3 (4)
•Combining the Ann Arbor and Detroit sites, pre-intervention quit rates for
psychiatric patients were 0% vs. 18.9% post-intervention (p=0.04)
compared to 6.6% in the Indianapolis control site during the intervention
period.
SUSTAINABILITY
•The program is now part of orientation for all new nurses.
•As more nurses were trained, the number of Tobacco Tactics manuals used
on the units steadily increased as shown in Figure 1.
Figure 1. Tobacco Tactics Manuals Used by Month during
the Intervention Period at the
Ann Arbor VA, July 2007 – May 2008
•A booster training module in the VA Learning Management System will
provide ongoing continuing education to inpatient nurses.
•Nurse champions from all of the units are responsible for sustaining the
intervention.
•Oversight of the program was transferred to the Tobacco Cessation
Coordinator (a pharmacist).
50
45
40
35
30
25
20
15
10
5
0
•Staff education was turned over to the nurse educators and patient
education materials were assigned to Patient Care Services.
CONCLUSION
6/21-7/19
8/17-9/17
10/10-11/5
12/12-1/9
1/30-2/27
3/31-4/30
•Since nurses constitute the largest number of front line providers, teaching
nurses how to conduct smoking education may be the quickest and most
efficient strategy to reach inpatient smokers.
This study was supported by the Department of
Veterans Affairs SDP 06-003.