Everyone recognizes the importance of tobacco cessation, but trying to squeeze that into the context of primary care, where doctors are trying to take care of patients with diabetes, high blood pressure, heart disease, high cholesterol, etc. We were trying to put this into a context that was both easy and convenient for them to carry out—kind of the bare-minimum basics. We felt that was one of the biggest challenges, just to get this on people’s radars.
What are the major takeaways from your study?
The initial results of our study have shown that there was, in the first month, a dramatic increase in some of the more relevant measures. All of our measures about tobacco cessation are made remotely by using a reporting system through our electronic health records. We are really using surrogate measures of the actual outcomes, and that’s, from a research perspective, probably one of the biggest weaknesses here.
We’re not really measuring tobacco cessation at the individual level, and we’re not even really measuring individual provider behavior. We’re looking at population-based data.
However, within the context of a very low-budget process, we have made some progress in terms of raising the importance of tobacco cessation on the radar of our providers, and making it easier for them by having expertise available in the clinic—somebody they can grab and say, “Hey, what do you think about this patient or this medication?” A few minutes of motivational interviewing for a patient on site is at least as effective as a one-time phone call from a centralized system, which we previously used for providing tobacco cessation advice.
Prior to this project, our tobacco treatment specialists were all located in a very centralized location, in one obscure, hard-to-find building in Ann Arbor, Michigan. When you’re trying to provide service to a statewide distribution of patients and providers, we thought that was a recipe for failure, so what we’re really trying to do is de-centralize the expertise and put best practices on everybody’s radars.
With that, we have made some progress, though we still have a long way to go. We have learned that there is still a lot more of the elephant there to take bites of, but there are more strategic ways to increase this important aspect of provider primary care.
What are the next steps?
We have tried to establish a monthly rotation of appearing in these clinics with our reports. Each of these clinics operates differently. We have learned a few things from some of the more successful clinics in terms of what they did that worked, and we take that practice and bring it to other clinics and say, “You may want to try this really simple solution.”
We’re not there to judge their performance. There are so many masters, if you will, in this quality improvement environment that we work in. People are measuring things, and you’re constantly being assessed by payers, supervisors, patients, and what we really want people to know is that we’re not there as part of that judgmental process. We’re there to make their jobs easier.
We’ve learned about some really simple interventions. In one clinic, for example, every patient who was a smoker was handed a real simple piece of paper asking, of course, about their smoking history, but specific questions asked, “Are you ready to quit?” and “Do you want to meet with a tobacco cessation specialist?”
And just that simple piece of paper, the second the physician walks in the room, they know that patient is anxious to quit, and that creates an opportunity in that 5- or 10-minute clinic visit for an intervention that can be pretty effective. This is just simple advice from a physician, which we often forget to do in the context of a busy primary care clinic. Simple advice from a physician goes a long way towards motivating quit attempts. Of course, we want to back that up with follow-up phone calls, and/or with providers’ prescriptions of pharmacotherapy.