Abstract
Objective To learn whether front-line personnel in primary care practices can increase delivery of clinical tobacco interventions and also help smokers address physical inactivity, at-risk alcohol use, and depression.
Design Uncontrolled before-and-after design.
Setting Vancouver, BC, area (4 practices); northern British Columbia (2 practices).
Participants Six practices, with 1 staff person per practice serving as a “health coordinator” who tracked and, after the baseline period, delivered preventive interventions to all patients who smoked. To assess delivery of preventive interventions, each practice was to sample 300 consecutive patient records, both at baseline and at follow-up 15 months later.
Interventions Front-office staff were recruited, trained, paid, and given ongoing support to provide preventive care. Clinicians supplemented this care with advice and guided the use of medication.
Main outcome measures Effectiveness of the intervention was based on comparison, at baseline and at follow-up, of the proportion of patients with any of the following 6 proven intervention components documented in their medical records: chart reminder, advice received, self-management plan, target quit date, referral, and follow-up date (as they applied to tobacco, physical inactivity, at-risk alcohol use, and depression). A Tobacco Intervention Flow Sheet cued preventive care, and its data were entered into a spreadsheet (which served as a smokers’ registry). Qualitative appraisal data were noted.
Results For tobacco, substantial increases occurred after the intervention period in the proportion of patients with each of the intervention components noted in their charts: chart reminder (20% vs 94%); provision of advice (34% vs 79%); self-management plan (14% vs 57%); target quit date (5% vs 11%); referral (6% vs 11%); and follow-up date (7% vs 42%). Interventions for physical inactivity and depression showed some gains, but there were no gains for at-risk alcohol use. Front-line staff, patients, and clinicians were enthusiastic about the services offered.
Conclusion Selected front-office personnel can substantially increase the delivery of evidence-based clinical tobacco intervention and increase patient and staff satisfaction in doing so. How far these findings can be generalized and their population effects require further study.
Clinical tobacco intervention, although highly effective, is inadequately delivered. Only half the Canadian smokers who saw physicians in 2005 received advice to stop smoking.1 The US guideline on tobacco use and dependence underscores this deficit: “Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions.”2
To address this, Katz and colleagues found that medical assistants (who in the United States are clinically trained to assist physicians) and nurses could improve the delivery of tobacco intervention components: asking about smoking (58% vs 87%); asking about willingness to quit (28% vs 73%); offering advice (41% vs 47%); providing literature about quitting (3% vs 38%); discussing pharmacotherapy (15% vs 39%); and setting a quit date (2% vs 27%).3 This study by Katz et al documented a significant increase in smoking cessation from the baseline year to the intervention year. They used 2 outcome measures: 7-day cessation prevalence at 6 months (P = .009) and continuous cessation (no smoking reported at both 2 and 6 months [P < .001]). Intervention practices demonstrated a baseline 10% 7-day cessation prevalence rising significantly to 15% during the intervention period (P = .009). Control practices had a baseline 9% 7-day cessation prevalence with little change (to 10%) during the intervention period (P = .62). The baseline rate of 3% for continuous cessation rose to 11% with the intervention, whereas control practices showed no change (4% to 4%).
We found only 2 published studies in which front-line staff were assigned substantial preventive roles. One, a randomized controlled trial, successfully employed a preventive care checklist.4 In the second, medical assistants offered brief counseling to obese patients, which resulted in significant weight loss (P < .001); the weight was regained when the medical assistants’ support was withdrawn.5 No Canadian study had ever explored whether existing primary care staff could improve multiple components of clinical tobacco intervention.
In 2006 to 2007, we did a substantial feasibility study examining whether medical office assistants (who in British Columbia typically have a clerical as opposed to a clinical role) should offer aid to smoking patients. Patients, health professionals, and the public approved of the idea.6 The feasibility study also recommended addressing smokers’ physical inactivity, at-risk alcohol use, and depression, which are factors that reduce the odds of quitting.
Thus, for tobacco, this study focused on whether front-line personnel could increase intervention components proven to improve smoking cessation: chart reminders, physician’s advice, self-management plans (including use of smoking cessation medication), setting a target quit date, referral, and scheduling follow-up visits. It also addressed whether these personnel could assist smokers with physical inactivity, at-risk alcohol use, and depression.
Design, setting, and participants
This pilot had an uncontrolled, before-and-after design involving delivery of selected preventive services in primary care settings.
The assessed populations comprised unselected, consecutive patients, aged 19 years or older, visiting the practice during the baseline and follow-up medical record surveys. For each survey, a convenience sample of consecutive patient visits (300 per practice) was set. With a prevalence of smoking of approximately 15% in BC in 2008,7 a sample was expected to include almost 50 smokers at baseline and at follow-up, a sufficient number to crudely estimate proportions within the sample.
Following the baseline survey, health coordinators (HCs) offered clinical tobacco intervention to all the identified smoking patients they could reach and tracked progress on a computer spreadsheet. We use the term clinical tobacco intervention to include all measures offered to patients for identification or assessment of and advice, assistance, and follow-up for tobacco use. This even includes identifying and using chart reminders for non-smokers and long-term ex-smokers. Smoking patients were those who had smoked more than 100 cigarettes in their lifetimes and were currently smoking or had had a cigarette in the past 2 weeks. Tobacco intervention and follow-up were offered to all current smokers and to ex-smokers who had stopped for less than 12 months. Screening and brief intervention or referral were also offered for physical inactivity, depression, and at-risk alcohol use.
Two rural and 4 metropolitan practices participated (from the Northern Health and Vancouver Coastal Health regions). One front-line staff member per practice—an HC—coordinated preventive care. With help from regional practice support programs, 6 practices were found that were willing to assign 1 front-office staff member to do the following:
-
use a patient-centred approach to offering basic information, practical problem solving, general support, and referral when needed;
-
complete flow sheets and computer spreadsheets;
-
encourage clinicians to provide advice and smoking cessation medication, as neither component was within the HC role;
-
attend a 2-day training session and participate in weekly consultative sessions; and
-
complete reports.
The HCs required communication skills, computer literacy, and the capacity to work with minimal supervision. The HCs coded medical record data from patients consecutively attending the practice. Demands on clinicians’ time were minimal.
Confidentiality was that already established between practice and patient. Front-line staff forwarded anonymous, coded spreadsheets to the project statistician who analyzed the data. Coded identity comprised 4 digits from the medical plan number and 4 digits for month and year of birth.
Outcome measures
The proven intervention components we selected matched the “5 As,” as shown below.2 Assessment of the effects of the project was based on the before-and-after change in documentation of these intervention components. To measure cessation of smoking would have required more resources; a much larger sample size; nonintervention, control practices; and a longer time period. Thus, the documentation of the following components was measured.
-
Ask—chart reminder: Chart reminder was defined as an alert to clinicians regarding the patient’s risk status by means of a sticker on a paper-based record, an electronic medical record alert, or listing the risk on a clinical problem list. The reminders were of 2 types: tobacco only or those covering all 4 risks.
-
Assess—target quit date: Readiness to change was assessed by notation of a target quit date in the chart.
-
Advise—advice: Strong, clear, and personalized advice is a responsibility of clinicians. We encouraged HCs to offer communication supportive of quitting smoking; they believed that strong advice was not within their role.
-
Assist—self-management plan and referral: Use of stop-smoking medication was considered part of the smoker’s self-management plan.
-
Arrange follow-up—follow-up date.
Training, intervention, and tracking
Table 1 summarizes the project plan. During the initial 9 months we trained the HCs and they also completed the baseline survey. In the next period we sought to provide further skills and experience in regard to physical inactivity, depression, and at-risk alcohol use. After a year, they completed the follow-up survey. In the final months we analyzed data and helped the practices to decide how they would approach the preventive measures we had offered after the project was complete.
Project plan for the Health Coordinator Pilot (2008–2010)
Initially, the Medical Director (F.B.) and project coordinator offered HCs face-to-face training (6 to 12 hours) that briefly involved the practice’s clinicians. The Medical Director had extensive experience training health professionals in clinical tobacco intervention. The HCs were paid for 8 hours per week during the program. Ongoing consultation was offered through weekly telephone conferences and Web conferencing. Training topics included the following:
-
approaching smokers—active listening, health risks, and ways to quit;
-
tobacco addiction—from brain chemistry to social factors, tobacco withdrawal, and nicotine’s useful effects on mood, attention, and reward;
-
comorbidities of tobacco addiction—schizophrenia, depression, etc;
-
how people quit—smokers’ reasons and preferences for quitting;
-
intervention—the “5 As,” smoking cessation medications, self-management, and social support;
-
use of tools—flow sheets, spreadsheets, smoker’s guide; and
-
physical inactivity, at-risk alcohol use, and depression—how they interact with tobacco, and screening and brief help for each.
After the baseline survey, HCs began tobacco intervention. After 6 months and further training, they added screening and brief intervention or referral for the other 3 risks.
Several tools facilitated record review, assessment of risks, and preventive interventions: chart reminders, the Tobacco Intervention Flow Sheet (a checklist and clinical record), and Clinical Tobacco Intervention Options (linked intervention to stage of stopping); the Smoker’s Guide offered patients strategies for controlling and stopping smoking. These are available in PDF format from ImpactBC (info{at}impactbc.ca).
The HCs were to track smoking patients’ progress on the spreadsheets in which smoking status and intervention components were recorded. For baseline and follow-up surveys, HCs sent the anonymous, coded spreadsheets to the project’s statistical consultant who entered the data into an SPSS file, identified and corrected inconsistencies, tabulated the results, and completed statistical analysis.
RESULTS
Health coordinators’ adaptation to their new role
Each of our practices developed its own approach. One had a clinic manager serving as HC. Another had a nurse in that role; the rest were medical office assistants. When one practice moved its offices, the HC worked from home. The HCs became front-line champions of prevention.
Initially, HCs hesitated to motivate patients who were not ready to quit, but they soon became comfortable doing so. They adjusted work hours and locations as needed. Telephone calls were often the best way to follow-up with patients. Later, when asking patients about depression and alcohol, HCs also initially believed they were being intrusive. They were pleased when screening, rather than intervention, for depression and alcohol was emphasized. In time, HCs became most comfortable addressing physical inactivity (less so for depression and least for alcohol). They identified 9% of patients to be at-risk alcohol drinkers compared with the Alcohol Risk Assessment and Intervention program’s estimate of up to 25%.8 Although brief intervention for at-risk drinking in primary care seems to be effective,9 HCs were reluctant to offer it. Those with depression can be considered a clinical tobacco intervention priority, as they are twice as likely to smoke as those without depression.10 As this pilot began, the provincial Practice Support Program targeted the clinical management of depression, and this helped the HCs to screen and refer smoking patients for depression.
Several HCs did not use the spreadsheets developed for tracking smoking patients as an active registry; instead they developed their own means of cueing follow-up. Baseline and follow-up surveys were completed in 5 of 6 practices.
In addition, HCs reported repeatedly that patients and clinicians were enthusiastic about the HCs’ new role. This was confirmed by a short, qualitative survey of physicians.
Patient characteristics
Practices varied in character, as shown in Table 2, specifically in the total number of records reviewed and in patients’ sex, age, and chronic disease status. The 5 practices that completed both baseline and follow-up surveys generated 1565 baseline records. The sixth practice’s results were omitted, as they did not complete the follow-up survey (Table 3).
Participant characteristics at each clinic site at baseline and follow-up
Patients reached in baseline and follow-up medical record surveys
Smoking
The prevalence of identified smokers was 21% at baseline and 22% at follow-up (Table 4). About 20% of smokers consumed fewer than 10 cigarettes daily. Assessment of smokers’ readiness to quit increased from 25% to 42% at follow-up (Table 3).
Proportion of smokers in each clinic with each of the intervention components noted in their charts at baseline and follow-up
Tobacco intervention components at baseline and follow-up
Intervention components increased substantially, especially chart reminders and advice to quit (Table 5). Self-management plans, target quit dates, referral, and follow-up dates—which apply to those ready to quit and to some contemplating quitting—increased to a lesser extent. Although HCs promoted the telephone- and computer-based QuitNow program, the response to referral was modest.
Documented intervention components offered to smokers
Physical inactivity
Canada’s Physical Activity Guide11 defined physical inactivity as fewer than 4 days per week of moderate activity. At baseline, 2% of participants were found to be at risk, 16% were not at risk, 5% were incapacitated, and 77% were at unknown risk. At follow-up, 11% were at risk, 70% were not at risk, 1% were incapacitated, and 17% were at unknown risk. Intervention for physical inactivity rose to modest levels (Table 5). Five of 6 intervention components for physical activity increased.
At-risk alcohol use
At-risk alcohol use was defined as reporting 4 or more drinks in 1 day during past 3 months for female patients and 5 or more in 1 day during past 3 months for male patients, or agreement with the statement “alcohol use is a problem for you or your family.” At baseline, 4% were at risk; at follow-up, 10%. No intervention component for at-risk alcohol use increased (Table 5).
Depression
Documentation of history of depression increased from 9% to 26%. Five of 6 intervention components for depression improved. Among the 3 associated risks, intervention for depression showed the greatest increase (Table 5).
DISCUSSION
Existing front-line staff (HCs) from 6 practices substantially improved clinical tobacco intervention. They increased the documentation of tobacco intervention, achieving a magnitude of improvement resembling that of Katz et al.3 The use of existing clinic staff to deliver preventive priorities within Canadian primary care merits much more attention.
To improve clinical prevention, Crabtree et al12 offered these recommendations:
-
recognize the competing demands of acute care, chronic illness care, and even other preventive measures;
-
develop a systematic approach, one not dependent on individual decision making;
-
encourage clinical champions of prevention;
-
address economic costs of prevention; and
-
adapt to local needs—do not expect one set of (preventive) measures to work across all practices.
Demands on physicians’ time are daunting. Thompson, reviewing the Prescription for Health initiative (which addressed tobacco, physical inactivity, unhealthy diet, and risky alcohol use) asked, “Why is this such a hard slog?” His answer: “Clinicians are drowning.”13
Limitations
The methodologic limitations of this study included that there was no external validation of the data obtained by HCs, no long-term tracking of changes in intervention, and no measurement of actual smoking cessation. The potency of our intervention was limited by our not working with the whole practice, not paying physicians and other staff, and not providing smokers free smoking cessation medication.
Conclusion
By providing front-line staff with training, clinical tools, expert consultation, and payment, we helped 6 practices substantially improve their treatment of tobacco addiction. The extent to which this result can be generalized across primary care merits further work. Without external support, primary care practices are unlikely to reduce the widespread deficit in clinical tobacco intervention and in other aspects of clinical prevention. Greater investment in knowledge translation is warranted.
Acknowledgments
This pilot project was made possible through a financial contribution from Health Canada. We thank the many members of ImpactBC who offered their logistical support and help with issues related to primary care innovation and training front-line staff. Without the bold and energetic contributions from the key front-line staff who served as health coordinators, this pilot project would not have achieved positive results. We thank the following health coordinators: Teressa Colosimo, Joseph Eliezer, Shelley Funnell, Josefa Kontogiannis, Robyn Savage, and Sanam Sepehry. We also thank the following: Gail Harrison, who coordinated this project in its second year; Bethina Abrahams, who coordinated the first year of the project, including recruitment of the practices and the initial training of the health coordinators; Angela O’Brien, who supported the development of training materials; Alex Green, co-op student, who helped develop Excel-based tools and Web-conference design; and Jessica Cheung, co-op student, who helped with Web-conference design and administrative support.
Notes
EDITOR’S KEY POINTS
-
Clinical tobacco intervention, although effective, is inadequately delivered. This pilot project aimed to investigate whether training existing clinic staff to provide such intervention would increase the proportion of patients offered assistance with smoking cessation.
-
The authors found that the health coordinators trained for this project substantially increased the proportion of patients offered tobacco intervention, and that they also managed to increase, to a lesser extent, intervention for some of the factors that reduce the odds of quitting.
-
The authors were unable to measure actual cessation of smoking, as that would have required more resources; a much larger sample size; nonintervention, control practices; and a longer study period. Thus, they used chart documentation of intervention components that have been shown to be effective for smoking cessation as a measure of the effectiveness of the health coordinator role.
POINTS DE REPÈRE DU RÉDACTEUR
-
Même si elles sont efficaces, les interventions cliniques visant le tabagisme ne sont pas effectuées de façon adéquate. Cette étude pilote voulait déterminer si le fait de former le personnel clinique existant pour qu’il effectue de telles interventions pourrait augmenter la proportion de patients auxquels on offre de l’assistance pour arrêter de fumer.
-
Les auteurs ont observe que les coordonnateurs de la santé formés pour ce projet augmentaient considérablement la proportion de patients à qui des interventions sur le tabagisme sont offertes; ils réussissaient aussi, mais à un moindre degré, à augmenter les interventions visant certains facteurs qui diminuent les chances de cesser de fumer.
-
Les auteurs n’ont pas pu quantifier l’arrêt du tabac, ce qui aurait nécessité advantage de ressources, un échantillon beaucoup plus large, un groupe témoin sans intervention, et une étude de plus longue durée. Afin d’évaluer l’efficacité du rôle des coordonnateurs de la santé, ils ont donc vérifié dans les dossiers, la presence des types d’intervention réputés efficaces pour l’arrêt du tabac.
Footnotes
-
This article has been peer reviewed.
-
Cet article a fait l’objet d’une révision par des pairs.
-
Contributors
Dr Bass served as medical consultant to the project, trained the health coordinators in terms of the clinical information they required, and wrote the initial drafts of the manuscript. Mr Naish was the principal administrator of the project, and reviewed and edited each draft of the manuscript; Mr Buwembo coordinated the project logistics, aided in Web-conference design and in training health coordinators, and reviewed and edited each draft of the manuscript.
-
Competing interests
Dr Bass has served on the Varenicline Advisory (Pfizer) and as an adviser to Johnson and Johnson on nicotine replacement therapy, as well as a consultant in the more distant past to other pharmaceutical companies that were marketing smoking cessation medications.
- Copyright© the College of Family Physicians of Canada
