Professional Abstract
Objective
To compare the effectiveness of health system infrastructure changes using the Ask-Advise-Connect (AAC) approach alone versus AAC plus the Teachable Moments Communication Process (TMCP)—a clinician-led counseling method—on improving tobacco cessation support and patient engagement with a quitline and increasing tobacco cessation medication prescriptions
Study Design
| Design Elements |
Description |
| Design |
Cluster randomized trial |
| Population |
224,079 visits by 176,061 adults receiving care at 8 primary care community health clinics in the Cleveland metropolitan area |
Interventions/
Comparators |
- Health system infrastructure changes using the AAC approach alone
- Health system infrastructure changes using AAC approach and TMCP (AAC+TMCP)
|
| Outcomes |
Percentage of visits where patients were asked about tobacco use status, advised to quit, and assessed readiness to quit; percentage of patients offered quitline referrals and percentage of patients who accepted a referral; percentage of patients who engaged with the quitline and percentage of patients who were prescribed medication to quit tobacco |
| Timeframe |
At least 1-year follow-up for study outcomes |
This stepped-wedge cluster randomized trial compared the effectiveness of two interventions—health system infrastructure changes alone or infrastructure changes plus a clinician-led counseling method—in improving tobacco cessation support outcomes.
Eight primary care community health clinics from one health system participated in the study. Researchers first led implementation of health system infrastructure changes at the clinics using the AAC approach, which included adding electronic referrals between clinics and an Ohio tobacco cessation quitline and expanding the role of medical assistants. Researchers trained medical assistants to ask about tobacco use, provide brief advice, and ask about readiness to quit and willingness to receive a referral to quitline counseling. After at least six months of the AAC approach, researchers trained clinicians in the TMCP counseling method. This method used patient concerns about tobacco to help clinicians guide discussions about behavior change. By the end of the study, all clinics received both interventions.
Researchers examined patients’ electronic health record (EHR) data for the 3 months before each clinic implemented the AAC, a minimum of 6 months of implementing the AAC only, and 12 months after the TMCP intervention to assess the effectiveness of the AAC approach and the added value of the TMCP approach.
The study included 224,079 EHR-recorded visits by 176,061 adult patients in the Cleveland metropolitan area. Of these patients, 50% were white, 46% were African American, and 4% were other races; also, 12% were Hispanic or Latino. The majority (57%) were ages 35–65, 70% were female, and 26% were tobacco users.
Primary care clinicians, clinic staff, Ohio’s health department staff, quitline staff, and patients who use tobacco helped design the study and review results.
Results
Implementation of the AAC approach showed increases in asking about tobacco use (27% vs. 50%), providing brief advice to quit (45% vs. 85%), asking about readiness to quit (13% vs. 66%), and referrals to quitline counseling (0% vs. 31%), (all p<0.05).
Compared with the AAC-only period, the AAC+TMCP period showed increases in providing brief advice to quit (85% vs. 91%, p<0.05). Overall, clinicians used the TMCP approach in only 8% of visits by tobacco users. When clinicians used the TMCP approach, prescriptions for tobacco cessation medication were higher (12% vs. 32%; p<0.05). Other outcomes did not improve significantly.
Limitations
The low clinician uptake of TCMP made it difficult to determine the effectiveness of this approach.
Conclusions and Relevance
Infrastructure changes increased assessments of tobacco use and advising patients to quit, assessing patient readiness to quit, and having patients accept quitline referrals. The counseling intervention, when used, increased clinician prescriptions for tobacco cessation medication.
Future Research Needs
Future research could look at ways to better integrate the two approaches and increase clinicians’ use of the counseling intervention.
