Adding a Teachable Moment Approach to a Team-Based Primary Care Ask-Advise-Connect Approach for Tobacco Cessation

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What was the research about?

Tobacco use is the leading cause of preventable death in the United States. Primary care teams, such as doctors, nurses, and medical assistants, can help patients quit using tobacco. But clinic staff don’t always have the support they need to talk with patients about tobacco or refer patients to quitlines. Quitlines are services people can call to get telephone counseling for tobacco addiction.

In this study, the research team compared two ways to help primary care clinic staff identify patients who use tobacco and offer them help:

• Ask-Advise-Connect, or AAC. AAC changes the role of medical assistants to ask patients about tobacco use. They also give brief advice and use the electronic health record, or EHR, to refer patients who want help to a quitline.
• AAC plus the Teachable Moments Communication Process, or TMCP. TMCP trains clinicians, like doctors and nurses, on how to talk with patients based on their concerns about tobacco use.

What were the results?

One year after AAC changes happened at the clinics, medical assistants were more likely to

• Ask patients if they used tobacco
• Advise patients to quit tobacco
• See how ready patients were to quit

Also, patients at these clinics were more likely to accept a referral to a quitline.

After adding TMCP, patients at the clinics were more likely to receive advice to quit tobacco.

Clinicians only used TMCP with 8 percent of patients. When they used TMCP, clinicians were more likely to prescribe medicine to help quit tobacco. Other outcomes did not improve.

Who was in the study?

The study used EHR data from 224,079 visits by 176,061 adult patients. Patients were from eight clinics in one health system in the Cleveland area. Of these patients, 50 percent were white, 46 percent were African American, and 4 percent were other races; 12 percent were Hispanic or Latino. Also, 57 percent were ages 35–65, 70 percent were women, and 26 percent were tobacco users.

What did the research team do?

The research team first worked with the health system to make changes to their EHR system, including

• Adding an electronic referral between clinics and a quitline in Ohio
• Adding AAC guidance to EHR systems
• Using a team-based approach to tobacco screening and training staff to use the new EHR system

Next, the research team trained clinicians in TMCP.

The research team looked at patient care at the clinics at three time periods: before making any changes, after putting AAC in place in clinics, and after adding TMCP.

Clinicians, clinic staff, Ohio’s health department staff, quitline staff, and patients who use tobacco helped design the study and review results.

What were the limits of the study?

Only eight percent of clinicians used TMCP to talk with patients. Results might differ if more clinicians used this approach.

Future research could look at ways to increase how often clinicians use TMCP.

How can people use the results?

Clinics and health systems can use the results when deciding how to help patients quit tobacco.

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

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 TMCP 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.