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For more information, please contact Dr. Christie Bartels at cb4@medicine.wisc.edu
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Overview
To reduce tobacco use, we improved quit line referrals for tobacco users by 20-fold through Quit Connect, a 90-second clinic staff protocol that integrates the electronic health record with the Wisconsin tobacco quit line. This protocol is being implemented in both primary care and specialty care clinics in multiple Wisconsin health systems including Gundersen and UW Health, with a recently funded grant with Emory University to implement at Grady Memorial public hospital in Atlanta (83% African American, 40% uninsured).
The Clinical Problem
“People are more likely to quit [smoking] for good after coaching because they’ve planned ahead and have the tools.” — Christie Bartels, MD, MS
Smoking is a known risk factor for developing chronic conditions such as rheumatoid arthritis (RA) and lung disease and is a leading preventable cause of early mortality. Additionally, smoking can exacerbate chronic conditions and cause premature cardiovascular disease. Specialty clinics treat many patients who have chronic conditions but do not systematically provide resources to help patients quit smoking.
In a study, Dr. Christie Bartels’ team found that only 10% of notes from eligible RA clinic visits documented cessation counseling; only one in 175 notes recommended to quit line services. Quit line phone services are free in every state and recommended by US guidelines to improve quit rates 4-fold. However, these resources are rarely leveraged in rheumatology or other specialty clinics, and the existing models used in primary care have not been tailored for use in specialty clinics.
Specialty clinic visits nearly equal US primary care visits. As such, specialty clinics have the opportunity to improve smoking cessation rates for patients with chronic conditions.
Our Response
The Quit Connect Protocol
To address these issues, the Quit Connect Health protocol was created to connect patients who are identified as smokers in a specialty clinic visit to a quit line so that they have a greater chance of succeeding at quitting smoking. The protocol uses the Ask-Advise-Connect model which has been shown to increase the proportion of patients receiving quit line support by 13-fold.
Development of the Protocol
The Quit Connect staff protocol was developed with three rheumatology clinics at a large academic health system in conjunction with nursing, systems engineering, and CTRI cessation experts, as well as patients and clinic staff.
Dr. Bartels and her team conducted a participatory work system redesign to develop the protocol and held two, hour-long focus group sessions with medical assistants (MAs) and nurses to (a) assess current processes and needs, and (b) develop a proposed electronic health record-based quit line referral process. Diverse patient stakeholders have endorsed this approach as well.
Results
In the Quit Connect pilot, at week 6, the protocol increased tobacco status documentation to 97%, documentation of 30-day readiness to quit increased from 3% to 76%, and 32% of those asked reported readiness in the next 30 days.
Overall, 12% of patients who smoked agreed to the quit line electronic referral versus 0.6% being offered the referral prior to the intervention—a 20-fold increase in quit line referrals. In addition, our specialty MA/RN staff self-efficacy rose from 10% to 90% reporting feeling very or extremely confident in their ability to support cessation care post implementation, supporting our approach.
Lasting Impact
The Quit Connect protocol is being implemented in both primary care and specialty care clinics in several health systems, including Gundersen Health System, UW Health, and Emory/Grady. Quit Connect has been sustained >3 years, reaching a population of over 5,783 patients from UW Health and Gundersen rheumatology clinics. Quit Connect was highlighted at 2 statewide symposia, including the Colorado Centers for Medicaid and Medicare Services Practice Transformation Network, and was included in the Centers for Disease Control and Prevention’s Tobacco Cessation Change Package (2020).
Dr. Bartels is currently completing a grant-funded project implementing Quit Connect at Grady Memorial public hospital in Atlanta, affiliated with Emory University, which serves an 83% African American, and 40% uninsured population. The Georgia Department of Public Health, coordinator of Georgia quit line, and Optum have been active partners in the Quit Connect intervention.
References
- Ramly E, Lauver DR, Gilmore-Bykovskyi A, Bartels CM. Interactive and Participatory Audit and Feedback (IPAF): theory-based development and multi-site implementation outcomes with specialty clinic staff. Implement Sci Commun. 2021 May 31;2(1):58.
- Bartels CM, Johnson L, Ramly E, Panyard DJ, Gilmore-Bykovskyi A, Johnson HM, McBride P, Li Z, Sampene E, Lauver DR, Lewicki K, Piper ME. Impact of a Rheumatology Clinic Protocol on Tobacco Cessation Quit Line Referrals. Arthritis Care Res (Hoboken). 2021 Apr 6:10.1002/acr.24589.
- Wattiaux A, Bettendorf B, Block L, Gilmore-Bykovskyi A, Ramly E, Piper ME, Rosenthal A, Sadusky J, Cox E, Chewning B, Bartels CM. Patient Perspectives on Smoking Cessation and Interventions in Rheumatology Clinics. Arthritis Care Res (Hoboken). 2020 Mar;72(3):369-377.
- Panyard DJ, Ramly E, Dean SM, Bartels CM. Bridging clinical researcher perceptions and health IT realities: A case study of stakeholder creep. Int J Med Inform. 2018 Feb;110:19-24.