smoking cessation interventions in hospital settings...
TRANSCRIPT
Smoking Cessation Interventions
In Hospital Settings:
Implementing the Evidence
Nancy Rigotti, MD
Tobacco Research & Treatment Center, General Medicine Division,
Massachusetts General Hospital, Harvard Medical School
HOSPITALIZATION ‘window of opportunity’ for smoking cessation
Smoke-free hospitals require temporary tobacco
abstinence
Illness motivates smokers to try to quit
Hospitalized smokers are accessible for treatment
Interventions starting in the hospital help smokers
to stay quit after discharge
What is the evidence?
Intervention Trials
in Hospitalized Smokers with MI
Author Interventions Cessation Rate
Control Intervention
Burt (1971) MD advice 28% * 62% RN home visit
Taylor (1991) RN counseling 32% * 61% at bedside+ 3 mo after d/c
Burt, Lancet, 1971; Taylor, Ann Intern Med 1991 * p<.05
Treating hospitalized smokers
1991: RCT showed efficacy in MI patients
1993: Cost effectiveness analysis
More cost-effective than other secondary cardiac
prevention interventions
Editorial: “An idea whose time has come”
1990-2002 – more studies
2002, 2008: Cochrane systematic reviews
2004, 2012: Hospital Quality Measures
META-ANALYSIS: INTERVENTIONS
FOR HOSPITALIZED SMOKERS
(Rigotti NA, Munafo MR, Stead L., Arch Int Med 2008)
RCT or quasi-experimental trials
Subjects: Current or recent smoker (past month)
Intervention:
Counseling or pharmacotherapy
Starts during hospital stay
May or may not continue after discharge
Follow-up: at least 6 months
Exclude: inpatient substance abuse / psychiatric units
META-ANALYSIS: INTERVENTIONS
FOR HOSPITALIZED SMOKERS
(Rigotti NA, Munafo MR, Stead L., Arch Int Med 2008)
Stop-smoking advice or counseling (33 trials)
Contact in hospital: 5 - 60 minutes
Nurse or trained counselor (32), MD (11)
Follow-up support after discharge (25)
Duration: 1 week - 6 months
Telephone (19) , in person visit (9)
Adding pharmacotherapy (6 trials)
Nicotine replacement (5), bupropion (1)
INTENSITY OF
COUNSELING INTERVENTIONS
Intensity
level
Duration of counseling
in the hospital
Duration of support
after discharge
1 < 15 min None
2 > 15 min None
3 Any < 1 mo
4 Any > 1 mo
RESULTS All hospital-initiated smoking interventions
(Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007)
In-hospital
counseling
Support
after d/c
#
trials
Odds
Ratio
95% CI
1 < 15 min None 1 1.16 0.80-1.67
2 > 15 min None 8 1.08 0.89-1.29
3 Any < 1 mo 6 1.09 0.91-1.31
4 Any > 1 mo 17 1.65 1.44-1.90
DOES DIAGNOSIS MATTER? (Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007)
Admission
Diagnosis
#
Trials
Odds
Ratio
95% CI
Cardiovascular
disease
11 1.81 1.54-2.15
All diagnoses 6 1.43 1.17-1.75
Intervention is effective regardless of diagnosis
Absolute cessation rates are higher for CVD
SHOULD MEDICATION BE ADDED
TO COUNSELING? (Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007)
Medication Patients # of
Trials
Odds
Ratio
95% CI
NRT
Noncardiac 5 1.47 0.92-2.35
Bupropion Cardiac 1 1.56 0.79-3.06
Effect of NRT is not statistically significant, but OR is
consistent with trials in other settings
Little evidence about bupropion, none for varenicline
CONCLUSIONS
(Rigotti NA, Munafo MR, Stead L. Cochrane Library 2007, Arch Int Med 2008)
Bedside counseling followed by telephone support
for > 1 month after discharge increases the odds
of smoking cessation by 65%
It is effective regardless of the reason for admission
It is not effective with less support after discharge
Adding NRT to counseling may increase cessation
rates (OR 1.47, CI 0.92-2.35) and relieves withdrawal
CHALLENGES Hospitalized smokers
Translating research into practice (usual care)
Sustaining treatment after discharge
What Stimulated Hospitals to Address Tobacco
NATIONAL HOSPITAL QUALITY MEASURES
2004: Among patients who
Smoked in past 12 months AND
Discharge diagnosis = MI or CHF or pneumonia
Does chart document that smoking cessation advice,
counseling or medication offered during hospital stay?
Data are publicly reported to compare hospital quality
2012: More comprehensive measures adopted
Apply to all hospital patients
Require documentation of both medication and
counseling both in hospital and after discharge
MGH INPATIENT MODEL
Step 1: Routine smoking status ID at admit
Step 2: Brief intervention on care unit
Step 3: Extended intervention (dedicated counselor)
Step 4: Post-discharge care
MGH SYSTEM for Inpatients
Step 1: Routine smoking status ID at admit
On doctors’ computerized admission order set
On nurses’ computerized order entry set
⇩ Generates electronic list of smokers for the
Tobacco Treatment Service
MGH SYSTEM for Inpatients
Step 1: Routine smoking status ID at admit in an electronic database
Step 2: Care team job - quit advice, NRT order Booklet put on every bed by housekeeping
MGH SYSTEM for Inpatients
Step 1: Routine smoking status ID at admit in an electronic database
Step 2: Care team job - quit advice, NRT order
Booklet put on every bed by housekeeping
Step 3: Smoking counselor visit
Assess nicotine withdrawal relief, desire to quit
Assist to make a plan to quit
Step 4: Link to post-discharge care
Refer to Quitline for counseling
Medication on discharge med list
SMOKING CESSATION OUTCOMES January- June 2007 (n=553)
Outcome All Patients (ITT)
Quit for past week
2 weeks after discharge 24%
3 months after discharge 18%
CHALLENGES Hospitalized smokers
Translating research into practice (usual care)
Sustaining treatment after discharge
CHALLENGE
Sustain Treatment after Discharge
Counseling support after discharge
Interactive voice response (IVR) system makes
automatic calls, offers counseling support
Use of medication after discharge
Institute for Health Policy
IVR-Smoking Status and Counseling
CHALLENGE
Sustain Treatment after Discharge
Counseling support after discharge
Interactive voice response (IVR) system makes
automatic calls, offers counseling support
Use of medication after discharge
Put on discharge medication list and offer free sample
at discharge to remove barrier to starting immediately
Helping HAND Study Improving tobacco treatment delivery after discharge
(RC1 HL099668)
Outcomes assessed at 1 and 6-month follow-up
Tobacco abstinence at 6 months
Tobacco abstinence at 1 month
Use of tobacco treatment (counseling or medication)
Cost effectiveness (cost/quit)
330 Smokers Admitted to MGH
Randomize
Standard Care
N=165
Extended Care*
N=165
* Extended Care = 5 IVR calls over 3 months with counselor call-back option
+ 30 days of free medication of patient’s choice in hand at discharge
CHALLENGE
Sustain Treatment after Discharge
Other ideas are being tested in 6 NHLBI & NCI-
funded randomized controlled trials under way
Enroll smoker in telephone quitline while in hospital,
start counseling before discharge and continue after
Offer free NRT through the quitline after discharge
Enroll in web-based counseling after discharge
Train nursing staff to do the intervention
BIG PICTURE
Tobacco use = chronic disease
Managing chronic disease requires a
continuum of care
Hospital = a node in the health care
continuum
Hospital-based → Hospital-initiated intervention
Start before admission, continue after discharge
(pre-op interventions)