Preventive Medicine 71 (2015) 77–82
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Primary care physician smoking screening and counseling for patients with chronic disease Kevin E. Nelson a,⁎, Adam L. Hersh a, Flory L. Nkoy a, Judy H. Maselli b, Raj Srivastava a, Michael D. Cabana b,c a b c
Department of Pediatrics, University of Utah, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA Departments of Pediatrics, Epidemiology and Biostatistics, University of California, 3333 California Street, Suite #245, San Francisco, CA 94118, USA Philip R. Lee Institute for Health Policy Studies, University of California, 3333 California Street, Suite #265, San Francisco, CA 94118, USA
a r t i c l e
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Available online 28 November 2014 Keywords: Smoking Tobacco Chronic disease Chronic obstructive pulmonary disease Cardiovascular disease Guideline Primary care
a b s t r a c t Background. Evidence-based guidelines recommend smoking cessation treatment, including screening and counseling, for all smokers, including those with chronic diseases exacerbated by smoking. Physician treatment improves smoking cessation. Little data describes smoking treatment guideline uptake for patients with chronic cardiopulmonary smoking-sensitive diseases. Objective. Describe U.S. primary care physician (PCP) smoking cessation treatment during patient visits for chronic cardiopulmonary smoking-sensitive diseases. Methods. The National (Hospital) Ambulatory Medical Care Survey captured PCP visits. We examined smoking screening and counseling time trends for smokers with chronic diseases. Multivariable logistic regression assessed factors associated with smoking counseling for smokers with chronic smoking-sensitive diseases. Results. From 2001–2009 smoking screening and counseling for smokers with chronic smoking-sensitive cardiopulmonary diseases were unchanged. Among smokers with chronic smoking-sensitive diseases, 50%–72% received no counseling. Smokers with chronic obstructive pulmonary disease (COPD) (odds ratio (OR) = 6.54, 95% confidence interval (CI) 4.85–8.83) and peripheral vascular disease (OR = 4.50, 95% CI 1.72–11.75) were more likely to receive smoking counseling at chronic/preventive care visits, compared with patients without smoking-sensitive diseases. Other factors associated with increased smoking counseling included non-private insurance, preventive and longer visits, and an established PCP. Asthma and cardiovascular disease showed no association with counseling. Conclusions. Smoking cessation counseling remains infrequent for smokers with chronic smoking-sensitive cardiopulmonary diseases. New strategies are needed to encourage smoking cessation counseling. © 2014 Elsevier Inc. All rights reserved.
Introduction Smoking and tobacco use remain the largest preventable causes of U.S. medical disease and costs (Centers for Disease Control and Prevention, 2006; CDC, 2008). Annually, over 480,000 preventable smoking-related deaths occur, and $280 billion in smoking-related costs are primarily manifested through chronic diseases exacerbated by smoking (CDC, 2008, 2014). In response to these concerns, the U.S. Public Health Service created the evidence-based Treating Tobacco Use and Dependence: Clinical Practice Guideline to reduce the effects of Abbreviations: COPD, chronic obstructive pulmonary disease; EMR, electronic medical record; NAMCS, National Ambulatory Medical Care Survey; NHAMCS, National Hospital Ambulatory Medical Care Survey; PCP, primary care physician; ACA, Affordable Care Act; PVD, peripheral vascular disease. ⁎ Corresponding author. E-mail addresses: [email protected] (K.E. Nelson), [email protected] (A.L. Hersh), fl[email protected] (F.L. Nkoy), [email protected] (J.H. Maselli), [email protected] (R. Srivastava), [email protected] (M.D. Cabana).
http://dx.doi.org/10.1016/j.ypmed.2014.11.010 0091-7435/© 2014 Elsevier Inc. All rights reserved.
smoking (Fiore et al., 2000, 2008). These guidelines recommended a chronic disease treatment strategy that includes systematically screening every patient to determine patient readiness to make a quit attempt and providing smoking cessation counseling with smoking cessation, prevention and referral information. The Guideline concluded that smoking screening and smoking cessation counseling improved cessation rates (Fiore et al., 2000). Therefore, routine preventive and chronic care visits for patients with chronic smoking-sensitive cardiopulmonary disease present important opportunities to address smoking screening and counseling to improve cessation rates in a population with substantial potential for benefit. Despite the obvious benefits of smoking cessation, multiple studies report poor uptake of smoking treatment guidelines in clinical practice. Outpatient physicians screen 60% of patients (Jamal et al., 2012) and provide smoking counseling to approximately 20% of patients who smoke (Payne et al., 2012; Bernstein et al., 2013; Jamal et al., 2012). Poor delivery of smoking interventions is also reflected by infrequent use of evidence-based smoking cessation treatments among smokers (Shiffman et al., 2008). Recent studies have not addressed smoking
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cessation treatment in preventive care among patients with chronic smoking-sensitive diseases. Multiple barriers to physician compliance with smoking treatment guidelines exist, including beliefs that evidence-based interventions will not change patient smoking behavior, competing clinical priorities, and insufficient time, knowledge, and training (Barnes Dodge et al., 2008; Burnett and Young, 1999; Cabana et al., 2000, 2004; Frankowski et al., 1993; Kaplan et al., 2004; Nader et al., 1987; Tanski et al., 2003; Thorndike et al., 1999; Zapka et al., 1999; Bonollo et al., 2002). Available studies are also limited by small sample sizes and the absence of data regarding practice changes over time (Bernstein et al., 2013; Jamal et al., 2012; Collins et al., 2007; Ferketich et al., 2006; Payne et al., 2012; Tanski et al., 2003; Thorndike et al., 2007). Gaps remain in understanding adult and child primary care physician (PCP) smoking screening and counseling practice patterns among patients with chronic smoking-sensitive diseases (Bernstein et al., 2013; Jamal et al., 2012; Payne et al., 2012). To address these gaps, we examined the 2001–2009 national practice patterns for PCP delivery of smoking screening and counseling at PCP visits among smokers with chronic smoking-sensitive cardiopulmonary diseases. Our goal was to identify key factors (patient, physician, disease, and healthcare system) associated with delivery of smoking counseling to smokers with chronic smoking-sensitive diseases.
maintenance or exacerbations of a chronic condition determined by the physician to be present for over three months. Smoking variables Physicians indicated in the “Tobacco Use” datafield whether patients reported tobacco use (all forms) as Current/Not current/Unknown. Physicians documented whether counseling about cessation of tobacco use or tobacco exposure was delivered during the visit using a checkbox in the “Heath Education/Counseling” section. NAMCS/NHAMCS define tobacco education/counseling as counseling, educational, or therapeutic services, excluding medications. Disease variables
Methods
Cardiopulmonary diseases considered sensitive to exacerbation by smoking are directly linked to poor outcomes in smokers (Fiore et al., 2008; CDC, 2004, 2014). These diseases included asthma, chronic obstructive pulmonary disease (COPD), and cardiovascular disease (heart failure, ischemic heart disease, cardiomyopathy, atherosclerosis, and atheroembolism). Additional diseases modulated by smoking and that lead to cardiovascular disease (hypertension, diabetes, obesity, hyperlipidemia, and peripheral vascular disease (PVD)) or that are respiratory illnesses (upper respiratory tract infection, influenza, otitis media, bronchiolitis, bronchitis, and pneumonia) were included (Fiore et al., 2008). We conducted a subgroup analysis on children (age b 18 years) with asthma, the most prevalent childhood smoking-sensitive disease. International Classification of Disease-9 Clinical Modification codes were used to identify chronic smoking-sensitive diseases (Appendix A).
Data source
Analysis of smoking screening
PCP smoking treatment was examined from the frequencies of PCP smoking screening and smoking counseling delivery during preventive care office visits using the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets from 2001–2009. NAMCS and NHAMCS are nationally representative datasets capturing visits to physician offices and hospital outpatient departments and include data on smoking screening and counseling during each visit. NAMCS and NHAMCS use a multistage strategy with random sampling from geographic, physician practice, and patient visit frames (www.cdc.gov/nchs/ahcd.htm) (National Center for Health Statistics, n.d.). Physician practices gather data from 30 random visits during one week from routine practice documentation. Person and visiting weighting factors adjust for nonresponse, selection probability, proportion of physicians per specialty (NAMCS only), and weighting smoothing adjusting for the range of physician visits.
The percentage of visits where smoking screening occurred was estimated using patient and visit weighting factors. Time trends for smoking screening were tested using the Wald χ2 test. Comparisons of estimates by patient, disease, and healthcare factors used the Mantel-Haenszel χ2 test.
Study population For the analysis of smoking screening, we included all patient visits to their PCP for patients ≥12 years old. We limited screening to ≥12 years old because the clinical significance of screening in children b12 years old was considered inapplicable. For the analysis of smoking counseling, we included PCP visits for patients of all ages. Data variables NAMCS/NHAMCS captured variables used to characterize patient, physician/healthcare system, and disease factors from physician reported data obtained from patients during office visits. Patient variables Patient demographics retrieved from NAMCS/NHAMCS included age, gender, race/ethnicity, and insurance type. Physician/healthcare system variables Healthcare system factors included visit length, clinic type, geographical location, urban/rural status, physician specialty, and if the patient saw their established care provider. Physician specialty was limited to primary care specialties (internal medicine, pediatrics, family medicine, and general practice). Preventive care visits were patient encounters for general medical and routine examinations. Chronic care visits were patient encounters for routine
Analysis of smoking counseling for current smokers We compared the percentage of visits where smoking counseling was provided to current smokers with and without chronic smoking-sensitive diseases. Time trends were examined using the Wald χ2 test. Estimates for patient, physician, disease, and healthcare factors were compared using the MantelHaenszel χ2 test. Variables associated with smoking counseling in univariate analyses (p b 0.20) were included in multivariable logistic regression models to identify patient, physician, disease, and healthcare system factors associated with delivery of smoking counseling. Analyses were two-sided using SAS software (version 9.2). Survey weighting factors were applied using SUDAAN (version 9.0). Because physician specialty and visit length variables were unavailable in the NHAMCS dataset, an analysis using NAMCS evaluated these variables.
Results Smoking screening From 2001–2009, 136,062 unweighted physician visits were sampled. Smoking screening was delivered at 68% of visits. The frequency of PCP smoking screening was unchanged over the nine years after guideline introduction (Fig. 1). Higher frequencies of smoking screening were observed for patients with the smoking-sensitive diseases asthma, cardiovascular disease, COPD, or hypertension, compared with patients with other smoking-sensitive diseases and without chronic smokingsensitive diseases (Table 1). Smoking counseling to smoking patients During the study period 59,229 unweighted visits for patients identified as smokers were sampled. Among 14,061 unweighted chronic/ preventive care visits for smokers, physicians delivered smoking counseling during 28% of visits. The frequency of smoking counseling for identified smokers was unchanged over the study period (Fig. 1).
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Table 2 PCP delivery of smoking counseling to smokers with chronic smoking-sensitive diseases 2001–2009. Total visits (n = 14,061)a
Fig. 1. Time trends for PCP smoking screening and delivery of smoking counseling.
Smoking counseling was provided more frequently during preventive (32%) and chronic care visits (27%), compared with other visit types (p b 0.001) (Table 2). Adolescent smokers (age 12–17 years) had a higher frequency of smoking counseling (36%, p = 0.01), compared with all other ages. Smoking counseling was also delivered more frequently at visits lasting ≥15 min (p b 0.001) compared with b 15 min. No differences were observed by gender, race, insurance type, or geographic location. Chronic smoking-sensitive diseases Smoking counseling was provided more frequently to smokers with the chronic smoking-sensitive diseases COPD (46%, p b 0.001), respiratory illness (40%, p = 0.008), and diabetes (28%, p = 0.047), compared with 25% for smokers without chronic smoking-sensitive diseases (Table 1). The frequency of smoking counseling among smokers was 51% for PVD (p = 0.16), 31% for asthma (p = 0.49), and 34% for cardiovascular disease (p = 0.24), compared with 25% among diseases that were not smoking-sensitive. Factors associated with smoking cessation counseling Multivariable analysis identified patient, physician, disease, and healthcare system factors associated with smoking counseling among
Table 1 Frequency of PCP smoking screening and delivery of smoking counseling 2001–2009. Smoking sensitive disease
Asthma Cardiovascular disease COPD Hypertension Diabetes Obesity Hyperlipidemia Peripheral vascular disease Respiratory illness All other diseases a b c d
Smoking screening frequencya
Smoking counseling frequencyb
Total visits (n = 136,062)c
Total visits (n = 14,061)c
%
p-Valued
%
p-Valued
75.1 71.8 74.6 70.5 69.4 63.8 69.0 63.5 66.5 66.1
b0.001 0.022 b0.001 0.004 0.11 0.44 0.44 0.37 0.24 –
31.1 33.9 46.3 31.1 28.4 27.9 32.7 50.5 40.3 24.8
0.49 0.24 b0.001 0.077 0.047 0.996 0.183 0.16 0.008 –
For patients age N12 years. For smokers, all ages. Unweighted visits. Statistical comparisons of smoking sensitive diseases with ‘all other diseases’ used the Mantel-Haenszel χ2 test.
Patient characteristics Age (years) 0–5 6–11 12–17 18–44 45–64 N65 Gender Female Male Race White Black Hispanic Other Insurance Private Non-private
Smoking counseling frequency %
p-Valuec 0.01
19.8 4.8 35.8 26.2 29.3 26.7 0.32 27.2 28.4 0.53 28.2 27.7 23.8 27.7 0.23 28.7 27.0
Physician/healthcare system characteristics Seen by established provider Yes 28.3 No 26.7 Unknown 21.9 Physician specialtyb GP/FP 26.2 IM 30.3 Pediatrics 36.4 Clinic type Office 27.9 Outpatient department 27.3 Visit type All visits 25.4 Preventive 31.7 Chronic problem/routine/flare-up 26.6 Acute/new 23.0 Visit length (min)b b15 18.9 15–30 28.8 31–60 39.8 N60 43.6 Geographic region Northeast 31.1 Midwest 28.7 South 25.8 West 27.2 Population density Urban 28.4 Rural 25.5
0.081
0.073
0.73
b0.001
b0.001
0.31
0.23
Note: GP/FP = general practice/family practice, IM = internal medicine. a Unweighted visits. b Results using NAMCS dataset only based on 5410 unweighted visits. c Statistical comparisons used the Mantel-Haenszel χ2 test.
smokers (Table 3). Patient factors associated with smoking counseling included male gender (OR 1.28, 95% CI: 1.16–1.41), age 12–17 years (OR 2.22, 95% CI: 1.65–2.98), and non-private insurance (OR 1.33, 95% CI: 1.16–1.53). Physicians were more likely to counsel smokers with COPD (OR 6.54, 95% CI: 4.85–8.83), compared with patients without chronic smoking-sensitive diseases. With the exception of PVD (OR 4.50, 95% CI: 1.72–11.75), other smoking-sensitive diseases, including asthma and cardiovascular disease, were not associated with smoking counseling. Although asthma is the most prevalent pediatric smokingsensitive disease, asthma was not associated with smoking counseling among pediatric patients with asthma. Healthcare system factors associated with smoking counseling included preventive visits (OR 1.42, 95% CI: 1.24–1.63), longer visit lengths (OR 1.76, 95% CI: 1.35–2.30), and seeing an established PCP (OR 1.50, 95% CI: 1.19–1.90).
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Table 3 Factors associated with PCP delivery of smoking counseling to smokers with chronic smoking-sensitive disease 2001–2009. Adjusted odds ratio (95% CI) Smoking-sensitive disease All other diseases COPD Peripheral vascular disease Patient characteristics Age 0–5 6–11 12–17 18–44 45–64 N65 Gender Female Male Race White Black Hispanic Other Insurance Private Non-private Physician/healthcare system characteristics Seen by established provider No Yes Physician specialtya GP/FP IM Pediatrics Visit type Chronic care Preventive Visit length (min)a b15 15–30 30–60 N60
Reference 6.54 (4.85–8.83) 4.50 (1.72–11.75)
Reference 1.16 (0.88–1.55) 2.22 (1.65–2.98) 1.45 (1.07–1.98) 1.40 (1.03–1.90) 0.47 (0.34–0.65) Reference 1.28 (1.16–1.41) Reference 0.83 (0.70–0.98) 0.69 (0.56–0.84) 0.92 (0.68–1.25) Reference 1.33 (1.16–1.53)
Reference 1.50 (1.19–1.90) Reference 0.91 (0.74–1.12) 2.16 (1.65–2.84) Reference 1.42 (1.24–1.63) Reference 1.76 (1.35–2.30) 2.23 (1.59–3.11) 3.91 (1.57–9.73)
Note: GP/FP = general practice/family practice, IM = internal medicine. a Results using NAMCS dataset only based on 5410 unweighted visits.
Discussion Over 2001–2009, fewer than one-third of smokers with chronic smoking-sensitive diseases received counseling about cessation during primary care visits. Smoking cessation counseling was highest for patients with COPD and PVD but only reached 54% and 51%, respectively. Smoking cessation counseling was also more likely to be delivered at preventive visits, by an established PCP, at longer visits, to adolescents and for patients with non-private insurance. Despite dissemination of smoking treatment guidelines, delivery of smoking screening and counseling to patients with chronic smoking-sensitive disease remains underused and has not improved over a decade. Compared with previous studies, our study focused on a different patient population of patients seen for chronic or preventive care, including those with chronic smoking-sensitive diseases. However, previous studies have shown that PCPs generally deliver smoking counseling for all patients more frequently than specialists and other physicians (Ferketich et al., 2006; Payne et al., 2012; Thorndike et al., 2007). Many factors may position PCPs to deliver smoking counseling, including providing a medical home, health promotion, evidence-based care, and frequently being the first health care contact for patients with chronic smoking-sensitive disease (Starfield and Shi, 2004; Starfield et al., 2005; Ulrik et al., 2010). Our study indicates that established PCPs may be better suited to provide smoking counseling to our patient
population, especially those seen for chronic or preventive care of a chronic smoking-sensitive disease. Our study identified physician and healthcare factors that affected delivery of smoking cessation counseling for patients with chronic smoking-sensitive diseases who are seen for chronic or preventive care. Increased smoking counseling has previously been reported with longer visit lengths (Ferketich et al., 2006; Jamal et al., 2012). Our study found significantly higher frequencies of smoking counseling at longer visit lengths. This suggests that PCPs are more likely to provide smoking cessation counseling when more time is available, suggesting that the commonly cited barrier of inadequate time (CDC, 1995; Collins et al., 2007) may be less relevant at preventive or chronic care visits. In addition, adolescents were more likely to receive smoking counseling compared with all other ages, and pediatricians were more likely to provide smoking counseling compared with internal medicine and general practitioners/family physicians. While the U.S. Preventive Services Task Force and AAP Bright Futures guidelines recommend smoking counseling to all children and adolescents (Moyer, 2013; Hagan et al., 2008), focusing smoking counseling efforts on pediatric patients with chronic smoking-sensitive diseases like asthma may be important in preventing avoidable health care utilization (Howrylak et al., 2014; McCarville et al., 2013). Differences among specialties in our study may also be due to differences in specialty training and knowledge, evidence-based smoking treatments, or the increased number of chronic diseases requiring coordination during adult versus pediatric visits (Frankowski and Secker-Walker, 1989; Perez-Stable et al., 2001). Consistent with previous studies, patients with non-private insurance were more likely to receive smoking counseling. Lack of reimbursement for delivery of smoking cessation counseling remains a significant barrier to routine physician initiated smoking treatment (Frankowski and Secker-Walker, 1989; Perez-Stable et al., 2001; Zapka et al., 1999). However, the Affordable Care Act (ACA) eliminated cost sharing for evidence-based smoking interventions, including physician delivered smoking counseling (University of Wisconsin Center for Tobacco Research and Intervention, 2010). Standardization of reimbursement, including elimination of cost sharing, may improve PCP smoking counseling for patients with chronic smoking-sensitive diseases and at preventive or chronic care visits. The availability of easily accessible smoking cessation consultation services may also help improve physician screening and subsequent referral without increasing the burden on PCPs (Barnes Dodge et al., 2008). Despite dissemination of smoking treatment guidelines, smoking cessation counseling for smokers with chronic smoking-sensitive diseases at visits for chronic or preventive care has not improved over a decade. Prior to 2003, evidence-based guidelines highlighted the importance of treating smoking in the chronic cardiopulmonary diseases asthma (National Institutes of Health, 2003; NIH, 1997), cardiovascular disease (Smith et al., 2001), and COPD (Pauwels et al., 2001). Primary care organizations also established smoking treatment as a high priority (American Academy of Pediatrics, 2009; American Academy of Family Physicians, 2009; American College of Physicians, 2010). Our study suggests that tobacco treatment guidelines may be insufficient to produce or sustain changes to physician practice or the healthcare delivery system to provide smoking cessation counseling to smokers with chronic smoking-sensitive diseases. Multiple barriers have limited implementation of tobacco treatment guidelines in routine clinical practice (Barnes Dodge et al., 2008; Burnett and Young, 1999; Cabana et al., 2000, 2004; Frankowski et al., 1993; Kaplan et al., 2004; Nader et al., 1987; Tanski et al., 2003; Thorndike et al., 1999; Zapka et al., 1999; Bonollo et al., 2002). Improved delivery of smoking counseling may be an increasingly important factor for preventive care of smoking-sensitive diseases as shared accountability and pay for performance models are adopted. Systems level strategies utilizing established providers as part of medical homes, longer preventive/ chronic care visits, physician training in smoking cessation counseling, physician reminders and decision support, incentives for meaningful
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EMR use, changes in reimbursement provided by the ACA, and improved accessibility of referral services may improve delivery of smoking interventions to smokers with COPD and other smokingsensitive diseases. Limitations Our study has the following limitations. First, patients who underreport smoking may lead to underestimates of smoking and remain an important population for future screening and counseling efforts. Second, physician recall bias or underreporting of smoking screening and counseling may also lead to underestimates of smoking treatment. Third, the granularity of the smoking screening and counseling datafields limits the information available on the content of smoking interventions between practices and specialties. Fourth, smoking screening and counseling at previous visits were not captured. Smoking screening and counseling may be higher if measured at the patient level, as patients may have received smoking interventions at a previous visit. Fifth, physicians who agree to participate in the survey may be more likely to overestimate their smoking screening and counseling practices. Sixth, practice patterns may also have changed since 2009. Despite these limitations, the strengths of our study lie in examining smoking counseling for patients with chronic smoking-sensitive diseases at chronic and preventive care visits over nine years, including time trends. We used a patient population at preventive or chronic care visits, including those with chronic smoking-sensitive diseases, not investigated in detail in previous studies. We also identified multiple factors that may contribute to strategies to encourage physician smoking cessation interventions for smokers with chronic smokingsensitive diseases.
Acknowledgment We thank Dr. Christopher G. Maloney, Dr. Bryan L. Stone, and Heather Oldroyd, CRC from the University of Utah, Department of Pediatrics and Dr. Karen Wilson from the University of Colorado, Denver, Department of Pediatrics for technical comments on the manuscript. We acknowledge the study design assistance from Tom Greene, PhD and Greg Stoddard, MPH, MBA from the University of Utah, Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764).
Appendix A International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) codes used to identify smoking-sensitive diseases for office visits in the NAMCS/NHAMCS datasets. Smoking-sensitive illness
ICD-9 CM codes
Asthma Cardiovascular disease
493.x 398.91, 402.01, 402.11, 402.91, 404.01‐404.03, 404.11, 404.13, 404.91, 404.93, 410.x‐414.x, 425.4‐425.9, 428.0‐428.9, 429.9, 440.x, 445.x 490‐492.8, 494, 496.x, 495.0‐505 401.0‐405.9, 642.00‐642.04, 642.10‐642.24, 642.70‐642.94 249.00‐249.91, 250.0‐250.9, 648.00‐648.04, 775.1 278.0 272 093.0, 437.3, 440‐440.9, 441.00‐441.9, 442.0‐442.9, 443.1‐443.9, 444.21‐444.22, 447.1, 449, 557.1, 557.9
COPD Hypertension Diabetes Obesity Hyperlipidemia Peripheral vascular disease
Conclusions Our findings demonstrate that delivery of smoking cessation counseling to patients with chronic smoking-sensitive diseases remains underused and has not improved over a decade, despite dissemination of smoking treatment guidelines. The patient and healthcare factors – preventive visits, an established PCP, longer visit length, adolescent age, and non-private insurance – were identified as potential facilitators that may be used to support smoking counseling at visits for preventive or chronic care for smokers with chronic smoking-sensitive disease. Further research is needed to identify the factors associated with translation of evidence-based smoking cessation interventions into the primary care setting. Future studies should investigate the effects of healthcare system changes made possible by EMR adoption, Meaningful Use incentives, and the ACA on smoking interventions. New strategies, including national efforts and quality benchmarks of smoking cessation counseling, may allow physicians and the healthcare system to overcome persistent barriers to implementing basic elements of guidelinebased tobacco treatment in routine primary care. Funding KEN is supported by grants from the American Academy of Pediatrics Julius B. Richmond Center of Excellence and the Primary Children's Hospital Foundation. FLN is supported by grants from the Agency for Healthcare Research and Quality (1R18HS018166-01A1 and 1R18HS018678-01A1) and the Patient Centered Outcomes Research Institute (5330). Funding sources had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. Conflict of interest statement The authors declare that there are no conflicts of interest.
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Respiratory disease Upper respiratory tract infection Influenza Otitis media Bronchiolitis Bronchitis Pneumonia
460, 462‐464, 465.x 487 381, 382 466.11, 466.19 460.x, 466.0 481‐486
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National Center for Health Statistics, d. Ambulatory health care data [online]. Available: http://www.cdc.gov/nchs/ahcd.htm ([Accessed 18 April 2014]). National Institutes of Health, 1997. National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. U.S. Dept. of Health and Human Services, Bethesda, MD. National Institutes of Health, 2003. Expert Panel Report Guidelines for the Diagnosis and Management of Asthma: Update on Selected Topics, 2002. NIH Publication No. 025074. U.S. Department of Health and Human Services, Bethesda, MD. Pauwels, R.A., Buist, A.S., Calverley, P.M., Jenkins, C.R., Hurd, S.S., Committee, G.S., 2001. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am. J. Respir. Crit. Care Med. 163, 1256–1276. Payne, T.J., Chen, C.I., Baker, C.L., Shah, S.N., Pashos, C.L., Boulanger, L., 2012. National Ambulatory Medical Care Survey: tobacco intervention practices in outpatient clinics. Psychol. Addict. Behav. 26, 644–648. Perez-Stable, E.J., Juarez-Reyes, M., Kaplan, C., Fuentes-Afflick, E., Gildengorin, V., Millstein, S., 2001. Counseling smoking parents of young children: comparison of pediatricians and family physicians. Arch. Pediatr. Adolesc. Med. 155, 25–31. Shiffman, S., Brockwell, S.E., Pillitteri, J.L., Gitchell, J.G., 2008. Use of smoking-cessation treatments in the United States. Am. J. Prev. Med. 34, 102–111. Smith Jr., S.C., Blair, S.N., Bonow, R.O., Brass, L.M., Cerqueira, M.D., Dracup, K., Fuster, V., Gotto, A., Grundy, S.M., Miller, N.H., Jacobs, A., Jones, D., Krauss, R.M., Mosca, L., Ockene, I., Pasternak, R.C., Pearson, T., Pfeffer, M.A., Starke, R.D., Taubert, K.A., 2001. AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 104, 1577–1579. Starfield, B., Shi, L., 2004. The medical home, access to care, and insurance: a review of evidence. Pediatrics 113, 1493–1498. Starfield, B., Shi, L., Macinko, J., 2005. Contribution of primary care to health systems and health. Milbank Q. 83, 457–502. Tanski, S.E., Klein, J.D., Winickoff, J.P., Auinger, P., Weitzman, M., 2003. Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement. Pediatrics 111, E162–E167. Thorndike, A.N., Ferris, T.G., Stafford, R.S., Rigotti, N.A., 1999. Rates of U.S. physicians counseling adolescents about smoking. J. Natl. Cancer Inst. 91, 1857–1862. Thorndike, A.N., Regan, S., Rigotti, N.A., 2007. The treatment of smoking by US physicians during ambulatory visits: 1994–2003. Am. J. Public Health 97, 1878–1883. Ulrik, C.S., Hansen, E.F., Jensen, M.S., Rasmussen, F.V., Dollerup, J., Hansen, G., Andersen, K.K., 2010. Management of COPD in general practice in Denmark—participating in an educational program substantially improves adherence to guidelines. Int. J. Chron. Obstruct Pulmon. Dis. 5, 73–79. University of Wisconsin Center for Tobacco Research and Intervention, 2010. Summary of selected tobacco, prevention, and public health previsions from H.R. 3590 and H.R. 4872 [online]. Madison, WI. Available: www.ctri.wisc.edu/Insurers/ HeathReformTobaccoSummary.pdf ([Accessed 20 March 2014]). Zapka, J.G., Fletcher, K., Pbert, L., Druker, S.K., Ockene, J.K., Chen, L., 1999. The perceptions and practices of pediatricians: tobacco intervention. Pediatrics 103, e65.
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Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Primary care physician smoking screening and counseling for patients with chronic disease Kevin E. Nelson a,⁎, Adam L. Hersh a, Flory L. Nkoy a, Judy H. Maselli b, Raj Srivastava a, Michael D. Cabana b,c a b c
Department of Pediatrics, University of Utah, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA Departments of Pediatrics, Epidemiology and Biostatistics, University of California, 3333 California Street, Suite #245, San Francisco, CA 94118, USA Philip R. Lee Institute for Health Policy Studies, University of California, 3333 California Street, Suite #265, San Francisco, CA 94118, USA
a r t i c l e
i n f o
Available online 28 November 2014 Keywords: Smoking Tobacco Chronic disease Chronic obstructive pulmonary disease Cardiovascular disease Guideline Primary care
a b s t r a c t Background. Evidence-based guidelines recommend smoking cessation treatment, including screening and counseling, for all smokers, including those with chronic diseases exacerbated by smoking. Physician treatment improves smoking cessation. Little data describes smoking treatment guideline uptake for patients with chronic cardiopulmonary smoking-sensitive diseases. Objective. Describe U.S. primary care physician (PCP) smoking cessation treatment during patient visits for chronic cardiopulmonary smoking-sensitive diseases. Methods. The National (Hospital) Ambulatory Medical Care Survey captured PCP visits. We examined smoking screening and counseling time trends for smokers with chronic diseases. Multivariable logistic regression assessed factors associated with smoking counseling for smokers with chronic smoking-sensitive diseases. Results. From 2001–2009 smoking screening and counseling for smokers with chronic smoking-sensitive cardiopulmonary diseases were unchanged. Among smokers with chronic smoking-sensitive diseases, 50%–72% received no counseling. Smokers with chronic obstructive pulmonary disease (COPD) (odds ratio (OR) = 6.54, 95% confidence interval (CI) 4.85–8.83) and peripheral vascular disease (OR = 4.50, 95% CI 1.72–11.75) were more likely to receive smoking counseling at chronic/preventive care visits, compared with patients without smoking-sensitive diseases. Other factors associated with increased smoking counseling included non-private insurance, preventive and longer visits, and an established PCP. Asthma and cardiovascular disease showed no association with counseling. Conclusions. Smoking cessation counseling remains infrequent for smokers with chronic smoking-sensitive cardiopulmonary diseases. New strategies are needed to encourage smoking cessation counseling. © 2014 Elsevier Inc. All rights reserved.
Introduction Smoking and tobacco use remain the largest preventable causes of U.S. medical disease and costs (Centers for Disease Control and Prevention, 2006; CDC, 2008). Annually, over 480,000 preventable smoking-related deaths occur, and $280 billion in smoking-related costs are primarily manifested through chronic diseases exacerbated by smoking (CDC, 2008, 2014). In response to these concerns, the U.S. Public Health Service created the evidence-based Treating Tobacco Use and Dependence: Clinical Practice Guideline to reduce the effects of Abbreviations: COPD, chronic obstructive pulmonary disease; EMR, electronic medical record; NAMCS, National Ambulatory Medical Care Survey; NHAMCS, National Hospital Ambulatory Medical Care Survey; PCP, primary care physician; ACA, Affordable Care Act; PVD, peripheral vascular disease. ⁎ Corresponding author. E-mail addresses: [email protected] (K.E. Nelson), [email protected] (A.L. Hersh), fl[email protected] (F.L. Nkoy), [email protected] (J.H. Maselli), [email protected] (R. Srivastava), [email protected] (M.D. Cabana).
http://dx.doi.org/10.1016/j.ypmed.2014.11.010 0091-7435/© 2014 Elsevier Inc. All rights reserved.
smoking (Fiore et al., 2000, 2008). These guidelines recommended a chronic disease treatment strategy that includes systematically screening every patient to determine patient readiness to make a quit attempt and providing smoking cessation counseling with smoking cessation, prevention and referral information. The Guideline concluded that smoking screening and smoking cessation counseling improved cessation rates (Fiore et al., 2000). Therefore, routine preventive and chronic care visits for patients with chronic smoking-sensitive cardiopulmonary disease present important opportunities to address smoking screening and counseling to improve cessation rates in a population with substantial potential for benefit. Despite the obvious benefits of smoking cessation, multiple studies report poor uptake of smoking treatment guidelines in clinical practice. Outpatient physicians screen 60% of patients (Jamal et al., 2012) and provide smoking counseling to approximately 20% of patients who smoke (Payne et al., 2012; Bernstein et al., 2013; Jamal et al., 2012). Poor delivery of smoking interventions is also reflected by infrequent use of evidence-based smoking cessation treatments among smokers (Shiffman et al., 2008). Recent studies have not addressed smoking
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cessation treatment in preventive care among patients with chronic smoking-sensitive diseases. Multiple barriers to physician compliance with smoking treatment guidelines exist, including beliefs that evidence-based interventions will not change patient smoking behavior, competing clinical priorities, and insufficient time, knowledge, and training (Barnes Dodge et al., 2008; Burnett and Young, 1999; Cabana et al., 2000, 2004; Frankowski et al., 1993; Kaplan et al., 2004; Nader et al., 1987; Tanski et al., 2003; Thorndike et al., 1999; Zapka et al., 1999; Bonollo et al., 2002). Available studies are also limited by small sample sizes and the absence of data regarding practice changes over time (Bernstein et al., 2013; Jamal et al., 2012; Collins et al., 2007; Ferketich et al., 2006; Payne et al., 2012; Tanski et al., 2003; Thorndike et al., 2007). Gaps remain in understanding adult and child primary care physician (PCP) smoking screening and counseling practice patterns among patients with chronic smoking-sensitive diseases (Bernstein et al., 2013; Jamal et al., 2012; Payne et al., 2012). To address these gaps, we examined the 2001–2009 national practice patterns for PCP delivery of smoking screening and counseling at PCP visits among smokers with chronic smoking-sensitive cardiopulmonary diseases. Our goal was to identify key factors (patient, physician, disease, and healthcare system) associated with delivery of smoking counseling to smokers with chronic smoking-sensitive diseases.
maintenance or exacerbations of a chronic condition determined by the physician to be present for over three months. Smoking variables Physicians indicated in the “Tobacco Use” datafield whether patients reported tobacco use (all forms) as Current/Not current/Unknown. Physicians documented whether counseling about cessation of tobacco use or tobacco exposure was delivered during the visit using a checkbox in the “Heath Education/Counseling” section. NAMCS/NHAMCS define tobacco education/counseling as counseling, educational, or therapeutic services, excluding medications. Disease variables
Methods
Cardiopulmonary diseases considered sensitive to exacerbation by smoking are directly linked to poor outcomes in smokers (Fiore et al., 2008; CDC, 2004, 2014). These diseases included asthma, chronic obstructive pulmonary disease (COPD), and cardiovascular disease (heart failure, ischemic heart disease, cardiomyopathy, atherosclerosis, and atheroembolism). Additional diseases modulated by smoking and that lead to cardiovascular disease (hypertension, diabetes, obesity, hyperlipidemia, and peripheral vascular disease (PVD)) or that are respiratory illnesses (upper respiratory tract infection, influenza, otitis media, bronchiolitis, bronchitis, and pneumonia) were included (Fiore et al., 2008). We conducted a subgroup analysis on children (age b 18 years) with asthma, the most prevalent childhood smoking-sensitive disease. International Classification of Disease-9 Clinical Modification codes were used to identify chronic smoking-sensitive diseases (Appendix A).
Data source
Analysis of smoking screening
PCP smoking treatment was examined from the frequencies of PCP smoking screening and smoking counseling delivery during preventive care office visits using the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets from 2001–2009. NAMCS and NHAMCS are nationally representative datasets capturing visits to physician offices and hospital outpatient departments and include data on smoking screening and counseling during each visit. NAMCS and NHAMCS use a multistage strategy with random sampling from geographic, physician practice, and patient visit frames (www.cdc.gov/nchs/ahcd.htm) (National Center for Health Statistics, n.d.). Physician practices gather data from 30 random visits during one week from routine practice documentation. Person and visiting weighting factors adjust for nonresponse, selection probability, proportion of physicians per specialty (NAMCS only), and weighting smoothing adjusting for the range of physician visits.
The percentage of visits where smoking screening occurred was estimated using patient and visit weighting factors. Time trends for smoking screening were tested using the Wald χ2 test. Comparisons of estimates by patient, disease, and healthcare factors used the Mantel-Haenszel χ2 test.
Study population For the analysis of smoking screening, we included all patient visits to their PCP for patients ≥12 years old. We limited screening to ≥12 years old because the clinical significance of screening in children b12 years old was considered inapplicable. For the analysis of smoking counseling, we included PCP visits for patients of all ages. Data variables NAMCS/NHAMCS captured variables used to characterize patient, physician/healthcare system, and disease factors from physician reported data obtained from patients during office visits. Patient variables Patient demographics retrieved from NAMCS/NHAMCS included age, gender, race/ethnicity, and insurance type. Physician/healthcare system variables Healthcare system factors included visit length, clinic type, geographical location, urban/rural status, physician specialty, and if the patient saw their established care provider. Physician specialty was limited to primary care specialties (internal medicine, pediatrics, family medicine, and general practice). Preventive care visits were patient encounters for general medical and routine examinations. Chronic care visits were patient encounters for routine
Analysis of smoking counseling for current smokers We compared the percentage of visits where smoking counseling was provided to current smokers with and without chronic smoking-sensitive diseases. Time trends were examined using the Wald χ2 test. Estimates for patient, physician, disease, and healthcare factors were compared using the MantelHaenszel χ2 test. Variables associated with smoking counseling in univariate analyses (p b 0.20) were included in multivariable logistic regression models to identify patient, physician, disease, and healthcare system factors associated with delivery of smoking counseling. Analyses were two-sided using SAS software (version 9.2). Survey weighting factors were applied using SUDAAN (version 9.0). Because physician specialty and visit length variables were unavailable in the NHAMCS dataset, an analysis using NAMCS evaluated these variables.
Results Smoking screening From 2001–2009, 136,062 unweighted physician visits were sampled. Smoking screening was delivered at 68% of visits. The frequency of PCP smoking screening was unchanged over the nine years after guideline introduction (Fig. 1). Higher frequencies of smoking screening were observed for patients with the smoking-sensitive diseases asthma, cardiovascular disease, COPD, or hypertension, compared with patients with other smoking-sensitive diseases and without chronic smokingsensitive diseases (Table 1). Smoking counseling to smoking patients During the study period 59,229 unweighted visits for patients identified as smokers were sampled. Among 14,061 unweighted chronic/ preventive care visits for smokers, physicians delivered smoking counseling during 28% of visits. The frequency of smoking counseling for identified smokers was unchanged over the study period (Fig. 1).
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Table 2 PCP delivery of smoking counseling to smokers with chronic smoking-sensitive diseases 2001–2009. Total visits (n = 14,061)a
Fig. 1. Time trends for PCP smoking screening and delivery of smoking counseling.
Smoking counseling was provided more frequently during preventive (32%) and chronic care visits (27%), compared with other visit types (p b 0.001) (Table 2). Adolescent smokers (age 12–17 years) had a higher frequency of smoking counseling (36%, p = 0.01), compared with all other ages. Smoking counseling was also delivered more frequently at visits lasting ≥15 min (p b 0.001) compared with b 15 min. No differences were observed by gender, race, insurance type, or geographic location. Chronic smoking-sensitive diseases Smoking counseling was provided more frequently to smokers with the chronic smoking-sensitive diseases COPD (46%, p b 0.001), respiratory illness (40%, p = 0.008), and diabetes (28%, p = 0.047), compared with 25% for smokers without chronic smoking-sensitive diseases (Table 1). The frequency of smoking counseling among smokers was 51% for PVD (p = 0.16), 31% for asthma (p = 0.49), and 34% for cardiovascular disease (p = 0.24), compared with 25% among diseases that were not smoking-sensitive. Factors associated with smoking cessation counseling Multivariable analysis identified patient, physician, disease, and healthcare system factors associated with smoking counseling among
Table 1 Frequency of PCP smoking screening and delivery of smoking counseling 2001–2009. Smoking sensitive disease
Asthma Cardiovascular disease COPD Hypertension Diabetes Obesity Hyperlipidemia Peripheral vascular disease Respiratory illness All other diseases a b c d
Smoking screening frequencya
Smoking counseling frequencyb
Total visits (n = 136,062)c
Total visits (n = 14,061)c
%
p-Valued
%
p-Valued
75.1 71.8 74.6 70.5 69.4 63.8 69.0 63.5 66.5 66.1
b0.001 0.022 b0.001 0.004 0.11 0.44 0.44 0.37 0.24 –
31.1 33.9 46.3 31.1 28.4 27.9 32.7 50.5 40.3 24.8
0.49 0.24 b0.001 0.077 0.047 0.996 0.183 0.16 0.008 –
For patients age N12 years. For smokers, all ages. Unweighted visits. Statistical comparisons of smoking sensitive diseases with ‘all other diseases’ used the Mantel-Haenszel χ2 test.
Patient characteristics Age (years) 0–5 6–11 12–17 18–44 45–64 N65 Gender Female Male Race White Black Hispanic Other Insurance Private Non-private
Smoking counseling frequency %
p-Valuec 0.01
19.8 4.8 35.8 26.2 29.3 26.7 0.32 27.2 28.4 0.53 28.2 27.7 23.8 27.7 0.23 28.7 27.0
Physician/healthcare system characteristics Seen by established provider Yes 28.3 No 26.7 Unknown 21.9 Physician specialtyb GP/FP 26.2 IM 30.3 Pediatrics 36.4 Clinic type Office 27.9 Outpatient department 27.3 Visit type All visits 25.4 Preventive 31.7 Chronic problem/routine/flare-up 26.6 Acute/new 23.0 Visit length (min)b b15 18.9 15–30 28.8 31–60 39.8 N60 43.6 Geographic region Northeast 31.1 Midwest 28.7 South 25.8 West 27.2 Population density Urban 28.4 Rural 25.5
0.081
0.073
0.73
b0.001
b0.001
0.31
0.23
Note: GP/FP = general practice/family practice, IM = internal medicine. a Unweighted visits. b Results using NAMCS dataset only based on 5410 unweighted visits. c Statistical comparisons used the Mantel-Haenszel χ2 test.
smokers (Table 3). Patient factors associated with smoking counseling included male gender (OR 1.28, 95% CI: 1.16–1.41), age 12–17 years (OR 2.22, 95% CI: 1.65–2.98), and non-private insurance (OR 1.33, 95% CI: 1.16–1.53). Physicians were more likely to counsel smokers with COPD (OR 6.54, 95% CI: 4.85–8.83), compared with patients without chronic smoking-sensitive diseases. With the exception of PVD (OR 4.50, 95% CI: 1.72–11.75), other smoking-sensitive diseases, including asthma and cardiovascular disease, were not associated with smoking counseling. Although asthma is the most prevalent pediatric smokingsensitive disease, asthma was not associated with smoking counseling among pediatric patients with asthma. Healthcare system factors associated with smoking counseling included preventive visits (OR 1.42, 95% CI: 1.24–1.63), longer visit lengths (OR 1.76, 95% CI: 1.35–2.30), and seeing an established PCP (OR 1.50, 95% CI: 1.19–1.90).
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Table 3 Factors associated with PCP delivery of smoking counseling to smokers with chronic smoking-sensitive disease 2001–2009. Adjusted odds ratio (95% CI) Smoking-sensitive disease All other diseases COPD Peripheral vascular disease Patient characteristics Age 0–5 6–11 12–17 18–44 45–64 N65 Gender Female Male Race White Black Hispanic Other Insurance Private Non-private Physician/healthcare system characteristics Seen by established provider No Yes Physician specialtya GP/FP IM Pediatrics Visit type Chronic care Preventive Visit length (min)a b15 15–30 30–60 N60
Reference 6.54 (4.85–8.83) 4.50 (1.72–11.75)
Reference 1.16 (0.88–1.55) 2.22 (1.65–2.98) 1.45 (1.07–1.98) 1.40 (1.03–1.90) 0.47 (0.34–0.65) Reference 1.28 (1.16–1.41) Reference 0.83 (0.70–0.98) 0.69 (0.56–0.84) 0.92 (0.68–1.25) Reference 1.33 (1.16–1.53)
Reference 1.50 (1.19–1.90) Reference 0.91 (0.74–1.12) 2.16 (1.65–2.84) Reference 1.42 (1.24–1.63) Reference 1.76 (1.35–2.30) 2.23 (1.59–3.11) 3.91 (1.57–9.73)
Note: GP/FP = general practice/family practice, IM = internal medicine. a Results using NAMCS dataset only based on 5410 unweighted visits.
Discussion Over 2001–2009, fewer than one-third of smokers with chronic smoking-sensitive diseases received counseling about cessation during primary care visits. Smoking cessation counseling was highest for patients with COPD and PVD but only reached 54% and 51%, respectively. Smoking cessation counseling was also more likely to be delivered at preventive visits, by an established PCP, at longer visits, to adolescents and for patients with non-private insurance. Despite dissemination of smoking treatment guidelines, delivery of smoking screening and counseling to patients with chronic smoking-sensitive disease remains underused and has not improved over a decade. Compared with previous studies, our study focused on a different patient population of patients seen for chronic or preventive care, including those with chronic smoking-sensitive diseases. However, previous studies have shown that PCPs generally deliver smoking counseling for all patients more frequently than specialists and other physicians (Ferketich et al., 2006; Payne et al., 2012; Thorndike et al., 2007). Many factors may position PCPs to deliver smoking counseling, including providing a medical home, health promotion, evidence-based care, and frequently being the first health care contact for patients with chronic smoking-sensitive disease (Starfield and Shi, 2004; Starfield et al., 2005; Ulrik et al., 2010). Our study indicates that established PCPs may be better suited to provide smoking counseling to our patient
population, especially those seen for chronic or preventive care of a chronic smoking-sensitive disease. Our study identified physician and healthcare factors that affected delivery of smoking cessation counseling for patients with chronic smoking-sensitive diseases who are seen for chronic or preventive care. Increased smoking counseling has previously been reported with longer visit lengths (Ferketich et al., 2006; Jamal et al., 2012). Our study found significantly higher frequencies of smoking counseling at longer visit lengths. This suggests that PCPs are more likely to provide smoking cessation counseling when more time is available, suggesting that the commonly cited barrier of inadequate time (CDC, 1995; Collins et al., 2007) may be less relevant at preventive or chronic care visits. In addition, adolescents were more likely to receive smoking counseling compared with all other ages, and pediatricians were more likely to provide smoking counseling compared with internal medicine and general practitioners/family physicians. While the U.S. Preventive Services Task Force and AAP Bright Futures guidelines recommend smoking counseling to all children and adolescents (Moyer, 2013; Hagan et al., 2008), focusing smoking counseling efforts on pediatric patients with chronic smoking-sensitive diseases like asthma may be important in preventing avoidable health care utilization (Howrylak et al., 2014; McCarville et al., 2013). Differences among specialties in our study may also be due to differences in specialty training and knowledge, evidence-based smoking treatments, or the increased number of chronic diseases requiring coordination during adult versus pediatric visits (Frankowski and Secker-Walker, 1989; Perez-Stable et al., 2001). Consistent with previous studies, patients with non-private insurance were more likely to receive smoking counseling. Lack of reimbursement for delivery of smoking cessation counseling remains a significant barrier to routine physician initiated smoking treatment (Frankowski and Secker-Walker, 1989; Perez-Stable et al., 2001; Zapka et al., 1999). However, the Affordable Care Act (ACA) eliminated cost sharing for evidence-based smoking interventions, including physician delivered smoking counseling (University of Wisconsin Center for Tobacco Research and Intervention, 2010). Standardization of reimbursement, including elimination of cost sharing, may improve PCP smoking counseling for patients with chronic smoking-sensitive diseases and at preventive or chronic care visits. The availability of easily accessible smoking cessation consultation services may also help improve physician screening and subsequent referral without increasing the burden on PCPs (Barnes Dodge et al., 2008). Despite dissemination of smoking treatment guidelines, smoking cessation counseling for smokers with chronic smoking-sensitive diseases at visits for chronic or preventive care has not improved over a decade. Prior to 2003, evidence-based guidelines highlighted the importance of treating smoking in the chronic cardiopulmonary diseases asthma (National Institutes of Health, 2003; NIH, 1997), cardiovascular disease (Smith et al., 2001), and COPD (Pauwels et al., 2001). Primary care organizations also established smoking treatment as a high priority (American Academy of Pediatrics, 2009; American Academy of Family Physicians, 2009; American College of Physicians, 2010). Our study suggests that tobacco treatment guidelines may be insufficient to produce or sustain changes to physician practice or the healthcare delivery system to provide smoking cessation counseling to smokers with chronic smoking-sensitive diseases. Multiple barriers have limited implementation of tobacco treatment guidelines in routine clinical practice (Barnes Dodge et al., 2008; Burnett and Young, 1999; Cabana et al., 2000, 2004; Frankowski et al., 1993; Kaplan et al., 2004; Nader et al., 1987; Tanski et al., 2003; Thorndike et al., 1999; Zapka et al., 1999; Bonollo et al., 2002). Improved delivery of smoking counseling may be an increasingly important factor for preventive care of smoking-sensitive diseases as shared accountability and pay for performance models are adopted. Systems level strategies utilizing established providers as part of medical homes, longer preventive/ chronic care visits, physician training in smoking cessation counseling, physician reminders and decision support, incentives for meaningful
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EMR use, changes in reimbursement provided by the ACA, and improved accessibility of referral services may improve delivery of smoking interventions to smokers with COPD and other smokingsensitive diseases. Limitations Our study has the following limitations. First, patients who underreport smoking may lead to underestimates of smoking and remain an important population for future screening and counseling efforts. Second, physician recall bias or underreporting of smoking screening and counseling may also lead to underestimates of smoking treatment. Third, the granularity of the smoking screening and counseling datafields limits the information available on the content of smoking interventions between practices and specialties. Fourth, smoking screening and counseling at previous visits were not captured. Smoking screening and counseling may be higher if measured at the patient level, as patients may have received smoking interventions at a previous visit. Fifth, physicians who agree to participate in the survey may be more likely to overestimate their smoking screening and counseling practices. Sixth, practice patterns may also have changed since 2009. Despite these limitations, the strengths of our study lie in examining smoking counseling for patients with chronic smoking-sensitive diseases at chronic and preventive care visits over nine years, including time trends. We used a patient population at preventive or chronic care visits, including those with chronic smoking-sensitive diseases, not investigated in detail in previous studies. We also identified multiple factors that may contribute to strategies to encourage physician smoking cessation interventions for smokers with chronic smokingsensitive diseases.
Acknowledgment We thank Dr. Christopher G. Maloney, Dr. Bryan L. Stone, and Heather Oldroyd, CRC from the University of Utah, Department of Pediatrics and Dr. Karen Wilson from the University of Colorado, Denver, Department of Pediatrics for technical comments on the manuscript. We acknowledge the study design assistance from Tom Greene, PhD and Greg Stoddard, MPH, MBA from the University of Utah, Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764).
Appendix A International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) codes used to identify smoking-sensitive diseases for office visits in the NAMCS/NHAMCS datasets. Smoking-sensitive illness
ICD-9 CM codes
Asthma Cardiovascular disease
493.x 398.91, 402.01, 402.11, 402.91, 404.01‐404.03, 404.11, 404.13, 404.91, 404.93, 410.x‐414.x, 425.4‐425.9, 428.0‐428.9, 429.9, 440.x, 445.x 490‐492.8, 494, 496.x, 495.0‐505 401.0‐405.9, 642.00‐642.04, 642.10‐642.24, 642.70‐642.94 249.00‐249.91, 250.0‐250.9, 648.00‐648.04, 775.1 278.0 272 093.0, 437.3, 440‐440.9, 441.00‐441.9, 442.0‐442.9, 443.1‐443.9, 444.21‐444.22, 447.1, 449, 557.1, 557.9
COPD Hypertension Diabetes Obesity Hyperlipidemia Peripheral vascular disease
Conclusions Our findings demonstrate that delivery of smoking cessation counseling to patients with chronic smoking-sensitive diseases remains underused and has not improved over a decade, despite dissemination of smoking treatment guidelines. The patient and healthcare factors – preventive visits, an established PCP, longer visit length, adolescent age, and non-private insurance – were identified as potential facilitators that may be used to support smoking counseling at visits for preventive or chronic care for smokers with chronic smoking-sensitive disease. Further research is needed to identify the factors associated with translation of evidence-based smoking cessation interventions into the primary care setting. Future studies should investigate the effects of healthcare system changes made possible by EMR adoption, Meaningful Use incentives, and the ACA on smoking interventions. New strategies, including national efforts and quality benchmarks of smoking cessation counseling, may allow physicians and the healthcare system to overcome persistent barriers to implementing basic elements of guidelinebased tobacco treatment in routine primary care. Funding KEN is supported by grants from the American Academy of Pediatrics Julius B. Richmond Center of Excellence and the Primary Children's Hospital Foundation. FLN is supported by grants from the Agency for Healthcare Research and Quality (1R18HS018166-01A1 and 1R18HS018678-01A1) and the Patient Centered Outcomes Research Institute (5330). Funding sources had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. Conflict of interest statement The authors declare that there are no conflicts of interest.
81
Respiratory disease Upper respiratory tract infection Influenza Otitis media Bronchiolitis Bronchitis Pneumonia
460, 462‐464, 465.x 487 381, 382 466.11, 466.19 460.x, 466.0 481‐486
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