RC-2006-0007
Title: Increasing QUITPLANSM Helpline Utilization by Surgical Patients
Applicant Organization: Mayo Clinic Rochester
Principal Investigator: David Warner
Amount of award: $517,397
Length of award: 36 months
Type of award: Full Standard award
ABSTRACT
Despite the wide availability of effective tobacco cessation tools such as the
QUITPLANSM services sponsored by MPAAT, there is a great need to increase the reach
of these tools in the general population, as only a small percentage of eligible smokers
currently elect to utilize these services. We believe that there is an excellent opportunity
to do so in a population that has received little prior attention in the tobacco control
literature — patients scheduled for elective surgical procedures. Each year,
approximately 100,000 smokers undergo elective surgery in Minnesota. In addition to the
fact that all these smokers contact the health care system, providing the opportunity to
intervene, there are other reasons that surgery is a particularly opportune time for
smokers to make a quit attempt. For example, because smoking increases the frequency
of postoperative complications including pneumonia and wound infections, and even
temporary abstinence from smoking reduces these complications, patients have a
powerful additional incentive to quit. Furthermore, our prior work funded by MPAAT
has shown that the forced abstinence that patients must maintain while in surgical
facilities mitigates typical nicotine withdrawal symptoms, and that nicotine replacement
therapy may be safe and effective in this population.
This prior work also shows that very few surgical patients currently receive any type
of tobacco cessation intervention, but has revealed some of the barriers to successful
intervention. Busy practitioners, most of whom have little training or experience in
tobacco interventions, simply do not have the time, skills, or motivation to consistently
address tobacco use in their patients who seek attention for other medical problems. Very
few surgical practices have ready access to referral to tobacco specialists, and patients
may not have the interest, time, or resources to pursue such specialist treatment. One
promising suggestion is that the recommended “5As” approach to brief clinician
intervention, which has not been adopted widely in clinical practice, be further simplified
to “ask, advise, and refer” — to resources such as QUITPLANSM; i.e., the clinician
simply Assesses tobacco use, Advises the participant to stop smoking, and then Refers to
a tobacco quitline. Although conceptually appealing from the standpoint of maximizing
potential dissemination, this approach needs to be validated in clinical settings. In
particular, the utilization of quitline resources is relatively low within the general
population of smokers, and it remains to be determined whether provider referral will
increase utilization. In preliminary work, we have identified several barriers to quitline
utilization. These are primarily related to misconceptions regarding the content, cost, and
configuration of these services, misconceptions that could be potentially addressed by
information given by providers at the time of referral to these services.
The overall goal of this proposal is to increase the utilization of the QUITPLANSM
Helpline by surgical patients who smoke. Two specific aims will be pursued using a
multidisciplinary research team. In the first aim, we will develop a practice-based
intervention to promote QUITPLANSM Helpline utilization by surgical patients
(SPECWIC AIM 1A), then develop methods to educate providers in its implementation
(SPECWIC AIM 1B). In the second aim, we will perform a randomized clinical trial of
this intervention in the Mayo Clinic Preorative Evaluation Clinic (POE), with the primary
outcome being utilization of the QUITPLANSM Helpline (SPECIFIC AIM 2). This
proposal thus aims to improve the reach and adoption of an existing tobacco cessation
services in Minnesota. It specifically falls within Research Area II, Tobacco Cessation
Services, and will address the full range of Minnesotans who require elective surgery.
This is a diverse group that provides a representative sampling of the state population.
The following is a brief overview of the proposed methodology.
SPECIFIC AIM 1A.—Develop a practice-based intervention to promote QUITPLANSM
Helpline utilization by surgical patients.--We will develop a brief (< 5 mm) practicebased intervention ensuring that patients scheduled for elective surgery are asked about
tobacco use, advised to quit, and receive a blend of motivational interviewing, the
removal of misperceptions about tobacco quit lines, and proactive recruitment of
participants to quit line participation. The goal of this intervention will be to increase the
proportion of surgical patients who utilize the QUITPLANSM Helpline. To develop the
intervention we will use a validated participatory research approach, combining key
informant interviews and focus groups.
SPECIFIC AIM 1B.—Develop methods to educate providers regarding intervention
delivery.-Having developed the intervention, we will develop means to educate the
providers in the preoperative clinic who will deliver it, including the physicians and
respiratory therapists. The development of the provider education component, both in
content and mode of delivery, will rely heavily on the outcomes from the provider focus
groups. We will use this information and the extensive experience of the investigative
team in training other health care providers in tobacco intervention to develop the
provider education. The method of education delivery will necessarily be determined by
how best to economically present the clinically relevant material in a time frame that is
acceptable to busy practitioners. We will also evaluate the effectiveness of the provider
education.
SPECIFIC AIM 2.—Evaluate the intervention in a surgical practice.—To evaluate the
effectiveness of the intervention to promote QUITPLANSM Helpline utilization, we will
perform a randomized clinical trial involving 300 smokers scheduled for elective surgery
to test the hypothesis that the intervention devised in SPECIFIC AIM 1 will increase
QUITPLANSM Helpline utilization. Subjects will be randomized to receive either the
Helpline utilization intervention (specifically promoting the Helpline, including proactive
referral) or a standard brief intervention that does not specifically encourage Helpline
utilization (to clarify, the term “intervention” here refers to the action by the clinical
provider to promote Helpline utilization, not the services provided b’ the Helpline itself).
Helpline utilization and smoking behavior will be followed up to three months
postoperatively. The primary outcome will be the rate of Helpline utilization, defined as
the completion of at least one Helpline counseling session. The secondary outcome will
be the 7-day point prevalence abstinence from smoking at three months postoperatively.
By the conclusion of the grant period, we will have implemented and evaluated a
brief practice- based smoking intervention strategy for surgical patients that leverages
existing QUITPLANSM services to bring an effective smoking cessation intervention to
more Minnesotans. If successful, the next step would be to disseminate this brief
intervention into surgical practices throughout Minnesota and the nation. This work may
also provide insight into how to increase the general reach of these valuable services by
utilizing other practice settings, including primary care, patients hospitalized for other
indications, dental offices, and others.