Demonstration of a ProcessProcessOutcome Link for
Smoking Cessation
Melissa M. Farmer, PhD1,2
Elizabeth M. Yano, PhD1,2
Brian S. Mittman, PhD1,2
Scott E. Sherman, MD, MPH1,3
Background: Smoking Cessation (SC)
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Nearly 25% of all Americans are smokers
SC has one of the lowest treatment delivery
rates of all preventive services.
Many SC interventions work
– NRT and/or buproprion
– SC programs
– Brief provider tobacco counseling
1VA HSR&D Center of Excellence for the Study
of Healthcare Provider Behavior; UCLA Schools
of Public Health2 and Medicine3
AcademyHealth Annual Meeting • Boston • June 2005
Background: Why the VA?
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Smoking is more prevalent among veterans.
VA is the largest health care system in U.S.
QUITS Intervention
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– Currently ~6 million VA users: ~2 million smokers
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Increased SC guideline adherence was among
VA’
VA’s first national performance goals
– Substantial improvements in detecting and
counseling smokers
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EvidenceEvidence-based quality improvement (QI)
guideline implementation study at 18
Southwestern VA’
VA’s in 19981998-2002
Intervention did not result in higher quits or
quit attempts
More research needed on contribution of
setting and the process of care
Funded by VA Health Services Research & Development Service
Objectives
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Examine the relationship between discrete
sitesite-level processprocess-ofof-care measures and
clinical outcomes for smoking cessation
(30(30-day abstinence) in a representative
sample of VA primary care patients
Sample and Methods
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SiteSite-level data: Primary/Ambulatory care
manager survey (n=18)
– Assessment, counseling, referral to SC programs,
treatment & resources available
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PatientPatient-level data: Telephone survey data from
QUITS sample of veterans smokers
– Baseline (n=1941), 12 month followfollow-up (n=1038) and
18 month followfollow-up (n=885).
– Sociodemographics,
Sociodemographics, health status, smoking status
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Analytic Strategy
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Facility Characteristics (n=18)
Logistic regression with clusterclusteradjustment at the sitesite-level to examine
processprocess-quality measures as predictors of
successful smoking cessation outcomes
– controlling for patient characteristics, baseline
health and smoking status.
% or
Mean/SD
Variable
Assessment of smoking status at visit
41%
Counseled at visit*
2.17 (0.54)
Referral to specialized SC clinic/program*
1.90 (0.84)
Medications prescribed w/out restrictions
31%
* 3 point scale: 1=less than half, 2=most, 3=all or almost all patients
Facility Characteristics (n=18)
Patient Population (n=1038)
Variable
Variable
%
%
Site measures assessment performance
19%
Age (22-91)
57.18
Site measures counseling performance
25%
Race: White
64%
Routine follow-up for those counseled
44%
Self rated health (1=poor-5=excellent)
2.49
Staff reminders to assess smoking status
81%
Had made quit attempt at baseline
45%
Logistic Model for 30-day
abstinence
Results
Has not smoked cigarette in past 30 days
%
Abstinence at 12 month followfollow-up
9%
Abstinence at 18 month followfollow-up
10%
12-month
N=1038
OR (95% CI)
18-month
N=885
OR (95% CI)
Assessment
2.10(1.15-3.83)
1.87(1.02-3.46)
Counsel
1.61(1.01-2.57)
1.58(1.06-2.35)
Referral
1.28(1.03-1.59)
1.08(0.86-1.36)
Measures assessment
2.38(1.43-3.95)
2.03(1.35-3.03)
2
Summary of Results:
Limitations
„At 1212- months increased odds of abstinence at
sites that report more frequent assessment,
counseling and referrals.
„At 1818-months, odds were further increased by
sites that report more frequent assessment and
counseling.
„Those sites that monitored their own performance
for tobacco use assessment had higher odds of
abstinence at 12 and 1818-months.
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Results limited to QUITS sample of
facilities and patients
Future research needed on the
measurement of processprocess-ofof-care
Conclusions and Implications
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SiteSite-level processprocess-ofof-care measures predict
clinical outcomes for smoking cessation.
The demonstration of a processprocess-outcome link
between smoking cessation performance
measures and veterans’
veterans’ actual cessation supports
VA’
VA’s process measurement as a valid marker for
ultimately helping veterans quit smoking.
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