Engaging Healthcare Practice Teams and Patients in Tobacco Cessation Intervention

每年有超过3000万的美国吸烟者去看初级保健医生。因此，卫生保健组织，包括卫生保健提供系统和一线实践团队，具有独特的优势，可以通过促进吸烟者使用循证戒烟治疗来帮助他们成功戒烟。2000年《公共卫生服务治疗烟草使用和依赖临床实践指南》包括一个基于证据的5-A（询问、建议、评估、协助、安排）算法，供提供者解决烟草依赖问题，并帮助吸烟者使用经证实的治疗方法戒烟（Fiore等人，2000年）。然而，2005年全国健康访谈调查（NHIS）表明，在每年尝试戒烟的49%的吸烟者中，使用经证实的行为治疗的不到5%，使用药物辅助的不到1/3，使用行为和药物联合干预的黄金标准的不到4% （Curry et al., 2007）。一种假设是，5-A算法的复杂性和时间要求可能会阻碍提供者在就诊期间解决烟草使用问题，而更简单的两步（询问和行动）方法可能会增加提供者的建议和援助，从而提高吸烟者使用循证治疗的比率（Schroeder， 2005年）。本研究在以社区为基础的初级保健实践环境中直接检验了这一假设。具体目的是：(1)确定电子病历（EMR）提示对5-A和2-A临床实践算法的有效性。采用三组随机试验，将两种算法相互比较，并与无emr提示对照条件进行比较。初级保健实践小组包括随机化和分析单元。结果测量是吸烟者转诊到行为干预和药物治疗的比率，由EMR、提供者自我报告、患者自我报告和威斯康星州戒烟热线获得的纵向数据决定。(2)检验某些执业团队特征是否对临床算法的有效性起到调节或中介作用。(3)评估与EMR提示相关的患者水平结果，包括使用行为或药物干预、戒烟和持续吸烟

More than 30 million American smokers visit a primary care clinician each year. As a result, health care organizations, including health care delivery systems and front-line practice teams are uniquely positioned to help smokers successfully quit by facilitating their use of evidence-based tobacco cessation treatments. The 2000 Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence includes an evidence-based 5-A (Ask,Advise, Assess, Assist, Arrange) algorithm for providers to address tobacco dependence and help smokers to quit using proven treatments (Fiore et al., 2000). However, the 2005 National Health Interview Survey (NHIS) indicates that, among the 49% of smokers who attempt cessation each year, fewer than 5% used proven behavioral treatment, less than 1/3 used pharmacological aids, and fewer than 4% used the gold standard of combined behavioral and pharmacological interventions (Curry et al., 2007). One hypothesis is that the complexity and time demands of the 5-A algorithm may discourage providers from addressing tobacco use during health care visits and that a simpler two-step (Ask and Act) approach may increase provider advice and assistance and, consequently, rates of evidence-based treatment use among smokers (Schroeder, 2005). This study directly tests this hypothesis in community-based primary care practice settings. The specific aims are: (1) To determine the effectiveness of electronic medical record (EMR) prompting for the 5-A and 2-A clinical practice algorithms. Using a three-arm group randomized trial, the two algorithms will be compared to each other and to a no-EMR prompt control condition. Primary care practice teams comprise the unit of randomization and analysis. Outcome measures are rates of referral of smokers to behavioral interventions and pharmacotherapy treatments determined by longitudinal data obtained from the EMR, provider self-reports, patient self-reports, and the Wisconsin Tobacco Quit Line. (2 To test whether certain practice team characteristics moderate or mediate the effectiveness of the clinical algorithms. (3) To estimate patient-level outcomes associated with EMR prompting, including use of behavioral or pharmacological interventions, smoking cessation and sustained abstinence. (4) To estimate the cost-effectiveness of the 5-A and 2-A clinical algorithms with reagrd to cost-per-treatment utilization.