Reducing Tobacco Use Disparities Among Adults in Safety Net Community Health Centers

估计有2600万吸烟者在初级保健就诊期间仍然没有得到治疗。 考虑到持续存在的临床系统，提供者和患者在解决吸烟问题上的障碍，特别是在 贫困人口，一种EHR自动化的人口健康管理方法， 通过临床和电子社区服务，让所有吸烟者参与进来， 有效治疗。对于得不到充分服务的低收入吸烟者来说， 并承担着与烟草有关的疾病的不成比例的负担。虽然90%的吸烟者还没有准备好戒烟， 许多人对减少吸烟感兴趣，减少吸烟增加了未来戒烟尝试的可能性， 戒烟。根据自决理论，以人为本的人口外联，针对低- 收入吸烟者，并为他们提供选择，要么戒烟，要么减少作为戒烟的第一步， 增加她们对治疗的参与和利用，增加实现禁欲的可能性。这2组 随机对照试验将评估以人为本的人群健康管理的有效性 对低收入吸烟者进行戒烟干预。参与者将是530名不同的低收入者， 芝加哥一家大型联邦健康中心（FHC）的吸烟者使用其电子健康识别 电子病历（EHR）系统。通过EHR系统自动化，参与者将代表他们的 提供者鼓励戒烟或减少吸烟作为戒烟的第一步，如果不准备 设定戒烟日期（选择更改; N=265）。这封信将与两个自动文本/语音配对 信息间隔三天，旨在加强信的中心信息（“选择 改变自己，实现自己的目标”。信件寄出两周后，参与者将收到来自 伊利诺伊州烟草戒烟热线，并提供免费的人为中心的行为咨询和免费尼古丁 替代疗法（NRT;贴剂、口香糖或锭剂）。治疗将继续接受或启动， 参与者26周治疗结果将直接从Quitline服务器传输到EHR 系统选择改变将与家庭护理（N=265）进行比较，其中， 戒烟治疗是在诊所就诊期间进行的。主要研究成果将是治疗参与 第6周时（完成初始咨询电话），第6周时（完成一次或多次额外咨询电话） 12周，26周时戒烟（生物等效7天点患病率戒烟）。探索性 研究的目的是探讨干预效果的调节因素。我们假设，选择改变将 增加参与和利用治疗并实现戒烟的吸烟者比例， 与护理相比。EHR自动化、以人为本的人群健康管理干预 这是由理论和病人的反馈，并针对低收入吸烟者可以减少关键 治疗获得、利用和停止方面的差异。如果确定为有效，选择更改 干预措施可以传播到美国各地的社区卫生组织和州戒烟热线。

An estimated 26 million smokers still receive no treatment for their smoking during their primary care visits. Given the persistent clinical system, provider, and patient barriers to addressing smoking, especially among poor populations, an EHR-automated population health management approach that links a healthcare system with community services both clinically and electronically to engage all smokers may increase access to effective treatment. Increased access is especially significant for low-income smokers who are underserved and carry a disproportionate burden of tobacco-related disease. While 90% of smokers are not ready to quit, many are interested in cutting down, and smoking reduction increases the likelihood of future quit attempts and smoking cessation. Based on self-determination theory, person-centered population outreach that targets low- income smokers and offers them the choice to either quit or cut down as a first step towards cessation may increase their engagement in and utilization of treatment and likelihood of achieving abstinence. This 2-group randomized controlled trial will evaluate the effectiveness of a person-centered population health management intervention for smoking cessation in low-income smokers. Participants will be 530 diverse, low-income smokers of a large Federally Qualified Health Center (FQHC) in Chicago identified using its electronic health record (EHR) system. Automated via the EHR system, participants will be mailed a letter on behalf of their providers that encourages smoking cessation or smoking reduction as a first step to cessation if not ready to set a quit date (Choose to Change; N=265). The letter will be paired with two automated text/voices messages three days apart that are designed to reinforce the central messaging of the letter (“Choose to change and make your own goal”). Two weeks after letter mailing, participants will receive a call from the Illinois Tobacco Quitline and be offered free person-centered behavioral counseling and free nicotine replacement therapy (NRT; patch, gum, or lozenge). Treatment will continue as either accepted or initiated by participants for 26 weeks. Treatment outcomes will be transmitted directly from the Quitline server to the EHR system. Choose to Change will be compared with Usual Care (N=265), in which a referral for proactive Quitline treatment is made during a clinic visit. The primary study outcomes will be treatment engagement (initial counseling call completed) at 6 weeks, utilization (one or more additional counseling calls completed) at 12 weeks, and smoking cessation (bioverified 7-day point-prevalence abstinence) at 26 weeks. An exploratory study aim will be to examine moderators of intervention effects. We hypothesize that Choose to Change will increase the proportion of smokers who engage in and utilize treatment and who achieve cessation, as compared with Usual Care. An EHR-automated, person-centered, population health management intervention that is informed by both theory and patient feedback and targeted to low-income smokers could reduce critical disparities in treatment access, utilization, and cessation. If determined to be effective, the Choose to Change intervention could be disseminated to FQHCs and state quitlines throughout the United States.