Changing the Default for Tobacco Treatment

 描述(申请人提供)：本世纪将有10亿人死于与烟草有关的疾病。然而，大多数医疗保健提供者未能治疗烟草依赖。这在一定程度上可能要归因于对“违约”的处理。目前的治疗指南建议提供者a)询问患者是否愿意戒烟，b)只向声称愿意戒烟的吸烟者提供戒烟药物和咨询。对于其他健康状况--糖尿病、高血压、哮喘，甚至药物滥用--默认的治疗方法是a)确定健康状况，b)启动循证治疗。例如，当一名患者被诊断为高血压时，他们不会被问及是否准备好开始治疗。医生只是简单地从开处方或讨论治疗方案开始。与任何医疗保健治疗方案一样，患者可以自由拒绝--如果他们想拒绝治疗，他们可以“选择退出”。如果患者什么都不做，他们将得到治疗。然而，对于烟草使用者来说，默认的做法是他们不得不接受戒烟帮助：提供者询问吸烟者 他们愿意戒烟，只向那些同意戒烟的人提供药物和戒烟支持。这极大地限制了戒烟服务的范围，因为在任何给定的遭遇中，只有三分之一的吸烟者表示他们准备戒烟。因此，很少有人接受药物治疗或戒烟咨询。最近的研究表明，当提供戒烟药物和咨询时，“非动机”吸烟者与“动机”吸烟者戒烟的可能性一样大。因此，迫切需要研究改变默认治疗对使用和戒烟的影响。该应用程序的目的是确定为所有吸烟者提供烟草治疗的影响，除非他们拒绝(Opt Out)，而不是目前的做法--筛查准备情况，只向表示准备戒烟的吸烟者提供治疗(Opt In)。这项研究采用了个人随机设计，在一家三级保健医院进行。我们将在随机选择的1000名住院吸烟者中进行试验，以确定改变默认治疗对人群的影响，确定结果的中介因素，并确定这一新的、高度积极主动的方法的成本效益。这是一项以人群为基础的研究，以至关重要的终点为目标；应用最低限度的资格标准来扩大普适性；并利用医院工作人员进行干预，以确保长期可持续性。这项研究采用了一种创新的贝叶斯自适应设计来评估我们的护理方法的重大转变。如果有效，这一变化将把烟草治疗的覆盖范围从30%扩大到100%。

 DESCRIPTION (provided by applicant): One billion people will die from tobacco-related illnesses this century. Most health care providers, however, fail to treat tobacco dependence. This may in part be due to the treatment "default." Current treatment guidelines recommend that providers a) ask patients if they are willing to quit and b) provide cessation-focused medications and counseling only to smokers who state they are willing to quit. For other health conditions-diabetes, hypertension, asthma, and even substance abuse-the treatment default is to a) identify the health condition and b) initiate evidence-based treatment. For example, when a patient is newly diagnosed with hypertension, they aren't asked if they are `ready' to start treatment. The physician simply begins with a prescription or discussion of treatment options. As with any healthcare treatment option, patients are free to decline-they can "opt out" if they wish to refuse care. If patients do nothing, they will receive care. For tobacco users, however, the default is that they have to "opt in" to receive cessation assistance: providers ask smokers if they are willing to quit, and only offer medications and cessation support to those who say "yes". This drastically limits the reach of cessation services because, at any given encounter, only 1 in 3 smokers say they are ready to quit. As a result, few receive medications or cessation counseling. Recent studies suggest that, when provided with cessation medications and counseling, "unmotivated" smokers are as likely to quit as "motivated" smokers. Hence, there is a critical need to examine the impact of changing the treatment default on utilization and quitting. The objective of this application is to determine the impact of providing all smokers wit tobacco treatment unless they refuse it (OPT OUT) versus current practice-screening for readiness and only offering treatment to smokers who say they are ready to quit (OPT IN). The study employs an individually-randomized design, and is conducted in a tertiary care hospital. We will conduct the trial among 1,000 randomly-selected hospitalized smokers to determine the population impact of changing the treatment default, identify mediators of outcome, and determine the cost-effectiveness of this new, highly proactive approach. This is a population-based study that targets an endpoint of vital interest; applies minimal eligibility criteria to broaden generalizability; and utilizes hospital staff for interventions to ensure long-term sustainability. The study employs an innovative Baysian adaptive design to evaluate a major shift in our approach to care. If effective, this change would expand the reach of tobacco treatment from 30% to 100% of smokers.