A behavioral economic intervention to improve psychiatrist adherence to tobacco treatment guidelines

摘要 精神健康患者吸烟的可能性是没有精神健康诊断的人的两倍， 与烟草有关的死亡率上升。有效的戒烟治疗对精神健康患者来说是存在的，但 有精神健康状况的吸烟者的烟草筛查和治疗率较低， 精神病医生文献和我们先前的工作已经确定了治疗烟草的多层次障碍， 精神病学和传统的选择性烟草治疗系统（提供者和患者必须启动 治疗）可以使这些障碍永久化。选择退出系统（患者自动入组 治疗，除非他们下降）显着改善了其他环境中与健康有关的行为。我们的目标是 对门诊精神病学中选择退出烟草治疗的方法进行首次评估。我们提出了一个 混合方法、双臂群集随机化初步试验，将：（1）估计选择退出与 选择加入烟草治疗系统对接受筛查和治疗的精神病患者比例的影响 （2）评估干预保真度，提供者对选择退出的看法 （3）评估实施“选择不参与”制度的成效 一个选择退出与选择加入烟草治疗系统对使用戒烟治疗和戒烟， 吸烟的精神病患者我们将采用混合方法、双臂随机分组研究设计。 我们将对纽约退伍军人事务部的门诊精神病医生实施烟草使用临床提醒 海港医疗保健系统（N = 20）。一半的精神科医生会收到一个提醒， 精神科医生提供戒烟药物，并为有兴趣戒烟的患者提供戒烟咨询 （选择加入提醒）。另一半将收到临床提醒，其中包括长期NRT订单和 除非提供者主动选择退出（Opt-Out），否则将自动生成的戒烟咨询转介 提醒）。在实施之前，两个部门的精神科医生将接受一个小时的烟草培训 治疗和学术细节。我们将使用VA管理数据来计算研究的主要 结果：1）接受吸烟筛查的患者百分比，2）规定戒烟的吸烟者百分比 （2）吸烟者接受咨询的比例。我们将使用培训日志和访视后 对400名患者进行整群抽样调查，以评估干预保真度。我们将进行半结构化 采访12-14名精神科医生，询问他们对干预成分的看法。我们还将 分析实施观察结果和文件，找出实施障碍和促进因素。六点 月，我们将再次调查400例患者样本，以评估研究的次要结局：1） 患者在前6个月内使用戒烟治疗，2）6个月时自我报告的7天戒烟。

ABSTRACT Mental health patients are twice as likely to smoke as those without mental health diagnoses and suffer from increased rates of tobacco-related mortality. Effective cessation treatments exist for mental health patients, but smokers with mental health conditions encounter low rates of tobacco screening and treatment by psychiatrists. The literature and our prior work have identified multi-level barriers to treating tobacco in psychiatry, and traditional opt-in tobacco treatment systems (where providers and patients must initiate treatment) can perpetuate these barriers. Opt-out systems (where patients are automatically enrolled in treatment unless they decline) have dramatically improved health-related behavior in other settings. We aim to conduct the first evaluation of an opt-out approach to tobacco treatment in outpatient psychiatry. We propose a mixed-methods, two-arm cluster-randomized pilot trial that will: (1) Estimate the effects of an Opt-Out versus Opt-In Tobacco Treatment System on the proportion of mental health patients who are screened and treated for tobacco use by their psychiatrist; (2) Assess intervention fidelity, provider perceptions of the Opt-Out System, and barriers and facilitators to implementation of the Opt-Out System; and (3) Estimate the effects of an Opt-Out versus Opt-In Tobacco Treatment System on use of cessation treatment and abstinence among mental health patients who smoke. We will use a mixed-methods, two-arm cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists practicing at the VA New York Harbor Healthcare System (N = 20). Half of the psychiatrists will receive a reminder that encourages the psychiatrist to offer cessation medications and referral to cessation counseling to patients interested in quitting (Opt-In Reminder). The other half will receive a clinical reminder that includes a standing NRT order and a referral to cessation counseling that will automatically generate unless the provider actively opts-out (Opt-Out Reminder). Prior to implementation, psychiatrists in both arms will receive a one-hour training on tobacco treatment and academic detailing. We will use VA administrative data to calculate the study's primary outcomes: 1) the percent of patients screened for smoking, 2) the percent of smokers prescribed a cessation medication and 2) the percent of smokers referred to counseling. We will use training logs and post-visit surveys with a cluster sample of 400 patients to assess intervention fidelity. We will conduct semi-structured interviews with 12-14 psychiatrists asking about their perceptions of the intervention components. We will also analyze implementation observations and documents for implementation barriers and facilitators. At six months, we will survey the clustered 400-patient sample again to evaluate the study's secondary outcomes: 1) patient use of cessation treatment in the prior 6 months and 2) self-reported 7-day abstinence at 6 months.