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那些没有精神健康诊断的患者的两倍 与烟草有关的死亡率上升。对精神健康患者来说，有效的戒断治疗是存在的，但 有心理健康问题的吸烟者通过以下方式获得烟草筛查和治疗的比率较低 精神病学家。文献和我们以前的工作已经确定了处理烟草的多个层次的障碍 精神病学和传统的选择加入烟草治疗系统(提供者和患者必须发起 治疗)会使这些障碍永久化。选择退出系统(其中患者自动登记在 治疗)极大地改善了其他环境中与健康相关的行为。我们的目标是 在精神科门诊首次对戒烟治疗方法进行评估。我们提出了一个 混合方法、双臂整群随机试点试验将：(1)评估选择退出与 Opt-in烟草治疗系统对心理健康患者筛查和治疗比例的影响 心理医生使用烟草；(2)评估干预的保真度、提供者对选择退出的看法 制度，以及实施选择不参与制度的障碍和促进者；以及(3)估计 选择退出与选择加入烟草治疗系统关于戒烟治疗和戒烟的使用情况 吸烟的精神健康患者。我们将采用混合方法、双臂整群随机研究设计。 我们将对在退伍军人管理局纽约执业的门诊精神科医生实施烟草使用临床提醒 港湾医疗系统(N=20)。一半的精神科医生将收到一份提醒，鼓励 精神科医生为有意戒烟的患者提供戒烟药物并转介至戒烟咨询 (选择加入提醒)。另一半人将收到临床提醒，其中包括一份长期的NRT命令和一份 推荐将自动生成的戒烟咨询，除非提供者主动选择退出(Opt-out 提醒)。在实施之前，双方的精神科医生将接受一小时的烟草培训 治疗和学术细节。我们将使用退伍军人管理局的数据来计算研究的主要 结果：1)筛查吸烟者的百分比，2)吸烟者开出戒烟处方的百分比 药物治疗和2)吸烟者咨询的百分比。我们将使用培训日志和访问后 对400名患者进行整群抽样调查，以评估干预的保真度。我们将进行半结构化 采访了12-14名精神病学家，询问他们对干预组成部分的看法。我们还将 为实施障碍和促进者分析实施观察和文档。六点 几个月后，我们将再次调查整群的400名患者样本，以评估研究的次要结果：1) 患者在前6个月内使用戒烟治疗，2)在6个月时自我报告7天戒断。

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.