Project 2: Centralized Health System Interventions to Enhance Reach: A Factorial Screening Experiment (HS Reach Interventions)

项目摘要 每年接受初级保健的2500万美国吸烟者中有一小部分人接受了循证医学。 吸烟治疗医疗保健系统具有巨大的潜力，可以将吸烟者与高质量， 循证护理。已采用各种战略来增加治疗的使用，但治疗范围 仍然很低。拟议的研究将是第一个严格的析因实验，以优化 一套集中的医疗保健系统干预措施，以提高戒烟治疗的覆盖面，以及 通过这一中介途径，在接触干预措施2年后降低吸烟率， 获得治疗。具有有希望的实证支持和行为基础的干预成分 在一项2x2x2x2析因实验中，将在1664名每天吸烟的8个主要吸烟区的患者中完全交叉理论。 护理诊所这些以患者为中心的干预措施包括：1）治疗的金钱激励 启动，2）电子健康记录（EHR）使季度定制治疗邀请自动化 提供低障碍治疗，3）积极的电话护理管理和激励 干预这些组成部分将用于促进使用标准护理（转诊到免费 戒烟热线和初级保健提供者），或更密集的治疗（3个电话咨询会议 联合尼古丁替代疗法或伐尼克兰），在第4天随机分配， 实验因素（获得强化治疗）。所有4个实验性干预组件将打开或关闭 (as随机分配）2年，以分析其对治疗覆盖率的累积影响， 最初不愿意尝试戒烟的初级保健患者的戒烟率。1之后的分析 一年的随访将确定一个特别有效的（优化的）接触干预包， 在这个项目中的优化护理项目。基于诊所的招聘将支持该项目的目标， 确定：1）一套高效的干预措施，促进常规和强化治疗的使用（reach）， 下游戒烟成本低，2）这些影响的介导途径，和3） 特别受益于这些干预成分的患者亚群（达到 代表性）。这个务实的项目将使用不同的现实世界的诊所，诊所工作人员干预， 患者参与者，进行最低限度的评估，以提高普遍性和传播潜力（根据 RE-AIM）。同时，严格的实验设计和统计分析将提高内部效度。 该项目将独特地优化干预措施，以提高戒烟治疗的覆盖面。该项目将 整合到计划项目中，以产生额外的信息（例如，是否有某些组件 比其他人更难实施;优化的接触干预如何与优化的戒烟一起工作 治疗）。该项目将确定可能预防癌症和其他慢性病的干预措施， 让更多的吸烟者接受有效的戒烟治疗。

Project Summary A small minority of the 25 million US smokers who receive primary care each year receive evidence-based smoking treatment. Healthcare systems have enormous potential to connect smokers with high quality, evidence-based care. Diverse strategies have been used to increase treatment use, but treatment reach remains stubbornly low. The proposed research study will be the first rigorous factorial experiment to optimize a package of centralized healthcare system interventions to enhance smoking cessation treatment reach, and through this mediating pathway, reduce smoking prevalence after 2 years of reach intervention exposure and treatment access. Intervention components with promising empirical support and grounding in behavioral theory will be fully crossed in a 2x2x2x2 factorial experiment in 1664 patients who smoke daily from 8 primary care clinics. These patient-focused intervention components include: 1) monetary incentives for treatment initiation, 2) electronic-health-record (EHR)-enabled automation of quarterly tailored treatment invitations offering low-barrier treatment access, and 3) proactive telephone care management and motivational intervention. These components will be used to promote use of either standard care (referral to a toll-free tobacco quitline and the primary care provider), or to more intensive treatment (3 phone counseling sessions with either combination nicotine replacement therapy or varenicline), as randomly assigned on a 4th experimental factor (access to intensive treatment). All 4 experimental intervention components will be on or off (as randomly assigned) for 2 years to permit analysis of their cumulative impact on treatment reach and abstinence among primary care patients who are not initially willing to make a quit attempt. Analyses after 1 year of follow up will identify an especially effective (optimized) reach-intervention package to be evaluated in the Optimized Care Project in this Program Project. Clinic-based recruitment will support the project aims to identify: 1) a highly effective intervention package that promotes usual and intensive treatment use (reach) and downstream abstinence from smoking at low cost, 2) the mediating pathways for these effects, and 3) subpopulations of patients who particularly benefit from these intervention components (reach representativeness). This pragmatic project will use diverse real-world clinics, clinic staff interventionists, and patient participants, with minimal assessment to enhance generalizability and dissemination potential (as per RE-AIM). At the same time, rigorous experimental design and statistical analyses will enhance internal validity. This project will uniquely optimize interventions to enhance smoking cessation treatment reach. The project will be integrated into the Program Project to yield additional information (e.g., whether some components are more difficult to implement than others; how an optimized reach intervention works with optimized cessation treatments). The project will identify interventions that may prevent cancer and other chronic illnesses by connecting more smokers with effective smoking cessation treatments.