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

项目摘要 在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 戒烟治疗。医疗保健系统有巨大的潜力将吸烟者与高质量、 循证护理。已经使用了多种策略来增加治疗使用量，但治疗覆盖范围 仍然居高不下。拟议的研究性研究将是第一个严格的析因实验来优化 一套集中的医疗保健系统干预措施，以扩大戒烟治疗的覆盖范围，以及 通过这一中介途径，降低REACH干预暴露2年后的吸烟率 治疗通道。有前景的经验支持和行为基础的干预组件 理论将在2x2x2x2析因实验中完全交叉进行，该实验对1664名每天吸烟的患者进行了研究，这些患者从8名 护理诊所。这些以患者为中心的干预措施包括：1)治疗的金钱奖励 启动，2)启用电子健康记录(EHR)的季度定制治疗邀请的自动化 提供低门槛的治疗途径，以及3)积极的电话护理管理和激励 干预。这些组件将用于促进使用任何一种标准护理(转介到免费 戒烟热线和初级保健提供者)，或接受更密集的治疗(3次电话咨询 联合尼古丁替代疗法或varenicline)，在4日随机分配 实验因素(获得强化治疗的机会)。所有4个实验干预组件都将打开或关闭 (随机分配)，为期2年，以便分析其对治疗范围和 最初不愿尝试戒烟的初级保健患者的禁欲。%1之后的分析 一年的跟踪将确定一个特别有效的(优化的)REACH-干预方案，以供评估 本计划项目中的优化护理项目。以诊所为基础的招聘将支持该项目旨在 确定：1)促进常规和强化治疗使用的高效干预方案(REACH)和 下游低成本戒烟，2)这些影响的中介途径，3) 特别受益于这些干预措施的患者亚群(REACH 代表性)。这个务实的项目将使用不同的现实世界诊所，诊所工作人员干预者，以及 患者参与者，进行最低限度的评估以增强推广和传播潜力(根据 重新对准)。同时，严谨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，以扩大戒烟治疗的覆盖范围。该项目将 集成到计划项目中以生成附加信息(例如，某些组件是否 比其他干预措施更难实施；优化的REACH干预如何在优化的停止情况下发挥作用 处理)。该项目将确定可通过以下方式预防癌症和其他慢性病的干预措施 将更多的吸烟者与有效的戒烟治疗联系起来。

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.