Addressing Rural Cancer Disparities via Proactive Smoking Cessation Treatment within Primary Care: A Hybrid Type 1 Effectiveness-Implementation Trial of a Scalable Smoking Cessation Electronic Visit

摘要 与城市居民相比，农村居民吸烟的可能性更大，戒烟的可能性更小。 因此，农村地区的个人患烟草相关癌症的发病率高出7%。 需要全面的戒烟治疗传播策略，以增加 循证治疗，改善戒烟结果，并最终降低农村癌症发病率 吸烟者。初级保健提供者（PCP）每年看到70%的吸烟者，农村居民更有可能比 城市居民有正常的医疗来源。因此，初级保健提供了一个提供 对农村吸烟者进行戒烟治疗。所有符合医疗保险中心资格的初级保健实践， 需要医疗补助服务报销来维护带有吸烟编码的电子健康记录（EHR） 成人患者的状态数据。这些数据可用于主动识别吸烟者并提供远程 治疗我们的团队最近完成了一项试点研究，以开发，完善和初步评估一个积极的 通过EHR提供的异步戒烟电子访视（e访视）。电子访问的目标是 通过初级保健实现戒烟治疗最佳实践指南的自动化，以确保所有吸烟者都能获得 循证干预。最初的基线电子访问收集有关吸烟史和动机的信息 戒烟，其次是一个算法，以确定最好的FDA批准的戒烟药物处方。一个- 一个月随访电子访视评估戒烟进展。我们的试点的临床结果（N=51， 三个月）是有希望的。在接受电子访视的农村参与者（n=6）中，17%报告了7天的时间点 戒烟率（PPA），67%的人每天减少吸烟量（CPD）> 50%，50%的人戒烟 药相对于常规治疗（TAU），电子访视受试者报告7天 PPA，4.1倍更有可能减少他们的CPD> 50%，4.7倍更有可能使用 停止用药。可接受性结果很强，100%的农村电子访问参与者报告说， 他们将来会再次使用电子访问。这些数据表明，电子访视可能是一种可行的，有效的 通过农村初级保健扩大循证戒烟治疗的覆盖面。我们现在提出一个 混合I型有效性-实施试验，以全面评估电子访视相对于TAU的有效性 同时评估在农村初级保健机构提供服务的执行情况。有效性 将通过6个月的随访评估结果，包括：1）经过生化验证的7天PPA，2） 减少CPD，3）循证戒烟治疗的利用。执行成果将是 在患者、提供者和组织层面进行评估。这项试验有可能扩大戒烟治疗 以可扩展的方式在农村医疗保健系统中提供服务，并最终减少农村癌症差异。

ABSTRACT Rural residents are both more likely to smoke cigarettes and less likely to quit than their urban counterparts. Consequently, individuals in rural areas have a 7% higher incidence of tobacco-associated cancers. Comprehensive smoking cessation treatment dissemination strategies are needed to increase utilization of evidence-based treatment, improve cessation outcomes, and ultimately decrease cancer incidence among rural smokers. Primary care providers (PCPs) see 70% of smokers annually, and rural residents are more likely than urban residents to have a usual source of health care. As such, primary care offers a ripe opportunity to deliver cessation treatment to rural smokers. All primary care practices that qualify for Centers for Medicare and Medicaid Services reimbursement are required to maintain electronic health records (EHRs) with coded smoking status data for adult patients. These data can be utilized to proactively identify smokers and deliver remote treatment. Our team recently completed a pilot study to develop, refine, and preliminarily evaluate a proactive asynchronous smoking cessation electronic visit (e-visit) delivered via the EHR. The goal of the e-visit is to automate best practice guidelines for cessation treatment via primary care to ensure that all smokers receive an evidence-based intervention. An initial baseline e-visit gathers information about smoking history and motivation to quit, followed by an algorithm to determine the best FDA-approved cessation medication to prescribe. A one- month follow-up e-visit assesses progress toward cessation. Clinical outcomes of our pilot (N=51 followed for three months) were promising. Among rural participants who received the e-visit (n=6), 17% reported 7-day point prevalence abstinence (PPA), 67% reduced their cigarettes per day (CPD) by >50%, and 50% used a cessation medication. E-visit participants, relative to treatment as usual (TAU), were 4.2 times more likely to report 7-day PPA, 4.1 times more likely to have reduced their CPD by >50%, and 4.7 times more likely to have used a cessation medication. Acceptability outcomes were strong, with 100% of rural e-visit participants reporting that they would use an e-visit again in the future. These data suggest that the e-visit may be a feasible, efficacious approach to extend the reach of evidence-based cessation treatment via rural primary care. We now propose a Hybrid Type I effectiveness-implementation trial to comprehensively assess e-visit effectiveness relative to TAU while simultaneously evaluating implementation when delivered across rural primary care settings. Effectiveness outcomes will be assessed through 6-months of follow-up and include: 1) biochemically verified 7-day PPA, 2) reduction in CPD, and 3) evidence-based cessation treatment utilization. Implementation outcomes will be assessed at patient, provider, and organizational levels. This trial has the potential to expand cessation treatment access in a manner scalable across rural healthcare systems and ultimately reduce rural cancer disparities.