Project 4: An Analysis of Implementation of Comprehensive Chronic Care for Smokers in Primary Care (Implementation)

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Project Summary Healthcare systems have tremendous potential to deliver evidence-based smoking cessation treatment to the roughly 25 million US smokers who receive primary care each year, but dissemination of smoking cessation treatment innovations has been slow and implementation of best-practices poses major challenges. For treatment advances to have a substantial impact on smoking prevalence and smoking-related morbidity and mortality, the reach of cessation treatments must increase; too few patients who smoke are offered quitting assistance, and only 5% of US smokers trying to quit use both counseling and pharmacotherapy, the recommended cessation treatment. This project seeks to generate a deeper understanding of factors associated with the reach and implementation of a comprehensive program (the Comprehensive Chronic Care for Smoking Program, CCCSTOP) for adult primary care patients who smoke that is being evaluated in this Program Project. The program is designed to motivate quitting (in those not initially willing to quit) and to help those ready to quit achieve abstinence. The key components of CCCSTOP are: systematic assessment of smoking status at primary care visits; automatic referral of patients who smoke to a centralized care manager who delivers proactive smoking interventions (unless patients opt out); coordination of pharmacotherapy and counseling with primary care providers and the state quitline; and screening and referring medically eligible patients who want help quitting to centralized intensive pharmacotherapy and counseling services. The current project will examine the reach and implementation of key facets of the program using assessments guided by the RE-AIM planning and evaluation framework and the PRISM approach to assessing intervention-translation context. Multilevel, multimethod data will be collected to address the following aims: 1) to evaluate the reach, representativeness of reach, and maintenance of reach across time in the 16 clinics that will host the project in 2 healthcare systems; 2) to evaluate intervention fidelity, adaptations, maintenance, correlates, and outcomes across patient groups, personnel, roles, and sites; and 3) to examine the extent to which implementation is associated with the key outcome of public health interest in this project: abstinence from smoking. Data to support these aims will be collected from electronic health records of patient smoking and smoking-related intervention exposure; patient ratings of satisfaction; front-line clinic staff and clinician surveys, interviews, observation, and performance metrics; in-depth interviews with and direct observation of care managers who will engage smokers and deliver interventions; and semi-structured interviews with clinic- and system-level leaders who influence adoption and implementation decisions. This project will cut across ecological levels (patient to system) using mixed methods in 2 separate implementation cohorts. This will advance our understanding of challenges in implementing systematic, sustained efforts to expand the reach and effectiveness of smoking cessation treatment, and thereby reduce morbidity and mortality related to smoking.