Engaging Healthcare Practice Teams and Patients in Tobacco Cessation Intervention

每年有3000多万美国吸烟者去看初级保健临床医生。因此，包括卫生保健提供系统和一线实践团队在内的卫生保健组织处于独特的地位，通过促进吸烟者使用循证戒烟治疗来帮助他们成功戒烟。2000年公共卫生服务《治疗烟草使用和依赖的临床实践指南》包括一种循证的5-A(询问、建议、评估、协助、安排)算法，供提供者解决烟草依赖问题并帮助吸烟者戒烟，使用经过验证的治疗方法(Fiore等人，2000年)。然而，2005年全国健康访谈调查(NHIS)表明，在每年尝试戒烟的49%的吸烟者中，不到5%的人使用了经过证实的行为治疗，不到三分之一的人使用了药理学辅助手段，不到4%的人使用了行为和药物干预相结合的黄金标准(Curry等人，2007年)。一种假设是，5-A算法的复杂性和时间要求可能会阻碍提供者在卫生保健访问期间解决烟草使用问题，而更简单的两步(询问和行动)方法可能会增加提供者的建议和帮助，从而增加吸烟者中循证治疗的使用率(Schroeder，2005)。这项研究直接在以社区为基础的初级保健实践环境中检验了这一假设。具体目标是：(1)确定电子病历(EMR)提示对5-A和2-A临床实践算法的有效性。使用三臂组随机试验，这两种算法将相互比较，并与无EMR即时控制条件进行比较。初级保健实践团队由随机和分析单元组成。结果指标是吸烟者转介到行为干预和药物治疗的比率，由EMR、提供者自我报告、患者自我报告和威斯康星州戒烟热线获得的纵向数据确定。(2)检验某些实践团队特征是否会影响临床算法的有效性。(3)评估与EMR提示相关的患者水平的结果，包括使用行为或药物干预、戒烟和持续 禁欲。(4)评价5-A和2-A临床算法的成本-效果与每治疗成本利用率的关系。

More than 30 million American smokers visit a primary care clinician each year. As a result, health care organizations, including health care delivery systems and front-line practice teams are uniquely positioned to help smokers successfully quit by facilitating their use of evidence-based tobacco cessation treatments. The 2000 Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence includes an evidence-based 5-A (Ask,Advise, Assess, Assist, Arrange) algorithm for providers to address tobacco dependence and help smokers to quit using proven treatments (Fiore et al., 2000). However, the 2005 National Health Interview Survey (NHIS) indicates that, among the 49% of smokers who attempt cessation each year, fewer than 5% used proven behavioral treatment, less than 1/3 used pharmacological aids, and fewer than 4% used the gold standard of combined behavioral and pharmacological interventions (Curry et al., 2007). One hypothesis is that the complexity and time demands of the 5-A algorithm may discourage providers from addressing tobacco use during health care visits and that a simpler two-step (Ask and Act) approach may increase provider advice and assistance and, consequently, rates of evidence-based treatment use among smokers (Schroeder, 2005). This study directly tests this hypothesis in community-based primary care practice settings. The specific aims are: (1) To determine the effectiveness of electronic medical record (EMR) prompting for the 5-A and 2-A clinical practice algorithms. Using a three-arm group randomized trial, the two algorithms will be compared to each other and to a no-EMR prompt control condition. Primary care practice teams comprise the unit of randomization and analysis. Outcome measures are rates of referral of smokers to behavioral interventions and pharmacotherapy treatments determined by longitudinal data obtained from the EMR, provider self-reports, patient self-reports, and the Wisconsin Tobacco Quit Line. (2 To test whether certain practice team characteristics moderate or mediate the effectiveness of the clinical algorithms. (3) To estimate patient-level outcomes associated with EMR prompting, including use of behavioral or pharmacological interventions, smoking cessation and sustained abstinence. (4) To estimate the cost-effectiveness of the 5-A and 2-A clinical algorithms with reagrd to cost-per-treatment utilization.