Changing Pediatric Office Systems Nationally to Address Parental Tobacco Use

描述（由申请人提供）：本次更新申请的目标是改变常规儿科门诊实践，以帮助父母戒烟，以帮助消除 家庭吸烟。在我们的I期RCT中，（R 01-CA 127127），从实践的角度使用慢性病护理模型（瓦格纳）和预防系统（Solberg）来构建干预措施，我们证明了在不增加实践资源的情况下办公系统的巨大变化，显示在基于实践的研究网络中提供烟草控制援助的比率增加了14倍，并证明了在全国范围内进行重大投资的合理性。干预措施包括三个关键的实施步骤，以解决父母吸烟的儿童保健设置：（1）动机信息;（2）主动转诊戒烟热线;（3）烟草依赖的药物管理。这项干预措施最近被AHRQ命名为“医学创新”。在拟议的II期试验中，我们将与美国最大的儿科专业组织美国儿科学会（AAP）密切合作，进行一项双臂RCT，以使用全国20步儿科实践样本解决干预的普遍性、可持续性和成本效益等关键性未回答问题。第二阶段干预措施将得到加强，以解决第一阶段确定的关键障碍，并通过以下方式提高普遍性和可持续性：（1）包括 促进尼古丁替代品的交付符合新的国家医疗补助覆盖标准，以及（2）包括创新的额外传播和可持续性组成部分，与单独的NCI ARRA赠款一起开发-一个在线，定制，自定进度的模块，临床医生在几个月的自学和实践改进周期中进行全面实践实施。该模块满足了新的美国儿科委员会的认证实践要求，为培训创造了自然的“拉力”。具体目标包括：“目标1。在临床层面实施并坚持循证指南;“目标2.促进父母的行为改变，并评估吸烟父母每次戒烟的成本;“目标3。研究系统的变化和影响他们在实践层面的过程。在第1阶段成功的基础上，在本申请中研究的可推广的培训系统将提高干预措施的采用、实施和可持续性，使其在全国儿科实践中广泛传播，并为NIH数十年来在开发烟草控制证据基础方面的投资提供关键回报。该项目将产生一个有效的，基于理论的，快速传播的，可持续的战略，以解决烟草使用的家庭通过儿童保健设置在美国的重大影响。

DESCRIPTION (provided by applicant): The goal of this renewal application is to transform routine pediatric outpatient practice to assist parents quitting smoking in order to help eliminate tobacco use in families. In our Phase I RCT (R01-CA127127), framing the intervention from the practice perspective using the Chronic Care Model (Wagner) and the Prevention System (Solberg), we demonstrated dramatic office systems changes without additional resource added to practices, showing 14-fold increased rates of delivering tobacco control assistance in a practice-based research network, and justifying significant investment to disseminate nationally. The intervention included three key implementation steps to address parental smoking in the child healthcare setting: (1) motivational messaging; (2) proactive referral to quitlines; and (3) pharmacologic management of tobacco dependence. The intervention was recently named an "innovation in medicine" by AHRQ. In the proposed Phase II trial, in close collaboration with the American Academy of Pediatrics (AAP), the largest pediatrics professional organization in the United States, we will perform a two-arm RCT to address the critical unanswered questions of generalizability, sustainability, and cost- effectiveness of the intervention using a national 20-ste sample of pediatric practices. The Phase II intervention will be augmented to address key barriers identified in Phase 1 and to enhance generalizability and sustainability by: (1) including facilitated nicotine replacement delivery-compliant with new national Medicaid coverage standards and (2) including an innovative additional dissemination and sustainability component, developed with a separate NCI ARRA grant--an online, tailored, self-paced module where clinicians work on a full practice implementation over the course of several months of self study and hands-on improvement cycles. The module satisfies the new American Board of Pediatrics Maintenance of Certification Performance in Practice requirement creating a natural "pull" for the training. The Specific Aims include: " Aim 1. to implement and sustain adherence to evidence-based guidelines at the clinical level; " Aim 2. to facilitate behavior change among parents and evaluate cost per quit among parents who smoke; " Aim 3. to study systems changes and the processes that affect them at the practice level. Building on the success of Phase 1, the generalizable training systems to be studied in this application will enhance the adoption, implementation, and sustainability of the intervention, making it widely transportable throughout pediatric practice nationally and providing a critical return on decades of NIH investment in developing the evidence base for tobacco control. The project will have significant impact by yielding an effective, theoretically-based, rapidly disseminable, and sustainable strategy to address tobacco use in families through child healthcare settings in the United States.