Changing Pediatric Office Systems Nationally to Address Parental Tobacco Use

描述(申请人提供)：本次续签申请的目的是改变儿科门诊的常规做法，以帮助父母戒烟，以帮助戒烟 家庭中的烟草使用。在我们的第一阶段随机对照研究(R01-CA127127)中，使用慢性病护理模式(Wagner)和预防系统(Solberg)从实践的角度制定了干预措施，我们展示了在没有向实践添加额外资源的情况下办公室系统发生了巨大变化，显示在以实践为基础的研究网络中提供控烟援助的比率增加了14倍，并证明了在全国推广的重大投资是合理的。干预措施包括在儿童保健环境中解决父母吸烟问题的三个关键实施步骤：(1)激励信息；(2)主动转介戒烟热线；以及(3)烟草依赖的药物管理。该干预措施最近被AHRQ命名为“医学上的创新”。在拟议的第二阶段试验中，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，进行一项双臂随机对照试验，以解决使用全国20个儿科实践样本进行干预的普适性、可持续性和成本效益等关键问题。将扩大第二阶段干预，以解决第一阶段确定的主要障碍，并通过以下方式加强普遍性和可持续性：(1)包括 促进尼古丁替代提供-符合新的国家医疗补助覆盖标准和(2)包括创新的额外传播和可持续性部分，由单独的NCI ARRA赠款开发--一个在线的、定制的、自定进度的模块，临床医生在几个月的自学和实际改进周期中致力于全面实践实施。该模块满足了新的美国儿科委员会在实践中维护认证绩效的要求，为培训创造了自然的“拉力”。具体目标包括：“目标1.在临床层面实施并维持对循证指南的遵守；”目标2.促进父母的行为改变，并评估吸烟父母的戒烟成本；“目标3.在实践层面研究系统变化和影响它们的过程。在第一阶段成功的基础上，将在这一应用中研究的通用培训系统将促进干预措施的采用、实施和可持续性，使其在全国儿科实践中广泛传播，并为NIH几十年来在发展烟草控制证据基础上的投资提供关键回报。该项目将产生重大影响，产生一个有效的、以理论为基础、可快速传播和可持续的战略，通过美国儿童保健机构解决家庭中的烟草使用问题。

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.