Telemedicine for Smoking Cessation in Rural Primary Care

描述（由申请人提供）：在美国农村吸烟很普遍，很少有戒烟服务，医生往往缺乏时间或资源来帮助吸烟者戒烟。本项目考察了将远程医疗咨询整合到农村医生的实践中，是否能优于标准的戒烟热线咨询。这是该应用程序的第二次也是最后一次修订。这项研究是在堪萨斯州的25个乡村医生的实践中进行的。在农村实习的医学生将招募吸烟者参加试验。自我决定理论指导了研究组成部分的结构和分析计划。患者将被随机分配接受标准的电话戒烟干预（QL）或综合远程医疗干预（ITM）。QL患者将在家中通过电话接受4次戒烟热线咨询。ITM的患者将接受4次远程医疗咨询，这些咨询由安装在医生办公室检查室的台式电脑上的双向网络摄像头提供。网络摄像头与功能强大的Polycom PVX软件配对，该软件允许文档共享和其他活动，以实现高度互动的咨询体验，而不会出现标准网络摄像头常见的“冻结”和音频延迟。QL和ITM咨询将由堪萨斯大学医学中心校区的专业戒烟顾问提供。咨询协议包括自主支持方法。保真监测将确保两个研究组的内容保持一致。两组都将收到纸质的戒烟提示和个人定制的戒烟计划和药物治疗指导。然而，ITM的所有方面都将被整合到初级保健实践中：会议将在医生办公室进行；在每次咨询期间，将通过远程医疗计算机打印机完成并打印ITM患者的学习材料，并打印会话材料的副本以插入患者的医疗记录中。我们假设ITM将通过视频界面增强咨询师的感知支持，并通过促进患者医疗团队的更多自主支持，包括戒烟支持，使用药物戒烟支持，以及获得药物治疗处方，从而优于QL。我们预计需要566例患者，每个研究组283例，才能在入组后12个月检测QL和ITM戒断率之间的差异。我们假设ITM将比QL更昂贵，但也更具成本效益。咨询保真度监测和强大的诊所支持将确保最佳实施。调查小组在戒烟研究、远程医疗、临床成本效益研究和初级保健质量改进方面具有专长。该干预措施是与美国历史最悠久、最成功的远程医疗项目之一合作实施的。该干预措施为接触到大量难以获得戒烟服务的农村吸烟者提供了一个场所。它具有广泛采用的强大潜力，并在未来适应其他紧迫问题，如肥胖。公共卫生相关性：吸烟在农村地区很普遍，医生往往缺乏时间和资源来帮助吸烟者戒烟。本项目考察通过医生办公室提供的远程医疗咨询对农村吸烟者戒烟是否有效。潜在的健康影响很大，因为农村地区的吸烟率很高，获得戒烟服务的机会很低，而且医疗保险报销的新规则具有广泛采用的巨大潜力。

DESCRIPTION (provided by applicant): In rural America cigarette smoking is prevalent, few cessation services are available, and physicians often lack the time or resources to help smokers quit. This project examines whether telemedicine counseling that is integrated into rural physician practices can outperform standard quitline counseling for smoking cessation. This is the second and final revision of this application. The study is conducted through 25 rural physician practices in Kansas. Medical students on rural preceptorships will recruit patients who are smokers into the trial. Self-Determination Theory guides the structure of study components and the analytic plan. Patients will be randomly assigned to receive a standard telephone quit line intervention (QL) or an integrated telemedicine intervention (ITM). Patients in QL will receive 4 sessions of quitline counseling delivered by telephone in their homes. Patients in ITM will receive 4 sessions of telemedicine counseling delivered by 2-way webcams mounted on desktop computers in their physician office examining room. Webcams are paired with powerful software, Polycom PVX, that permits document sharing and other activities for a highly interactive counseling experience free of the "freeze-ups" and audio delays common with standard webcams. QL and ITM counseling will be delivered by professional smoking cessation counselors from the University of Kansas Medical Center Campus. The counseling protocol involves an autonomy-supportive approach. Fidelity monitoring will ensure the content remains the same across both study arms. Both groups will receive paper-copy Quit Tips and individually-tailored quit plans and pharmacotherapy guidance. However, all aspects of ITM will be integrated into primary care practice: sessions will take place in the physician's office; study materials will be completed and printed for ITM patients during each counseling session via the telemedicine computer printer, and copies of session materials will be printed for insertion into the patients' medical record. We hypothesize that ITM will outperform QL by enhancing perceived support from the counselor through the video interface, and by facilitating more autonomy support from the patients' health care team, including support for quitting, support for using medications to quit, and access to pharmacotherapy prescriptions. We project that 566 patients, 283 in each study arm, are necessary to detect differences between abstinence rates in QL and ITM at 12-months post enrollment. We hypothesize that ITM will be more costly, but also more cost- effective, than QL. Counseling fidelity monitoring and strong clinic support will ensure optimal implementation. The investigative team has expertise in smoking cessation research, telemedicine, clinical cost- effectiveness research, and quality improvement in primary care. The intervention is delivered in collaboration with one of the oldest and most successful telemedicine programs in the U.S. This intervention provides a venue for reaching a large population of rural smokers who have poor access to smoking cessation services. It has strong potential for widespread adoption, and future adaptation for other pressing issues such as obesity. Public Health Relevance: Cigarette smoking is prevalent in rural areas, and physicians often lack the time and resources to help smokers quit. This project examines whether telemedicine counseling that is delivered through physician offices is effective for smoking cessation among rural smokers. The potential health impact is large because the prevalence of smoking is high in rural areas, access to smoking cessation services is low, and new rules for Medicare reimbursement creates a strong potential for widespread adoption.