Telemedicine for Smoking Cessation in Rural Primary Care

描述(由申请者提供)：在美国农村，吸烟很普遍，戒烟服务很少，医生往往缺乏时间或资源来帮助吸烟者戒烟。该项目调查了整合到农村医生实践中的远程医疗咨询是否可以优于标准的戒烟咨询。这是本申请的第二次也是最后一次修订。这项研究是通过堪萨斯州的25家乡村医生诊所进行的。农村教师的医学生将招募吸烟者参加试验。自主学习理论指导着学习内容的结构和分析计划。患者将被随机分配到接受标准电话退出线路干预(QL)或综合远程医疗干预(ITM)。QL的患者将在家中通过电话接受4次戒烟咨询。ITM的患者将接受4次远程医疗咨询，由安装在医生办公室检查室台式计算机上的双向网络摄像头提供。网络摄像头与功能强大的软件Polycom PVX配合使用，该软件允许文件共享和其他活动，从而获得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。咨询方案涉及一种支持自主的方法。Fidelity监控将确保两个研究部门的内容保持相同。两组都将收到纸质的戒烟提示，以及个性化的戒烟计划和药物治疗指导。然而，ITM的所有方面都将纳入初级保健实践：会议将在医生办公室举行；在每次咨询会议期间，将通过远程医疗计算机打印机为ITM患者完成和打印学习材料，并将打印会议材料的副本，以便插入患者的医疗记录。我们假设，ITM将通过视频界面增强来自咨询师的感知支持，并通过促进来自患者健康护理团队的更多自主支持，包括支持戒烟、支持使用药物戒烟以及获得药物治疗处方，从而超越QL。我们预计566名患者，每个研究组283名，是在注册后12个月检测QL和ITM禁酒率差异所必需的。我们假设ITM将比QL更昂贵，但也更具成本效益。咨询、忠诚度监测和强有力的临床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拥有专业知识。这项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进行的。这种干预措施为接触到大量获得戒烟服务的农村吸烟者提供了场所。它有很大的潜力被广泛采用，并在未来适应其他紧迫的问题，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。该项目调查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。潜在的健康影响是巨大的，因为农村地区吸烟的流行率很高，获得戒烟服务的机会很少，而且医疗保险报销的新规则创造了广泛采用的强大潜力。

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.