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OBJECTIVES: Transdermal nicotine patches have shown considerable promise in improving smoking cessation outcomes. The present study assessed telephone support as an adjunct to a managed care-based, single-session group orientation smoking cessation program with nicotine patch therapy. METHODS: The unit of randomization was the orientation session (n = 35). Subjects (n = 509) were randomly assigned to a group session without telephone support, the session plus access to a toll-free help line, or the session with telephone help line plus active telephone outreach. RESULTS: Contrary to hypothesis, there were no differences between treatment conditions. Overall abstinence rates were 22% at 6 months and 21% at 1 year. Fewer than 1% of eligible subjects called the toll-free help line. An average of 3.8 of a possible 4 calls were completed in the telephone outreach condition. CONCLUSIONS: Abstinence results obtained in this program were comparable to those obtained with more extensive counseling. However, there was no evidence of benefit from telephone support beyond the initial physician-led group orientation session.

Objective: To demonstrate that one physician can dramatically improve care of diabetes patients by taking a systems approach and getting support from leaders and other team members Material and Methods: Pre-/postcomparison of quality measures for the diabetes patients of one primary care physician, compared with those of his entire large multi-specialty medical group. Working with a mentor and with clinic and medical group leaders, he established a clear goal, focused on a repeatable and important performance measure, and used repeated rapid cycle trials to make systems changes in care, with extensive task delegation to team members and emphasis on repeated testing and treatment intensification. The composite outcome measure requires that each diabetes patient meet all 5 of the following: LDL <100, HbA 1C <7, systolic blood pressure <130, regular aspirin use, and tobacco-free status.Results: Over a 24-month period, quarterly measures for this physician's patients rose from 5.7% to 42.9%, while the 7000 diabetes patients of the entire medical group only increased from 4.2% to 12.1%. The change for those patients who stayed under his care for the entire period was even more dramatic-from 2.3% to 46.5% (P ‫؍‬ <.0001). The largest improvements were for smoking documentation, aspirin use, and LDL control, with little change in HbA 1C levels. Diabetes is one of the most common and costly chronic conditions. Most patients with diabetes have multiple comorbidities, and the major source of the extensive morbidity and mortality is cardiovascular disease.1-3 Although there have been some improvements over the past 30 years, there is still much to do, with greater need to reduce cardiovascular risk factors than to improve glycemic control. 4 -7 It is now clear that the old model of education and exhortation will not be adequate to accomplish such broad-based and difficult improvements. Even the intermediate behavior change approaches demonstrated to have some effect in randomized trials, like measurement feedback, opinion leaders, disease management programs, and academic detailing, are unlikely to help very much. 8 -10 Instead, significant redesign of care that emphasizes team care, task delegation, a proactive population approach, facilitation of patient self-management, and extensive use of improved clinical information systems will be needed, similar to the components of the Chronic Care Model of Wagner and colleagues [11][12][13] Perlin and Pogach 14have urged physicians to a higher standard-to review data and care processes, identify goals and strategies, develop action plans, track results, and get feedback. However, clinicians tend to feel discouraged about their ability to improve diabetes care, often blaming patient nonadherence for low performance rates. 15,16 Other clinician barriers include lack of time, simple oversight, lack of payment incentives, other clinical priorities in diabetic patients, other competing projects and priorities, lack of skills in diabetes management, concerns about drug side effects a...

Smoking cessation guideline development has become widespread, outpacing guideline implementation efforts. To address this problem, HealthPartners undertook a randomized trial of strategies to enhance compliance of a smoking cessation guideline. The intervention aimed at clinic leadership resulted in significantly more compliance, as measured by physicians coding "tobacco use" on a billing form. The intervention aimed at all clinic physicians had no significant effect. The study suggests that smoking cessation guideline efforts should focus on clinic leadership and system changes rather than on all staff physicians.