Closed-Loop Electronic Referral From Primary Care Clinics to a State Tobacco Cessation Quitline: Effects Using Real-World Implementation Training

Abstract

Introduction: Patients who use tobacco are too rarely connected with tobacco use treatment during healthcare visits. Electronic health record enhancements may increase such referrals in primary care settings. This project used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the implementation of a healthcare system change carried out in an externally valid manner (executed by the healthcare system). Methods: The healthcare system used their standard, computer-based training approach to implement the electronic health record and clinic workflow changes for electronic referral in 30 primary care clinics that previously used faxed quitline referral. Electronic health record data captured rates of assessment of readiness to quit and quitline referral 4 months before implementation and 8 months (May−December 2017) after implementation. Data, analyzed from October 2018 to June 2019, also reflected intervention reach, adoption, and maintenance. Results: For reach and effectiveness, from before to after implementation for electronic referral, among adult patients who smoked, assessment of readiness to quit increased from 24.8% (2,126 of 8,569) to 93.2% (11,163 of 11,977), quitline referrals increased from 1.7% (143 of 8,569) to 11.3% (1,351 of 11,977), and 3.6% were connected with the quitline after implementation. For representativeness of reach, electronic referral rates were especially high for women, African Americans, and Medicaid patients. For adoption, 52.6% of staff who roomed at least 1 patient who smoked referred to the quitline. For maintenance, electronic referral rates fell by approximately 60% over 8 months but remained higher than pre-implementation rates. Conclusions: Real-world implementation of an electronic health record−based electronic referral system markedly increased readiness to quit assessment and quitline referral rates in primary care patients. Future research should focus on implementation methods that produce more consistent implementation and better maintenance of electronic referral.

Achieving Equity in the Reach of Smoking Cessation Services Within the NCI Cancer Moonshot-Funded Cancer Center Cessation Initiative

“…For example, females and adults age >65 years have been found to be prescribed cessation medications at lower rates, 19 whereas males and younger adults are reached by quitline interventions at lower rates. 20 However, the evidence is mixed with regard to gender in that some research suggests that women have equivalent or higher rates of treatment referral in primary care than do men 21 , 22 and there is also evidence that women have equal or higher overall rates of smoking treatment engagement rates in population-based studies. 23 , 24 Furthermore, younger adults are more likely to make unassisted versus assisted quit attempts, 15 which are associated with lower abstinence rates.…”

Point of care tobacco treatment sustains during COVID-19, a global pandemic

“…Flocke et al [ 28 ] report improved and sustained reach of tobacco treatment delivery by comparing data during 3 months pre- and 6 months post-implementation of a EHR-based program in the primary care setting [ 28 ]. Baker and colleagues [ 26 ] examined reach of an EHR based referral system over 4 months pre-implementation and 8 months post-implementation; this showed elevated, but declining rates of electronic referral post-implementation. We present data on sustainment of program impact across a much longer time frame of 30 months post-implementation.…”

“…Efficient in-person clinic workflows and telehealth tools to address tobacco cessation, especially during a pandemic, remain an important component of comprehensive care [ 24 , 25 ]. Very few studies have evaluated the sustainability of evidence-based interventions overtime in the real world settings [ 26 ], highlighting a critical research and practice gap in its own right, and particularly within the context of an ongoing pandemic.…”

The Role of Quitlines in Tobacco Cessation: An Introduction

“…Baker and colleagues 8 partnered with primary care clinics in a large health system, UW Health, to evaluate the real-world implementation of an electronic health record−based eReferral system in place of traditional fax referral. The closed-loop eReferral intervention involved training clinic staff to respond to electronic health record prompts to assess smokers' readiness to quit and make eReferral to the Wisconsin Tobacco Quit Line.…”