Smoking Cessation

Best Practices in Tobacco Control within the VA

Programs to Support Treatment In Primary or Mental Health Care

By Scott E. Sherman, MD
New York Harbor Veterans Health Care System

The vast majority of VA patients see their primary care provider at least once a year, and many have considerably more primary care visits. The main barriers limiting primary care-based treatment have been competing demands on the provider’s time[1] and providers’ lack of knowledge about and experience with smoking cessation treatment. Several VAs have designed innovative medical record-based systems to support the primary care provider. For example, the Erie, Pennsylvania, VA Medical Center[2] designed a primary care-based program to address concerns about time constraints, staff knowledge and skills, and impact on the pharmacy budget. They modified an existing computerized clinical reminder for smoking cessation in several ways (see Figure 2 below for reference).

Figure 2: Screen shot of computer-based program to support smoking cessation treatment by primary care providers – developed by the Erie, PA, VA Medical Center. This approach simultaneously addresses two issues—support and education. It supports providers by automating the tasks that they will likely need, such as ordering medications and arranging follow-up. It also provides ongoing education, as can be seen with the warning above that “bupropion is contraindicated in persons with a seizure disorder.”

First, the reminder guided the clinician about how to approach the patient and what treatment options were available. Second, the clinician could click on pre-made order sets to automatically generate a prescription for nicotine patches, nicotine gum, or bupropion. Third, additional check boxes were available in the reminder to automatically schedule telephone follow-up at two weeks and three months and to print out patient education materials. Finally, the reminder also included a hyperlink to the clinical practice guidelines for additional information. Evaluation of the program is still underway, but during the first three months the program resulted in a 400 percent increase in the number of patients given smoking cessation treatment. Since all VAMCs use the same computer system, this approach could easily be replicated at other facilities.

Andrews et al. [3] examined the effect of education and feedback on providers’ compliance with the Public Health Service guidelines in two primary care teams at a southeastern VA Medical Center. The intervention team received a single 90-minute education session and later received written individual and team-level performance feedback, while the control team received no special training or intervention. Based on chart reviews conducted four to eight weeks after each phase, education had no effect on behavior but audit and feedback led to significant increases in advising smokers to quit, assisting them in quitting (with treatment and/or referral), and in arranging follow-up.

The VA population in general has significantly more physical and mental health problems than the general population and than patients in other health care systems.[4] For many VA patients, the mental health care provider is either the actual or the de facto primary care provider. Programs to increase treatment within primary care would in most cases miss these patients. The VA has taken a two-pronged approach to increasing treatment rates within mental health care. First, adherence to smoking cessation guidelines is assessed and reported separately for primary care and mental health care. This has led to dramatic increases in asking mental health care patients about tobacco use and advising users to quit, much as it had done several years earlier for primary care. The second component is a nationwide program (funded by the VA’s National Public Health Prevention Program and led by Dr. Miles McFall and Dr. Victoria McKeever) to train selected mental health care providers in smoking cessation techniques and have them go back and train additional people at their respective facilities. In addition, these leaders would work to reduce barriers to treatment at their institutions. The first set of mental health care providers attended a two-day training session in June 2004 and is now reporting monthly on its progress. The training will be held again next year, allowing another set of providers to participate. Dr. McFall and Dr. McKeever are currently evaluating the program’s impact, both at the organization level and at the patient level.

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