Division of General Internal Medicine and.
Research Computing Services Group, Information Services and Technology, Boston University, Boston, Massachusetts.
Ann Am Thorac Soc. 2020 Jan;17(1):63-71. doi: 10.1513/AnnalsATS.201906-424OC.
Hospitalization is an opportunity to engage smokers who may not seek tobacco treatment. Our safety-net hospital developed and implemented an inpatient intervention consisting of an "opt-out" electronic health record-based Best Practice Alert (BPA)+order-set, designed to trigger referral to the Tobacco Treatment Consult (TTC) service (a team staffed by tobacco treatment specialists) for all hospitalized smokers, regardless of motivation to quit. We performed a sequential explanatory mixed-methods study to evaluate the feasibility, acceptability, and adoption of the TTC service. Among all admissions of adult "current smokers" between July 2016 and June 2017, we calculated the percentage of patients whose clinicians accepted the order-set (through a simple "order" click), thus generating the TTC referral. We then determined the extent of clinician follow-through of TTC recommendations for prescribing nicotine replacement therapy among 1,651 consecutive smokers seen by the TTC service. Finally, we conducted qualitative interviews with inpatient clinicians ( = 25) to understand their rationale for adoption or nonuse of the TTC intervention, including perceived usefulness, barriers to adoption, and strategies to improve the utility of the service. Clinicians accepted the TTC order-set for 4,100 out of 6,598 "current smokers" (62.1%) for whom the BPA fired, typically after initially deferring the BPA. Rates of acceptance significantly differed across clinical services (range: 8% [obstetrics-gynecology] to 82.2% [cardiology]; < 0.00001). A chart review showed that 43.5% (719/1,651) of the patients seen by the TTC service desired outpatient nicotine replacement therapy, but only half of these patients (48.8%; 351/719) received a discharge prescription from the inpatient team. Clinicians expressed that they valued the TTC service, but that BPA fatigue, time constraints, competing priorities, and poor communication with the TTC service were barriers to using the service and following recommendations. Clinicians suggested strategies to address barriers to the use of tobacco treatment interventions during hospitalization and after discharge. Implementing a large-scale "opt-out" tobacco treatment service for hospitalized smokers at a safety-net hospital is feasible and acceptable, but suffers from inconsistent adoption due to a variety of clinician barriers. System-level changes are needed to increase uptake and sustain inpatient tobacco treatment interventions to promote smoking cessation.
住院治疗为接触那些可能不寻求烟草治疗的吸烟者提供了机会。我们的医疗保障医院开发并实施了一项住院干预措施，包括基于“退出”电子健康记录的最佳实践警报 (BPA)+订单集，旨在为所有住院吸烟者（无论戒烟动机如何）转介至烟草治疗咨询 (TTC) 服务（该服务由烟草治疗专家组成的团队提供）。我们进行了一项顺序解释性混合方法研究，以评估 TTC 服务的可行性、可接受性和采用情况。在 2016 年 7 月至 2017 年 6 月期间所有成年“当前吸烟者”的住院治疗中，我们计算了临床医生接受订单集的患者百分比（通过简单的“订单”点击），从而生成 TTC 转诊。然后，我们确定了 TTC 服务为 1651 名连续吸烟者开尼古丁替代疗法处方的临床医生的 TTC 建议的遵循程度。最后，我们对 25 名住院临床医生进行了定性访谈，以了解他们采用或不采用 TTC 干预措施的理由，包括感知有用性、采用障碍和提高服务效用的策略。临床医生接受了 TTC 订单集，为 6598 名“当前吸烟者”中的 4100 名（62.1%）触发 BPA 的吸烟者提供服务，通常是在最初推迟 BPA 之后。接受率在不同的临床科室之间差异显著（范围：8%[妇产科]至 82.2%[心脏病学]；<0.00001）。病历审查显示，TTC 服务就诊的 1651 名患者中有 43.5%（719 名）希望获得门诊尼古丁替代疗法，但这些患者中只有一半（48.8%；351/719）从住院团队获得了出院处方。临床医生表示，他们重视 TTC 服务，但 BPA 疲劳、时间限制、优先事项竞争以及与 TTC 服务沟通不良是使用服务和遵循建议的障碍。临床医生提出了一些策略，以解决住院和出院期间使用烟草治疗干预措施的障碍。在医疗保障医院为住院吸烟者实施大规模“退出”烟草治疗服务是可行且可接受的，但由于各种临床医生的障碍，采用率不一致。需要进行系统层面的变革，以提高采用率并维持住院烟草治疗干预措施，以促进戒烟。
