Increasing Rates of Tobacco Treatment Delivery in Primary Care Practice: Evaluation of the Ottawa Model for Smoking Cessation

Sophia Papadakis; Adam G. Cole; Robert D. Reid; Mustafa Coja; Debbie Aitken; Kerri-Anne Mullen; Marie Gharib; Andrew L. Pipe

doi:10.1370/afm.1909

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Figure 1
Flow of practices and patients through the study.
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Figure 2
Clinic performance in the 3 A’s delivery before and after OMSC knowledge translation intervention.
AOR = adjusted odds ratio; OMSC = Ottawa Model for Smoking Cessation; 3 A’s = Ask, Advise, Act.
Note: The AORs presented control for clinic- and provider-level variance between clusters, availability of cost-free nicotine replacement therapy, gender of the patient, self-reported time of first cigarette, and purpose of visit; based on inclusion of 32 clinics and 481 providers. P values are based on the Wald statistic.

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Table 1

Summary of the Multicomponent Knowledge Translation Intervention

Component	Description
Outreach facilitation visits	A trained outreach facilitator worked with each primary care clinic over a 3-month period to do the following: • Provide information and recommendations on the integration of evidence-based smoking cessation strategies into clinical practice • Facilitate the development of a clinic tobacco control protocol for integrating evidence-based smoking cessation strategies into all clinic appointments • Define roles and responsibilities of clinic staff in delivering evidence-based smoking cessation treatments • Support communications and training activities for members of the clinic staff
Clinic staff training	Frontline physicians and nurse practitioners participated in a 3-hour training session that provided information and skills training for addressing tobacco use with patients in a busy primary care practice Key staff who would be responsible for delivering quit plan visits (typically nurses, nurse practitioners, or pharmacists) attended an intensive 1-day training session that taught them how to conduct the quit plan visit and follow-up visits based on evidence-based practice
Standardized staff and patient tools	All materials were designed to support 3 A’s delivery and reduce the amount of face-to-face time required. They included the following: • A patient tobacco use survey to document smoking history • A checklist-style smoking cessation consult form • A quit plan booklet for smokers ready to quit • A booklet for smokers not ready to quit • Clinic waiting room posters and materials
Real time prompts and EMR tools	Real time, point-of-care reminders (eg, standard smoking status questions and prompts to deliver brief advice) were introduced and embedded in vital signs screening forms Standardized forms were embedded in EMR systems to guide 3 A’s delivery for advice, quit plan, and follow-up visits
Follow-up support and counseling	Practices were introduced to a telephone-based Smoker’s Follow-up System for patients ready to quit (5 triage calls over a 2-month period delivered by Interactive Voice Response System) with additional support from trained smoking cessation counselors available for patients struggling with their quit attempts
Audit and feedback	Practices were given feedback reports on the results of pre- and postintervention assessments They also received audit and feedback regarding implementation activities 1 to 4 months following initiation of intervention program

EMR = electronic medical record; 3 A’s = Ask, Advise, Act.

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Table 2

Patient Demographics at Times of Assessment

Parameter	Preintervention n = 1,919	Postintervention n = 1,951	Combined N = 3,870	χ²	P Value
Age range, %				4.6	.33
18–24 y	8.76	8.06	8.41
25–39 y	20.92	23.61	22.27
40–54 y	36.23	34.37	35.30
55–64 y	21.55	21.42	21.49
≥65 y	12.53	12.53	12.53
Sex, %				38.4	<0.001
Female	62.70	52.81	57.74
Male	37.30	47.19	42.26
Years of formal education, %				0.9	.81
<High school	3.96	3.83	3.89
High school	51.70	50.35	51.01
University	37.75	39.29	38.53
Graduate school	6.59	6.54	6.57
Smoking-related illness,^a %				0.7	.41
No	72.33	73.50	72.92
Yes	27.67	26.50	27.08
Cigarettes per day, %				2.5	.29
<15	45.54	47.92	46.74
15–25	46.53	44.08	45.30
>25	7.92	8.00	7.96
Time to first morning cigarette, %				7.9	.005
>30 minutes	37.59	42.03	39.82
≤30 minutes	62.41	57.97	60.18
Readiness to quit,^b %				0.1	.81
>30 days	69.05	68.68	68.87
next 30 days	30.95	31.32	31.13
Average self-efficacy with quitting,^c %				0.2	.64
Low (1–6)	86.15	85.60	85.88
High (7–10)	13.85	14.40	14.12
Anxiety/Depression, %				0.3	.57
No	55.21	56.11	55.66
Yes	44.79	43.89	44.34
Psychiatric Co-Morbidity, %				0.8	.38
No	88.08	87.13	87.60
Yes	11.92	12.87	12.40
Purpose of visit, %				5.0	.03
Follow-up/other	80.86	77.93	79.36
Periodic exam	19.14	22.07	20.64

↵a “Do you have… heart disease, stroke, heart failure/cancer/chronic obstructive pulmonary disease (COPD)?” (1 = yes, 0 = no for each condition).
↵b “Which of the following best describes your feelings about smoking right now?” (responses: 1 = ready to quit in next 30 days, 0 = ready to quit in next 6 months or not ready to quit).
↵c ”On a scale of 1 to 10, how confident are you that you would be able to quit smoking at this time?” (1 = not at all confident, 10 = extremely confident).

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Table 3

Final Model for the Multi-Level Analysis of Clinic-, Clinician-, and Patient-Level Characteristics Associated With Rates of Clinician Delivery of the 3 A’s (Ask, Advise, Act)

Parameter	Ask		Advise	Act to Assist With Cessation
Time, AOR (95% CI)
Preintervention (reference)	1.00		1.00	1.00
Postintervention	2.07 (1.77–2.43)		2.32 (1.95–2.76)	2.49 (2.09–2.97)
Clinic-level variables, AOR (95% CI)
Presence of a physician champion
No (reference)	1.00		1.00	1.00
Yes	1.66 (1.13–2.44)
Provider-level variables, AOR (95% CI)
Importance of cessation^a
Low (reference)	1.00		1.00	1.00
High			1.25 (1.02–1.53)	1.35 (1.10–1.64)
Patient-level variables, AOR (95% CI)
Age, y
18–24 (reference)	1.00		1.00	1.00
25–39			1.11 (0.80–1.54)	1.55 (1.10–2.19)
40–54			1.31 (0.95–1.81)	1.85 (1.33–2.58)
55–64			1.55 (1.09–2.20)	1.85 (1.30–2.64)
≥65			1.53 (1.05–2.25)	1.69 (1.14–2.49)
Formal education
<High school (reference)	1.00		1.00	1.00
High school	0.77 (0.50–1.18)
University	0.66 (0.43–1.02)
Graduate school	0.54 (0.32–0.90)
Smoking-related illness^b
No (reference)	1.00		1.00	1.00
Yes	1.28 (1.07–1.53)		1.26 (1.02–1.54)
Cigarettes per day, No.
<15 (reference)	1.00		1.00	1.00
15–25			1.38 (1.14–1.67)	1.52 (1.25–1.84)
>25			1.25 (0.89–1.78)	1.62 (1.14–2.29)
Time to first morning cigarette
>30 min (reference)	1.00		1.00	1.00
<30 min	1.23 (1.05–1.45)		1.23 (1.02–1.49)	1.31 (1.08–1.59)
Readiness to quit^c
Not ready in next 30 d (reference)	1.00		1.00	1.00
Ready in next 30 d	1.29 (1.10–1.53)		1.50 (1.25–1.80)	1.60 (1.33–1.92)
Self-efficacy with quitting^d
Low (reference)	1.00		1.00	1.00
High				1.36 (1.06–1.74)
Purpose of visit
Follow-up (reference)	1.00		1.00	1.00
Annual exam	2.79 (2.26–3.45)		1.98 (1.59–2.46)	1.84 (1.49–2.27)
Random Variance, Variance (SE)
Provider	0.214 (0.068)	0.128 (0.059)		0.088 (0.058)
Clinic	0.154 (0.060)	0.087 (0.043)		0.083 (0.041)
Model fit statistics
Akaike information criterion	3,921.93	3,123.72		3,001.19
Bayesian information criterion	3,939.52	3,150.10		3,030.50

Note: Models are adjusted for clinic- and provider-level clustering effects and all other variables in the column.
↵a “As a practitioner, how would you describe the importance you place personally on helping your patients quit smoking?” (Responses: 1–5 Likert scale, 1 = not important, 5 = extremely important)
↵b “Do you have... heart disease/ stroke/ heart failure/ cancer/ chronic obstructive pulmonary disease (COPD)?” (1 = yes, 0 = no for each condition)
↵c “Which of the following best describes your feelings about smoking right now?” (Responses: 1 = Ready to quit in next 30 days, 0 = Ready to quit in next 6 months or not ready to quit.)
↵d “On a scale of 1 to 10, how confident are you that you would be able to quit smoking at this time?” (1 = Not at all confident, 10 = Extremely confident.)

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Table 4

Implementation of Ottawa Model for Smoking Cessation 10 Best Practices Before and After Intervention

	Before Intervention	After Intervention
Clinics with the OMSC 10 Best Practices implemented, by best practice, %
1. Clinic task force formed	3.1	93.8
2. Clinic tobacco control protocol developed	0.0	96.9
3. Tobacco use queried and documented for all clinic patients	28.1	81.3
4. Training in tobacco dependence treatment offered to health care providers in last year	28.1	90.6
5. Staff trained and available to provide tobacco dependence treatment	59.4	96.9
6. Self-help materials readily available to patients, family members, and staff	68.8	90.6
7a. EMR or other real time prompt in place to inform clinician of patient smoking status	3.1	90.6
7b. EMR supports in place (smoking status identification, consult form, etc)	3.1	93.8
8. Process to follow-up tobacco users for at least 1 month after clinic visit in place	43.8	93.8
9. Process to evaluate quality or program implementation in place	3.1	71.9
10. Process to provide feedback to clinicians about performance in place	3.1	81.3
Average number of best practices implemented, No.	2.4	8.9
Clinics with 10 best practices implemented, %	0.0	59.3

EMR = electronic medical record; OMSC = Ottawa Model for Smoking Cessation.
Note: Based on data from 32 primary care practices.

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The Article in Brief

Increasing Rates of Tobacco Treatment Delivery in Primary Care Practice: Evaluation of the Ottawa Model for Smoking Cessation

Sophia Papadakis , and colleagues

Background The Ottawa Model for Smoking Cessation (OMSC) provides clinicians with multiple components to help patients quit smoking. It includes use of the three As: Ask (identify smoking status), Advise (counsel patients to quit smoking), and Act (assist with cessation). This study examines the association between implementation of the OMSC program and rates at which the 3 As are delivered to tobacco users in primary care practices.

What This Study Found The OMSC is successful in increasing rates of tobacco treatment delivery. In 32 primary care practices with 481 clinicians and 3,870 patients, rates of delivery of the three As increased significantly following implementation of the program. Clinicians are significantly more likely to address tobacco use during periodic exams, indicating that they may be missing opportunities when patients present for other reasons.

Implications

The results of this evaluation lend support to existing evidence about the effectiveness of multicomponent interventions in influencing tobacco treatment delivery in primary care settings.