Practice-Based Referrals to a Tobacco Cessation Quit Line: Assessing the Impact of Comparative Feedback vs General Reminders

The paper by Wadland and colleagues in this issue of the Annals of Family Medicine addresses an important question: how to integrate evidence-based tobacco dependence treatment into the routine delivery of health care. The evidence base supporting the efficacy and effectiveness of quitlines is clear.(1) Less clear are optimal strategies for linking quitlines with front-line clinical practice in ways that ensure broad reach of evidence-based behavioral treatment to the general population of smokers.

A Cochrane review of audit and feedback in clinical practice found that these strategies can improve provider performance.(2) The findings reported in this study are consistent with research by Bentz et al. that evaluated whether performance feedback generated from electronic health record systems affected rates of referral to the state quitline. Bentz et al. also found that performance feedback improved the desired behaviors compared to the control condition.(3) Other studies examining whether performance feedback influences delivery of the 5 A’s (ask, advise, assess, assist, arrange-follow-up) as delineated in the 2000 U.S. Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence also report encouraging results.(4,5)

It is essential to ensure that strategies that increase rates of quitline referrals ultimately result in increased delivery of treatment. For example, in this study, although the number of fax referrals greatly exceeded the number of telephone referrals to the quitline, the likelihood of the referred patient enrolling in quitline services was markedly higher if the patient was referred by telephone versus fax. There are several possible explanations. Patients may agree to a fax referral rather than say “no” to their clinician. Clinicians may more aggressively refer patients via fax as a strategy to motivate patients that are “on the fence” about quitting, hoping that patients will agree to enroll in services when contacted by the quitline. It is also possible that patients do not understand the purpose of the fax referral and thus decline services once contacted by the quitline. Additional research, including qualitative studies of patients referred to quitlines, could allow these differences to be better understood and thus facilitate use of fax referral and other strategies in the most efficient and cost-effective manner.

Performance feedback has the promise to improve the delivery of preventive healthcare. Based on the paper by Wadland et al. and other studies, performance feedback, as part of a comprehensive, multi-faceted systems approach to treating tobacco dependence, improves the delivery of such treatments.

References: 1. Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2006;3:CD002850. 2. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2003(3):CD000259. 3. Bentz CJ, Bayley BK, Bonin KE, Fleming L, Hollis JF, Hunt JS, Leblanc B, McAfee T, Payne N, Siemienczuk J. Provider feedback to improve 5A's tobacco cessation in primary care: A cluster randomized clinical trial. Nicotine Tob Res. 2007;9(3):341-9. 4. Swartz SH, Cowan TM, DePue J, Goldstein MG. Academic profiling of tobacco-related performance measures in primary care. Nicotine Tob Res. 2002;4 Suppl 1:S38-44. 5. McAfee T, Grossman R, Dacey S, McClure J. Capturing tobacco status using an automated billing system: steps toward a tobacco registry. Nicotine Tob Res. 2002;4 Suppl 1:S31-7.

Competing interests:   None declared