Bridge to Cessation (B2C): Utilization of an Electronic Referral System for Smoking Cessation, a Pilot Study

Context: Smoking-related disparities exist across socioeconomic status and while Tobacco Quitlines are effective at promoting cessation, they are underutilized. Implementing Electronic Quitline referral system (eReferral) into primary care settings to facilitate a connection to the Quitline has the potential to reach a large number of patients who smoke however, there is a knowledge gap in how best to implement this system.

Objective: To understand the utilization and factors influencing the adoption of the Quitline eReferral system by studying a cohort of self-selected clinics in Oregon that implemented the eReferral system.

Study Design: Sequential mixed method observational.

Setting or Dataset: Community Health Centers (CHC) from the OCHIN Network.

Population Studied: EHR data from patients with a documented smoking status from 27 CHCs (07/01/2017-03/31/2021) across five health systems in Oregon that implemented the eReferral in 2017. Qualitative data from 13 clinic staff.

Outcome Measures: Quitline outcomes; CHC factors influencing adoption of the eReferral.

Results: Across the study period 56,654 visits triggered the eReferral however, only 3% of those visits resulted in a patient being offered the eReferral to the Quitline. The majority of the referrals offered were within the first 18 months after implementation. Patient characteristics (e.g., age, race, insurance type) among eligible patients who were ever offered versus never offered a Quitline eReferral were similar . Out of the 299 patients offered the eReferral, 88 patients accepted. Of those, 7% were recorded as actively enrolled, 8% accepted service but were subsequently unreachable, 15% declined, and 70% declined, were ineligible, excluded or unreachable. CHC staff who were interviewed reported challenges related to patient engagement (reluctance in using telephone, unfamiliarity with Quitline coaches), and their own lack of knowledge of the functionality (lack of training, limited understanding of closed-loop system) as barriers to using the eReferral. The design of the system was not perceived as a barrier, and many interviewees provided suggestions to increase adoption such as training, access to outcomes data, and alternative modes of outreach.

Conclusions: Very few clinics with the eReferral system referred patients who smoke to the Quitline. Most clinical staff agreed that comprehensive training around the functionalities and workflow of the system would promote system adoption.