Improving Tobacco Cessation Rates Using Inline Clinical Decision Support

Abstract

Background Tobacco use is a significant cause of morbidity and mortality in the United States. Even brief advice from a clinician can significantly influence cessation rates among tobacco users, but clinicians often miss opportunities to provide this simple intervention.

Objectives The intent of this quality improvement project was to increase tobacco cessation among tobacco users by nudging clinicians using a clinical decision support (CDS) tool.

Methods We developed a CDS tool using principles of user-centered design and the CDS Five Rights to dynamically insert actionable information about current tobacco users into the Assessment and Plan section of clinicians' notes. We conducted a retrospective analysis of patients at four primary care practices in the Denver Metro area evaluating the impact of the CDS tool on time to tobacco cessation. A multivariable Cox proportional-hazards model was used in this determination. Kaplan–Meier curves were used to estimate tobacco cessation probabilities at 90, 180, and 365 days.

Results We analyzed 5,644 patients with a median age of 45 years, most of whom lived in an urban location (99.5%) and the majority of whom were males (60%). The median follow-up time for patients was 16 months. After adjustment for age, gender, practice site, and patient location (rural, urban), the intervention group had significantly greater risk of tobacco cessation compared to those in the control group (hazard ratio: 1.22, 95% confidence interval: 1.08–1.36; p = 0.001).

Conclusion This study suggests a CDS intervention which respects the CDS Five Rights and incorporates user-centered design can affect tobacco use rates. Future work should expand the target population of this CDS tool and continue a user-centered, iterative design process.

Keywords

tobacco cessation - clinical decision support - physician - primary care - user-centered design - workflow

Protection of Human and Animal Subjects

The Colorado Multiple Institutional Review Board determined this study was not human subjects research.

Publication History

Received: 09 May 2022

Accepted: 19 September 2022

Accepted Manuscript online:
17 October 2022

Article published online:
23 November 2022

• References

• 1 National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (US); 2014
• 2 U.S. Department of Health and Human Services, Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020
• 3 International Agency for Research on Cancer. Tobacco Control: Reversal of Risk After Quitting Smoking. Geneva: World Health Organization; 2007
• 4 Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: US Department of Health and Human Services; 2008 . Accessed October 13, 2022 at: http://www.ncbi.nlm.nih.gov/books/NBK63943/
• 5 Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013; 2013 (05) CD000165
• 6 Lavinghouze SR, Malarcher A, Jama A, Neff L, Debrot K, Whalen L. Trends in quit attempts among adult cigarette smokers - United States, 2001-2013. MMWR Morb Mortal Wkly Rep 2015; 64 (40) 1129-1135
• 7 Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the 2001-2004 national ambulatory medical care survey (NAMCS). Prev Med 2006; 43 (06) 472-476
• 8 Clinical Decision Support. Agency for Healthcare Research and Quality. Updated June 2019. Accessed June 30, 2022 at: https://www.ahrq.gov/cpi/about/otherwebsites/clinical-decision-support/index.html
• 9 van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13 (02) 138-147
• 10 Slight SP, Nanji KC, Seger DL, Cho I, Volk LA, Bates DW. Overrides of clinical decision support alerts in primary care clinics. Stud Health Technol Inform 2013; 192: 923
• 11 Stonesifer C, Crusco S, Rajupet S. Improving smoking cessation referrals among elective surgery clinics through electronic clinical decision support. Tob Prev Cessat 2021; 7: 14
• 12 Jenssen BP, Shelov ED, Bonafide CP, Bernstein SL, Fiks AG, Bryant-Stephens T. Clinical decision support tool for parental tobacco treatment in hospitalized children. Appl Clin Inform 2016; 7 (02) 399-411
• 13 Jenssen BP, Karavite DJ, Kelleher S. et al. Electronic health record-embedded, behavioral science-informed system for smoking cessation for the parents of pediatric patients. Appl Clin Inform 2022; 13 (02) 504-515
• 14 Bernstein SL, Rosner J, DeWitt M. et al. Design and implementation of decision support for tobacco dependence treatment in an inpatient electronic medical record: a randomized trial. Transl Behav Med 2017; 7 (02) 185-195
• 15 Bernstein SL, Weiss J, DeWitt M. et al. A randomized trial of decision support for tobacco dependence treatment in an inpatient electronic medical record: clinical results. Implement Sci 2019; 14 (01) 8
• 16 Khanna N, Klyushnenkova E, Rao V, Siegel N, Wolfe S. Electronic referrals to the tobacco Quitline: implementation strategies in a large health system to optimize delivery of tobacco cessation to patients. Transl Behav Med 2021; 11 (05) 1107-1114
• 17 Sharifi M, Adams WG, Winickoff JP, Guo J, Reid M, Boynton-Jarrett R. Enhancing the electronic health record to increase counseling and quit-line referral for parents who smoke. Acad Pediatr 2014; 14 (05) 478-484
• 18 Matulewicz RS, Bassett JC, Kwan L. et al. Using a multilevel implementation strategy to facilitate the screening and treatment of tobacco use in the outpatient urology clinic: a prospective hybrid type I study. Cancer 2022; 128 (06) 1184-1193
• 19 Saman DM, Chrenka EA, Harry ML. et al. The impact of personalized clinical decision support on primary care patients' views of cancer prevention and screening: a cross-sectional survey. BMC Health Serv Res 2021; 21 (01) 592
• 20 Jenssen BP, Bryant-Stephens T, Leone FT, Grundmeier RW, Fiks AG. Clinical decision support tool for parental tobacco treatment in primary care. Pediatrics 2016; 137 (05) e20154185
• 21 Marcy TW, Kaplan B, Connolly SW, Michel G, Shiffman RN, Flynn BS. Developing a decision support system for tobacco use counselling using primary care physicians. Inform Prim Care 2008; 16 (02) 101-109
• 22 Montini T, Schenkel AB, Shelley DR. Feasibility of a computerized clinical decision support system for treating tobacco use in dental clinics. J Dent Educ 2013; 77 (04) 458-462
• 23 Campbell R. The five “rights” of clinical decision support. J AHIMA 2013; 84 (10) 42-47
• 24 Osheroff JA. Improving Medication Use and Outcomes with Clinical Decision Support: A Step-By-Step Guide. Chicago, IL: The Healthcare Information and Management Systems Society; 2009
• 25 U.S. Department of Agriculture. Rurbal-Urban Commuting Area (RUCA) Codes. 2020. . Accessed October 13, 2022 at: https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx
• 26 Krist AH, Davidson KW, Mangione CM. et al; US Preventive Services Task Force. Interventions for Tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA 2021; 325 (03) 265-279