Faculty Bibliography

INTRODUCTION: Smoking is the leading preventable cause of death among women in the United States. It is a particular problem for women using the Veterans Health Administration (VA), where the prevalence of smoking among women is 30%. We compared the baseline characteristics of male and female smokers and then assessed the smoking cessation services they received to determine whether there are important gender differences in care. METHODS: As part of a study of implementing national guidelines for smoking cessation taking place at 18/23 VA centers in the southwestern and western United States, we conducted a baseline survey of a random sample of 1,941 smokers in primary care (129 women, 1,812 men) to assess the smoking cessation services received by female and male veterans. Subjects were followed 1 year later (73 women, 1007 men). Results for men and women were compared using chi-square tests and analysis of variance. Logistic regression analyses were conducted to determine factors that were independently associated with receipt of smoking cessation services. RESULTS: Female smokers were younger, more educated, and less likely to be married than male smokers. Women were equally likely to report being advised to quit smoking or referred to a smoking cessation program but were much less likely to report receiving a prescription for nicotine patches (OR .5, 95% CI .3-.9). One year later, female smokers were less likely to have successfully quit smoking. CONCLUSION: Women were less likely to report receiving nicotine patches for smoking cessation. Future interventions to increase use of smoking cessation medications for female smokers will also hopefully increase their quit rate

OBJECTIVES: To evaluate the effectiveness of the Veterans Health Administration (VHA) in providing treatment for tobacco dependence, accomplished by estimating national trends in the number and percent of smokers receiving smoking cessation aids (SCAs) within the VHA, trends in SCA utilization and expenditures, and the impact of lifting restrictions on patient access to SCAs. STUDY DESIGN AND METHODS: All patients receiving an outpatient SCA prescription were identified within the Veterans Affairs (VA) Pharmacy Benefits Management database over a 4-year period- October 1, 1998 (n = 61 968) to September 30, 2002 (n = 76 641). Smoking prevalence was based on data from the VA's 1999 Large Health Survey of Enrollees. A subsample of sites was classified as having restricted access to SCAs if patients were required to attend smoking cessation classes. Changes in annual SCA utilization rates and expenditures by SCA type and restriction status were measured to assess changes in treatment of tobacco dependence. RESULTS: Approximately 7% of smokers received SCA prescriptions, and SCAs accounted for less than 1% of the VHA's annual outpatient pharmacy budget in any given year. Following downward trends in the cost of 30-day SCA prescriptions, annual SCA expenditures per patient decreased over time. Expenditures were lower for restricted than unrestricted sites. More than two thirds of smokers who were prescribed medications received the nicotine patch, a quarter received bupropion sustained-release, and fewer than 10% received nicotine gum. CONCLUSIONS: Measures of SCA utilization and cost are low, stable, and less than the recommended rates in national smoking cessation guidelines, suggesting that this population of smokers is undertreated. Removing SCA restrictions is not prohibitively expensive and improves access to cost-effective care

Given the prevalence of smoking, its impact, and the benefits of cessation, helping smokers quit should be a top priority for health care organizations. To restructure health care delivery and guide future policy, the authors used baseline survey data from an 18-site Veterans Health Administration group randomized trial to assess the level of interest in quitting smoking for a practice population and determine what smoking cessation services they reported receiving. Among 1941 current smokers, 55% did not intend to quit in the next 6 months, and the remainder intended to quit in the next month (13%) to 6 months (32%). Forty-five percent reported a quit attempt in the prior year. While nearly two thirds of smokers reported being counseled about cessation within the past year, only 29% were referred to a cessation program, and 25% received a prescription for nicotine patches. Tobacco control efforts within this population should focus on increasing the rate of assisting patients with quitting

OBJECTIVE: To synthesize the evidence on the effectiveness of smoking-cessation interventions by type of provider. METHODS: A random effects meta-regression was estimated to examine the effect of provider and whether the intervention contained nicotine replacement therapy (NRT), on the intervention's relative risk of quitting as compared to placebo or usual care from studies published in databases from inception to 2000. Thirty additional studies not included in the previous 1996 and 2000 U.S. Public Health Service clinical practice guidelines were used to provide the most comprehensive analysis to date of the comparative effectiveness of different types of providers in interventions for smoking cessation that have been published. RESULTS: The effectiveness without NRT follows: psychologist (1.94, 95% confidence interval [CI]: 1.04-3.62); physician (1.87, CI=1.42-2.45); counselor (1.82, CI=0.84-3.96); nurse (1.76, CI=1.21-2.57); unknown (1.27, CI=0.57-2.82); other (1.18, CI=0.67-2.10); and self-help (1.28, CI=0.89-1.82). Effectiveness of most providers increased by almost twofold with the use of NRT. CONCLUSIONS: Smoking-cessation interventions without NRT delivered by psychologists, physicians, or nurses are all effective. NRT increases the effectiveness of most providers

BACKGROUND: Depression's high prevalence and large amount of potentially modifiable morbidity make it an excellent candidate for quality improvement (QI) techniques. Yet there is little evidence on how to promote adherence to evidence-based guidelines. A locally run research and QI project that was part of a larger National Institute of Mental Health-funded study to implement depression guidelines was implemented by a primary care team at a Department of Veterans Affairs (VA) ambulatory care center in 1997 and 1998. DEVELOPMENT OF THE QI INTERVENTION: The plan to improve screening and recognition entailed systematically screening all patients attending the primary care clinic; sending computer reminders to clerical staff, nursing assistants, and primary care providers; and auditing team performance with monthly feedback. RESULTS: Once the intervention was in place, nearly all patients were screened. The primary care provider documented the assessment of whether a patient was depressed for nearly all patients who screened positive. Few resources were needed to maintain the project once it was implemented. DISCUSSION: An evidence-based QI intervention led to profound and lasting changes in primary care providers' recognition of depression or depressive symptoms. The QI implementation continued for one year after the intervention's end, but a new VA computerized medical record system uses similar computer-generated reminders

Smoking is the main cause of chronic obstructive pulmonary disease (COPD), and smoking cessation is the only effective intervention to slow its progression. We examined whether smokers with COPD received more cessation services than smokers without COPD. Current smokers from 18 Veterans Health Administration primary care clinics completed baseline and 12 month follow-up surveys (baseline n = 1,941; 12 month n = 1,080), composed of validated questions on smoking habits, history, and attitudes; health/functional status; and sociodemographics. Both at baseline and 12 month follow-up, smokers with COPD were more likely to report that they had been advised to quit, prescribed nicotine patches, or referred to a smoking cessation program within the last year. However, the rate of quitting smoking was the same for smokers with COPD and smokers without COPD. The increase in cessation services received by smokers with COPD was noted primarily among smokers not interested in quitting. New approaches may be required, particularly to help smokers not interested in quitting

PURPOSE: To determine the behaviors, knowledge, and attitudes of resident physicians regarding exercise counseling. METHOD: In 1997, a self-administered questionnaire was sent to 313 internal medicine resident physicians at six U.S. training programs. Pearson correlation coefficients examined associations between the resident physicians' practices, attitudes, and personal habits. Stepwise multiple linear regression identified predictors of exercise counseling by the resident physicians. RESULTS: A total of 251 resident physicians responded. Only 15.5% reported counseling more than 80% of the clinic patients about exercise. Over 93% understood the benefits of exercise, and almost all (96%) felt that it was a physician's responsibility to counsel patients about exercise. Only 29% felt successful at getting their patients to start exercising, and only 28% felt confident in their skills to prescribe exercise for patients. Ninety-one percent felt that training in exercise counseling would be worthwhile. The significant predictors of physician exercise counseling were perception of exercise counseling as a priority (p <.001), confidence in exercise-counseling skills (p <.001), and postgraduate year of training (p <.05) (R(2) =.18). The significant predictors of physicians' confidence in exercise-counseling skills included physician's gender (i.e., men) (p <.001), perception that exercise is important for a healthy 35-year-old (p <.01), feeling successful at exercise counseling (p <.001), perceiving less interference with counseling by barriers (p <.001), and prior training in exercise counseling (p <.05) (R(2) =.44). CONCLUSIONS: Resident physicians' perceptions of exercise counseling as a priority, confidence in counseling skills, and postgraduate year of training are important predictors of their providing exercise counseling. These factors should be addressed in future educational programs