Category: Federal Forum Posters
Purpose: Cigarette smoking remains the leading cause of preventable death and disease in the United States, and the prevalence of smoking among Veterans has been reported as higher than in civilians. Effective smoking cessation interventions for veterans are, therefore, critically needed. The purpose of this program evaluation was to investigate the impact of comprehensive medication management provided through the Clinical Pharmacist Specialist (CPS) smoking cessation clinic at the South Texas Veterans Health Care System (STVHCS) versus smoking cessation therapy provided by primary care providers (PCPs). We hypothesized that patients in the CPS clinic would have greater 6-month quit attempt success.
Methods: The present investigation consisted of a retrospective chart review using the Veterans Affairs Computerized Patient Record System (CPRS). Actively smoking, adult veterans enrolled in the CPS smoking cessation clinic from July 2014 through May 2018 who received a prescription for nicotine replacement therapy (NRT), including nicotine patches, nicotine lozenges, or nicotine gum, or NRT and bupropion issued on the same day were included for review, along with a matched number of PCP patients. Veterans prescribed varenicline during the evaluation period and those who used smokeless tobacco were excluded. The primary outcome of interest was 6-month smoking cessation attempt success. Success rates were measured by self-reported tobacco abstinence documented in CPRS or, if CPRS documentation not available, reported via telephone contacts, if veteran was successfully reached by phone. Secondary outcomes consisted of number of successful follow-up contacts where smoking was addressed after prescription issuance, time to successful quit attempt if achieved, relapse rates, number of relapses, time to relapse, and comparison of the amount of information documented and available between the CPS and PCP cohorts. Chi-squared and Wilcoxon Rank Sums tests were utilized where appropriate to analyze results, and an intention-to-treat (ITT) sensitivity analysis was additionally performed for the primary outcome.
Results: A total of 334 patient charts were reviewed in order to obtain data for 100 patients in each group, 200 patients total. The population was predominantly male, with an average age of 58 years. Approximately 2/3 of patients had at least 1 concomitant psychological or substance-related comorbidity. The majority of patients smoked only cigarettes. Significantly more female patients were seen by PCP providers, and patients in the CPS groups smoked significantly more at baseline. Numerically more veterans in the CPS cohort smoked multiple tobacco products. Pharmacotherapy provided differed significantly between groups. No significant difference in 6-month smoking cessation success rates was observed, with 16 out of 70 patients in the PCP group (22.9%) reporting cessation versus 25 out of 98 patients in the CPS group (25.5%), P=0.69. The difference remained nonsignificant in the ITT analysis when all veterans in whom smoking cessation could not assessed were presumed to have not successfully quit, P=0.11. For secondary outcomes, patients in the CPS smoking cessation clinic received significantly more follow-up contacts (P<0.0001) and achieved initial tobacco cessation success in a shorter period of time. Documentation of information relevant to smoking cessation was also significantly greater in the CPS cohort (P<0.0001 for all observations).
Conclusion: This retrospective program evaluation sought to compare smoking cessation attempt success amongst patients receiving NRT with or without bupropion from the STVHCS CPS smoking cessation clinic with success of patients managed by PCPs. While a statistically significant difference in quit attempt success was not demonstrated, the number of follow-up contacts and pharmacotherapeutic differences may justify expansion of this care model to provide enhanced smoking cessation assistance to our veterans. Offering veterans desiring additional behavioral assistance or with past difficulties in their quit attempts CPS smoking cessation clinic enrollment may represent a mean of clinically improving tobacco abstinence rates.
Sarah Hallowell– Ambulatory Care and Behavioral Health Resident, South Texas Veterans Health Care System, San Antonio, TX