QuitLink: Partnering Clinical Practices and Telephone Quit Lines to Leverage an Improvement in the Quality of Tobacco Counseling in Primary Care
Counseling by clinicians promotes smoking cessation, but routinely providing more than brief advice is difficult in most U.S. primary care practices. Barriers include competing demands and inadequate office support systems. Telephone quit lines, whose staff deliver more effective intensive counseling, are available throughout the U.S., but few work closely with clinicians to provide feedback or forward requests for cessation medications. Whether such a partnership improves counseling outcomes has not been studied.
To test whether patient-reported delivery of intensive smoking cessation counseling in primary care practices (beyond simple advice to quit) is enhanced by an office systems approach that combined identifying smokers, advising cessation, assessing readiness to quit, and the ability to provide fax referral to the American Cancer Society Quitline for proactive telephone counseling coupled with feedback to practices, including progress reports and prescription requests.
The question was examined in a cluster-randomized randomized trial (ClinicalTrials.gov #NCT00112268), with practices as the unit of analysis and a control group consisting of practices using a traditional vital sign methodology to routinely screen for tobacco use. The study therefore compared what counseling practices accomplished beyond simply identifying patients who use tobacco. All practices implemented smoking status as a routine vital sign before a 3-month baseline, followed by allocation and analysis by practice. Outcomes were measured with 1,815 adult smokers participated in an exit survey over 9 months.
Sixteen primary care practices in metropolitan Richmond, Virginia participating in the Virginia Ambulatory Care Outcomes Research Network (ACORN).
The QuitLink intervention included the following components: (1) an expanded vital sign intervention that prompts nurses (or medical assistants) to determine tobacco use status, offer brief advice, and assess readiness to quit as they obtain vital signs; (2) fax referral of preparation-stage patients (those interested in quitting in the next 30 days) for proactive telephone counseling; and (3) feedback to the clinician, including fax requisitions for prescription aids to facilitate quit attempts, progress reports on the results of counseling, and quarterly aggregate analyses of practice and clinician team referral outcomes.
Primary outcome was the frequency of intensive counseling (more than brief advice to quit) reported by patients in exit surveys. The study includes a qualitative component with interviews of practice staff.
Smokers at QuitLink intervention practices were 11.9% more likely (p<0.001) to report receiving intensive counseling. The ACS Quitline received 329 referrals.
QuitLink is an effective system for increasing the delivery of intensive cessation counseling to primary care patients beyond what is accomplished with the traditional tobacco-use vital sign screening alone. Integrated into practice, this collaboration with an effective and available community resource has potential for wide applicability across primary care practices and quit lines.
Stephen F. Rothemich, M.D., M.S.
Associate Professor, Virginia Commonwealth University Department of Family Medicine
srothemich@vcu.edu