January 04, 2013
By David Martin
|Kimber Richter, Ph.D., M.P.H|
The University of Kansas Hospital prohibited smoking on all its property in 2006. At about the same time, the Department of Preventive Medicine and Public Health at the University of Kansas Medical Center began to provide bedside counseling services to KU Hospital patients who use tobacco. Funded by the hospital, the program is called UKanQuit.
Lisa Silverman, a social worker by training, is one of the counselors. On a recent Wednesday morning, she worked from a list generated by the hospital's electronic medical records system. The patients she wanted to see included a 74-year-old woman in the cardiovascular unit and a 22-year-old recovering from a gunshot wound.
When she enters a room, Silverman is polite, cheerful — and mindful that some patients will not want to discuss their tobacco use with her. "I always give people the option — you can throw me out of your room if you want," she says. "I hope you don't, but you can."
Silverman and her fellow counselors make an effort to be non-confrontational. They start not with a lecture on the hazards of smoking but by asking the patients about their withdrawal symptoms. Patients with cravings can place an order for nicotine gum or a patch.
Once the patients' comfort level is established, counselors broach the idea of trying to break the addiction. "What's your plan for quitting smoking when you leave the hospital?," they will ask.
The question is designed to elicit information as well as to get the patient to imagine life without cigarettes. Researchers who work in the tobacco field describe hospitalization as a teachable moment for the more than 6 million smokers who are admitted to U.S. hospitals each year.
University of Kansas Hospital patients who express an interest in quitting are eligible to receive telephone-based counseling and information about obtaining medication known to reduce cravings. Studies have shown that nicotine replacement therapy doubles smokers' chances of becoming ex-smokers.
But what's the best way to make the teachable moment last after hospitalization? Researchers at KU Medical Center are conducting a study on that very question. The project is supported by a grant from the National Heart, Lung and Blood Institute and other sources.
"If you start care in the hospital, that's great," says Kimber Richter, Ph.D., M.P.H, professor of preventive medicine and the principal investigator of the research study. "But it has to continue afterwards to make a difference."
The ‘warm handoff'
Silverman and the other tobacco treatment counselors who work in the hospital have been enrolling patients in the study, which is open to Kansas residents who want to try to quit smoking.
The counselors carry computer tablets to help them log information. The tablets also decide how the study participants are going to be put in touch with the Kansas Tobacco Quitline, the state's phone-based coaching service. At the touch of a button, the tablets randomize the patients into one of two groups. One group is connected to the Quitline via fax referral, after the patient is discharged from the hospital. The other half receives what's called a "warm hand-off." In these instances, the counselors dial the Quitline from the hospital room, enabling patient and quit coach to have their first session on the spot.
The study hypothesizes that the warm handoff will connect more inpatient smokers with counseling, and that once they try it, they will like it. After smokers connect with the Quitline, they are eligible for additional free, proactive counseling, so completing that first call is vital. Because fax referral delays that connection, it may not work as well. Richter says patients often lose their enthusiasm for quitting once they get home and many never take that first call from the quit coach.
Silverman was able to enroll the patient with the gunshot wound into the study. He identified the day he was admitted as the day he quit smoking. His injury, it appeared, had prompted some reflection. "Before this happened, I wasn't really interested in quitting," he said after signing the consent form.
The randomization button —- or "magic coin toss," as Silverman put it — assigned the patient to the group that is put in touch with the Quitline via fax. "You're stuck with me," she told him.
Silverman then offered the patient the typical bedside counseling service that hospital patients receive. She asked questions about his tobacco use and tried to get him to think about how he might handle a situation that might cause him to want a cigarette, such as the end of a meal.
If it had been a warm handoff, Silverman would have left the room while the patient spoke to the counselor. She says most patients want the magic coin to land on "fax referral." But, she adds, the ones who end up speaking to a counselor seem to like it more than they think they would.
One of seven sites
Data on the program will be collected from nearly 1,000 patients at The University of Kansas Hospital and Stormont-Vail Regional Health Center in Topeka. One month and six months after discharge, counselors call the patients and ask about their smoking status. To ensure accurate results, the ones who say they have stopped smoking are sent a kit that can detect if they have used nicotine. (Study participants receive a gift card at the time of enrollment and at the one- and six-month points of follow-up.)
The data set should be complete in February or March. Richter credits project director Laura Musselman, M.P.H., and the rest of the team with helping her manage such a large study. "It's like a military campaign running a study like this," she says. "You have to plan how you're going to recruit people. You have to look at the data as it comes in and make sure it's complete and correct."
Richter also lauds The University of Kansas Hospital's commitment to tobacco treatment, which is not reimbursed well through insurance and other sources. "It's not like a procedure that has a price tag attached to it, like a stent," Richter says.
KU is one of seven institutions receiving funding to test ways of integrating tobacco treatment into hospital care. Researchers at the sites are looking at the effectiveness of different methods, such as interactive voice response, or "robo-calling" as it's more commonly known.
As for Richter, she is thinking about her next tobacco-related study. One question on her mind is the best approach to take with patients who smoke but say they are not ready to quit. Her belief is that health care professionals should offer them the same treatment as those motivated to become ex-smokers.
"Why do you make people beg for treatment or say, ‘Yes, I am ready to quit in the next two weeks'?" she asks. "You don't make people with diabetes say, ‘Yes, I am ready to lose 100 pounds in the next year' before you are willing to provide treatment. You just offer to help them with the best treatments available. It should be the same with smoking."
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