Background: Tobacco use remains the leading cause of preventable morbidity and mortality in the United States. Hospitalization is known to be an opportune time to initiate cessation interventions, and interventions with sustained postdischarge contact may increase the relative likelihood of cessation by 65% compared to usual care. Additionally, compared to physicians and nursing staff, clinical psychologists may possess unique skills relevant to behavioral approaches to smoking cessation. For these reasons, we initiated the Quality for Inpatient Tobacco Cessation (QUITS) program at a large VA medical center in Spring 2018. Here we describe our design, implementation, and results of the program to date.
Methods: The QUITS program was designed as a collaborative effort between hospitalist faculty and clinical psychology faculty and trainees. Following an implementation phase of the program, a nurse-led screening process identified smokers admitted to the medicine service with any degree of interest in cessation. These patients were then offered a bedside motivational interview, review of VA resources related to cessation, and consideration of pharmacotherapy and/or outpatient followup. Additionally, supportive post-discharge phone followup was offered at two, four, eight, and 12 weeks. Process measures assessed were percentage of patients prescribed nicotine replacement therapy (NRT), stage of change (SoC) at initial and followup encounters, and rates of postdischarge contact by phone. Outcome measures included patient-reported reduction and cessation rates at two or more weeks following hospital discharge. Hospital-wide tobacco quality metrics including rate of tobacco treatment offered or provided at discharge were measured before and after initiation of the program.
Results: Eighty-nine patients were enrolled between April and November 2018, and 86 completed an initial encounter. Of these, 67 (78%) reported a SoC of contemplation or higher. NRT was prescribed to 37 (43%). Successful followup at two, four and eight weeks occurred with 46 (53%), 30 (35%), and 19 (22%) patients, respectively. Thirty-four patients (40%) self-reported reduction in tobacco use, and 18 (21%) self-reported cessation at two or more weeks following discharge. Of all smokers admitted to our facility, the mean rate of tobacco treatment provided or offered at discharge improved from 19% to 60% (p<0.01), as measured through SAIL, a national VA quality reporting program.
Conclusions: The QUITS program, a collaboration between hospitalists and clinical psychologists, appears to be effective at supporting cessation among smokers admitted to our facility. Our preliminary cessation outcomes are comparable to other high-intensity inpatient cessation interventions reported in the literature. Additionally, significant improvement in nationally reported tobacco quality metrics was observed following implementation of the program.