Evaluation of a Systems-Based Tobacco Cessation Program Using Bedside Volunteers.

INTRODUCTION: Hospitalization and post-discharge provide an opportune time for tobacco cessation. This study tested the feasibility, uptake, and cessation outcomes of a hospital-based tobacco cessation program, delivered by volunteers to the bedside with post-discharge referral to Quitline services. Patient characteristics associated with Quitline uptake and cessation were assessed. METHODS: Between February and November 2016, trained hospital volunteers approached inpatient tobacco users on six pilot units. Volunteers shared a cessation brochure and used the ASK-ADVISE-CONNECT model to connect ready to quit patients to the Delaware Quitline via fax-referral. Volunteers administered a follow-up survey to all admitted tobacco users via telephone or email at 3-months post-discharge. RESULTS: Of the 743 admitted tobacco users, 531 (72%) were visited by a volunteer, and 97% (531/547) of those approached, accepted the visit. Over one-third (201/531; 38%) were ready to quit and fax-referred to the Quitline, and 36% of those referred accepted Quitline services. At 3 months post-discharge, 37% (135/368) reported not using tobacco in the last 30 days; intent-to-treat cessation rate was 18% (135/743). In a multivariable regression model of Quitline fax-referral completion, receiving nicotine replacement therapy (NRT) during hospitalization was the strongest predictor (odds ratios [OR] = 1.97; 95% confidence interval [CI] = 1.34 to 2.90). In a model of 3-month cessation, receiving Quitline services (OR = 3.21, 95% CI = 1.35 to 7.68) and having coronary artery disease (OR = 2.28; 95% CI = 1.11 to 4.68) were associated with tobacco cessation, but a volunteer visit was not. CONCLUSIONS: An "opt-out" tobacco cessation service using trained volunteers is feasible for connecting patients to Quitline services. IMPLICATIONS: This study demonstrates the feasibility of a systems-based approach to link inpatients to evidence-based treatment for tobacco use. This model used trained bedside volunteers to connect inpatients to a state-funded Quitline after discharge that offers free cessation treatment of telephone coaching and cessation medications. Receiving NRT during hospitalization positively impacted Quitline referral, and engagement with Quitline resources was critical to tobacco abstinence post-discharge. Future work is needed to evaluate the cost-effectiveness and sustainability of this volunteer model.

Quitline Treatment Enrollment and Cessation Outcomes Among Smokers Linked With Treatment via Ask-Advise-Connect: Comparisons Among Smokers With and Without HIV.

INTRODUCTION: Given that people living with HIV (PLWH) are disproportionately burdened by tobacco-related morbidity and mortality, it is critically important to understand the degree to which evidence-based cessation interventions are utilized by and are effective among PLWH. AIMS AND METHODS: This secondary data analysis aimed to examine differences in Quitline treatment enrollment and 6-month cessation outcomes among smokers seeking care at 1 HIV clinic and 12 non-HIV clinics that were part of a large healthcare system in the greater Houston, Texas metropolitan area, United States. Data were from a 34-month (April 2013-February 2016) one-group implementation trial that evaluated the Ask-Advise-Connect (AAC) approach to linking smokers with Quitline treatment. Primary outcomes included (1) treatment enrollment and (2) 6-month self-reported and biochemically confirmed abstinence. RESULTS: The smoking status of 218 915 unique patients was recorded in the electronic health record; 5285 (2.7%) of these patients were seen at the HIV clinic where the smoking prevalence was 45.9%; smoking prevalence at the non-HIV clinics was 17.9%. The proportion of identified smokers who enrolled in treatment was 10.8% at the HIV clinic and 11.8% at the non-HIV clinics. The self-reported abstinence rate was 18.7% among HIV clinic patients and 16.5% among non-HIV clinic patients. Biochemically confirmed abstinence was lower at 4.2% and 4.5%, respectively (all ps > .05). CONCLUSIONS: AAC resulted in rates of Quitline treatment enrollment and abstinence rates that were comparable among patients seen at an HIV clinic and non-HIV clinics. Findings suggest that AAC should be considered for widespread implementation in HIV clinics. IMPLICATIONS: PLWH were as likely as other patients to enroll in evidence-based tobacco cessation treatment when it was offered in the context of a primary care visit. Cessation outcomes were also comparable. Therefore, standard care for PLWH should include routine screening for smoking status and referrals to cessation treatment.

Telephone-Based Shared Decision-making for Lung Cancer Screening in Primary Care.

The national rate of  lung cancer screening, approximately 3-5%, is too low and strategies which include shared decision-making and increase screening are needed. A feasibility study in one large primary care practice of telephone-based delivery of decision support via an online tool, the Decision Counseling Program© (DCP) was administered to patients eligible for lung cancer screening according to USPSTF screening guidelines. We collected data on demographics, decisional conflict, and conducted chart audits to ascertain screening. From electronic medical record data, we identified 829 age-eligible current or former smokers. Of the 297 individuals reached, 54 were eligible and 28 were recruited to the study and 20 underwent the DCP© intervention. Participants in the intervention were more likely to complete low-dose CT scans at 90 days. Current smokers were less likely to complete the DCP. Women were less likely to complete LDCT. This non-persuasive, high-quality shared decision-making intervention significantly increased lung cancer screening and was feasible in real-world clinical care. This intervention offers a promising model whereby patients can be supported in a decision, based on their values and beliefs while also supporting gains in lung cancer screening.

Reducing Missed Appointments for Patients With HIV: An Evidence-Based Approach.

BACKGROUND: High rates of missed appointments for routine HIV care are associated with unsuppressed viremia, increasing morbidity. LOCAL PROBLEM: The Clinic no-show rate ranged between 30% and 35%, and only 69% of patients were considered retained in care within a 24-month time frame. METHODS: The Woodward Risk Prediction Tool was completed on all patients to stratify patient risk for missing the next appointment. INTERVENTIONS: All patients were offered text message along with standard phone message appointment reminders, and patients who missed appointments were called within 24 hours to reschedule. Medium-risk patients received a previsit planning call to remove barriers to appointment attendance, and high-risk patients received a home visit from the peer navigator. RESULTS: The project resulted in a 3.8% reduction rate in the overall no-show rate in the first 5 months of implementation. Using risk stratification and targeted interventions allowed valuable resources to be allocated where they were needed.

Nurse-led postdischarge telephone follow-up calls: A mixed study systematic review.

AIMS AND OBJECTIVES: To explore the quantitative and qualitative literature on the impact of nurse-led postdischarge telephone follow-up (TFU) call interventions on patient outcomes. BACKGROUND: Adverse patient outcomes such as postdischarge problems, premature contact with health systems, inability to self-manage conditions and hospital readmissions all have an impact on the health and well-being, and satisfaction of patients as well as a financial impact on healthcare systems. DESIGN: A mixed-study systematic review. REVIEW METHODS: A systematic search of CINAHL, Ebsco, PubMed, Quest and Cinch-Health databases was undertaken using the key terms "nurs*," "nurse-led," "nurse initiated," "discharge," "hospital," "telephone," "follow-up" and "telephone follow-up" to identify relevant original peer-reviewed studies published between 2010-2016. Ten articles were selected for inclusion. The selected papers were critically appraised. A sequential explanatory approach with a convergent synthesis was used to report findings following PRISMA guidelines. RESULTS: The findings demonstrate that nurse-led TFU interventions have the potential to improve patient outcomes. The studies suggest patient satisfaction with TFU is one of the strongest positive outcomes from the interventions. However, the results do not support improvement in patient readmission or mortality. CONCLUSIONS: Of the 10 studies reviewed, only two were methodologically strong limiting the conclusions that can be drawn from the current research on this topic. Telephone follow-up interventions improve patient satisfaction and have the potential to meet patient information and communication needs, improve self-management and follow-up appointment attendance and reduce postdischarge problems. Further research is required to explore patients' perceptions of the most useful content of TFU calls, the efficacy of TFU calls and nurses' perceptions and experiences of conducting TFU interventions. RELEVANCE TO CLINICAL PRACTICE: When conducted by a nurse, these interventions have the potential to enhance postdischarge care to patients and meet care needs. Patients perceive TFU as acceptable and are satisfied with this form of postdischarge care.

A 3-Arm randomised controlled trial of Communicating Healthy Beginnings Advice by Telephone (CHAT) to mothers with infants to prevent childhood obesity.

BACKGROUND: With an increasing prevalence of obesity in young children globally, there is an urgent need for the development of effective early interventions. A previous Healthy Beginnings Trial using a nurse-led home visiting program has demonstrated that providing mothers with evidence-based advice can improve maternal practice regarding obesity prevention, and can reduce Body Mass Index (BMI) in the first few years of life. However, the costs for scale-up of home visiting limit its population reach. This trial aims to determine the efficacy of Communicating Healthy Beginnings Advice by Telephone (CHAT) to mothers with infants in improving infant feeding practices and preventing the early onset of childhood overweight and obesity. METHODS/DESIGN: We propose a 3-arm randomised controlled trial (RCT) with a consecutive sample of 1056 mothers with their newborn children in New South Wales (NSW) Australia. Pregnant women who are between weeks 28 and 34 of their pregnancy will be invited to participate in the CHAT trial. Informed consent will be obtained, and after baseline data collection, participants will be randomly allocated to the telephone intervention, text messaging intervention, or the control group. The intervention comprises telephone consultations or text messages, together with 6 intervention packages being mailed at specific times from the third trimester of pregnancy until 12 months post birth. The main trial outcome measures include a) duration of breastfeeding, b) timing of introduction of solids, c) nutrition behaviours, physical activity and television viewing, and d) weight and BMI z-score at 12 and 24 months, e) cost-effectiveness, as well as f) feasibility and acceptability of the interventions. DISCUSSION: The results will ascertain whether early intervention using telephone consultation or text messaging together with staged mailed intervention resources can be feasible and effective in improving infant feeding practices, physical activity and reducing children's BMI in the early years of life. If proven to be feasible, effective as well as cost-effective, the trial results will inform a series of recommendations for policy and practice related to promoting healthy infant feeding and physical activity in young children in the first years of life. TRIAL REGISTRATION: The CHAT Trial is registered with the Australian Clinical Trial Registry ( ACTRN12616001470482p ). It was registered on October 21, 2016.

Use and effectiveness of quitlines versus Web-based tobacco cessation interventions among 4 state tobacco control programs.

BACKGROUND: Comparative effectiveness studies of state tobacco quitlines and Web-based tobacco cessation interventions are limited. In 2009, the US Centers for Disease Control and Prevention undertook a study of the comparative effectiveness of state quitlines and Web-based tobacco cessation interventions. METHODS: Standardized questionnaires were administered to smokers who enrolled exclusively in either quitlines or Web-based tobacco cessation services in 4 states in 2011-2012. The primary outcome was the 30-day point prevalence abstinence (PPA) rate at 7 months both between and within interventions. RESULTS: A total of 4086 participants were included in the analysis. Quitline users were significantly older, more heterogeneous in terms of race and ethnicity, less educated, less likely to be employed, and more often single than Web-based users. The 7-month 30-day PPA rate was 32% for quitline users and 27% for Web-based users. Multivariate models comparing 30-day PPA rates between interventions indicated that significantly increased odds of quitting were associated with being partnered, not living with another smoker, low baseline cigarette use, and more interactions with the intervention. After adjustments for demographic and tobacco use characteristics, quitline users had 1.26 the odds of being abstinent in comparison with Web-based users (95% confidence interval, 1.00-1.58; P = .053). CONCLUSIONS: This is one of the largest comparative effectiveness studies of state tobacco cessation interventions to date. These findings will help public health agencies develop and tailor evidence-based tobacco cessation programs. Further research should focus on users of Web-based cessation interventions sponsored by state health departments and their cost-effectiveness.

Innovative strategies to improve diabetes outcomes in disadvantaged populations.

Diabetes disproportionately affects disadvantaged populations. Eighty percent of deaths directly caused by diabetes occurred in low- and middle-income countries. In high-income countries, there are marked disparities in diabetes control among racial/ethnic minorities and those with low socio-economic status. Innovative, effective and cost-effective strategies are needed to improve diabetes outcomes in these populations. Technological advances, peer educators and community health workers have expanded methodologies to reach, educate and monitor individuals with diabetes. In the present manuscript we review the outcomes of these strategies, and describe the barriers to and facilitators of these approaches for improving diabetes outcomes.

A psychosocial oncology program: perceptions of the telephone-triage assessment.

PURPOSE: Cancer can be a significant source of distress for patients and family members, which led to the creation of psychosocial oncology (PSO) programs across Canada. To access the PSO program at this institution, individuals are first triaged over the telephone by a clinical nurse specialist (CNS) who also provides psychosocial support during the call. In our study, we explored the perceptions of cancer patients or family members about their psychosocial telephone-triage assessment conducted by a CNS for a PSO program. METHODS: A qualitative descriptive design was used to explore the perceptions of nine cancer patients and family members triaged by the CNS for the PSO program. Audiotaped in-person interviews were transcribed verbatim and analyzed for themes and categories using a constant comparative method. RESULTS: Three major themes emerged: (1) Triage as a bridge to care, referred to the structure of telephone-triage and link to psychosocial services; (2) feeling a supportive presence, referred to the CNS' actions to foster a therapeutic relationship; and (3) different paths to tailored care, referred to the individualized strategies targeted to the participant's unique needs. As most participants described trusting the CNS, these three themes were found to emerge through a lens of trust. CONCLUSION: Overall, the telephone triage was able to address the concerns of many participants and provide individualized coping strategies and support. This study further demonstrates that psychosocial support can be provided during triage over the telephone.

Evaluation of the telephone and clinical NHS urgent dental service in Sheffield.

OBJECTIVE: Evaluate an NHS in- and out-of-hours urgent dental service (UDS) including both a telephone triage provider (TTP) and a sole clinical provider (CP) using a quality framework. BASIC RESEARCH DESIGN: Analysis of activity and patient experience data. MAIN OUTCOME MEASURES: Ratio of volume of services to activity provided; distance and time travelled; appropriateness of referrals and treatments; equity of utilisation; patient experience; cost per patient. RESULTS: Almost all calls (96.6%) to the TTP were answered within 60 seconds and of people referred to the CP 96.0% needed treatment. Proportionately more people from deprived areas used the TTP. Highest utilisation of the TTP was by people aged 20 to 44 years and lowest was by people over 54 years. Cost per patient utilising the TTP was £5.06. Of the available appointments provided by the CP, 90.9% were booked the TTP. Travel time to the CP was less than 30 minutes for 78.0% of patients. Of treatments provided, 77.9% were clinical interventions and 18.1% were prescription only. Proportionately more people from deprived areas attended the CP. Highest utilisation was by people aged 20 to 44 years and lowest by people over 54 years. Nearly half (47.0%) of those attending reported they did not have a dentist. There was a high level of patient satisfaction. Cost per course of treatment at the CP was £67.41. CONCLUSION: Overall the UDS provided a high quality service in line with Maxwell's dimensions of quality. Timely advice and treatment was provided with high levels of patient satisfaction with the CP. Comparison with other urgent dental service models would determine the relative efficiency of the UDS.

Listening to the nurse pays off: an integrated Nurse HealthLine programme was associated with significant cost savings.

AIM: To estimate the relationship between adherence to nurse recommendations about where to seek care and expenditures for health-care services received by callers to a Nurse HealthLine telephone-based triage programme. METHODS: Health-care utilization and claims data from callers to the Nurse HealthLine were included. Adherent callers were those who followed the nurse recommendations, while those who did not were classified as non-adherent. Programme-related savings were estimated using differences in downstream health-care expenditures between adherent and non-adherent callers after using multivariate modelling to adjust for between-group differences. RESULTS: Fifty-five per cent of callers were adherent. Nurses were over three times as likely (41% vs. 13%) to recommend seeking a higher level of care (e.g. emergency room vs. urgent care). Regression analyses showed that the impact of getting members to the appropriate place of care was associated with significant annual savings of $13.8 million (P < 0.05), attributable mostly to Medicare, generating a positive return on investment of $1.59. CONCLUSIONS: This is the first known Nurse HealthLine triage programme exclusively for Medicare beneficiaries with supplemental coverage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should consider promoting telephone-based triage programmes as complementary to clinical nursing, which has a direct impact on health-care utilization and costs.

Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus Bacteremia.

BACKGROUND: Infectious disease specialist (IDS) consultation improves the outcome of Staphylococcus aureus bacteremia (SAB). Although telephone consultations constitute a substantial part of IDS consultations, their impact on treatment outcome lacks evaluation. METHODS: We retrospectively followed 342 SAB episodes with 90-day follow-up, excluding 5 methicillin-resistant S. aureus SAB cases. Patients were grouped according to bedside, telephone, or no IDS consultation within the first week. Patients with fatal outcome within 3 days after onset of SAB were excluded to allow for the possibility of death occurring before IDS consultation. RESULTS: Seventy-two percent of patients received bedside, 18% telephone, and 10% no IDS consultation. Patients with bedside consultation were less often treated in an intensive care unit during the first 3 days compared to those with telephone consultation (odds ratio [OR], 0.53; 95% confidence interval [CI], .29-.97; P = .037; 21% vs 34%), with no other initial differences between these groups. Patients with bedside consultation more often had deep infection foci localized as compared to patients with telephone consultation (OR, 3.11; 95% CI, 1.74-5.57; P < .0001; 78% vs 53%). Patients with bedside consultation had lower mortality than patients with telephone consultation at 7 days (OR, 0.09; 95% CI, .02-.49; P = .001; 1% vs 8%), at 28 days (OR, 0.27; 95% CI, .11-.65; P = .002; 5% vs 16%) and at 90 days (OR, 0.25; 95% CI, .13-.51; P < .0001; 9% vs 29%). Considering all prognostic markers, 90-day mortality for telephone-consultation patients was higher (OR, 2.31; CI, 95% 1.22-4.38; P = .01) as compared to bedside consultation. CONCLUSIONS: Telephone IDS consultation is inferior to bedside IDS consultation.

Supporting health behaviour change in chronic obstructive pulmonary disease with telephone health-mentoring: insights from a qualitative study.

BACKGROUND: Adoption and maintenance of healthy behaviours is pivotal to chronic disease self-management as this influences disease progression and impact. This qualitative study investigated health behaviour changes adopted by participants with moderate or severe chronic obstructive pulmonary disease (COPD) recruited to a randomised controlled study of telephone-delivered health-mentoring. METHODS: Community nurses trained as health-mentors used a patient-centred approach with COPD patients recruited in general practice to facilitate behaviour change, using a framework of health behaviours; 'SNAPPS' Smoking, Nutrition, Alcohol, Physical activity, Psychosocial well-being, and Symptom management, through regular phone calls over 12 months. Semi-structured interviews in a purposive sample sought feedback on mentoring and behaviour changes adopted. Interviews were analysed using iterative thematic and interpretative content approaches by two investigators. RESULTS: Of 90 participants allocated to health-mentoring, 65 (72%) were invited for interview at 12-month follow up. The 44 interviewees, 75% with moderate COPD, had a median of 13 mentor contacts over 12 months, range 5-20. Interviewed participants (n=44, 55% male, 43% current smokers, 75% moderate COPD) were representative of the total group with a mean age 65 years while 82% had at least one additional co-morbid chronic condition. Telephone delivery was highly acceptable and enabled good rapport. Participants rated 'being listened to by a caring health professional' as very valuable. Three participant groups were identified by attitude to health behaviour change: 14 (32%) actively making changes; 18 (41%) open to and making some changes and 12 (27%) more resistant to change. COPD severity or current smoking status was not related to group category. Mentoring increased awareness of COPD effects, helping develop and personalise behaviour change strategies, even by those not actively making changes. Physical activity was targeted by 43 (98%) participants and smoking by 14 (74%) current smokers with 21% reporting quitting. Motivation to maintain changes was increased by mentor support. CONCLUSIONS: Telephone delivery of health-mentoring is feasible and acceptable to people with COPD in primary care. Health behaviours targeted by this population, mostly with moderate disease, were mainly physical activity and smoking reduction or cessation. Health-mentoring increased motivation and assisted people to develop strategies for making and sustaining beneficial change. TRIAL REGISTRATION: ACTR12608000112368.

Understanding the barriers to use of free, proactive telephone counseling for tobacco dependence.

We sought to gain an empirical and practical understanding of the barriers experienced by residents of the Mississippi River Delta in Arkansas to using the free, proactive telephone counseling (quitline) for tobacco dependence. Barriers included a lack of appropriate telephone service, lack of knowledge about the quitline, and lack of trust in the providers, as well as multiple root causes to seeking and achieving abstinence from tobacco, including stress related to the poor socioeconomic context and concerns about negative health effects of quitting. A strong belief in the role of faith was expressed. Participants suggested strategies for increasing knowledge and trust levels, but were not hopeful about addressing root causes. Given the considerable resources being allocated to quitlines and the burden of tobacco use and disease in lower socioeconomic and minority groups, understanding utilization of quitlines by these groups has implications for policy development, the promotion of quitlines, and the provision of alternate tobacco treatment services.

Interactional misalignment in the UK NHS 111 healthcare telephone triage service.

BACKGROUND: A recent review of primary care serious incidents suggests that diagnosis and assessment problems, underpinned by communication failures, involving the UK telephone triage service, NHS 111, may contribute to patient harm. METHODS: The present study utilised conversation analysis to address the lack of evaluative research examining the NHS 111 system and in particular interactions between system components (call handler, computerized decision support system, patients/caller). RESULTS: Analysis of audio recorded call interactions revealed interactional misalignment across four mapped call phases (eliciting caller details, establishing reason for call, completing the Pathways assessment, and agreeing the outcome). This misalignment has the capacity to increase the risk of system failure, particularly in relation to assessment problems and issues related to the accurate transfer of care advice. Our analysis suggests that efforts to enhance the NHS 111 system, similar telehealth services, and patient safety management more generally, should shift their focus from a limited set of individual components towards a system-specific interactionist perspective encompassing all elements. CONCLUSIONS: Further evaluative research is required in order to build a comprehensive evidence-base concerning the multiple interacting factors influencing patient safety in the NHS 111 system.