Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients.

CONTEXT: Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree. OBJECTIVES: Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families. METHODS: This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness. RESULTS: Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending. CONCLUSIONS: IA is a feasible and reasonable approach to CPR discussions in selected patient populations.

Developing a decision support system for tobacco use counselling using primary care physicians.

BACKGROUND: Clinical decision support systems (CDSS) have the potential to improve adherence to guidelines, but only if they are designed to work in the complex environment of ambulatory clinics as otherwise physicians may not use them. OBJECTIVE: To gain input from primary care physicians in designing a CDSS for smoking cessation to ensure that the design is appropriate to a clinical environment before attempts to test this CDSS in a clinical trial. This approach is of general interest to those designing similar systems. Design and approach: We employed an iterative ethnographic process that used multiple evaluation methods to understand physician preferences and workflow integration. Using results from our prior survey of physicians and clinic managers, we developed a prototype CDSS, validated content and design with an expert panel, and then subjected it to usability testing by physicians, followed by iterative design changes based on their feedback. We then performed clinical testing with individual patients, and conducted field tests of the CDSS in two primary care clinics during which four physicians used it for routine patient visits. RESULTS: The CDSS prototype was substantially modified through these cycles of usability and clinical testing, including removing a potentially fatal design flaw. During field tests in primary care clinics, physicians incorporated the final CDSS prototype into their workflow, and used it to assist in smoking cessation interventions up to eight times daily. CONCLUSIONS: A multi-method evaluation process utilising primary care physicians proved useful for developing a CDSS that was acceptable to physicians and patients, and feasible to use in their clinical environment.

Radon awareness and mitigation in Vermont: a public health survey.

Radon exposure is associated with an increased incidence of lung cancer, and elevated levels may be found in as many as 1 out of 15 homes. The U.S. EPA recommends testing homes for radon and mitigating over the advisory level of 4 picocuries per liter (4 pCi L(-1), or 148 Bq m(-3)). A sample population from a list of Vermont residents who had tested their residence for radon through the Vermont Department of Health and who had elevated levels were mailed a survey to assess demographic characteristics, knowledge about radon, mitigation rates, types of mitigation, as well as barriers to mitigation. The response rate was 63%. Forty-three percent of respondents mitigated. Roughly half were not completely knowledgeable of radon based upon the ability to associate radon exposure with lung cancer risk. Reasons not to mitigate radon levels in homes were cost and lack of concern over elevated levels. A multivariate logistic regression analysis revealed factors associated with mitigating: an education level of college or higher (p = 0.02), concern that a high radon level would affect real estate value (p = 0.04), and home age less than 10 y (p = 0.05). In summary, less than half of Vermonters with elevated radon levels participating in the Department of Health program mitigated. We identify factors associated with radon mitigation that may lead to improved radon education and mitigation practice.

Knowledge and use of office spirometry for the detection of chronic obstructive pulmonary disease by primary care physicians.

BACKGROUND: The importance of office spirometry has been strongly advocated in the pulmonary community, but whether its importance is recognized and accepted by primary care physicians is less well established. METHODS: To assess primary care physicians' knowledge and use of office spirometry for the detection of chronic obstructive pulmonary disease, we conducted a brief mail survey on the local practice of office spirometry, barriers to performing office spirometry, and general knowledge about spirometry. We also provided 60-min educational workshops to assess whether such an approach would increase spirometry testing or perceptions about spirometry. RESULTS: Twenty-nine of 57 (51%) primary care offices responded to the survey. Of these, 66% owned their own spirometer. The most common reasons for not performing spirometry were uncertainty about the impact of the test (41%), physician and staff unfamiliarity (38%), and lack of training (34%). Twenty-one respondents participated in the workshops. In the 3 months following the workshops, the number of spirometry tests increased by 59% (p = 0.004). After the workshops, the proportion of clinics that reported reasons for not performing the test decreased by 13% (p = 0.01), but important barriers to performing office spirometry were still present, including physician and staff unfamiliarity (22%), uncertain interpretation of results (22%), time (22%), and reimbursement (22%). CONCLUSIONS: The general knowledge and use of office spirometry in the primary care community is poor, but can be improved, at least in the short-term, by a simple educational workshop.

Smoking status identification: two managed care organizations' experiences with a pilot project to implement identification systems in independent practice associations.

OBJECTIVE: To determine whether managed care organizations (MCOs) can effectively promote the sustained use of smoking status identification systems among independent practice associations. STUDY DESIGN: Quasi-experimental design measuring smoking status documentation before and after an intervention. METHODS: A chart review of the MCOs' patients at 4 participating primary care clinics determined the baseline for smoking status documentation before intervention. Baseline data were unavailable from a fifth participating clinic. Two quality improvement personnel were sent by the MCOs to help the clinics chose and implement a system for identifying smoking status. All of the clinics chose a sticker system. The change in smoking status documentation was assessed by chart reviews of patients enrolled in the MCOs who were seen during the period between 3 and 16 months after implementation of the system. RESULTS: Following the intervention, a significant increase in smoking status documentation was noted among participating clinics. The proportion of patients whose smoking status was identified and documented by any method increased from 50% to 87% (P < .01) at the 4 clinics with baseline data. By clinic, the increase varied from 6% to 60%. The sticker system was the method by which most patients' smoking status was documented (77%). There were no controls, so the influence of outside factors, including a regional smoking cessation campaign that coincided with this study, cannot be quantified. CONCLUSIONS: Managed care organizations may be an effective change agent for implementing the guidelines for tobacco use and dependence treatment.

Using a guideline-centered approach for the design of a clinical decision support system to promote smoking cessation.

Knowledge acquisition for the design of clinical decision support systems can be facilitated when clinical practice guidelines serve as a knowledge source. We describe application of the Guideline Elements Model (GEM) in the design of a decision support system to promote smoking cessation. Following selection of relevant recommendations and markup of knowledge components with the GEM Cutter editor, the Extractor stylesheet was used to create a list of decision variables and actions for further processing. Decision variables and actions that reflect similar concepts were consolidated. Action types were identified. Extracting the critical concepts from the narrative text facilitates clarification of necessary content. The guideline-centric approach promotes accurate translation of guideline knowledge.

Interest in treatments to stop smoking.

We surveyed 884 Vermont (VT) tobacco smokers by random digit dialing to determine past and future use of treatment. Among those who had recently attempted to quit, 61% had ever used a treatment, 21% had ever used a psychosocial treatment, and 57% had used a medication. Among those who planned to quit in the next month, 68% stated they would use a treatment, 35% would use a psychosocial treatment, and 62% would use a medication. The major predictors of past or future use of treatment were greater cigarettes per day, older age, being a woman, and seeing a health professional. Although this survey suggests many smokers have used or plan to use a smoking cessation treatment, program data indicate less than 10% of VT smokers who try to quit use the state quitline, counseling, or free medication provision. Why smokers do not use these treatments needs to be determined.

Facilitating adherence to the tobacco use treatment guideline with computer-mediated decision support systems: physician and clinic office manager perspectives.

BACKGROUND: A majority of physicians do not adhere to all the elements of the evidence-based USPHS guideline on tobacco use and dependence treatment. Among physicians and clinic office managers in Vermont we assessed perceived barriers to guideline adherence. We then assessed attitudes towards a computer-mediated clinical decision support system (CDSS) to gauge whether this type of intervention could support performance of the guideline. METHODS: A random sample of 600 Vermont primary care and subspecialty physicians were surveyed with a mailed survey instrument. A separate survey instrument was mailed to the census of 93 clinic office managers. RESULTS: The response rates of physicians and clinic office managers were 67% and 76%, respectively. Though most physicians were aware of the guideline and had positive attitudes towards it, there was a lack of familiarity with Vermont's smoking cessation resources as 35% would refer smokers to non-existent counseling resources and only 48% would refer patients to a toll-free quit line. Time constraints and the perception that smokers are unreceptive to counseling were the two most common barriers cited by both physicians and office managers. The vast majority of physicians (92%) have access to a computer in their outpatient clinics, and 68% have used computers during the course of a patient's visit. Four of the eight information management services that a CDSS could provide were highly valued by both physicians and clinic office managers. CONCLUSIONS: Interventions to improve adherence to the guideline should address the inaccurate perception that smokers are unreceptive to counseling, and physicians' lack of familiarity with resources. A CDSS may improve knowledge of these resources if the design addresses cost, space, and time limitations.

Does extended proactive telephone support increase smoking cessation among low-income women using nicotine patches?

BACKGROUND: It is unclear whether proactive telephone support enhances smoking cessation beyond the provision of nicotine replacement therapy alone. METHODS: We randomly assigned 330 low-income women smokers to receive either free nicotine patches (control condition) or free nicotine patches with up to 16 weeks of proactive telephone support (experimental condition). All participants were assessed by telephone at baseline and at 2 weeks, 3 months, and 6 months post-baseline to determine smoking status. RESULTS: Results revealed a significant effect for the telephone support at 3 months, with 43% of experimental versus 26% of control condition women reporting 30-day point prevalent abstinence (P = 0.002). The difference was no longer significant at 6 months. A metaanalysis conducted with five randomized studies revealed a slight but non-significant long-term benefit of proactive telephone support when added to the provision of free nicotine patches for smoking cessation. CONCLUSIONS: This is the second study to demonstrate a short-term effect for proactive telephone support added to free nicotine replacement therapy; however, neither the current study, nor the metaanalysis including the four other published trials, confirmed a longer-term benefit.

Genetic testing for lung cancer risk: if physicians can do it, should they?

Advances in genetics have increased our ability to assess an individual's genetic risk for disease. There is a hypothesis that genetic test results will motivate high-risk individuals to reduce harmful exposures, to increase their surveillance for disease, or to seek preventive treatments. However, genetic testing for genes associated with an increased risk of lung cancer would not change physicians' recommendations regarding smoking cessation. Limited studies suggest that test results that demonstrate an increased risk of lung cancer do not improve smoking cessation success. These test results may even distort an individual's risk perceptions. Before recommending genetic testing to assess risk for disease, physicians need to consider whether knowledge about genetic susceptibility will alter patient management.