Rheumatology Clinic Staff Needs: Barriers and Strategies to Addressing High Blood Pressure and Smoking Risk.

OBJECTIVE: Patients with rheumatologic conditions are at elevated risk of cardiovascular disease (CVD) due to inflammatory and traditional risk factors, such as high blood pressure (BP) and smoking. However, rheumatology clinics rarely address traditional risk factors, although they are routinely assessed and modifiable in primary care. The present study sought to (1) characterize rheumatology clinic staff's work process for addressing high BP and smoking and (2) identify barriers and strategies for effective management of these risk factors. METHODS: We conducted 7 focus groups with medical assistants, nurses, and scheduling staff from 4 adult rheumatology clinics across 2 health systems (BP focus groups, n = 23; smoking, n = 20). Transcripts were analyzed using thematic analysis to elucidate barriers and strategies. RESULTS: We found 3 clinic work processes for the management of high BP and smoking risk: (1) risk identification, (2) follow-up within the clinic, and (3) follow-up with primary care and community resources. Within these processes, we identified barriers and strategies grouped into themes: (1) time, (2) clinic workflows, (3) technology and resources, (4) staff's attitudes and knowledge, and (5) staff's perceptions of patients. The most pervasive barriers were (1) no structured system for follow-up and (2) staff confidence and skill in initiating conversations about health-related behavior change. CONCLUSIONS: Our study identified generalizable gaps in rheumatology staff's work processes and competencies for addressing high BP and smoking in patients. Future efforts to support staff needs should target (1) systems for follow-up within and outside the clinic and (2) conversation support tools.

Impact of a Rheumatology Clinic Protocol on Tobacco Cessation Quit Line Referrals.

OBJECTIVE: Smoking increases cardiopulmonary and rheumatic disease risk, yet tobacco cessation intervention is rare in rheumatology clinics. This study aimed to implement a rheumatology staff-driven protocol, Quit Connect, to increase the rate of electronic referrals (e-referrals) to free, state-run tobacco quit lines. METHODS: We conducted a quasi-experimental cohort study of Quit Connect at 3 rheumatology clinics comparing tobacco quit line referrals from 4 baseline years to referrals during a 6-month intervention period. Nurses and medical assistants were trained to use 2 standardized electronic health record (EHR) prompts to check readiness to quit smoking within 30 days, advise cessation, and connect patients using tobacco quit line e-referral orders. Our objective was to use EHR data to examine the primary outcome of tobacco quit line referrals using pre/post design. RESULTS: Across 54,090 pre- and post-protocol rheumatology clinic visits, 4,601 were with current smokers. We compared outcomes between 4,078 eligible pre-implementation visits and 523 intervention period visits. Post-implementation, the odds of tobacco quit line referral were 26-fold higher compared to our pre-implementation rate (unadjusted odds ratio [OR] 26 [95% confidence interval (95% CI) 6-106]). Adjusted odds of checking readiness to quit in the next 30 days increased over 100-fold compared to pre-implementation (adjusted OR 132 [95% CI 99-177]). Intervention led to e-referrals for 71% of quit-ready patients in <90 seconds; 24% of referred patients reported a quit attempt. CONCLUSION: Implementing Quit Connect in rheumatology clinics was feasible and improved referrals to a state-run tobacco quit line. Given the importance of smoking cessation to reduce cardiopulmonary and rheumatic disease risk, future studies should investigate disseminating cessation protocols like Quit Connect that leverage tobacco quit lines.

Patient Perspectives on Smoking Cessation and Interventions in Rheumatology Clinics.

OBJECTIVE: Although smoking is a risk factor for cardiovascular and rheumatic disease severity, only 10% of rheumatology visits document cessation counseling. After implementing a rheumatology clinic protocol that increased tobacco quitline referrals 20-fold, we undertook this study to examine patients' barriers and facilitators to smoking cessation based on prior rheumatology experiences, to solicit reactions to the new cessation protocol, and to identify patient-centered outcomes or signs of cessation progress following improved care. METHODS: We recruited 19 patients who smoke (12 with rheumatoid arthritis [RA] and 7 with systemic lupus erythematosus [SLE]) to participate in 1 of 3 semistructured focus groups. Transcripts of the focus group discussions were analyzed using thematic analysis to classify barriers, facilitators, and signs of cessation progress. RESULTS: Participant-reported barriers and facilitators to cessation involved psychological, health-related, and social and economic factors, as well as health care messaging and resources. Commonly discussed barriers included viewing smoking as a crutch amid rheumatic disease, rarely receiving cessation counseling in rheumatology clinics, and very limited awareness that smoking can worsen rheumatic diseases or reduce efficacy of some rheumatic disease medications. Participants endorsed our cessation protocol with rheumatology-specific education and accessible resources, such as a quitline. Beyond quitting, participants prioritized knowing why and how to quit as signs of progress outcomes. CONCLUSION: Focus groups identified themes and categories of facilitators/barriers to smoking cessation at the levels of patient and health system. Two key outcomes of improving cessation care for patients with RA and SLE were knowing why and how to quit. Emphasizing rheumatologic health benefits and cessation resources is essential when designing and evaluating rheumatology smoking cessation interventions.