Impact of Adding Telephone-Based Care Coordination to Standard Telephone-Based Smoking Cessation Counseling Post-hospital Discharge: a Randomized Controlled Trial.

BACKGROUND: Cessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation. OBJECTIVE: To compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation. DESIGN: Unblinded, randomized clinical trial PARTICIPANTS: Hospitalized smokers referred from primarily rural hospitals INTERVENTIONS: Counseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker's health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C. MAIN MEASURES: Utilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge. KEY RESULTS: Among 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6-12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)). CONCLUSION: Supplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications. TRIAL REGISTRATION: NCT01063972.

Concomitant HPV and MenACWY vaccination among sixth and seventh graders receiving Tdap.

OBJECTIVE: To describe use of human papilloma virus (HPV) and meningococcal (MenACWY) vaccines among sixth and seventh grade Kansas children receiving their school-required tetanus, diphtheria, and acellular pertussis (Tdap) booster. METHODS: We used Medicaid and commercial claims data in Kansas from 2013, 2014, and 2015 to identify HPV and MenACWY vaccinations among sixth and seventh graders receiving a Tdap booster. Rates of concomitant vaccinations were calculated at the state and county level, and logistic regression was used to identify predictors of concomitant vaccination. RESULTS: Of sixth and seventh graders in Kansas receiving their required Tdap booster, 53-82% failed to receive a concomitant HPV vaccine and 36-47% failed to receive a concomitant MenACWY vaccine from 2013 to 2015. Rates of concomitant vaccinations varied more than four-fold across counties. Female gender, younger age, and Medicaid (versus commercial insurance) were positively associated with concomitant vaccination; concomitant vaccination rates increased from 2013 to 2015 (p < 0.001). Of children continuously enrolled in Medicaid from 2013 to 2015, who did not receive concomitant vaccination in 2013, 72.3% and 68.6% remained unvaccinated against HPV and MenACWY, respectively by the end of 2015. CONCLUSIONS: Failure to get a concomitant vaccination at the time of their Tdap booster identifies children at high risk of not getting immunized in the ensuing 2-3 years. 'Back to school' programs focusing only on school-required vaccinations could have negative impacts on overall vaccination rates. Tracking rates of concomitant vaccination might be useful in supporting quality assessment and improvement efforts. CLINICAL TRIAL REGISTRATION: This study was not a clinical trial.

Effect of Long-term Nicotine Replacement Therapy vs Standard Smoking Cessation for Smokers With Chronic Lung Disease: A Randomized Clinical Trial.

Importance: Smokers with chronic obstructive pulmonary disease (COPD) have particular difficulty quitting. Long-term nicotine replacement therapy (LT-NRT) might offer a strategy for reducing harm from cigarettes and provide a pathway for later cessation. Objective: To compare the effect of LT-NRT vs standard smoking cessation (SSC) on exposure to cigarette smoke, harm related to smoking, and cessation among smokers with COPD. Design, Setting, and Participants: This unblinded, randomized clinical trial recruited smokers who self-reported a diagnosis of COPD at any level of readiness to quit from May 23, 2014, through November 30, 2015. The 12-month follow-up was completed December 6, 2016. Patients were recruited at a clinical research unit of an academic medical center. Analysis was based on intention to treat and performed from March 8 through November 30, 2017. Interventions: Standard smoking cessation treatment included 10 weeks of NRT and 4 follow-up counseling sessions for those willing to make a quit attempt. Long-term NRT included 12 months of NRT and 6 follow-up counseling sessions regardless of initial willingness to quit. Overall, 198 patients were randomized to SSC, and 197 were included in the primary analysis; 200 patients were randomized to LT-NRT, and 197 were included in the primary analysis. Main Outcomes and Measures: The primary outcome was 7-day abstinence verified by carbon monoxide (CO) levels at 12 months. Secondary outcomes included cigarettes smoked per day (CPD), exposure to CO, urinary excretion of 4-methylnitrosamino-1-3-pyridyl-1-butanol (NNAL) (a smoking-related carcinogen), and adverse events. Results: Among 398 patients who were randomized (59.8% female; mean [SD] age, 56.0 [9.3] years), the mean (SD) CPD was 23.1 (12.3). Twelve-month follow-up was completed by 373 participants (93.7%), and 394 (99.0%) were included in the primary analysis. At 12 months, CO-verified abstinence occurred in 23 of 197 participants (11.7%) in the SSC arm and 24 of 197 (12.2%) in the LT-NRT arm (risk difference, 0.5%; 95% CI, -5.9% to 6.9%). Continuing smokers in the SSC and LT-NRT arms had similar, significantly reduced harms caused by smoking, including cigarette consumption by 12.4 and 14.5 CPD, respectively, exhaled CO level by 5.5 and 7.8 ppm, respectively, and mean urinary NNAL excretion by 21.7% and 23.0%, respectively. In multivariate analyses, continuing smokers with greater adherence to NRT experienced less reduction in NNAL exposure. The frequency of major adverse cardiac events was similar in both groups. Conclusions and Relevance: Similar rates of cessation and similar reductions in exposure to tobacco smoke resulted with LT-NRT and SSC. Among continuing smokers, ongoing use of NRT was not associated with reductions in smoke exposure. Trial Registration: ClinicalTrials.gov Identifier: NCT02148445.

Impact of Telephone-Based Care Coordination on Use of Cessation Medications Posthospital Discharge: A Randomized Controlled Trial.

INTRODUCTION: Smokers benefit from ongoing cessation support upon leaving the hospital and returning to their home environment. This study examined the impact of telephone-delivered care coordination on utilization of and adherence to cessation pharmacotherapy after hospital discharge. METHODS: Inpatient smokers (n = 606) were randomized to receive counseling with care coordination (CCC) or counseling alone (C) for smoking cessation. Both groups received written materials and telephone-based cessation counseling during hospitalization and postdischarge. CCC recipients received help in selecting, obtaining, and refilling affordable pharmacotherapy prescriptions during and after hospitalization. Study outcomes included self-reported utilization, duration of use, and type of medication during the 3 months postdischarge. RESULTS: Of the 487 (80%) of participants completing 3-month follow-up, 211 (43.3%) reported using cessation pharmacotherapy postdischarge; this did not differ by study arm (CCC: 44.7%, C: 42.0%, p = .55). Use of pharmacotherapy postdischarge was associated with smoking at least 20 cigarettes/day at baseline (odds ratio [OR]: 1.48; 95% confidence interval [CI]: 1.00-2.19) and receipt of pharmacotherapy during hospitalization (OR: 4.00; 95% CI: 2.39-6.89). Smokers with Medicaid (OR: 2.29; 95% CI: 1.32-4.02) or other insurance (OR: 1.69; 95% CI: 1.01-2.86) were more likely to use pharmacotherapy postdischarge than those with no health care coverage. Less than one in four (23.8% of CCC; 22.2% of C) continued pharmacotherapy beyond 4 weeks. CONCLUSIONS: Supplemental care coordination did not improve use of postdischarge pharmacotherapy beyond that of inpatient treatment and behavioral counseling. Insurance coverage and use of medications during the hospitalization are associated with higher use of evidence-based treatment postdischarge. IMPLICATIONS: Many hospitalized smokers do not receive the benefits of cessation pharmacotherapy postdischarge and telephone quitline programs often fail to help smokers procure pharmacotherapy. Thus, effective strategies are needed to improve utilization and adherence to evidence-based cessation therapies when smokers leave the hospital. We found that use of postdischarge pharmacotherapy was strongly associated with receipt of pharmacotherapy during the hospitalization and with the availability of insurance to cover the costs of treatment. Additional efforts to coordinate pharmacotherapy services did not improve either utilization or adherence to therapy.

Improving Quality of Care for Hospitalized Smokers with HIV: Tobacco Dependence Treatment Referral and Utilization.

BACKGROUND: Most persons living with HIV smoke cigarettes and tend to be highly dependent, heavy smokers. Few such persons receive tobacco treatment, and many die from tobacco-related illness. Although advancements in antiretroviral therapy (ART) have increased the quality and quantity of life, the health harms from tobacco use diminish these gains. Without cessation assistance, thousands will benefit from costly ART, only to suffer the consequences of tobacco-related disease and death. A study was conducted to examine in detail inpatient tobacco treatment for smokers with HIV. METHODS: Data collected at hospital admission and data collected by tobacco treatment specialists were examined retrospectively for all inpatients with HIV who were admitted to an academic medical center for a five-year period. Specifically, the prevalence of cigarette smoking, factors predictive of referral to tobacco treatment, referral for tobacco treatment, treatment participation, and abstinence at six months posttreatment were measured. Differences in referral and treatment participation between all smokers and smokers with HIV were also assessed. RESULTS: Among the 422 admitted persons with HIV, 54.5% smoked and 21.7% were referred to inpatient tobacco treatment services. Substance abuse and tobacco-related diagnoses were predictive of referral to inpatient tobacco treatment specialists. Among the 14 treatment participants reached for follow-up, 11 (78.6%) made quit attempts and 3 (21.4%) reported abstinence. Smokers with HIV were less likely to be referred to and treated by tobacco treatment services than all smokers admitted during the same time frame. CONCLUSIONS: Although tobacco is a major cause of mortality, few smokers with HIV are offered treatment during hospitalization. Those who are treated attempt to quit. Hospitalization offers a prime opportunity for initiating smoking cessation among those with HIV.

Addressing the needs of Latinos with type 2 diabetes through online patient education.

Patients with Type 2 diabetes are increasingly turning to the Web for information about diabetes and self-management. These sites, however, fail to address the cultural and linguistic needs of the growing community of Latinos with diabetes. The Juntos Controlamos la Diabetes Web site was designed as a low-cost patient education tool to be used by patients, caregivers, and healthcare providers to provide ongoing information about diabetes self-management tailored to the needs of the regional Latino community.

Creating patient and family education web sites: assuring accessibility and usability standards.

This article gives details about the methods and processes used to ensure that usability and accessibility were achieved during development of the Home Parenteral Nutrition Family Caregivers Web site, an evidence-based health education Web site for the family members and caregivers of chronically ill patients. This article addresses comprehensive definitions of usability and accessibility and illustrates Web site development according to Section 508 standards and the national Health and Human Services' Research-Based Web Design and Usability Guidelines requirements.

Creating patient and family education web sites: design and content of the home parenteral nutrition family caregivers web site.

When managing chronic illnesses, caregivers repeatedly seek online information about providing complex, long-term care but often neglect to find information about how to care for themselves. Poor health among caregivers is not only detrimental to their own well-being but may also result in harm to those for whom they care. For this reason, caregivers need access to information and activities about caring for themselves in addition to the information about managing home care they are already likely to seek. The HPN Family Caregivers Web site was developed to guide caregivers through the process of caring for themselves by establishing a caregiving routine, self-monitoring their mental and physical health, and practicing good sleep hygiene, while also managing the complexities of home care. While Web site information, activities, and algorithms for managing chronic illnesses need to be specific to each population, the content guiding caregivers to care for their own health is universal.

Comparing patient and nurse specialist reports of causative factors of depression related to heart failure.

PURPOSE: The purpose of this study was to compare participants' and a psychiatric nurse specialist's reports on factors precipitating depression and to validate a depression screening instrument. DESIGN AND METHODS: Participants were screened for and asked to self-report causative factors of their depression. Participants with moderately severe and severe depressive symptoms received a psychiatric nurse specialist assessment. FINDINGS: Participants self-reported several causative factors of depression. The psychiatric nurse specialist discovered these plus additional factors. The screening instrument was found to be reliable and valid for the measurement of depressive symptoms. PRACTICE IMPLICATIONS: Participant self-report identifies many causative factors of depression. The psychiatric nurse specialist identifies additional factors, allowing individualized diagnoses and treatments.

Association of polychlorinated biphenyls (PCBs) with live algae and total lipids in rivers-a field-based approach.

The association of PCBs and live algal cells in rivers was studied at four locations during four seasons in two Wisconsin rivers. Positive relations between particle-associated PCBs and both chlorophyll-a and algal carbon concentrations indicated that live algal cells were a significant sorption phase for dissolved PCBs. Large Pennate diatoms (Navicula, Synedra, Pinnularia, Diatoma, and Cocconeis), or more rarely, Euglenoids (Trachelomonas sp.), dominated most sample assemblages on an algal carbon basis. These assemblages made up the highest percentage of total SOC during spring (average=50%) and lowest during summer (average=15%). At the three impounded sites, most individual PCB congeners were relatively enriched in samples characterized by: (1) high concentrations of algal carbon (as a percent of SOC), (2) algal assemblages dominated (or co-dominated) by Euglenoids, and (3) high concentrations of total lipids. Despite relatively higher masses of sorbed PCBs in the most lipid-rich samples, there was no robust correlation between total lipid content and particle-associated PCBs when aggregating all samples from the study. A possible explanation is that PCBs are associated with other structural components in live algae and (or) departure from chemical equilibrium in the river due to algal growth kinetics. A kinetic uptake model was used to calculate the mass of PCBs associated with the total organic carbon content of live algae. Based on this model, PCBs were enriched in algal cells during bloom seasons (spring and fall) compared to non-bloom seasons (summer and winter). Further, although individual PCB congener partition coefficients (log) to live algal cells (range=5.3-6.4) overlapped to those for detritus (range=3.6-7.4), PCBs tended to be enriched in detrital carbon pools during non-bloom conditions. The larger range of estimated PCB partition coefficients for detritus likely reflects the more heterogeneous nature of this material compared to live algal cells.