A Perioperative Smoking Cessation Intervention With Varenicline, Counseling, and Fax Referral to a Telephone Quitline Versus a Brief Intervention: A Randomized Controlled Trial.

BACKGROUND: The effectiveness of perioperative interventions to quit smoking with varenicline has not been compared with brief interventions. Our objective was to determine the efficacy of a comprehensive smoking cessation program versus a brief intervention for smoking cessation. METHODS: In this prospective, multicenter study, 296 patients were randomized to participate in a smoking cessation program (one 10- to 15-minute counseling session, pharmacotherapy with varenicline, an educational pamphlet, and a fax referral to a telephone quitline); or brief advice and self-referral to a telephone quitline. The primary outcome was the 7-day point prevalence (PP) abstinence at 12 months after surgery. Secondary outcomes included abstinence at 1, 3, and 6 months. Multivariable generalized linear regression was used to identify independent variables related to abstinence. RESULTS: The 7-day PP abstinence for the smoking cessation program versus brief advice group was 42.4% vs 26.2% (relative risk [RR], 1.62; 95% confidence interval [CI], 1.16-2.25; P = .003) at 12 months. The 7-day PP abstinence at 1, 3, and 6 months was higher in the smoking cessation group versus the brief advice group: 45.7% vs 25.5% (RR, 1.79; 95% CI, 1.29-2.49; P < .001), 46.4% vs 26.9% (RR, 1.72; 95% CI, 1.25-2.37; P< .001), and 45.0% vs 26.2% (RR, 1.72; 95% CI, 1.24-2.38; P < .001), respectively. Participating in the smoking cessation group predicted abstinence at 12 months (RR, 1.58; 95% CI, 1.12-2.21; P = .0087). CONCLUSIONS: A perioperative smoking cessation program with counseling, pharmacotherapy with varenicline, an educational pamphlet, and a fax referral to a quitline increased abstinence from smoking 1, 3, 6, and 12 months after surgery versus a brief intervention.

[Fax Survey to Elucidate the Information Needs of General Practitioners in Lower Saxony Regarding the Topic of Medical Implants]. / Faxumfrage zum Informationsbedarf niedersächsischer Hausärzte zum Thema "Medizinische Implantate".

Background: Medial implants help a multitude of patients to gain more health, mobility and thus, quality of life. In collaboration with a still growing expectation of life especially, i.e., within Western industrial countries, this has led to an increasing use of implants over the last years. However, although biomechanical characteristics of modern implant materials have improved considerably, one big challenge still exists - the implant-associated infection. Early diagnostic and therapeutic interventions could clearly mitigate this issue, but are general practitioners sufficiently informed regarding this topic? Material and Methods: In March 2013 and in close cooperation with the Lower Saxony association of general practitioners, we initiated a survey to elucidate the information demands of general practitioners regarding the topic of medical implants. A total of 939 members of the association were contacted via fax and 101 (10.8 %) responded. Based on the obtained data, we then evaluated which topics are most interesting for this group of medical professionals. Results: The survey clearly indicates that general practitioners request more general implant-related data, e.g., type and specification of an implant as well as its location within the individual patient and contact addresses of the implanting hospital, but also want more specific information regarding diagnostic and therapeutic strategies in the case of implant-associated complications. Conclusion: The present article reports in detail on the conducted fax survey and shows some initial strategies as to how the identified challenges might be faced.

Smoothing out the transition of care between maternity and child and family health services: perspectives of child and family health nurses and midwives'.

BACKGROUND: In Australia, women who give birth are transitioned from maternity services to child and health services once their baby is born. This horizontal integration of services is known as Transition of Care (ToC). Little is known of the scope and processes of ToC for new mothers and the most effective way to provide continuity of services. The aim of this paper is to explore and describe the ToC between maternity services to CFH services from the perspective of Australian midwives and child and family health (CFH) nurses. METHOD: This paper reports findings from phase two of a three phase mixed methods study investigating the feasibility of implementing a national approach to CFH services in Australia (the CHoRUS study). Data were collected through a national survey of midwives (n = 655) and CFH nurses (n = 1098). Issues specifically related to ToC between maternity services and CFH services were examined using descriptive statistics and content analysis of qualitative responses. RESULTS: Respondents described the ToC between maternity services and CFH services as problematic. Key problems identified included communication between professionals and services and transfer of client information. Issues related to staff shortages, early maternity discharge, limited interface between private and public health systems and tension around role boundaries were also reported. Midwives and CFH nurses emphasised that these issues were more difficult for families with identified social and emotional health concerns. Strategies identified by respondents to improve ToC included improving electronic transfer of information, regular meetings between maternity and CFH services, and establishment of liaison roles. CONCLUSION: Significant problems exist around the ToC for all families but particularly for families with identified risks. Improved ToC will require substantial changes in information transfer processes and in the professional relationships which currently exist between maternity and CFH services.

Effects of immediate telephone follow-up with providers on sweat chloride test timing after cystic fibrosis newborn screening identifies a single mutation.

OBJECTIVE: To assess whether reporting "possible cystic fibrosis (CF)" newborn screening (NBS) results via fax plus simultaneous telephone contact with primary care providers (PCPs) versus fax alone influenced 3 outcomes: undergoing a sweat chloride test, age at sweat chloride testing, and undergoing sweat testing before age 8 weeks. STUDY DESIGN: This was a retrospective cohort comparison of infants born in Wisconsin whose PCP received a telephone intervention (n = 301) versus recent historical controls whose PCP did not (n = 355). Intervention data were collected during a longitudinal research and quality improvement effort; deidentified comparison data were constructed from auxiliary NBS tracking information. Parametric and nonparametric statistical analyses were performed for group differences. RESULTS: Most infants (92%) with "possible CF" NBS results whose PCP lacked telephone intervention ultimately underwent sweat testing, underlining efficacy for fax-only reporting. Telephone intervention was significantly associated with improvements in the infants undergoing sweat testing at age ≤6 weeks and <8 weeks and a slight, statistically nonsignificant 3.5-day reduction in the infants' age at sweat testing. The effect of telephone intervention was greater for PCPs whose patients underwent sweat testing at community-affiliated medical centers versus those whose patients did so at academic medical centers (P = .008). CONCLUSION: Reporting "possible CF" NBS results via fax plus simultaneous telephone follow-up with PCPs increases the rate of sweat chloride testing before 8 weeks of age, when affected infants are more likely to receive full benefits of early diagnosis and treatment.

Evaluation of a drug-drug interaction: fax alert intervention program.

BACKGROUND: Clinicians often encounter information about drug-drug interactions (DDIs) during clinical practice. This information is found within product information (hardcopy and electronic) and various electronic systems. Prescribers may receive medication-related communications in practice that are distributed by facsimile (fax), mail, or telephone from pharmacies and pharmacy benefit managers (PBMs). The purpose of this study was to determine if near-real time fax alerts for potential drug-drug interactions (PDDIs) would influence prescribing. METHODS: A prospective study, in cooperation with a pharmacy benefit manager (PBM), was conducted targeting 18 clinically important PDDIs. Fax alerts included an individualized letter to the prescriber with a list of the interacting drugs, PDDI evidence summaries with citations, and recommended clinical management strategies. Among the 18 PDDIs, 13 PDDIs could be assessed for prescription therapy changes using pharmacy claims data. A prospective cohort design was used to evaluate changes in prescription dispensing 90-days following a PDDI fax alert. RESULTS: A total of 8,075 fax alerts were sent to prescribers and there were 4,712 alerts for the 13 PDDIs that could be assessed for change using pharmacy claims data. There were 2,019 patients (interventions) for which fax alerts were sent to their prescribers who were matched with a control group consisting of patients with the same PDDIs but for whom no fax alert was sent. Overall, this study found 154 (7.6%) of patients in the fax alert group compared to 132 (6.5%) in the control group had changes in therapy (p = 0.177). CONCLUSIONS: This fax alert intervention program observed no statistically significant differences in prescribing with a fax alert compared to the control group. If PBMs chose to send individualized, evidence-based information to clinicians regarding drug-drug interactions, this study suggests it may not be an effective intervention to mitigate harm.

Initial experience of mobile cloud ECG system contributing to the shortening of door to balloon time in an acute myocardial infarction patient.

It is important for myocardial infarction patients to undergo immediate reperfusion of the affected coronary artery. In order to improve the prognosis, efforts to shorten the door to balloon time to within 90 minutes have been made. However, conventional methods such as faxing electrocardiograms (ECG) have not become widespread due to their high cost and lack of sharpness of the ECG. The "Doctor Car" (rapid response car system) of Kitasato University Hospital is now equipped with a Mobile Cloud ECG system. With this system, 12-lead ECG data obtained in the field are transmitted to the cloud server via a standard mobile telephone network. Since it uses an existing phone network, the cost of this system is low and it is fairly reliable. Cardiologists at the hospital read the ECG waveforms on the cloud server and decide whether emergency cardiac catheterization is necessary. In our fi rst case using this Mobile Cloud ECG system, the door to balloon time could be shortened.

Encouraging smoking cessation during pregnancy in West Virginia: using Fax-to-Quit as a cessation strategy.

Despite known dangers of smoking, a majority of pregnant women continue to smoke or relapse following delivery. West Virginia women have high unmet needs for smoking cessation, and the prenatal period presents a critical and unique opportunity for education and quitting assistance. West Virginia's Fax-to-Quit program uses provider-faxed referrals to the Quitline to engage smokers and connect them with cessation services. A 12-month feasibility evaluation of this Fax-to-Quit program for pregnant women was conducted. In February 2009, providers and staff from three OB/GYN clinics in three adjoining West Virginia counties were recruited. All participating sites received an intensive half-day training program. Adult pregnant smokers receiving prenatal care in these OB/GYN clinic sites were eligible to participate. Recruitment sites screened pregnant women for smoking; assessed readiness-to-quit; and enrolled consenting participants in the Fax-to-Quit Program. The Quitline measured cessation attempts with six-month follow-up of enrolled participants. Between March-December 2009, 58 referrals were made at these OB/GYN clinic sites, with 15 women (25.9%) enrolling in Quitline services. These enrolled women account for approximately one-quarter of calls from pregnant smokers to the West Virginia Quitline in the past 12 months. Contact, communication, and cooperation with office staff were relevant and important to successful project implementation. Findings indicate that Fax-to-Quit is feasible to engage providers and pregnant smokers with the West Virginia Quitline. Successful referrals and enrollment demonstrate Fax-to-Quit may support cessation by increasing Quitline use and connecting pregnant women who smoke with quitting services through provider-faxed referrals to the West Virginia Quitline.

Integrating tobacco cessation quitlines into health care: Massachusetts, 2002-2011.

QuitWorks is a Massachusetts referral program that links health care organizations, providers, and patients to the state's tobacco cessation quitline and provides feedback reporting. Designed collaboratively with all major Massachusetts health plans, QuitWorks was launched in April 2002. In 2010, approximately 340 institutions and practices used QuitWorks. Between April 2002 and March 2011, approximately 3,000 unique providers referred patients and 32,967 tobacco users received referrals. An analysis of QuitWorks data showed 3 phases in referrals between April 2002 and March 2011: referrals increased from April 2002 through November 2005, plateaued during December 2005 through January 2009, then substantially increased during February 2009 through March 2011. Factors responsible include partnerships with stakeholders, periodic program promotions, hospital activities in response to Joint Commission tobacco use measures, service evolutions, provision of nicotine replacement therapy for referred patients, and electronic referral options. QuitWorks' history demonstrates that tobacco cessation referral programs can be successfully sustained over time; reach substantial numbers of tobacco users, benefit providers and health care organizations; and contribute to sustainable systems-level changes in health care.

Electrocardiograms transmitted via facsimile may not allow accurate interval interpretation.

BACKGROUND: Electrocardiograms (ECGs) are sent via facsimile by pediatricians and psychiatrists to cardiologists for assessment. The validity of this method of transmission has not been established. METHODS: ECGs were collected from 100 consecutive patients from the cardiology clinic of the Children's Hospital at Montefiore. The ECGs were faxed and also electronically faxed (efax) and printed. Two electrophysiologists (EP1 and EP2) interpreted the intervals on original, faxed, and efaxed ECGs and intervals (RR, PR, and QT) were compared. A three-way analysis of variance to examine differences between raters, among ECG intervals, and among methods (repeated factor) was performed. Because no interaction terms were significant, a Duncan's multiple range test was used to evaluate where differences occurred among the three intervals and three methods, given these main effects were significant. RESULTS: The difference between raters EP1 and EP2 was not significant (P = 0.6681). Although the interval measurements of the faxed and efaxed ECGs were not significantly different from each other (P > 0.05), each was significantly different from the original across all three ECG intervals and both raters (P = 0.0138). The RR interval yielded mean (SD) values for the original, faxed, and efaxed methods of 0.6986 seconds (0.2074), 0.6646 seconds (0.1938), and 0.6838 seconds (0.1935), respectively. For the QT interval, the mean (SD) values for the original, faxed, and efaxed methods were 0.3370 seconds (0.0524), 0.32134 seconds (0.0466), and 0.3284 seconds (0.0515), respectively. CONCLUSIONS: ECG transmission via facsimile or efax may introduce significant distortion of the intervals. Alternative means of sending ECGs for interpretation should be considered.

A comparison of faxed referrals and eConsult questions for rheumatology referrals: a descriptive study.

BACKGROUND: In Canada, wait times for access to specialized rheumatology services have increased, leading to new strategies to improve timely care; electronic consultations (eConsults) enable providers to ask specialists a clinical question using a secure platform, often reducing the need for a face-to-face visit. In this study, we sought to compare the types of referrals received through fax versus eConsult and to determine whether faxed referrals could be addressed using eConsult. METHODS: We conducted a descriptive study of consecutive faxed referrals sent to a tertiary care centre between Feb. 1 and Mar. 6, 2017, and a convenience sample of eConsults directed to rheumatology between Feb. 1, 2015, and Sept. 30, 2016, through the Champlain BASE eConsult Service, an Ontario-based service. We reviewed all referrals and categorized them by clinical content and question type. A rheumatologist with experience completing eConsult referrals assessed faxed referrals for their suitability to be answered through eConsults. Descriptive statistics were generated. RESULTS: We analyzed 300 consecutive faxed referrals and 300 (of 470) eConsult referrals. Faxed questions more often pertained to rheumatoid arthritis (32/300 [10.7%] v. 17/300 [5.7%]), systemic lupus erythematosus (24/300 [8.0%] v. 10/300 [3.3%]), and polyarthritis (30/300 [10.0%] v. 18/300 [6.0%]). eConsults more often addressed abnormal serology without joint symptoms (27/300 [9.0%] v. 8/300 [2.7%]) and gout (15/300 [5.0%] v. 4/300 [1.3%]). Faxed referrals were more likely to have no specific question (116/300 [38.7%]), and eConsults were more likely to have more than 1 question posed (99/300 [33.0%]) and a drug-related question (67/300 [22.3%]). The rheumatologist identified potential benefit from eConsult in 216/300 (72.0%) faxed referrals and 55/59 (93.2%) declined faxed referrals. INTERPRETATION: Despite differences in diagnosis between eConsults and faxed referrals, most faxed referrals showed the potential to be addressed through eConsult. Using eConsult may allow primary care providers to obtain answers to questions without requesting a face-to-face specialist referral, or provide support for patients awaiting face-to-face consultation.

The effect of linking community health centers to a state-level smoker's quitline on rates of cessation assistance.

BACKGROUND: Smoking cessation quitlines are an effective yet largely untapped resource for clinician referrals. The aim of this study was to assess the effect of a fax referral system that links community health centers (CHCs) with the New York State Quitline on rates of provider cessation assistance. METHODS: This study was conducted in four CHCs using a quasi experimental study design. Two comparison sites offered usual care (expanded vital sign chart stamp that prompted providers to ask about tobacco use, advice smokers to quit, assess readiness, and offer assistance (4As)) and two intervention sites received the chart stamp plus an office-based fax referral link to the New York State Quitline. The fax referral system links patients to a free proactive telephone counseling service. Provider adherence to the 4 As was assessed with 263 pre and 165 post cross sectional patient exit interviews at all four sites. RESULTS: Adherence to the 4As increased significantly over time in the intervention sites with no change from baseline in the comparison sites. Intervention sites were 2.4 (p < .008) times more likely to provide referrals to the state Quitline over time than the comparison sites and 1.8 (p < .001) times more likely to offer medication counseling and/or a prescription. CONCLUSIONS: Referral links between CHCs and state level telephone quitlines may facilitate the provision of cessation assistance by offering clinicians a practical method for referring smokers to this effective service. Further studies are needed to confirm the efficacy of fax referral systems and to identify implementation strategies that work to facilitate the utilization of these systems across a wide range of clinical settings.

Evaluation of a direct mailing campaign to increase physician awareness and utilization of a quitline fax referral service.

Research has shown that fax referral services play an important role in linking people who are ready to quit tobacco use with effective cessation support provided through telephone-based quitlines. While many states have implemented fax referral services to assist health care providers in connecting their patients to quitlines, few published studies delineate optimum ways to promote this service to providers, particularly the role of direct mail educational campaigns. This is one of the first studies to evaluate the effectiveness of a small-scale educational and promotional campaign designed to increase health care providers' awareness and utilization of a state tobacco cessation quitline fax referral service. The campaign included a direct mailing to 6,197 health care providers in North Carolina. The mailing consisted of a large tube, in the shape of cigarette, with enclosed fax referral promotional materials. An 8-month follow-up survey was mailed to a 10% random sample of family physicians, pediatricians, dentists, and orthodontists who were sent the promotional tube mailing. Valid surveys were returned by 271 providers (response rate = 46%). Forty-four percent of respondents remembered receiving the tube mailing, and 40% reported familiarity with the fax referral service. While only 3.5% of respondents reported referring a patient to the quitline using the fax referral service in the previous 6 months, almost one-third reported an intention to use the fax referral service in the future. The pilot promotional campaign increased awareness of the fax referral service more than service utilization. While increased utilization of the service by health care providers appears promising, additional research is needed on how to maximize educational and promotional campaigns that influence clinician fax referral behaviors. The results of this study can help guide the development of future fax referral promotional campaigns to increase clinician access to and utilization of state quitlines.

Development of a Fax-based system for incorporating nondigital paper-based data into DICOM imaging examinations.

We describe the development of software that allows and automates the routine inclusion of nondigital paper-based data directly into DICOM examinations. No human intervention is required. The software works by allowing the direct faxing of nondigital paper-based patient data directly into DICOM imaging examinations and is added as the first series in the examination. The software is effective in any typical PACS/DICOM server environment.

Pharmacy experience with facsimile prescriptions.

The purpose of this mixed qualitative/quantitative study was to review the impact of a policy to accept facsimile (fax) prescriptions as standard operating procedure. Between February and April 2009 the pharmacy processed 4,792 new prescriptions of which 363 (7.6%) were received through fax. Of the fax prescriptions, 19 (5.2%) concerned clarification of information, which took approximately 30 minutes to resolve. The fax prescription process allowed the pharmacy to adjust the distribution of its workload, provided quicker service for new prescriptions, and allowed more time for medication consultation that resulted in a high level of customer satisfaction. It appeared the policy allowing fax prescriptions was a "win-win" situation for both the pharmacy and its customers. Military pharmacies should consider running trials of accepting fax prescriptions to see whether it improves their prescription filling process.

The Wisconsin Tobacco Quit Line's Fax to Quit program: participant satisfaction and effectiveness.

OBJECTIVE: The purpose of this study was to assess the Wisconsin Tobacco Quit Line's (WTQL) clinic-based Fax to Quit (FTQ) provider referral program in terms of participant satisfaction and short-term quit outcomes, and to compare those findings to a non-FTQ provider referral group. METHODS: A sample of 432 WTQL callers completed a telephone survey approximately 3 months after they received WTQL services. Of these, 265 contacted the WTQL based on a clinic referral and served as the basis for analyses. Of these 265, 158 FTQ respondents were compared to 107 non-FTQ respondents in terms of satisfaction with the WTQL as well as quit attempts and tobacco abstinence. RESULTS: Overall, survey respondents reported high levels of satisfaction with the WTQL (FTQ = 96.8%, non-FTQ = 92.7%). Other measures of satisfaction (cultural sensitivity, respondent needs and concerns understood) showed similarly high levels of respondent satisfaction for both groups. FTQ respondents reported a statistically significantly higher 30-day abstinence rate (46.8%) compared to non-FTQ respondents (32.7%). CONCLUSIONS: Participants expressed high levels of satisfaction with WTQL services and demonstrated high short-term quit rates. FTQ-referred WTQL users reported higher rates of tobacco cessation than non-FTQ-referred WTQL users. These findings suggest that fax referral has potential to successfully link smokers visiting primary care clinics to the WTQL, an evidence-based cessation option.

Changes in Concurrent Opioid and Benzodiazepine Use Following a Low-Touch Prescriber Fax Intervention.

BACKGROUND: Concurrent use of opioids and benzodiazepines (COB) can lead to additive respiratory and central nervous system effects, putting patients at increased risk of fatal overdose. In 2016, the Centers for Disease Control and Prevention released an opioid-prescribing guideline recommending against COB, and the Pharmacy Quality Alliance (PQA) endorsed a COB measure in its core opioid set. From May 1, 2017, to December 4, 2017, a California Medicaid plan launched a COB-focused prescriber outreach intervention for members receiving recent opioid and benzodiazepine claims with the intent of decreasing concurrent use. OBJECTIVE: To assess the effect of a prescriber fax intervention by a Medicaid plan on COB. METHODS: Two retrospective analyses were conducted using administrative pharmacy claims data: a comparison of the PQA COB rate among selected California Medicaid plans for 2016 and 2017 and a cohort utilization analysis of members identified for the fax intervention compared with controls. Intervention and control members were matched based on 12 pre-index utilization characteristics. Outcomes assessed included proportion of members with resolution of COB in the post-index period, change in mean number of COB days before and after the index date, and proportion of members with decreased benzodiazepine daily dose after the index date. Analyses were also performed for the subgroups of members with < 30 days of COB and ≥ 30 days of COB in the pre-index period. RESULTS: All California Medicaid plans in the study saw an improvement in the PQA COB rate between 2016 and 2017. In the utilization analysis, 4,182 intervention members were eligible according to study criteria and matched to similar control members. Many differences in medication use existed between the subgroups with < 30 days and ≥ 30 days of COB in the pre-index period, with the latter group consisting of much more chronic, complex users. The intervention cohort had a statistically significant higher proportion of members with complete resolution of COB compared with the control cohort (43.8% vs. 40.0%; P < 0.01), which was also statistically significant for the 2 subgroups. The intervention cohort had a decrease in the mean number of COB days from pre- to post-index periods, but this was only statistically significant for the subgroup with < 30 COB days (-2.5 vs. -1.5; P = 0.0217). No statistically significant differences were detected between cohorts in proportion of members with decreased benzodiazepine dose. CONCLUSIONS: Our analyses demonstrated that this low-touch prescriber fax intervention produced statistically significant improvements in COB outcomes, despite the overall trend of declining COB among the other California Medicaid plans. Low-touch, targeted prescriber outreach can be an inexpensive yet effective tool to affect prescriber behavior, particularly before COB becomes chronic. DISCLOSURES: No outside funding was used to support this study. The authors do not have any financial relationships or potential conflicts of interest relevant to this article to disclose. At the time of conducting this research, all authors were employees of MedImpact Healthcare Systems. The results of this study were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2019; March 25-28, 2019; San Diego, CA.

Two pharmacy interventions to improve refill persistence for chronic disease medications: a randomized, controlled trial.

BACKGROUND: Despite the proven effectiveness of many medications for chronic diseases, many patients do not refill their prescriptions in the required timeframe. OBJECTIVE: Compare the effectiveness of 3 pharmacist strategies to decrease time to refill of prescriptions for common chronic diseases. RESEARCH DESIGN/SUBJECTS: A randomized, controlled clinical trial with patients as the unit of randomization. Nine pharmacies within a medium-sized grocery store chain in South Carolina were included, representing urban, suburban, and rural areas and patients from a variety of socioeconomic backgrounds. Patients (n = 3048) overdue for refills for selected medications were randomized into 1 of 3 treatment arms: (1) pharmacist contact with the patient via telephone, (2) pharmacist contact with the patient's prescribing physician via facsimile, and (3) usual care. MEASURES: The primary outcome was the number of days from their recommended refill date until the patient filled a prescription for any medication relevant to his/her chronic disease. Prescription refill data were obtained routinely from the pharmacy district office's centralized database. Patient disposition codes were obtained by pharmacy employees. An intent-to-treat approach was used for all analyses. RESULTS: There were no significant differences by treatment arm in the study outcomes. CONCLUSIONS: Neither of the interventions is more effective than usual care at improving persistence of prescription refills for chronic diseases in overdue patients.

Implementing a fax referral program for quitline smoking cessation services in urban health centers: a qualitative study.

BACKGROUND: Fax referral services that connect smokers to state quitlines have been implemented in 49 U.S. states and territories and promoted as a simple solution to improving smoker assistance in medical practice. This study is an in-depth examination of the systems-level changes needed to implement and sustain a fax referral program in primary care. METHODS: The study involved implementation of a fax referral system paired with a chart stamp prompting providers to identify smoking patients, provide advice to quit and refer interested smokers to a state-based fax quitline. Three focus groups (n = 26) and eight key informant interviews were conducted with staff and physicians at two clinics after the intervention. We used the Chronic Care Model as a framework to analyze the data, examining how well the systems changes were implemented and the impact of these changes on care processes, and to develop recommendations for improvement. RESULTS: Physicians and staff described numerous benefits of the fax referral program for providers and patients but pointed out significant barriers to full implementation, including the time-consuming process of referring patients to the Quitline, substantial patient resistance, and limitations in information and care delivery systems for referring and tracking smokers. Respondents identified several strategies for improving integration, including simplification of the referral form, enhanced teamwork, formal assignment of responsibility for referrals, ongoing staff training and patient education. Improvements in Quitline feedback were needed to compensate for clinics' limited internal information systems for tracking smokers. CONCLUSIONS: Establishing sustainable linkages to quitline services in clinical sites requires knowledge of existing patterns of care and tailored organizational changes to ensure new systems are prioritized, easily integrated into current office routines, formally assigned to specific staff members, and supported by internal systems that ensure adequate tracking and follow up of smokers. Ongoing staff training and patient self-management techniques are also needed to ease the introduction of new programs and increase their acceptability to smokers.