Tobacco use continues to be the single most preventable cause of death and disease in the U.S., contributing to 480,000 deaths per year, 42,000 of these associated with second-hand tobacco exposure.1 Tobacco use costs Americans over $289 billion in lost productivity and health care costs every year.1
Within the VA, where prevalence exceeds that in the general population, tobacco use among patients is as follows: 19.7% of new enrollees (compared with 19.4% of the general population), 72% of those with a psychiatric disorder, 23% of Operation Enduring Freedom/Operation Iraqi Freedom veterans, and up to 98% of substance use disorder patients in treatment.2-4 In one report, veterans with posttraumatic stress disorder (PTSD) smoked at rates 2 to 3 times that of the general veteran population.5 In 2008, the VA spent over $5.2 billion on treatment of chronic obstructive pulmonary disease alone, a disease highly correlated with smoking tobacco.6 Within the VA, it is clear that tobacco abuse is a costly issue in both health matters as well as dollars spent.
To combat this preventable loss of human life, health, and financial capital, the VA offers high-quality, evidence-based tobacco cessation counseling programs with medical adjunct therapy. In 2010, the Center for Integrated Healthcare developed a training manual to assist tobacco cessation providers in conducting integrated smoking cessation treatment across the VA.7 The Atlanta VA Medical Center (VAMC) in Georgia has had an active and highly successful tobacco cessation treatment program for many years, and in 2004, participants who completed the 5-session treatment program self-reported an abstinence rate of 69.5%, reflecting both quit (28.9%) and smoking less (40.6%) rates for the sample.8
Since that time, tobacco cessation policy within VA has transitioned to offer pharmacotherapy upon veteran request and has eliminated copays for outpatient tobacco cessation visits. In addition, the electronic medical record used within the VA Health Care System includes clinical reminders for providers to assess tobacco use and offer treatment options at several visits per year. Despite these many improvements and enhancements for tobacco cessation care, reduced attendance, including last minute cancellations and “no-shows” for tobacco cessation appointments, remain an ongoing challenge at the Atlanta VAMC.
The purpose of this investigation was to examine through a telephone survey the reasons why identified veterans had not taken advantage of smoking cessation opportunities at the Atlanta VAMC. Specifically, the study evaluated the referral completion rate for veterans referred to the program, analyzed the potential barriers behind these utilization rates, and explored possible opportunities for overcoming them.
The VA computerized patient record system (CPRS) provides a reliable means of identifying patients who use tobacco and is replete with clinical reminders for a variety of preventive health issues, including tobacco use cessation counseling. Tobacco use screening is considered a vital sign, and this information is solicited through automatic prompts for every visit. Patients who express an interest in receiving help for tobacco cessation are referred to in-house tobacco cessation counseling services, which consist of weekly, 1-hour sessions of psycho-educational counseling and medical adjunct therapy.
This project was conducted at the Atlanta VAMC, which was recognized in 2010 by The Joint Commission as a Top Performer on Key Quality Measures. The proposed plan was presented to the Research & Development (R&D) office (an International Review Board equivalent). After careful review and consideration, it was determined to be a quality improvement initiative and did not require full R&D approval.
The CPRS was used to generate a tally of all veterans referred to the tobacco cessation treatment program from January 2008 through November 2011. A total of 3,489 consults were referred by primary care and mental health providers, of which 2,358 patients (67.6%) cancelled or did not attend the program. Names and contact information for patients who did not attend the program for the more recent period of April 1, 2011, to September 8th, 2011 (n = 229) were then selected to participate in this survey study. For the purposes of this analysis, patients were considered a “non-attend” regardless of whether they called to cancel the appointment or simply did not show up for it.
For the survey portion of this study, each of these 229 individuals were contacted by telephone to inquire about potential barriers to participation, using a close-ended survey tool. The following 4 questions were asked: (1) Are you currently using tobacco in any form?; (2) Did you recently (in the past year) receive a referral for tobacco cessation counseling or classes?; (3) Did you attend the tobacco cessation program?; and (4) If you did not attend, what was/were the reason(s)?