Jamie J. Hunt

How is tobacco treatment provided during drug treatment

The purpose of this study was to obtain descriptions of tobacco treatment services across different substance abuse treatment settings. We conducted mixed-method assessments in eight facilities among eight directors, 25 staff, 29 clients, and 82 client charts. Measures included systems assessment, chart reviews, and semistructured interviews. Although many programs reported they offer key components of evidence-based treatment, few actually provided any treatment and none did so systematically. Many addressed tobacco as part of drug education or part of a health promotion session. Chart reviews suggested that provision of tobacco treatment is rare. By many reports, clients had to specifically request treatment and few staff reported encouraging unmotivated smokers to quit. Systems to facilitate consistent, evidence-based tobacco treatment and to implement quality improvement were nonexistent. The findings imply that drug treatment facilities may need to build capacity in several domains to deliver care that is consistent with national guidelines.

Comparative and cost effectiveness of telemedicine versus telephone counseling for smoking cessation.

Background In rural America, cigarette smoking is prevalent and health care providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services in rural areas, but they are poorly integrated with local health care resources. Objective The intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering expert tobacco treatment at a distance: telemedicine counseling that was integrated into smokers’ primary care clinics (Integrated Telemedicine—ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes (Phone). Methods Smokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling, similar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered the counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both groups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome was verified 7-day point prevalence smoking abstinence at month 12, using an intent-to-treat analysis. Results There were no significant baseline differences between groups, and the trial achieved 88% follow-up at 12 months. Verified abstinence at 12 months did not significantly differ between ITM or Phone (9.8%, 27/280 vs 12%, 34/286; P=.406). Phone participants completed somewhat more counseling sessions than ITM (mean 2.6, SD 1.5 vs mean 2.4, SD 1.5; P=.0837); however, participants in ITM were significantly more likely to use cessation medications than participants in Phone (55.9%, 128/280 vs 46.1%, 107/286; P=.03). Compared to Phone participants, ITM participants were significantly more likely to recommend the program to a family member or friend (P=.0075). From the combined provider plus participant (societal) perspective, Phone was significantly less costly than ITM. Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions. From the provider perspective, counseling costs were similar between ITM (US

Using “warm handoffs” to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial

45.46, SD 31.50) and Phone (US

The index of tobacco treatment quality: development of a tool to assess evidence-based treatment in a national sample of drug treatment facilities

49.58, SD 33.35); however, total provider costs varied widely depending on how the clinic space for delivering ITM was valued. Conclusions Findings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking. ITM increased utilization of cessation pharmacotherapy and produced higher participant satisfaction, but Phone counseling was significantly less expensive. Future interventions could combine elements of both approaches to optimize pharmacotherapy utilization, counseling adherence, and satisfaction. Such an approach could commence with a telemedicine-delivered clinic office visit for pharmacotherapy guidance, and continue with telephone or real-time video counseling delivered via mobile phones to flexibly deliver behavioral support to patients where they most need it—in their homes and communities. Trial Registration Clinicaltrials.gov NCT00843505; http://clinicaltrials.gov/ct2/show/NCT00843505 (Archived by WebCite at http://www.webcitation.org/6YKSinVZ9).

Commitment and capacity for providing evidence-based tobacco treatment in US drug treatment facilities

BackgroundPost-discharge support is a key component of effective treatment for hospitalized smokers, but few hospitals provide it. Many hospitals and care settings fax-refer smokers to quitlines for follow-up; however, less than half of fax-referred smokers are successfully contacted and enrolled in quitline services. “Warm handoff” is a novel approach to care transitions in which health care providers directly link patients with substance abuse problems with specialists, using face-to-face or phone transfer. Warm handoff achieves very high rates of treatment enrollment for these vulnerable groups.MethodsThe aim of this study—“EQUIP” (Enhancing Quitline Utilization among In-Patients)—is to determine the effectiveness, and cost-effectiveness, of warm handoff versus fax referral for linking hospitalized smokers with tobacco quitlines. This study employs a two-arm, individually randomized design. It is set in two large Kansas hospitals that have dedicated tobacco treatment interventionists on staff. At each site, smokers who wish to remain abstinent after discharge will be randomly assigned to groups. For patients in the fax group, staff will provide standard in-hospital intervention and will fax-refer patients to the state tobacco quitline for counseling post-discharge. For patients in the warm handoff group, staff will provide brief in-hospital intervention and immediate warm handoff: staff will call the state quitline, notify them that a warm handoff inpatient from Kansas is on the line, then transfer the call to the patients’ mobile or bedside hospital phone for quitline enrollment and an initial counseling session. Following the quitline session, hospital staff provides a brief check-back visit. Outcome measures will be assessed at 1, 6, and 12 months post enrollment. Costs are measured to support cost-effectiveness analyses. We hypothesize that warm handoff, compared to fax referral, will improve care transitions for tobacco treatment, enroll more participants in quitline services, and lead to higher quit rates. We also hypothesize that warm handoff will be more cost-effective from a societal perspective.DiscussionIf successful, this project offers a low-cost solution for more efficiently linking millions of hospitalized smokers with effective outpatient treatment—smokers that might otherwise be lost in the transition to outpatient care.Trial registrationClinical Trials Registration NCT01305928

Adapting screening, brief intervention, and referral to treatment to tobacco: a hospital trial of warm handoffs for smoking cessation

BackgroundQuitting smoking improves health and drug use outcomes among people in treatment for substance abuse. The twofold purpose of this study is to describe tobacco treatment provision across a representative sample of U.S. facilities and to use these data to develop the brief Index of Tobacco Treatment Quality (ITTQ).MethodsWe constructed survey items based on current tobacco treatment guidelines, existing surveys, expert input, and qualitative research. We administered the survey to a stratified sample of 405 facility administrators selected from all 3,800 U.S. adult outpatient facilities listed in the SAMHSA Inventory of Substance Abuse Treatment Services. We constructed the ITTQ with a subset of 7 items that have the strongest clinical evidence for smoking cessation.ResultsMost facilities (87.7%) reported that a majority of their clients were asked if they smoke cigarettes. Nearly half of facilities (48.6%) reported that a majority of their smoking clients were advised to quit. Fewer (23.3%) reported that a majority of their smoking clients received tobacco treatment counseling and even fewer facilities (18.3%) reported a majority of their smoking clients were advised to use quit smoking medications. The median facility ITTQ score was 2.57 (on a scale of 1–5) and the ITTQ displayed good internal consistency (Cronbach’s alpha = .844). Moreover, the ITTQ had substantial test-retest reliability (.856), and ordinal confirmatory factor analysis found that our one-factor model for ITTQ fit the data very well with a CFI of 0.997 and an RMSEA of 0.042.ConclusionsThe ITTQ is a brief and reliable tool for measuring tobacco treatment quality in substance abuse treatment facilities. Given the clear-cut room for improvement in tobacco treatment, the ITTQ could be an important tool for quality improvement by identifying service levels, facilitating goal setting, and measuring change.

Understanding the drug treatment community's ambivalence towards tobacco use and treatment

BACKGROUND Although people with mental illness, including substance use disorders, consume 44% of cigarettes in the United States, few facilities provide tobacco treatment. This study assesses staff- and facility-level drivers of tobacco treatment in substance use treatment. METHODS Surveys were administered to 405 clinic directors selected from a comprehensive inventory of 3800 US outpatient facilities. The main outcome was the validated 7-item Index of Tobacco Treatment Quality. Other measures included the validated Tobacco Treatment Commitment Scale and indicators of facility resources for providing tobacco treatment. RESULTS Stepwise model selection was used to determine the relationship between capacity/resources and treatment quality. The final model retained 7 items and had good fit (adjusted R2 = 0.43). Four capacities significantly predicted treatment quality. Structural equation modeling (SEM) was used to test the impact of staff commitment on treatment quality; the model had good fit and the relationship was significant (comparative fit index [CFI] = 0.951, root mean square error of approximation [RMSEA] = 0.054). Adding the 7 capacity/resources maintained similar model fit (CFI = 0.922, RMSEA = 0.053). Staff commitment was slightly strengthened in this model, with a rise in parameter estimate from 0.449 to 0.560. All resource/capacity items were also significant predictors of treatment quality; the strongest was receiving training in how to provide tobacco treatment (0.360), followed by dedicated staff time (0.279) and having a policy that requires staff to offer treatment (0.272). CONCLUSIONS Staff commitment to providing tobacco treatment was the strongest predictor of tobacco treatment quality, followed by resources for providing treatment. Interventions to change staff attitudes and improve resources for tobacco treatment have the strongest potential for improving quality of care.

Capacity of US Drug Treatment Facilities to Provide Evidence-Based Tobacco Treatment

Post-discharge support is key to effective treatment for hospitalized smokers. The few hospitals that systematically address tobacco refer smokers via fax to tobacco quitlines, yet few smokers enroll. “Warm handoff” (direct referral by one provider to another provider) is used in some cases of tobacco screening and brief intervention (SBI) to link patients with treatment, but little data exists on process or outcomes. We present pilot outcomes and early implementation data on an ongoing randomized controlled trial (RCT). Recruitment began in July 1, 2011. The purpose of the trial (Enhancing Quitline Utilization by Inpatients [EQUIP]) is to determine the effectiveness and cost-effectiveness of warm handoff versus fax referral for linking hospitalized smokers with tobacco quitlines. The EQUIP trial is a two-arm RCT funded by the National Institutes of Health (trial registration: NCT01305928) in which smokers who wish to quit permanently after discharge are randomized to either fax referral (standard in-hospital intervention with fax-referral for counseling post-discharge) or warm handoff (brief in-hospital intervention and immediate staff call to the state quitline and transfer of the call to the patient’s mobile or bedside hospital phone for enrollment and an initial counseling session). Outcomes, including costs, are assessed at one, six, and 12 months following baseline. We hypothesize that warm handoff will outperform fax referral in terms of enrollment in services, cessation, and cost-effectiveness. This study explores what alcohol and other drug trials have done to strengthen handoffs and the evidence for efficacy; how EQUIP compares with AOD handoffs, and what pitfalls might be expected; and whether tobacco SBI and referral to treatment would or could be incorporated into alcohol and other drug SBI and referral to treatment.