William C. Wadland

Are higher doses of nicotine replacement more effective for smoking cessation

This study determined whether higher dose nicotine patches are more efficacious than lower dose patches among heavy smokers. A randomized double-blind study compared 0, 21, 35, and 42 mg/day of a 24-h patch in 1039 smokers (> or = 30 cigarettes/day) at 12 clinical sites in the USA and one in Australia. Daily patches were used for 6 weeks followed by tapering over the next 10 weeks. Weekly group therapy occurred. Biochemically validated self-reported quit rates at 6, 12, 26, and 52 weeks post-cessation were measured. Quit rates were dose-related at all follow-ups (p < 0.01). Continuous, biochemically verified abstinence rates for the 0, 21, 35, and 42 mg doses at the end of treatment (12 weeks) were 16, 24, 30, and 39%. At 6 months, the rates were 13, 20, 20, and 26%. Among the 11 sites with 12 month follow-up (n = 879), the quit rates were 7, 13, 9, and 19%. In post-hoc tests, none of the active doses were significantly different from each other at any follow-up. The rates of dropouts due to adverse events for 0, 21, 35, and 42 mg were 3, 1, 3, and 6% (p = n.s.). Our results are similar to most prior smaller studies; i.e., in heavy smokers higher doses increase quit rates slightly. Longer durations of treatment may be necessary to show greater advantages from higher doses.

Practice-Based Referrals to a Tobacco Cessation Quit Line: Assessing the Impact of Comparative Feedback vs General Reminders

PURPOSE We undertook a study to assess the impact of comparative feedback vs general reminders on practice-based referrals to a tobacco cessation quit line and estimated costs for projected quit responses. METHODS We conducted a group-randomized clinical trial comparing the impact of 6 quarterly (18 months) feedback reports (intervention) with that of general reminders (control) on practice-based clinician referrals to a quit-line service. Feedback reports were based on an Achievable Benchmark of Care approach using baseline practice, clinician, and patient survey responses, and referrals per quarter. Comparable quit responses and costs were estimated. RESULTS Three hundred eight clinicians participated (171 family medicine, 88 internal medicine, 49 obstetrics-gynecology) from 87 primary care practices in Michigan. After 18 months, there were more referrals from the intervention than from the control practices (484 vs 220; P <.001). Practice facsimile (fax) referrals (84%, n = 595) exceeded telephone referrals (16%, n = 109), but telephone referrals resulted in greater likelihood of enrollment (77% telephone vs 44% fax, P <.001). The estimated number of smokers who quit based on the level of services utilized by referred smokers was 66 in the feedback and 36 in the gentle reminder practices. CONCLUSION Providing comparative feedback on clinician referrals to a quit-line service had a modest impact with limited increased costs.

Clinician perceptions of factors influencing referrals to a smoking cessation program

BackgroundReferral of patients to smoking cessation telephone counseling (i.e., quitline) is an underutilized resource by primary care physicians. Previously, we conducted a randomized trial to determine the effectiveness of benchmarked feedback on clinician referrals to a quitline. Subsequently, we sought to understand the successful practices used by the high-referring clinicians, and the perceptions of the barriers of referring patients to a quitline among both high and non-referring clinicians in the trial.MethodsWe conducted a qualitative sub-study with subjects from the randomized trial, comparing high- and non-referring clinicians. Structured interviews were conducted and two investigators employed a thematic analysis of the transcribed data. Themes and included categories were organized into a thematic framework to represent the main response sets.ResultsAs compared to non-referring clinicians, high-referring clinicians more often reported use of the quitline as a primary source of referral, an appreciation of the quitline as an additional resource, reduced barriers to use of the quitline referral process, and a greater personal motivation related to tobacco cessation. Time and competing demands were critical barriers to initiating smoking cessation treatment with patients for all clinicians. Clinicians reported that having one referral source, a referral coordinator, and reimbursement for tobacco counseling (as a billable code) would aid referral.ConclusionFurther research is needed to test the effectiveness of new approaches in improving the connection of patients with smoking cessation resources.Trial Registration NumberClinicaltrials.gov NCT00529256

The Impact of Screening Tools on Diagnosis of Chronic Obstructive Pulmonary Disease in Primary Care

BACKGROUND Chronic obstructive pulmonary disease (COPD) is frequently misdiagnosed or undiagnosed, which can delay disease management interventions. PURPOSE The Screening, Evaluating and Assessing Rate CHanges of diagnosing respiratory conditions in primary care 1 (SEARCH1) study assessed whether screening using the COPD Population Screener (COPD-PS) questionnaire to detect COPD risk factors and symptoms, with or without a handheld spirometer (copd-6) to detect airflow limitation, can increase yields of COPD diagnosis and respiratory-related clinician actions in primary care. DESIGN A prospective, multi-center, pragmatic, comparative-effectiveness, cluster-randomized study conducted from September 2010 to October 2011 (data analyzed from December 2011 to January 2013). PARTICIPANTS Men and women aged ≥40 years visiting their participating primary care practice for any reason. INTERVENTION Practices were randomized to three study arms: COPD-PS + copd-6, COPD-PS alone, and usual care (no interventions). No practices received any specific education about COPD or its diagnosis. MAIN OUTCOME MEASURES The primary endpoint was yield of new clinical COPD diagnosis; the secondary endpoint was yield of respiratory-related clinician actions. RESULTS Of 9,704 patients enrolled, 8,770 had no prior COPD diagnosis and were included in endpoint analyses. Both interventions significantly increased COPD diagnostic yield over 8 weeks. Compared with a mean yield of 0.49% (0.13%) (controls), yields were 1.07% (0.20%) (OR=2.20, 95% CI=1.26, 3.84, p=0.006) and 1.16% (0.22%) (OR=2.38, 95% CI=1.38, 4.13, p=0.002) for COPD-PS and COPD-PS+copd-6 study arms, respectively. Respiratory-related clinician actions were not significantly different across study arms. CONCLUSIONS Office-based assessment can significantly increase COPD diagnosis by primary care physicians. Future trials must evaluate whether screening can improve outcomes for patients with COPD.

Evolution of faculty affairs and faculty development offices in U.S. medical schools: a 10-year follow-up survey

Purpose To determine how U.S. MD-granting medical schools manage, fund, and evaluate faculty affairs/development functions and to determine the evolution of these offices between 2000 and 2010. Method In December 2010, the authors invited faculty affairs designees at 131 U.S. MD-granting medical schools to complete a questionnaire developed by the Association of American Medical Colleges Group on Faculty Affairs, based on a 2000 survey. Schools were asked about core functions, budget, staffing, and performance metrics. The authors analyzed the data using descriptive statistics. Results A total of 111 schools (84.7%) responded. Fifty percent of the offices were established since 2000. Seventy-eight percent reported their top core function as administrative support for appointments, promotions, and tenure, as in 2000. Faculty policies, appointments, databases, governance support, grievance proceedings, management issues, and annual trend analyses continued as major functions. All 11 core functions identified in 2000 remain predominantly provided by central offices of faculty affairs, except support of major leadership searches. Web site communication emerged as a new core function. Similar to 2000, several other offices were responsible for some faculty development functions. Office size and budget correlated positively with size of the faculty and age of the office (P < .05 for all). Thirty-five schools (31.5%) reported formally evaluating their faculty affairs office. Conclusions The number of faculty affairs offices and their responsibilities have substantially increased since 2000. Most major core functions have not changed. These offices are now an established part of the central administration of most medical schools.

Connecting the dots: Bridging patient and population health data systems

The digital age has arrived in full force. Searching “big data” on Google returns more than 4 million hits. There is even a Wikipedia page that defines big data as “an all-encompassing term for any collection of data sets so large and complex that it becomes difficult to process using traditional data processing applications.” But big data could be too much of a good thing. Like a dot-to-dot puzzle, it is impossible to interpret big data without connecting the dots. The electronic health record (EHR) is transforming how information is gathered and used in clinical care and will become an increasingly important source of big data in the future. In 2013, 78% of office-based physicians used any type of EHR system, up from only 18% in 2001. If this rate of adoption continues, nearly all health systems will be using EHRs soon, providing an opportunity to improve the quality of health care, lower healthcare costs, and permit patients to become more involved in their own health care. Similarly, there has been an explosion of information available to describe the characteristics of populations, ranging from air and water quality to neighborhood walkability. These population-based data systems are often linked to specific addresses. The IOM’s recent report supports the use of these data, and points out that geographically linked data can capture health-relevant information that cannot be obtained directly from the patient. Bridging patient and population health data systems can enhance our ability to care for patients and improve the health of populations (Figure 1). Population health data can be linked to individual patients to provide the “context” that each patient experiences, to not only improve the quality of care but also provide the context for assessing the quality of care provided. On the other hand, communities can develop higher-quality and lower-cost population health surveillance systems by “building up” from the EHRs.

Patient Factors Influencing Respiratory-Related Clinician Actions in Chronic Obstructive Pulmonary Disease Screening.

INTRODUCTION The purpose of this study was to identify patient-related factors that may explain the increased likelihood of receiving a respiratory-related clinician action in patients identified to be at risk for chronic obstructive pulmonary disease in a U.S.-based pragmatic study of chronic obstructive pulmonary disease screening. METHODS This post hoc analysis (conducted in 2014-2015) of the Screening, Evaluating and Assessing Rate Changes of Diagnosing Respiratory Conditions in Primary Care 1 (SEARCH1) study (conducted in 2010-2011), used the chronic obstructive pulmonary disease Population Screener questionnaire in 112 primary care practices. Anyone with a previous chronic obstructive pulmonary disease diagnosis was excluded. Multivariate logistic regression modeling was used to assess patient factors associated with the likelihood of receiving an respiratory-related clinician action following positive screening. RESULTS Overall, 994 of 6,497 (15%) screened positive and were considered at risk for chronic obstructive pulmonary disease. However, only 187 of the 994 patients (19%) who screened positive received a respiratory-related clinician action. The chances of receiving a respiratory-related clinician action were significantly increased in patients who visited their physician with a respiratory issue (p<0.05) or had already been prescribed a respiratory medication (p<0.05). Most (81%) patients who screened positive or had a respiratory-related clinician action had one or more comorbidity, including cardiovascular disease (68%), diabetes (30%), depression/anxiety (26%), asthma (11%), and cancer (9%). CONCLUSIONS Routine chronic obstructive pulmonary disease screening appears to promote respiratory-related clinician actions in patients with a high likelihood for disease who have respiratory complaints or already use prescribed respiratory medication.