Addressing Rural Cancer Disparities via Proactive Smoking Cessation Treatment within Primary Care: A Hybrid Type 1 Effectiveness-Implementation Trial of a Scalable Smoking Cessation Electronic Visit

通过初级保健中的主动戒烟治疗解决农村癌症差异：可扩展戒烟电子就诊的 1 型混合有效性实施试验

• 批准号: 10701074
• 负责人: Jennifer Renee Dahne
• 金额: $ 90.9万
• 依托单位: MEDICAL UNIVERSITY OF SOUTH CAROLINA
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-08 至 2027-08-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10701074
• 关键词: Abstinence; Address; Adoption; Adult; Algorithms; Area; Biochemical; Cancer Control; Cancer Prevention Intervention; Caring; Cigarette; Clinical; Clinical assessments; Clinical effectiveness; Code; Commuting; Consolidated Framework for Implementation Research; Counseling; Data; Data Collection; Disparity; Effectiveness; Electronic Health Record; Evidence based intervention; Evidence based treatment; FDA approved; Face; Familiarity; Future; Goals; Guidelines; Health Services Accessibility; Healthcare; Healthcare Systems; Hybrids; Incidence; Individual; Intervention; Intervention Studies; Interview; Knowledge; Malignant Neoplasms; Methods; Modeling; Motivation; Outcome; Participant; Patient Recruitments; Patients; Penetration; Pharmaceutical Preparations; Pilot Projects; Practice Guidelines; Prevalence; Primary Cancer Prevention; Primary Care; Proctor framework; Provider; Qualifying; Randomized; Reporting; Research Personnel; Research Project Grants; Resources; Risk; Risk Factors; Rural; Rural Population; Site; Smoker; Smoking; Smoking Cessation Intervention; Smoking History; Smoking Status; Source; South Carolina; Testing; Time; Tobacco; Tobacco use; United States; United States Centers for Medicare and Medicaid Services; United States Public Health Service; cancer health disparity; cancer prevention; cigarette smoke; dissemination strategy; eVisit; effectiveness evaluation; effectiveness outcome; effectiveness trial; effectiveness/implementation trial; electronic health record system; evidence base; follow-up; implementation barriers; implementation cost; implementation evaluation; implementation facilitators; implementation outcomes; improved; informant; information gathering; modifiable risk; patient-level barriers; pilot trial; primary care clinic; primary care practice; primary care provider; primary care setting; provider-level barriers; psychosocial; randomized, clinical trials; relative effectiveness; remote delivery; remote therapy; rural area; rural dwellers; rural healthcare; smoking cessation; tool; treatment as usual; urban disparity

ABSTRACT Rural residents are both more likely to smoke cigarettes and less likely to quit than their urban counterparts. Consequently, individuals in rural areas have a 7% higher incidence of tobacco-associated cancers. Comprehensive smoking cessation treatment dissemination strategies are needed to increase utilization of evidence-based treatment, improve cessation outcomes, and ultimately decrease cancer incidence among rural smokers. Primary care providers (PCPs) see 70% of smokers annually, and rural residents are more likely than urban residents to have a usual source of health care. As such, primary care offers a ripe opportunity to deliver cessation treatment to rural smokers. All primary care practices that qualify for Centers for Medicare and Medicaid Services reimbursement are required to maintain electronic health records (EHRs) with coded smoking status data for adult patients. These data can be utilized to proactively identify smokers and deliver remote treatment. Our team recently completed a pilot study to develop, refine, and preliminarily evaluate a proactive asynchronous smoking cessation electronic visit (e-visit) delivered via the EHR. The goal of the e-visit is to automate best practice guidelines for cessation treatment via primary care to ensure that all smokers receive an evidence-based intervention. An initial baseline e-visit gathers information about smoking history and motivation to quit, followed by an algorithm to determine the best FDA-approved cessation medication to prescribe. A one- month follow-up e-visit assesses progress toward cessation. Clinical outcomes of our pilot (N=51 followed for three months) were promising. Among rural participants who received the e-visit (n=6), 17% reported 7-day point prevalence abstinence (PPA), 67% reduced their cigarettes per day (CPD) by >50%, and 50% used a cessation medication. E-visit participants, relative to treatment as usual (TAU), were 4.2 times more likely to report 7-day PPA, 4.1 times more likely to have reduced their CPD by >50%, and 4.7 times more likely to have used a cessation medication. Acceptability outcomes were strong, with 100% of rural e-visit participants reporting that they would use an e-visit again in the future. These data suggest that the e-visit may be a feasible, efficacious approach to extend the reach of evidence-based cessation treatment via rural primary care. We now propose a Hybrid Type I effectiveness-implementation trial to comprehensively assess e-visit effectiveness relative to TAU while simultaneously evaluating implementation when delivered across rural primary care settings. Effectiveness outcomes will be assessed through 6-months of follow-up and include: 1) biochemically verified 7-day PPA, 2) reduction in CPD, and 3) evidence-based cessation treatment utilization. Implementation outcomes will be assessed at patient, provider, and organizational levels. This trial has the potential to expand cessation treatment access in a manner scalable across rural healthcare systems and ultimately reduce rural cancer disparities.

抽象的 与城市居民相比，农村居民吸烟的可能性更大，戒烟的可能性更小。 因此，农村地区的人们患烟草相关癌症的发病率要高出 7%。 需要全面的戒烟治疗传播策略，以提高戒烟治疗的利用率 循证治疗，改善戒烟结果，最终降低农村癌症发病率 吸烟者。初级保健提供者 (PCP) 每年接诊 70% 的吸烟者，农村居民的吸烟率比 城镇居民有正常的医疗保健来源。因此，初级保健提供了一个成熟的机会来提供 对农村吸烟者进行戒烟治疗。所有符合医疗保险中心资格的初级保健实践 需要医疗补助服务报销才能维护带编码吸烟的电子健康记录 (EHR) 成年患者的状态数据。这些数据可用于主动识别吸烟者并提供远程服务 治疗。我们的团队最近完成了一项试点研究，以开发、完善和初步评估积极主动的 通过 EHR 提供异步戒烟电子访视 (e-visit)。电子访问的目标是 通过初级保健自动化戒烟治疗最佳实践指南，以确保所有吸烟者都能得到 循证干预。初始基线电子访问收集有关吸烟史和动机的信息 戒烟，然后通过算法来确定 FDA 批准的最佳戒烟药物处方。一个一—— 一个月的后续电子访问评估戒烟进展。我们试点的临床结果（N=51 三个月）很有希望。在接受电子访问的农村参与者 (n=6) 中，17% 的人报告了 7 天点 戒烟率 (PPA)，67% 的人每天吸烟量 (CPD) 减少超过 50%，50% 的人选择戒烟 药物。相对于常规治疗 (TAU)，电子访问参与者报告 7 天治疗情况的可能性高出 4.2 倍 PPA，将 CPD 降低超过 50% 的可能性增加了 4.1 倍，使用 PPA 的可能性增加了 4.7 倍 戒断药物。接受度结果很高，100% 的农村电子访问参与者表示 他们将来会再次使用电子访问。这些数据表明，电子访问可能是一种可行、有效的方法。 通过农村初级保健扩大循证戒烟治疗范围的方法。我们现在提出一个 混合 I 型有效性实施试验，全面评估电子就诊相对于 TAU 的有效性 同时评估在农村初级保健机构中实施的情况。效力 结果将通过 6 个月的随访进行评估，包括：1) 经过生化验证的 7 天 PPA，2) 减少 CPD，以及 3) 循证戒烟治疗的利用。实施成果将是 在患者、提供者和组织层面进行评估。该试验有可能扩大戒烟治疗范围 以可扩展的方式在整个农村医疗保健系统中提供服务，并最终减少农村癌症差异。