University of Wisconsin–Madison

Referral Rates Vary Across Clinics in Quit-Smoking Study

UW-CTRI partnered with 11 health care clinics at two health systems to invite patients to participate in the UW Partnership to Assist and Serve Smokers (UW-PASS) study to help them quit smoking or reduce their smoking, and found different clinics invited various patients at unequal rates.

The goal was to use a standardized electronic health record (EHR) to prompt medical assistants and other rooming staff during clinic visits to screen patients for smoking and then uniformly invite all patients who smoke to learn more about the study. Overall, 89% of patients were screened for smoking. Nearly 70% of smokers were invited to learn more about the UW-PASS study.

Yet, despite this systematic approach, researchers found some inequalities in who were invited.

“The big takeaway is there is no quick and easy fix that would mean automatically everyone is being invited into a study or treatment to quit smoking,” said Dr. Kristin Berg, lead author on a paper in the Wisconsin Medical Journal detailing the results, including:

  • Health system A had a lower tobacco screening rate (88%), higher tobacco use prevalence (22%), and only 62% of smokers were invited to learn more about UW-PASS.
  • Health system B had a 96% tobacco screening rate, 14% tobacco use prevalence, and nearly 80% of smokers were invited to learn more about UW-PASS.

Health System A had lower invitation rates for younger smokers, and those with high-risk diagnoses. In Health System B, invitation rates were higher among women.

The project incorporated multiple recommendations from the Clinical Practice Guideline: Treating Tobacco Use and Dependence as part of the research protocol. Nevertheless, it turned out that, overall, younger individuals, those who identify as a race other than White or African American, and those with high-risk diagnoses were invited less frequently. The age and racial differences have been noted in previous research, although age has shown mixed results.

Individuals with high-risk diagnoses received fewer invitations to treatment than those with low-risk diagnoses. This could be explained by time demands in caring for patients with high-risk diagnoses. Alternatively, perhaps high-risk individuals frequented the clinics more often, resulting in clinical staff anticipating that they would not be interested in smoking cessation based on past knowledge of their interactions with the patient, leading to fewer invitations.

The fact that Health System A had clinics in less affluent areas may have contributed to the lower study invitation rates. Different clinics had unequal levels of clinical staff engagement in the study, reflecting clinic-specific factors such as staff turnover, clinic support, or the presence of a smoking-cessation “champion,” potentially contributing to the wide range of intervention rates seen in the different clinics.

One element that could warrant future study is the health care workers’ past experiences related to smoking, working with smokers, and past successes referring patients to get help to quit smoking. For example, is the health care worker a smoker, a former smoker, or related to a smoker? Does the health care worker feel s/he is well trained to intervene? Is the health care worker reluctant to ask a patient something that could be emotional or confrontational?

“Unfortunately, there’s no magic solution to make sure everyone is invited,” Berg said. “We have to keep trying different strategies to see what works.”