Innovative VA Study Removes Barriers to Care

A team of UW-CTRI researchers at the William S. Middleton Memorial Veterans Hospital in Madison are the first ever to fully recruit for a Veterans Affairs (VA) study to evaluate a chronic-care system designed to help veterans who are not ready to quit smoking. Led by UW-CTRI Researcher Dr. Jessica Cook, the team has enrolled more than 500 veterans and referred nearly 500 more to care.

The team includes Kirsten Webster and Elana Brubaker at the Madison VA, as well as UW-CTRI Researcher Mark Zehner.

Left to right: Dr. Jessica Cook, Kirsten Webster, Elana Brubaker, and Mark Zehner celebrate the full recruitment of their study designed to help veterans learn about treatment options to quit tobacco use.
Left to right: Dr. Jessica Cook, Kirsten Webster, Elana Brubaker, and Mark Zehner celebrate the full recruitment of their study designed to help veterans learn about treatment options to quit tobacco use.

Webster, Brubaker and Zehner (himself a veteran) prepped more than 53,000 postcards advertising the study that were mailed to fellow veterans using the VA electronic medical records. They used postcards because they had learned from a previous study that the letters they mailed often went unopened.

“With the postcard, it’s colorful and branded and they can’t help but read it on the way to the recycling bin,” Zehner joked. “It’s directly related to smoking and tactful.”

VA postcard

The postcards, which featured the VA logo, also offered $40 just to call and learn about the study.

Veterans who saw the postcard and called but were not ready to quit smoking were randomized to either Enhanced Chronic Care or Standard Care. Enhanced Chronic Care involved four coaching calls per year, including brief motivational counseling with facilitated access to either cessation treatment or tools to change their smoking. Standard Care involved one call a year offering cessation treatment. The interventions span two years. Participants in either condition may choose to repeat treatment or shift to getting help to quit smoking.

Brubaker said that some veterans who called were skeptical that the study team was going to push them to quit smoking. But, once the callers realized the team was ready to help when the callers felt ready to make a change, they were pleased.

“The postcards were a great way of getting people with at least some interest in learning about treatment options to come to us,” Cook said. “We tell them, ‘You’re in the driver’s seat, we’re here to share information and support you and help you make changes when you feel you’re ready. We’ve had a high percentage of people enroll in treatment.”

Participants appreciated how the study team empowered them.

The research team has enrolled 502 veterans who smoke and aren’t initially quite ready to quit. If veterans said they were ready to quit smoking, the researchers referred them to the VA’s Tobacco Treatment Clinic (TTC). At last count, 444 veterans who called in response to receiving the postcard took them up on that referral to quit smoking.

Pharmacists at the VA TTC who specialize in tobacco treatment get the referrals. “The VA TTC has been an important and valued partner in our research,” Cook said gratefully. “We’ve worked very closely with the Tobacco Treatment Clinic, which is led by Dr. Megan Heim. Dr. Heim has been a wonderful collaborator and has been on the forefront of delivering effective tobacco treatment at the Madison VA. TTC pharmacists prescribe all the medication for the study, which is sent to participants in the mail.”

And the TTC has appreciated the 444 referrals for veterans ready to quit. Brubaker and Webster also refer veterans who are struggling with other issues to other VA clinics, such as the Mental Health clinic. Brubaker said it’s great to have everything baked within the VA healthcare system so referrals to virtually any type of care is easy, secure, and seamless. It’s one of the many benefits of the VA Healthcare System.

“We know this works in terms of enrolling people in treatment” using medical records and postcards, Cook said. “We aren’t sure yet whether it’s the $40 incentive that works, or offering treatment for people not ready to quit that gets them to call. It might be a combination of both, and we are planning a future study to test this question.” Cook thinks the postcard is something that is scalable for the VA since it reduces barriers to treatment entry for both providers and for veterans.

“We were surprised that about half the people that called us after getting the postcard were ready to quit right away,” Brubaker said. “Because we’re part of the VA, we could transfer them and offer one-stop shopping.”

Since the study was conducted via telemedicine, the team could follow up with veterans no matter where they moved during the study.

“Being able to treat people nationwide has been lovely and we didn’t expect it,” Cook said.

It also allows the staff to reach rural veterans, those with disabilities or those who struggle to travel.

“We’re reaching a population that probably doesn’t see a doctor regularly,” Brubaker said. “Veterans would call us and we’d tell them about the study and they’d say, ‘This sounds like an amazing program but I can’t come in.’ We’d say, ‘You don’t have to, we do this over the phone.’ They were elated because they thought they were going to miss out. But they could participate because we removed those barriers. It’s one of the reasons why we didn’t want to rely on a traditional healthcare referral model.”

Veteran in wheelchair speaking on the phone
The telemedicine study is removing barriers for veterans to access care.

It’s all thanks to support from the US Department of Veteran Affairs.

“It’s the first test of a chronic-care intervention for veterans who aren’t feeling ready to quit smoking,” Cook said. “We use motivational interviewing strategies, like discussion of values and goals to help people sort out how they feel about their smoking and health, with ongoing access to different treatment options. That has never been tested at the VA.”

Cook said it helps that Brubaker and Webster have been reaching out to veterans for years now, building relationships so patients feel supported, in control and can trust the study team to have their best interests at heart. They pay attention to details, like the names of the veteran’s spouse, kids or pet. It’s all part of showing they care about the whole person.

“Elana and Kirsten do an amazing job connecting patients to all sorts of VA care with a holistic approach,” Cook said.

Zehner said he hears the same from patients. “They’re gushing about Elana and Kirsten, their level headedness and their care.”

“It’s remarkable how this study has connected veterans to the VA,” Brubaker said, since many who enter the study rarely receive VA treatment.

“Kirsten, Mark and Elana are doing an incredible job enrolling in the study, running the study, and providing top notch clinical care,” Cook said.

While the study is full, any veteran can get free help to quit tobacco use at: