Developing Quality Improvement Plans

Effective and equitable tobacco treatment programs for cancer patients require ongoing assessment of both program processes (e.g., implementation strategies) and outcomes (e.g., treatment reach, effectiveness in terms of tobacco use abstinence and cancer outcomes, and equity). This can help identify successes, challenges, and gaps to be addressed in adaptations and expansions of the program. Ongoing monitoring can also generate feedback for care teams and implementers that can help enhance performance.

Engage both IT and business analytics experts in program development to ensure that the tobacco screening and documentation data can be pulled and analyzed to assess program performance. These experts can design tailored program monitoring and evaluation tools (e.g., dashboards, weekly program snapshots, automated monthly reports) in tandem with program interventions. See this general guidance on continuous quality improvement strategies.

Assessment Measures

• Number and proportion of patients screened for tobacco among all patients at the cancer center
• Number and proportion of patients who used tobacco in the past 30 days
• Number and proportion of patients who used tobacco in the past 30 days who were offered tobacco treatment by a program component
• Number and proportion of patients who used tobacco in the past 30 days who initiated tobacco treatment
• Number and proportion of patients who changed their tobacco use (operationalized primarily as self-reported abstinence from tobacco but perhaps also as at least 50% sustained reduction of tobacco use)
• Prevalence or severity of treatment toxicity, complication, side effects, cancer control, cancer recurrence, new primary cancers, and other clinical outcomes of interest
• Equity in outcomes across patient subgroups (e.g. by cancer diagnosis, age, gender, race, ethnicity, income level, insurance type, and geographic region)

Focus Efforts

You may choose to focus on evaluating the reach of your tobacco treatment programs rather than effectiveness in terms of abstinence or downstream clinical outcomes such as cancer survival. This was the primary dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (i.e., the RE-AIM) framework (Glasgow et al., 2018) emphasized in C3I (D’Angelo et al., 2020).

Consider Scope

Your assessment strategy may vary depending on the scope of your program. You may initially focus on a couple of clinics and limit data collection to these sites; later, you may adopt a broader scope and include survivors, family members, or those with only second-hand exposure.

Utilize Multiple Data Sources

You may need to rely on multiple data sources when monitoring your program. For example, it may be useful to use EHR data, but you may want to supplement this with tumor registry data, billing records, medication records, and reports from external treatment providers (e.g., quitlines). Particularly for tobacco abstinence data, establishing follow-ups by IVR or staff (e.g. TTS or nursing) can be valuable.

Align Assessment with Goals

Develop your reporting approach to meet both your quality improvement goals and reporting requirements of accreditation bodies such as the Joint Commission, the Commission on Cancer, or the National Accreditation Program for Breast Centers (e.g., the Beyond ASK program). Work backwards from which outcomes will be important to leadership and interested parties, and develop automated data reports and tracking for these outcomes.