“It’s on everyone’s plate”: a qualitative study into physicians’ perceptions of responsibility for smoking cessation

Background

Little research has investigated in-depth how physicians perceive their role in smoking cessation care. This qualitative study sought to understand physicians’ perceptions of responsibility for smoking cessation.

Methods

Data were collected through individual semi-structured interviews and focus group interviews between June and November 2017 in The Netherlands. We interviewed 5 addiction specialists, 5 anesthesiologist, 4 cardiologists, 8 GPs, 5 internists, 5 neurologists, 2 pediatricians, 6 pulmonologists, 7 surgeons, and 8 youth healthcare physicians (N?=?55). Data analysis followed the framework approach.

Results

The analysis showed that three actors were perceived as responsible for smoking cessation: physicians, patients, and the government. Participants perceived physicians as responsible for facilitating smoking cessation -albeit to different extents-, patients as carrying the ultimate responsibility for quitting smoking, and the government as responsible for creating a society in which smoking uptake is more difficult and quitting smoking easier. Perceptions of smoking itself were found to be important for how participants viewed responsibility for smoking cessation. It remained unclear for many participants which healthcare provider is responsible for smoking cessation care.

Conclusions

The organization of smoking cessation care within health systems should be a focus of intervention, to better define physician roles and perceptions of responsibility. In addition, it seems important to target perceptions of smoking itself on the level of physicians and –as suggested by comments by several participants- the government.

     

Prozessevaluation einer Intervention zur kooperativen Raucherentwöhnung

Background

The study “ENTER: Evaluation of a collaborative smoking cessation intervention” is a cluster-randomized controlled trial to assess the effectiveness of a smoking cessation intervention implemented in the German primary care setting in collaboration with AOK NORDWEST in Westphalia-Lippe and Schleswig-Holstein.

Objectives

A process evaluation was performed with the aim of investigating barriers and facilitators to intervention implementation and giving recommendations for future interventions.

Materials and methods

Between November 2015 and January 2016 semistructured qualitative interviews were conducted with AOK employees and general practitioners of the intervention group. Interviews focused on contextual factors (e.?g. responsibilities for implementing the intervention), the communication between network partners and the process of referring patients to smoking cessation courses.

Results

Overall, 21 interviews were completed (8 AOK employees, 13 general practitioners). Intervention implementation was facilitated because physicians perceived smoking cessation counseling to be important and were supported by their office staff. Challenges were seen in patients’ motivation for participation in smoking cessation courses and meeting the minimum number of course participants.

Conclusions

Successful intervention implementation would be facilitated by motivating patients to participate in smoking cessation courses and informing them about the effectiveness of the courses. Patient’s preferences for different smoking cessation aids should be investigated in order to increase the use of effective aids.

     

Physicians discuss the risks of smoking with their patients,but seldom offer practical cessation support

Background

Our aim was to study the smoking cessation-related 1) attitudes & experiences and 2) consultation practices of Finnish physicians and to determine if there is a relationship between the two.

Methods

An online survey on smoking cessation was sent to 39 % of all Finnish physicians, with emphasis on physicians working in fields relevant to smoking cessation. A total of 1141 physicians (response rate 15 %) responded to the online survey, 53 % of whom were employed in primary health care. A total of 1066 respondents were eligible for the analysis. The questionnaire included questions on the physician’s own smoking status, their attitudes and experiences on smoking cessation, and the implementation of smoking cessation in clinical practice. Two sub-scales concerning smoking-related consultation activities were constructed: one for conversation, and another for practical actions.

Results

The most common consultation activities (respondents who reported doing the following actions “nearly always”) were asking how much the patient smokes (65 %), marking smoking status in patient records (58 %) and recommending quitting to the patient (55 %). The least common activity was prescribing withdrawal medication (4 %). Primary care physicians were more active than those working in secondary health care in nearly all activities mapped. A positive attitude and experiences on smoking cessation were associated with actively offering withdrawal support. Those who were familiar with the local treatment guidelines for tobacco addiction were 30 % more active in offering practical cessation help to their patient. The respondents were more active in discussing smoking with their patients than in offering practical cessation help.

Conclusion

Physicians offer their patients practical cessation support relatively infrequently. Practical cessation calls for continuous education of physicians about the nature of tobacco and nicotine addiction, the role of smoking as a risk factor for various diseases, and the practical measures needed for smoking cessation. Secondary care physicians should acknowledge the authority they pose toward smoking patients.

     

Economic evaluation of a telephone- and face-to-face-delivered counseling intervention for smoking cessation in patients with coronary heart disease

Objective

This study examined the cost-effectiveness and cost-utility of two smoking cessation counseling interventions differing in their modality for patients diagnosed with coronary heart disease from a societal perspective.

Methods

In a randomized controlled trial conducted in Dutch hospital wards, cardiac patients who smoked prior to admission were allocated to usual care (n = 245), telephone counseling (n = 223) or face-to-face counseling (n = 157). The counseling interventions lasted for 3 months and were complemented by nicotine patches. Baseline histories were obtained, and interviews took place 6 months after hospitalization to assess self-reported smoking status and quality adjusted life years (QALYs). Incremental cost-effectiveness ratios per quitter and cost-utility ratios per QALY were calculated and presented in acceptability curves. Uncertainty was accounted for by sensitivity analysis.

Results

Using continued abstinence as the outcome measure showed that telephone counseling had the highest probability of being cost-effective. Face-to-to-face counseling was also more cost-effective than usual care. No significant improvements and differences in QALYs between the three conditions were found. Varying costs and effect estimations revealed that the results of the primary analyses were robust.

Conclusions

Assuming a willingness-to-pay of €20,000 per abstinent patient, telephone counseling would be a highly cost-effective smoking cessation intervention assisting cardiac patients to quit. However, the lack of consensus concerning the willingness-to-pay per quitter impedes drawing firm conclusions. Moreover, studies with extended follow-up periods are needed to capture late relapses and possible differences in QALYs.

     

Rauchgewohnheiten von deutschen Medizinstudierenden in Deutschland und Ungarn

Background

Although many anti-tobacco measures have reduced the number of smokers in Germany, every fourth person still smokes and smoking is still an enormous burden for both the affected person and their relatives as well as for the healthcare system and society. Physicians have a key position in tobacco cessation, their health and smoking behavior is therefore of great importance.

Objective

To provide information about the distribution of tobacco consumption among medical students and to examine the influence of study site on tobacco consumption.

Material and methods

In a multicenter cross-sectional study, data on the health behavior of German medical students in two German and two Hungarian universities were collected in 2014 using a questionnaire.

Results

Of the 1384 students, 7.3% smoked daily, 9.1% occasionally and 11.9% were ex-smokers. The consumption of e?cigarettes was rare, whereas shisha smoking was more widespread among medical students. Among the study locations Munich had the lowest rates of occasional smoking for men and for women consuming shisha.

Conclusions

Medical students must be encouraged not to smoke. Our results highlight the need for smoking cessation programs at medical schools, including education about detrimental health effects of shisha use.

     

Analysis of smoking cessation beliefs in pregnant smokers and ex-smokers using the Theory of Planned Behavior

Aim

To analyze the association between smoking cessation beliefs and smoking status, and between smoking cessations beliefs and intention to quit, using the Theory of Planned Behavior (TPB).

Subjects and methods

An observational study using a questionnaire was performed; data were collected from 264 Flemish pregnant smokers and ex-smokers before week 16 of pregnancy.

Results

There was a significant difference in the behavioral beliefs of the TPB between smokers and ex-smokers, after controlling for education and age. All respondents experienced more support from their non-smoking partners to maintain abstinence during pregnancy. We found no significant difference in the behavioral beliefs of the TPB between respondents with low and high intention to quit smoking.

Conclusion

Our results suggest that attitude, subjective norms, support especially from the partner, and perceived behavioral control are associated with actual smoking behavior in pregnant women and not with intention to quit smoking. It is important to engage the partner and/or significant others in smoking cessation counselling so that they can support the pregnant woman in an attempt to quit or to maintain abstinence.

     

Forensic expertise and child abuse: a survey among preventive child healthcare workers in Amsterdam,the Netherlands

Aim

In the Netherlands, preventive child healthcare workers (PCHWs) have an important role in identifying signs of abuse, because they reach virtually all children. A closer cooperation of PCHWs and forensic physicians could improve the detection of child abuse. The aim of the study was to evaluate the use of forensic expertise by PCHWs.

Subjects and methods

In November 2013, a survey was distributed among PCHWs employed by the Amsterdam Public Health Service (n?=?221).

Results

Forty-nine percent of PCHWs indicated suspicions of physical abuse during the last 6 months (response rate: 43 %). In all, 89 % rated the consultation of forensic physicians as useful. In a 1-year period, only three respondents sought advice from a forensic doctor.

Conclusions

Although PCHWs regularly have suspicions of physical child abuse and have a very positive attitude towards consulting a forensic physician, consultation rates are very low. More research is needed to understand barriers to consultation of forensic physicians.

     

Pre Frail 80: Multifactorial Intervention to Prevent Progression of Pre-Frailty to Frailty in the Elderly

Objectives

Preventing or delaying frailty has important benefits in the elderly, and in health and social services. Studies have demonstrated the effectiveness of multifactorial interventions in the frail elderly, but there are fewer studies on community-dwelling pre-frail individuals. Identifying pre-frail individuals susceptible to intervention could prevent or delay frailty and its consequences and associated disability and might reverse the state from pre-frail to robust. To evaluate a multifactorial, interdisciplinary primary care intervention in community-dwelling pre-frail elderly patients aged ≥ 80 years.

Design

Randomized clinical trial in a Barcelona primary healthcare centre.

Setting

We included 200 community-dwelling subjects aged ≥ 80 years meeting the Fried pre-frailty criteria. Participants were randomized to intervention and control groups.

Intervention

The intervention group received a 6-month interdisciplinary intervention based on physical exercise, Mediterranean diet advice, assessment of inadequate prescribing in polypharmacy patients and social assessment, while the control group received standard primary healthcare treatment.

Results

173 pre-frail participants (86.5%) completed the study; mean age 84.5 years, 64.5% female. At twelve months, frailty was lower in the intervention group (RR 2.90; 95%CI 1.45 to 8.69). Reversion to robustness was greater in the intervention group (14.1% vs.1.1%, p <0.001). Functional and nutritional status, adherence to Mediterranean diet, quality of life, and functional mobility were improved in the intervention group (p ≤0.001).

Conclusion

A multifactorial, interdisciplinary primary healthcare intervention focused on physical exercise, nutrition, review of polypharmacy and social assessment prevented frailty in pre-frail elderly patients, and improved functional capacity, quality of life and adherence to the Mediterranean diet.

     

Individually tailored dietary counseling among old home care clients - Effects on nutritional status

Objective

To evaluate the effect of individually tailored dietary counseling on nutritional status among home care clients aged 75 years or older.

Design

Non-randomised controlled study.

Setting and participants

The study sample consisted of 224 home care clients (≥ 75 years) (intervention group, n = 127; control group, n = 100) who were at protein-energy malnutrition (PEM) or risk of PEM (MNA score <24 and plasma albumin <35 g/L).

Intervention

Individually tailored dietary counseling; the persons were instructed to increase their food intake with energy-dense food items, the number of meals they ate and their consumption of energy-, protein- and nutrient-rich snacks for six months.

Measurements

The Mini Nutritional Assessment (MNA), Body Mass Index (BMI) and plasma albumin were used to determine nutritional status at the baseline and after the six-month intervention.

Results

The mean age of the home care clients was 84.3 (SD 5.5) in the intervention group and 84.4 (SD 5.3) in the control group, and 70 percent were women in both groups. After the six-month nutritional intervention, the MNA score increased 2.3 points and plasma albumin 1.6 g/L in the intervention group, against MNA score decreased -0.2 points and plasma albumin -0.1 g/L in the control group.

Conclusions

Individually tailored dietary counseling may improve nutritional status among older home care clients.

     

Smoking behaviour,knowledge and attitudes among Family Medicine physicians and nurses in Bosnia and Herzegovina

Background

Smoking rates among the general population in Bosnia and Herzegovina are extremely high, and national campaigns to lower smoking rates have not yet begun. As part of future activities of the Queen's University Family Medicine Development Program in the Balkans Region, technical assistance may be provided to Bosnia and Herzegovina to develop of national tobacco control strategies. This assistance may focus on training doctors and nurses on smoking cessation strategies with a view to helping their patients to stop smoking. Given this important role that health professionals have, data is needed on smoking rates as well as on smoking behaviour among doctors and nurses in Bosnia and Herzegovina. This study therefore seeks to determine the smoking rates and behaviour of family medicine physicians and nurses in Bosnia and Herzegovina and to determine how well prepared they feel with respect to counselling their patients on smoking cessation strategies.

Methods

The WHO Global Health Professional Survey, a self-administered questionnaire, was distributed to physicians and nurses in 19 Family Medicine Teaching Centres in Bosnia and Herzegovina in June 2002. Smoking rates and behaviour, as well as information on knowledge and attitudes regarding smoking were determined for both physicians and nurses.

Results

Of the 273 physicians and nurses currently working in Family Medicine Teaching Centres, 209 (77%) completed the questionnaire. Approximately 45% of those surveyed currently smoke, where 51% of nurses smoked, compared to 40% of physicians. With respect to knowledge and attitudes, all respondents agreed that smoking is harmful to one's health. However, "ever" smokers, compared to "never" smokers, were less likely to agree that health professionals who smoke were less likely to advise patients to quit smoking than non-smoking health professionals. Less than half of physicians and nurses had received formal training in smoking cessations strategies, but about two thirds of health professionals felt very or somewhat prepared to counsel their patients on how to quit smoking.

Conclusions

Our study indicates that almost half of Family Medicine health professionals in Bosnia and Herzegovina are smokers. This indicates a severe public health problem throughout the country. Steps need to be taken at a national level to address the fight against tobacco.

     

Evaluation of a continuing educational intervention for primary health care professionals about nutritional care of patients at home

Objective

Evaluate the effectiveness of a continuing educational intervention on primary health care professionals’ familiarity with information important to nutritional care in a palliative phase, their collaboration with other caregivers, and their level of knowledge about important aspects of nutritional care.

Design

Observational cohort study.

Setting

10 primary health care centers in Stockholm County, Sweden.

Participants

140 district nurses/registered nurses and general practitioners/physicians working with home care.

Intervention

87 professionals participated in the intervention group (IG) and 53 in the control group (CG). The intervention consisted of a web-based program offering factual knowledge; a practical exercise linking existing and new knowledge, abilities, and skills; and a case seminar facilitating reflection.

Measurements

The intervention’s effects were measured by a computer-based study-specific questionnaire before and after the intervention, which took approximately 1 month. The CG completed the questionnaire twice (1 month between response occasions). The intervention effects, odds ratios, were estimated by an ordinal logistic regression.

Results

In the intra-group analyses, statistically significant changes occurred in the IG’s responses to 28 of 32 items and the CG’s responses to 4 of 32 items. In the inter-group analyses, statistically significant effects occurred in 20 of 32 statements: all 14 statements that assessed familiarity with important concepts and all 4 statements about collaboration with other caregivers but only 2 of the 14 statements concerning level of knowledge. The intervention effect varied between 2.5 and 12.0.

Conclusion

The intervention was effective in increasing familiarity with information important to nutritional care in a palliative phase and collaboration with other caregivers, both of which may create prerequisites for better nutritional care. However, the intervention needs to be revised to better increase the professionals’ level of knowledge about important aspects of nutritional care.

     

Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline

Background

Clinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals – but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes.

Methods

The TDFI approach was used in a pre-post study in three NHS hospitals with a fourth acting as a control (with usual care and no TDFI). The target behavior identified for change was to increase the use of pH testing as the first line method for checking the position of a nasogastric tube. Repeat audits were undertaken in each hospital following intervention implementation. We used Zou’s modified Poisson regression approach with robust standard errors to estimate risk ratios for the use of pH testing. The projected return on investment (ROI) was also calculated.

Results

Following intervention implementation, the use of pH first line increased significantly across intervention hospitals [risk ratio (95% CI) ranged from 3.1 (1.14 to8.43) p?<?.05, to 8.14 (3.06 to21.67) p?<?.001] compared to the control hospital, which remained unchanged [risk ratio (CI)?=?.77 (.47-1.26) p?=?.296]. The estimated savings and costs in the first year were £2.56 million and £1.41 respectively, giving an ROI of 82%, and this was projected to increase to 270% over five years.

Conclusion

The TDFI approach improved the uptake of a patient safety guideline across three hospitals. The TDFI approach is clinically and cost effective in comparison to the usual practice.

     

A modified response of NAFLD patients with non-significant fibrosis in nutritional counseling according to GCKR rs1260326

Aim

To investigate the association between GCKR gene and nutritional treatment in NAFLD-related biomarkers.

Methods

This was an open-label and single-arm clinical trial in 44 overweight or obese adults with NAFLD receiving nutritional counseling for 6 months. Nutritional data, MedDietScore, clinical, biochemical, inflammatory and oxidative stress biomarkers were evaluated before and after intervention. Further, we genotyped GCKR rs1260326 and in T-allele carriers and non-Τ-carriers we assessed associations between the GCKR variant and nutritional counseling related to change in all biomarkers evaluated.

Results

Anthropometric measurements were significantly reduced after the end of the intervention in patients assigned to nutritional counseling. Liver imaging and fibrosis were significantly improved. GCKR rs1260326 T-allele frequency was 46.7%. T-carriers responded better to nutritional counseling regarding fasting blood glucose levels (mean_6-0 change = ?4.94 mg/dL (±9.33), p = 0.005), whereas non-T-carriers did not benefit from the intervention regarding glucose. On the other hand, levels of oxLDL decreased in the non-T-carriers group after the intervention, but not in T-carriers.

Conclusions

Our results show that GCKR rs1260326 T-allele is associated with better response of NAFLD patients to nutritional treatment regarding fasting blood glucose, but not oxLDL levels. Despite this important finding in the field of nutrigenetics, it is tricky to generalize this effect unless larger studies are conducted.

     

Cost-Effectiveness Analysis of Smoking Cessation Interventions in Japan Using a Discrete-Event Simulation

Background

Smoking cessation medications have been shown to yield higher success rates and sustained abstinence than unassisted quit attempts. In Japan, the treatments available include nicotine replacement therapy (NRT) and varenicline; however, unassisted attempts to quit smoking remain common.

Objective

The objective of this study was to compare the health and economic consequences in Japan of using pharmacotherapy to support smoking cessation with unassisted attempts and the current mix of strategies used.

Methods

A discrete-event simulation that models lifetime quitting behaviour and includes multiple quit attempts (MQAs) and relapses was adapted for these analyses. The risk of developing smoking-related diseases is estimated based on the duration of abstinence. Data collected from a survey conducted in Japan were used to determine the interventions selected by smokers initiating a quit attempt and the time between MQAs. Direct and indirect costs are assessed (expressed in 2014 Japanese Yen).

Results

Using pharmacotherapy (NRT or varenicline) to support quit attempts proved to be dominant when compared with unassisted attempts or the current mix of strategies (most are unassisted). The results of stratified analyses by age imply that smoking cessation improves health outcomes across all generations. Indirect costs due to premature death leading to lost wages are an important component of the total costs, exceeding the direct medical cost estimates.

Conclusions

Increased utilisation of smoking cessation pharmacotherapy to support quit attempts is predicted to lead to an increase in the number of smokers achieving abstinence, and provide improvements in health outcomes over a lifetime with no additional costs.

     

Ansichten und Erfahrungswerte über die Praxis der Früherkennungs- und Präventionsmaßnahmen von Gebärmutterhalskrebs

Background

The introduction of vaccination against human papillomavirus (HPV) has increased physicians’ and women’s awareness about the prevention of cervical cancer.

Methods

To gain further knowledge about prevention measures against cervical cancer and HPV vaccination in daily practice, 112 physicians were interviewed by means of a standardized questionnaire in an outpatient setting in Mecklenburg–Western Pomerania, Germany.

Results

Regardless of specialisation area, the physicians regarded HPV vaccination positively. They expect not only a reduction in human suffering caused by cervical cancer and its prestages but also, because of less need for therapy and monitoring, a reduction in costs. In addition, they expect increasing awareness of cervical cancer prevention and more regular attendance at cervical cancer screening.

Conclusions

The majority of interviewed physicians showed a positive attitude toward HPV vaccination and do not expect a trade-off between screening and vaccination.

     

Acute coronary syndromes occurring while driving: frequency and patient characteristics

Background

Acute coronary syndrome (ACS) may occur during any human activity, including driving. The objectives of this study were to report the frequency of ACS occurring while driving, clarify patient characteristics, and analyze the behavioral patterns of drivers who sustained ACS.

Methods

A single-center, retrospective observational study was conducted using prospectively acquired data. Among 1605 ACS patients admitted between January 2011 and December 2016, 65 (60 men/5 women) patients who sustained ACS while driving were identified. Clinical variables were compared between these 65 patients and 1540 patients who sustained ACS while performing other activities. Furthermore, multivariable regression analysis was performed to identify variables associated with ACS.

Results

The frequency of ACS occurring while driving was 4.0% (65/1605). Compared with patients who sustained ACS while performing other activities, those who sustained ACS while driving were significantly younger (66.2?±?13.0 vs. 57.5?±?12.2 years, p?<?0.001) and more likely to smoke (34.2 vs. 60.0%, p?<?0.001). Multivariable regression analysis showed that age (OR 0.961; 95% CI 0.940–0.982) and current smoking (OR 1.978; 95% CI 1.145–3.417) were associated with ACS. While 55 drivers (85%) who remained conscious after ACS could seek medical attention without causing accidents, the other 10 (15%) who sustained cardiac arrest caused accidents.

Conclusions

The association between current smoking and ACS occurring while driving suggests that smoking cessation is advised for smokers who drive from the standpoint of driving safety. We expect that prospective studies be conducted to verify our findings and identify individuals at risk for ACS while driving.