摘要：Objectives. We examined electronic health records (EHRs) to assess the impact of systems change on tobacco use screening, treatment, and quit rates among low-income primary care patients in Louisiana. Methods. We examined EHR data on 79 777 patients with more than 1.2 million adult primary care encounters from January 1, 2009, through January 31, 2012, for evidence of systems change. We adapted a definition of “systems change” to evaluate a tobacco screening and treatment protocol used by medical staff during primary care visits at 7 sites in a public hospital system. Results. Six of 7 sites met the definition of systems change, with routine screening rates for tobacco use higher than 50%. Within the first year, a 99.7% screening rate was reached. Sites had a 9.5% relative decrease in prevalence over the study period. Patients were 1.03 times more likely to sustain quit with each additional intervention (95% confidence interval = 1.02, 1.04). Conclusions. EHRs can be used to demonstrate that routine clinical interventions with low-income primary care patients result in reductions in tobacco use and sustained quits. Despite reductions in prevalence, tobacco use or tobacco smoke remains 1 of the major modifiable risk factors for 4 of the 5 leading causes of death in the United States. 1 Estimated direct medical costs from tobacco use have reached $133 billion annually. 2 Until evidence-based interventions to increase population quit attempts and quit rates become routine, especially in health care settings, national objectives to reduce tobacco use will be difficult to achieve. 3 Brief tobacco cessation interventions are effective in helping smokers quit. 4,5 Clinical protocols such as the 5 A’s (ask, advise, assess, assist, arrange), 6 2 A’s and a C (ask, advise, connect), 7 and 2 A’s (ask, act) 8 promote tobacco use screening and treatment. However, in addition to clinician interventions, the US Public Health Service guideline for treating tobacco use and dependence advocates that health care organizations adopt systems change supporting delivery of tobacco dependence treatments. 6 The use of health care delivery systems has the potential to reach a large number of smokers, 80% of whom see a doctor at least once a year. 2 Systems change enhances the identification and treatment of tobacco users within health care settings. The guideline recommends systems strategies to facilitate integration of evidence-based treatments for tobacco use, including electronic documentation of screening and intervention. 6 Use of electronic health records (EHRs) improves adherence to clinical protocols. 9 Legislation incentivizing nationwide adoption of EHRs will accelerate integration of this technology into diverse delivery systems. 10 Still, long-term follow-up and measurements are needed to verify changes in patterns of care and to determine whether such changes result in improved health outcomes. By examining EHR data, Land et al. 11 demonstrated the ability to measure the effect of systems change on smoking prevalence and health care utilization. Their results illustrated the importance of consistent exposure to evidence-based interventions and showed that a system-wide adoption of standardized evidence-based tobacco measures decreased smoking prevalence in a relatively affluent, primarily White suburban population with lower than average smoking prevalence. Because people in lower socioeconomic classes have difficulty sustaining quits, 12,13 it is important to show that routine clinical interventions with low-income patients promote successful quit attempts and help recent quitters remain so. In 2002, the Louisiana legislature enacted a cigarette excise tax as part of a statewide tobacco control program, 14 including the Tobacco Control Initiative (TCI). The TCI, an early adopter of EHR-supported, clinic-based interventions for tobacco use, offers standardized cessation services, with a focus on implementation in ambulatory care settings. The TCI’s goal is to identify tobacco users and deliver evidence-based treatments. It provides designated personnel, clinician training, behavioral counseling, free or low-cost pharmacotherapy, quit line referral, and bedside consultation, along with performance appraisal and feedback. Systems thinking was used as the framework for program conceptualization and development. The TCI program is described in greater detail elsewhere. 15 Over several years, the TCI integrated treatment of tobacco use into routine care for all patients in the Health Care Services Division of Louisiana State University Health New Orleans (LSUHNO) public hospital system using US Public Health Service guidelines. Therefore, the impact of this systems change on quit attempts, quits, and health outcomes should reflect what can be achieved when evidence-based tobacco measures are evaluated for their impact on population health. In this article, we examine the impact of systems change on a public health care network and the capacity of EHR data to capture these changes. We evaluate the effectiveness of the system-wide implementation of tobacco interventions to promote quitting.
