Design and baseline characteristics from the KAN-QUIT disease management intervention for rural smokers in primary care

Abstract

Objective

To describe the design, implementation, baseline data, and feasibility of establishing a disease management program for smoking cessation in rural primary care.

Method

The study is a randomized clinical trial evaluating a disease management program for smoking cessation. The intervention combined pharmacotherapy, telephone counseling, and physician feedback, and repeated intervention over two years. The program began in 2004 and was implemented in 50 primary care clinics across the State of Kansas.

Results

Of eligible patients, 73% were interested in study participation. 750 enrolled participants were predominantly Caucasian, female, employed, and averaged 47.2 years of age (SD = 13.1). In addition to smoking, 427 (57%) had at least one additional major risk factor for cardiovascular disease (diabetes, hypertension, high cholesterol, heart disease or stroke). Participants smoked on average 23.7 (SD = 10.4) cigarettes per day, were contemplating (61%) or preparing to quit (30%), were highly motivated and confident of their ability to quit smoking, and reported seeing their physicians multiple times in the past twelve months (Median = 3.50; Mean = 5.48; SD = 6.58).

Conclusion

Initial findings demonstrate the willingness of patients to enroll in a two-year disease management program to address nicotine dependence, even among patients not ready to make a quit attempt. These findings support the feasibility of identifying and enrolling rural smokers within the primary care setting.

Introduction

Although cigarette smoking is commonly considered a voluntary social act, nicotine dependence can be more accurately characterized as a chronic disease typically involving cycles of repeated quit attempts and smoking relapse (Fiore, 2000, Fiore et al., 2008). Most models of drug dependence account for the majority of drug users experiencing challenges with abstinence and expect relapse prior to achieving long-term abstinence. However, most smoking cessation interventions offer only a single, short-term (i.e., 1–12 week) intervention and do not include a mechanism for assisting non-responders or those who relapse (Fiore, 2000, Silagy et al., 1994).

Physicians have contact with over 70% of smokers each year (Lopez-Quitero et al., 2007). Physicians who intervene, even with brief advice, can impact a patient's smoking behavior (Pine et al., 1999, Russell et al., 1979). Unfortunately, physicians' offices often are poorly equipped to provide management of nicotine addiction in accordance with established guidelines (Rothemich et al., 2008, Orlandi, 1987, Kottke et al., 1988). Smoking cessation counseling competes with other clinical tasks and, beyond brief advice, many physicians do not routinely counsel patients who smoke (Rothemich et al., 2008, Steinberg et al., 2007, Ockene, 1987a, Ockene, 1987b, Wells et al., 1986). Further, only a subset of smokers trying to quit receive pharmacotherapy (Steinberg et al., 2007, Ellerbeck et al., 2001, Control, 1993). However, when smoking cessation treatment is offered within primary care, the majority of patients who smoke choose to participate (Fiore et al., 2004).

Disease management programs have been created to address problems commonly encountered in chronic disease care (Eberhardt et al., 2001, Epstein and Sherwood, 1996). Chronic illness management and smoking cessation have been inadequately addressed in a clinical practice environment designed for acute complaints (Ellerbeck et al., 2001, Ashton, 1999, Jencks et al., 2000). Effective chronic disease management and smoking cessation programs both require systems to identify patients in need of service, track changes in health care needs over time, assure treatment in accordance with best practices, and pro-actively engage patients in behavior change (Fiore, 2000, Glasgow et al., 2001a, Glasgow et al., 2001b, Kottke et al., 1988). Many disease management programs utilize ‘case managers’ and proactive telephone contacts to coordinate and deliver specific elements of evidence-based care (Philbin, 1999, Rich, 1999, Rich, 2001, Wagner, 1998, Wagner, 2000). Case managers function as an entity outside of the physician's office, providing resources unavailable in the typical practice.

We developed KAN-QUIT, a disease management smoking cessation program integrated into primary care clinics in the state of Kansas. KAN-QUIT was designed to provide the support systems needed to address nicotine dependence as a chronic disease within the existing primary care system. Within this disease management program, ‘case managers’ (counselors) are part of an external intervention team able to assess and track smokers, provide behavioral counseling, and coordinate management of nicotine dependence with the primary care physician. KAN-QUIT also provides multiple opportunities for smokers to make new or repeated quit attempts.

A disease management program may be particularly suitable for primary care practices with reduced access to community-level behavioral change programs. Rural communities have higher smoking prevalence (Doescher et al., 2006) and limited cessation resources (Ellerbeck et al., 2001, Ellerbeck et al., 2003). Rural-dwelling adults have lower rates of health insurance coverage (Rowland and Lyons, 1989), travel longer distances for health care, and have access to fewer health care providers, particularly fewer specialists (Eberhardt et al., 2001). Higher rates of tobacco use, high rates of poverty, and limited access to health care strongly support the need for developing new avenues for smoking cessation in rural communities.

The goal of the KAN-QUIT study is to evaluate the effectiveness of high and low intensity disease management programs for nicotine dependence. This paper provides a preliminary report to describe the design, early implementation, and implications for adoption of disease management concepts in addressing nicotine dependence.