Association between Quitline Facility Type and Subsequent Client Contact

Abstract

Objectives:

We conducted secondary analysis on the Arizona Smokers’ Helpline data from 2009 to 2011 to assess the relationship between type of referring facility and number of referred patients reached, enrolled, and quit 7 months post-enrollment.

Methods:

We used logistic regression to compare rates for hospitals, community health centers, and primary service providers.

Results:

Staff members were more likely to reach patients referred by community health centers and to enroll patients referred by primary service providers. At 7 months post-enrollment, there were no differences in the 30-day point prevalence quit rates.

Conclusions:

Patients referred to quitlines engage at different rates depending on facility type. Training of healthcare professionals may need to differ by facility type.

Quitlines are well established as an effective modality for the treatment of tobacco dependence.^1–3 They are easily accessible, and if the client chooses, anonymous. The Arizona Smokers’ Helpline (ASHLine) provides free tobacco cessation counseling via a proactive multiple-call protocol to all Arizona residents requesting help to quit using tobacco. All services are provided in English and Spanish. The ASHLine allows healthcare providers to refer patients directly. Healthcare providers refer patients to the quitline via fax or Web portal that includes the patient’s name, date of birth, telephone number, preferred language for calls, and best time to contact for an enrollment call.

The ASHLine employs a team of health educators who train healthcare providers to use the ASHLine referral program. The health educators’ primary focus is to provide training in cessation interventions recommended by the United States Public Health Service Guidelines for Treating Tobacco.¹ In addition, health educators provide training on how to utilize office staff to complete tobacco cessation interventions as opposed to a physician-only approach. Finally, the educators deliver a modified educational intervention in policy change to the providers. The goal of health educator trainings is to encourage consistent assessment for tobacco use and to refer smokers to the ASHLine for assistance with cessation.

Despite the advantages of quitlines and efforts to increase utilization, too few smokers seek assistance from quitlines.⁴ Little is known about the determinants of quitline use beyond those at the client level. Moreover, researchers know little about the relationship between the type of healthcare facility that initiates referrals into quitlines and the subsequent contact between quitline staff members and patients. Our study addresses this gap by assessing the relationship among the type of facility making a quitline referral and subsequent referral reach rate, enrollment rates, and 30-day point prevalence quit rates at 7 months after enrollment.

METHODS

We conducted a retrospective study of 13,743 quitline patient referrals received between April 1, 2009 and March 31, 2011. The study used referrals from 3 types of healthcare facilities: hospitals, primary service providers - some of which are specialty service providers, and community health centers. When a facility makes its first referral on the standardized referral form, the facility is provided a customized referral form that requires a minimal amount of client information to be collected and faxed to the ASHLine. After a referral is received, ASHLine staff members call each referred patient up to 5 times over 2 weeks to enroll patients in the counseling program.

Upon reaching the patient, staff members describe the ASHLine’s services, and if the patient is interested, complete the ASHLine Client Information Form and enroll the patient in the counseling program.⁵ The ASHLine uses a proactive multiple-call protocol to assist callers in the quit process until they reach 90 days post-cessation. Once enrolled in the program, clients receive as many calls as necessary to achieve their goals. Because relapse is common among those attempting to quit, patients are not exited from the program for relapsing. All patients who enroll in the counseling program and consent to follow-up receive a survey call 7 months post-enrollment to assess tobacco quit status and program satisfaction.

Data Sources

All healthcare referrals to the ASHLine are required to include the patient’s name and phone number. Patient date of birth is also requested, thereby providing the ASHLine the age of most referred patients. If the patient enrolls, the ASHLine staff member collects demographic, tobacco use, and health status information with the Client Information Form. Finally, the ASHLine contacts the patient at 7 months post-enrollment to assess 30-day point prevalence quit status and program satisfaction via a follow-up survey. This survey is administered to all clients who consent to a follow-up call when enrolled.

Although the ASHLine provides training for professionals in a variety of settings, healthcare facilities are the primary focus of referral training. For the purpose of this study, we analyzed data collected from the 3 most common healthcare categories: hospitals, private or small primary service providers (PSP), and community health centers (CHC). We excluded other types of healthcare facilities due to too few referrals. Clients who were referred to the ASHLine without valid contact information such as wrong number or disconnected phone were excluded. About 6% of all the ASHLine referrals comprise this group, and eliminating this cohort allowed us to estimate differences among healthcare facility types that were due to factors other than invalid contact information. The term “valid referrals” is used henceforth to designate referrals used in the sample of 13,743 for analysis.

Data Analysis

Descriptive demographic statistics were used to characterize the participants under study. We used logistic regression to test differences in valid referral reach rates, enrollment rates, and quit rates among the 3 types of healthcare facilities. Odds ratios are reported to compare differences in these outcomes by facility type, and chi-square statistics were used to test differences in −2 log likelihood. This latter statistic is used to evaluate the overall model for predicting each outcome. The LOGISTIC procedure in SAS^® 9.3 was used to run the logistic regressions from which the aforementioned statistics were generated. In addition to the inferential information of odds ratios, descriptive statistics were calculated to produce standard rate metrics for the outcomes. The definitions for these descriptive rate statistics are as follows: Referral Reach Rate – number referrals reached / number referrals; Enrollment Rate – number enrolled / number reached; and Quit Rate – number who self-report no tobacco use within the last 30 days / number of patients enrolled, measured at 7 months post enrollment. This intent to treat (ITT) calculation was based on the number of patients enrolled, not referred. Restricting this ITT to enrollees allowed us to estimate differences in patient quit rate without the confounding effects of differences in reach and enrollment rates among the 3 facility types. For the ITT calculation, any clients who were not reached for the 7-month follow-up survey were recorded as currently using tobacco.

Age is the only demographic variable on the referral form, and therefore, no other demographic information was available to model referrals. Additional demographic data, such as race, sex, and education, are collected at the time of program enrollment, allowing us to estimate such variables on quit rate.

RESULTS

The ASHLine enrollee demographics were similar across the 3 types of healthcare facilities. Of the patients referred by hospitals who enrolled in the ASHLine services, 58% were female. Sixty-three percent and 62% of patients referred by PSPs and CHCs, respectively, were female. Most enrollees were white, with percentages ranging from 69% to 80% across all 3 types of healthcare facilities. Most patients referred from all types of healthcare facilities had high school level education, ranging from 55% to 60%; however, CHCs referred the greatest number of the ASHLine enrollees with less than a high school education (33%). PSP referrals produced the lowest proportion of patients enrolling with less than a high school education (23%). CHC referrals produced the highest rate of Hispanic enrollees (26%), whereas PSPs generated the lowest rate of Hispanic enrollees (15%). Table 1 details demographics for the sample of enrolled participants. Chi-square tests of association were run to test differences in the levels within each demographic category across the 3 facility types. The p values were statistically significant for all demographic comparisons (Table 1).

Table 1.

Demographics of Patients Who Enrolled after Being Reached (N = 3422)

			Hospital	PSP	CHC
	p value		N (%)	N (%)	N (%)
Sex	.04	Male	377 (42%)	563 (37%)	363 (38%)
		Female	524 (58%)	970 (63%)	591 (62%)
Race	< .001	White	621 (73%)	1172 (80%)	605 (69%)
		African American	76 (9%)	91 (6%)	54 (6%)
		Asian	8 (1%)	5 (0.3%)	2 (0.2%)
		American Indian	24 (3%)	18 (1%)	35 (4%)
		Other Race
Education	< .001	Did Not Graduate High School	229 (26%)	351 (23%)	313 (33%)
		High School Graduate	504 (56%)	915 (60%)	524 (55%)
		College Graduate	164 (18%)	254 (17%)	111 (12%)
Insurance	< .001	Yes	786 (88%)	1415 (93%)	815 (86%)
		No	108 (12%)	116 (8%)	137 (14%)
Hispanic	< .001	Yes	222 (19%)	289 (15%)	311 (26%)
		No	969 (81%)	1609 (85%)	875 (74%)
Referral Language	< .001	English	2706 (96%)	3444 (97%)	1999 (91%)
		Spanish	99 (4%)	93 (3%)	209 (9%)

Note.

Percentages are based on non-missing data. PSP = Primary Service Provider; CHC = Community Health Center. The p value indicates differences in proportion of demographic variables across the 3 facility types.

Type of healthcare facility, when controlling for patient age, was related to whether or not referred patients were reached by the ASHLine enrollment staff, χ² = 87.79, p < .0001 (Tables 2 and 3). Patients referred by hospitals had the lowest reach rate (59.50%), with the highest reach rate coming from patients referred from CHCs (67.05%). Patients referred from CHCs were 36.3% more likely to be reached than patients referred from hospitals. Patients referred by PSPs were 20.0% more likely to be reached than patients referred from hospitals and 20.5% less likely to be reached than patients referred from CHCs.

Table 2.

Referral, Reach, Enrollment, and Quit Rates by Quitline Referral Facility Type

Location Type	Referrals (p < .0001)	% Total Referrals	Reached (p < .0001)	Reach Rate	Enrolled (p < .0001)	Enrollment Rate	Quit (p = .99)	Quit Rate
Primary Service Provider	5585	41%	3538	63%	1550	44%	153	17%
Hospital	4714	35%	2805	60%	909	32%	263	17%
Community Health Center	3293	24%	2208	67%	963	44%	149	16%
Total Sample	13,592	100%	8551	63%	3422	40%	3333

Note.

Referrals: ASHLine receives a completed fax or online referral form from a healthcare organization. Reached: a client referred to the ASHLine spoke to an ASHLine staff member. Enrolled: the referred client enrolled in ASHLine’s behavioral support service. Quit: a client self-reported no tobacco us within 30 days of follow-up survey that administered 7 months post-enrollment.

Table 3.

Odds Ratios for Comparisons in Percent Reached, Percent Enrolled, and Percent Quit among Quitline Referral Facility Types (Controlled for Age)

Variable	Odds Ratio	OR 95% CI
Reached
Hospital vs PSP	.80	.74 – .87
Hospital vs CHC	.64	.58 – .70
PSP vs CHC	.80	.73 – .87
Enrolled
Hospital vs PSP	.62	.56 – .69
Hospital vs CHC	.63	.56 – .71
PSP vs CHC	1.02	.92 – 1.14
Quit
Hospital vs PSP	.98	.79 – 1.23
Hospital vs CHC	.99	.77 – 1.28
PSP vs CHC	1.01	.81 – 1.26

Note.

PSP = Primary Service Provider; CHC = Community Health Center; OR = Odds Ratio; CI = Confidence Interval.

Reached: a client referred to the ASHLine spoke to an ASHLine staff member.

Enrolled: the referred client enrolled in ASHLine’s behavioral support service.

Quit: a client self-reported no tobacco us within 30 days of follow-up survey that administered 7 months post-enrollment.

After controlling for patient age, significant differences were still found in patient enrollment among the types of healthcare facilities from which they were referred, χ² = 93.13, p < .0001 (Tables 2 and 3). Patients referred by hospitals had the lowest enrollment rate (32.41%), whereas patients referred from PSPs had the highest enrollment rate (43.81%). Patients referred from PSPs were 38% more likely to enroll than patients referred from hospitals. Patients referred from CHCs were 36.6% more likely to enroll than patients referred from hospitals. There was no significant difference in enrollment rate between patients referred from PSPs and CHCs (OR = 1.02).

Controlling for patient age, no difference in ITT quit rate was observed among the 3 types of healthcare facilities, χ² = .03, p = .99 (Tables 2 and 3). A total of 3333 clients were called for a follow-up survey. For hospitals, 153 clients of the 879 (17%) who were called reported being quit, for PSPs, 263 clients of the 1516 (17%) who were called reported being quit, and for CHCs, 149 of the 938 (16%) who were called reported being quit. None of the demographic variables listed in Table 1 were significantly related to quit rate (p > .05) and therefore, were eliminated from the final, restricted model predicting quit rate from type of healthcare facility presented in Table 3. The reach rate for patients completing the 7-month follow-up survey was 50%.

DISCUSSION

To increase the use of quitlines, the Community Preventive Services Task Force (CPSTF) (http://www.the-communityguide.org/tobacco/quitlines.html) has suggested the implementation of mass-reaching health communication interventions, the provision of free tobacco cessation medications, and has proposed greater integration of quitlines into larger healthcare systems by way of an increase of provider-initiated referrals of smokers to the quitlines. Research has suggested that personal contact between patients and their healthcare providers may influence compliance and follow through on a referral to a quitline^5,6 and that providers play a critical role in guiding smokers to quitlines.⁷ Following the evidence base established in other studies,⁸ the ASHLine consistently has targeted healthcare systems and providers to increase the odds of patients receiving cessation messages from multiple sources, including clinicians. However, as with many tobacco control stakeholders, the CPSTF has not considered whether the type of referring provider and, equally important, the type of healthcare facility from which the provider refers may have implications for smokers’ enrollment into quitlines and cessation outcomes.

Studies of healthcare referrals have reported quitline contact rates that range from 40% to 70%.^10–17 Whereas parsing out the type of healthcare facility was beyond the scope of these previous studies, the ASHLine referral reach rates across all facility types fell midway between the lowest and highest published contact rates at ~63%. Within the ASHLine healthcare referral program, the type of healthcare facility making the referral was associated with reach rate and enrollment rate of patients being referred. CHCs had the highest reach rate of 67%, whereas PSPs and CHCs had the highest enrollment rate each at 44%. The rate of 44% clients who enrolled in quitline services and received at least minimum service that resulted from referrals by PSPs and CHCs is higher than that of 35% as reported by the North American Quitline Consortium from the 2012 Annual Survey data. Broad differences in reach, enrollment, and quit rates reported in previous studies may be contributed to variations in provider and healthcare facility training within and between studies. Studies have shown that academic detailing that includes on-site training, technical assistance, and performance feedback can yield an increase in provider referrals to quitlines.¹⁸ Training is comprised of these basic elements of academic detailing and expectations of the different types of healthcare facilities referring to the ASHLine are similar; therefore, the association between the type of healthcare facility and the rate at which smokers are proactively contacted and enrolled after referral cannot be attributed solely to the training. Partnering healthcare facilities are charged with implementation of the referral program, and differences in how the referral program is implemented may, in part, explain the varying reach, enrollment, and overall rates of quitline utilization.

Whereas various departments within hospital facilities have been examined as a reliable source for tobacco cessation interventions,^19–21 the nature of a hospital visit may contribute to the lower level of engagement in and utilization of a quitline program. Patients may be facing an acute condition that may take a higher priority than tobacco use, thus resulting in lower rates of engagement. Furthermore, hospitals often complete the referral during the discharge process when patients may not be focused on the significance of the consent to the referral. Finally, because there is rarely follow-up after a hospital visit, a patient’s compliance with the referring healthcare provider’s recommendation may be low. Further research is needed to examine the timing and priority of referrals in hospital settings to understand how hospital protocol and prioritization regarding tobacco affects a patient’s engagement. Until further research is conducted, hospital administration should consider timing of interventions and referrals that allow for the highest level of engagement. Enrolling patients prior to discharge may provide a patient with an opportunity to become engaged in a quit attempt prior to being released with more likelihood of continuing that relationship post-discharge.

One limitation of this study is that valid referrals received by the ASHLine did not include any demographic data beyond the patient’s age at the time of referral, making it difficult to evaluate whether there are significant demographic or tobacco use differences in the overall population being referred by the type of healthcare facility. Only after contacting the patient and enrolling the patient in the program are demographic and tobacco use history collected. Whereas this study indicates that the demographics of those who enroll in the program are similar and quit at similar rates, we know little about those smokers who do not enroll in the program. Further research could help determine which patient-related factors are associated with enrollment into tobacco cessation programs. To reduce invalid referrals, the ASHLine implemented a new procedure to follow up with referring facilities that provided incorrect contact information.

Our findings show that after enrollment, the ASHLine counseling program was equally effective regardless of the type of referring facility. Given that patient priorities and timing of referrals may contribute to different reach and enrollment rates, providing the same training to each type of facility may not best suit the outcome. Whereas studies have shown academic detailing, such as targeted training for healthcare providers and/or facilities, to yield a significantly higher number of referrals,¹⁷ our findings suggest that customized academic detailing at different types of facilities may be of use. For those hospitals or other healthcare facilities that have lower response rates despite having adequate referral rates, additional research could identify factors, whether institutional or patient-related, that might improve response rates of referred smokers who do not accept calls from or enroll in tobacco cessation quitline programs. Quitlines could be asked to consider testing different models of timing of interventions to illuminate whether timing is a factor. With the advent of electronic medical records, more demographic data could be shared with the quitline to also look for patient-related differences.

Although no significant difference was found in the quit rates of referred patients after enrolling in the ASHLine, the primary findings do indicate that the type of healthcare facility making a referral is important in a patient’s enrollment in a quitline program. Little is known about the effect of procedures employed by facilities and the psychosocial factors of referred patients at the time of referral, making identification of evidence-based best referral practices difficult. This research contributes to the growing knowledge base regarding tobacco cessation referrals and supports the need for further research regarding the unique differences of facility operations and possible patient differences at each type of healthcare facility.

IMPLICATIONS FOR HEALTH BEHAVIOR OR POLICY.

With a lack of clear evidence about what factors contribute to the differences found in enrollments in tobacco cessation service related to the type of healthcare facility that makes the referral, more research needs to be conducted to establish what might contribute to the differences. We recommend more research that examines factors including: (1) patient demographics of all referred patients; (2) the nature of the patient experience – acute care versus preventative or routine care; and (3) timing of tobacco cessation interventions at the facility. Until more data are available about facility or patient related factors, data-driven policy remains problematic. Until further research is conducted establishing factors necessary to make informed decisions, we recommend that facilities increase accountability for referrals by changing internal policy to reflect a successful intervention as an enrollment in tobacco cessation service rather than a referral to services.