The CHICA Smoking Cessation System

Abstract

Environmental tobacco smoke (ETS) exposure remains an important cause of morbidity and mortality in children. Pediatricians are well positioned to help smoking parents quit. Parents who smoke may be particularly responsive to advice to quit, repeated smoking cessation messages can be effective, and parents visit the pediatrician 8–10 times for well care in the first two years of their child’s life. Yet most pediatricians do not provide smoking cessation advice.

We developed a parental smoking cessation module for an established pediatric primary care decision support system (CDSS) that runs as a front-end to the Regenstrief Medical Record System. The system collects data directly from parents and guides the physician through smoking cessation counseling, using “stages of change.”

We present the CDSS and the smoking module as well as descriptive data from our smoking cessation system. We also describe a randomized controlled trial of the system that is now underway.

Introduction

Environmental tobacco smoke (ETS) exposure remains a significant health problem, affecting 35% to 80% of US children,¹ and most smokers with children (70%) smoke inside their homes despite the adverse health effects on their children.²

ETS exposure during childhood is associated with an increased risk and severity of respiratory infections and wheezing illnesses.³ At least one third of children with asthma are exposed to ETS on a regular basis. There is convincing evidence for a causal relationship between exposure to ETS and development of asthma in children, and exposure to ETS worsens asthma control in children with asthma.⁴

ETS is also associated with Sudden infant death syndrome (SIDS)⁵ and has also been linked to neurocognitive and behavioral problems that can disrupt learning and school performance in childhood, and parents who smoke are more likely to have children that smoke.³ Finally, child health care expenditures are 19% higher for children of smokers compared with children of nonsmokers.²

Physicians can improve screening and increase cessation rates by asking patients about tobacco use at every office visit. Even brief (five minutes or less) advice on smoking cessation during an office visit can increase cessation rates.⁶ In meta-analyses, the odds ratio for successful smoking cessation with counseling was 1.56, and even brief counseling appears to be as effective as intensive counseling.⁷

Parents of young children may be especially receptive to smoking cessation efforts. Parent smokers usually see their child’s Pediatrician more often than their own physicians. Pediatricians can advise parents to quit during all of the child’s 10 well-child care visits as well as numerous illness visits. Fully 89% of parents feel that asking about smoking is a very important part of a pediatrician's job and very few nonsmokers or smokers believe that pediatricians have no business asking about parental smoking. Most parent smokers would appreciate getting smoking cessation help from pediatricians, and it is feasible for pediatricians to provide smoking cessation assistance to parent smokers with little additional time commitment at pediatric office visit.⁸

Despite this, fewer than a third of pediatricians provide such basic smoking cessation help as referring a parent to a smoking cessation program (30%), giving pamphlets on smoking cessation (28%), asking for a quit date (18%), scheduling a follow-up visit to discuss quitting (5%), or recommending nicotine replacement therapy (13%).⁹

The most common barriers for pediatricians to intervene with parents who smoke are the time constraints, the lack of tools which can help pediatricians adhere to the smoking cessation guidelines, and the anticipation of negative parental reaction. American medical education also lacks training about counseling parents and children on smoking prevention and cessation.⁷ Finally, physicians are rarely reimbursed for addressing tobacco use in the clinical setting.⁶

Computer-based clinical decision support systems (CDSS) can improve physician performance with drug dose determination, diagnostic accuracy, quality of preventive care and active medical care. Computerized reminders increase physician compliance with preventive care protocols about vaccination, and blood pressure screening and increase clinician response rates to clinical events for several common medical problems,¹² including smoking cessation.¹³ We developed and evaluated a parental smoking cessation CDSS module for a pediatric primary care decision support system running as a front-end to the Regenstrief Medical Record System (RMRS).¹⁴

Methods

CHICA (Child Health Improvement through Computer Automation) is a CDSS that has been operating in the pediatric clinic at Wishard Memorial Hospital for almost 4 years.¹⁵ CHICA incorporates clinical decision support for pediatric guidelines in the form of dynamic risk factor assessment questionnaires for parents and physician reminders. CHICA uses adaptive turnaround document (ATD) technology.¹⁶ ATDs are computer generated paper forms that are optically scanned to capture structured data. ATDs are used to generate two tailored, scannable paper forms: the Pre-Screening Form (PSF) and the Physician Work Sheet (PWS).

To determinate what information needs to be printed on each ATD, CHICA employs a library of computer readable rules (Arden Syntax) that evaluate the underlying electronic medical records (RMRS and CHICA databases). CHICA also uses a global prioritization scheme to ensure the most important content is printed.¹⁷

When a patient registers through the electronic appointment system, a standard HL7 message is sent to the CHICA system. This triggers CHICA to request a download of medical information from the Regenstrief medical record system (RMRS).¹⁴ CHICA uses this information to generate the PSF. The PSF has two sections: The top section has a space to record vital signs, and the bottom section has the 20 most important yes/no questions for the parent to answer in a particular visit in order to guide preventive care or disease management. The questions are selected by a set of rules encoded in Arden Syntax Medical Logic Modules (MLMs).

The PSF questions are completed by the parents in the waiting room. Then the nurse registering the patient enters the vital sign information and scans the PSF. After the PSF is scanned, the patient’s information is sent to CHICA and analyzed along with the existing patient record in RMRS. MLMs are applied to generate the PWS, the worksheet that the physicians complete during the encounter. The PWS contains three sections: (1) vital sign data transferred from the PSF, including calculations such as height and weight percentiles and body mass index; (2) an area for the physician to write free text notes, assessment and plan; and (3) a section with 6 guideline reminders. Each reminder has a “stem” which explains the reason for the prompt and up to 6 “leaves” with check boxes for the physician to document his or her response to the prompt.

At the same time the PWS is printed, a Just-InTime (JIT) handout can be generated for the physician to share with the families. A JIT handout is an informational sheet that is tailored to the patient needs and generated with certain PWS prompts. It can be used as a counseling aid to the physician, improving physicians’ self-efficiency and effectiveness as a counselor.

The PWS is scanned into the computer after the encounter. Coded data are extracted from the form and stored along with a TIFF image of the PWS in the CHICA database. CHICA uses a commercial software package, Teleforms (Cardiff, Vista, CA), to interpret and verify the handwritten and checkbox responses. CHICA is currently used by 12 attending physicians, 16 resident physicians and a variety of medical students on their outpatient pediatrics rotation. The positive and negative predictive value of the scanning to capture data entered by the physicians was 99.3% and 98.9% respectively, significantly better than more traditional sources of physician generated data such as ICD-9 billing codes.¹⁸ CHICA 1.0 was developed with C# and SQL Server (Microsoft). A new open source version of CHICA built on the OpenMRS platform is under development.

A very high rate of form completion (99.4%) has been observed. Family responses to CHICA questions addressing maternal depression symptoms, firearms in the home, domestic violence risk, hot water heater adjustments to avoid burns, sleep position to prevent sudden infant death syndrome, family history of deafness (a risk factor for congenital deafness), sickle cell disease, environmental tobacco smoke exposure, concerns regarding child abuse, smoke detector use, risk factors for tuberculosis, and adolescent psychosocial issues uncover risk factors in 11.3% of responses that alert providers to preventive care counseling and intervention.¹⁹

Integrating Parental Smoking Cessation into CHICA

A number of effective smoking cessation strategies have been built on Prochaska’s Transtheoretical model of health behavior change, also known as the “stages of change” model.²⁰ The Transtheoretical Model of Change focuses on the decision making of the individual and the new behavior to be adopted. The central organizing construct of the model is the 5 Stages of Change (Pre-contemplation, contemplation, preparation, action, and maintenance). The model also includes a series of independent variables, the processes of Change, and a series of outcome measures that are sensitive to progress through all stages.⁷

We implemented a series of smoking cessation steps into CHICA based on this model. Our strategy included using the PSF to assess smoking behavior, the PWS to assess the smoker’s “stage” and to tailor counseling guidance to the physicians based on that stage according to the algorithm in figure 1.

Figure 1.

CHICA’s smoking cessation algorithm

Assessment of ETS exposure was obtained through the PSF. The PWS was used to prompt the physician to assess for readiness to change behavior and, based on the assessed readiness, advised to motivate the smoker to quit or advise how to quit (figure 2).

Figure 2.

Prompts generated by the CHICA smoking cessation module

Algorithm Testing Mechanism

To study the effectiveness of CHICA’s smoking cessation module, we are utilizing a built-in mechanism for randomizing patients to receive CHICA services with or without the module. CHICA maintains a data dictionary containing a controlled vocabulary of coded terms representing clinical observations. The dictionary maps to standard vocabularies like LOINC or SNOMED when possible. To test the algorithm, we created a special study variable term. A study variable is added to the data dictionary any time a guideline is to be evaluated. The addition of the study variable causes the system to randomly assign a value to the variable as a “clinical observation” for any patient who has not had the variable assigned previously. This happens in a completely automated fashion. An arbitrary number of values can be assigned to a study variable, such as “control,” “intervention,” or “study-arm-2.”

The value of a study variable can be added to the data and logic slots of an MLM, causing it to fire only for patients who have been randomly assigned a particular value for the study variable. For example, the logic section of an MLM that prints a screening question for ETS might include the clause, “if SMOKING-STUDY = CONTROL, then conclude FALSE” so that the rule will only cause a prompt to print if the patient is not in the control group.²¹ For the smoking cessation study. This approach had to be modified to cluster randomize based on household address so as to avoid contamination.

For the randomized controlled trial (RCT), we enhanced the existing CHICA smoking cessation modules with JIT handouts. For precontemplative smokers, the JIT discusses risks of smoking and benefits of quitting. For contemplative and preparation stage smokers, the JIT aids physician counseling, provides contact information for smoking cessation programs, and provide advice on the use of nicotine replacement therapy. For the action and maintenance stages, the JIT includes a certificate of congratulations. The RCT was initiated in July, 2008. Here we present the results of the CHICA module prior to the initiation of the trial.

Results

Since the activation of the CHICA system with the smoking cessation module in November of 2004, ETS status has been assessed at 14,314 patient visits. At these visits, 3043 (21%) families reported that someone in the child’s home smoked. Among these families 1848 (60%) were assessed for readiness to quit. (In 40% of families, the pediatrician did not address the parent’s smoking presumably because of time constraints.) Of those, 678 (37%) were motivated to quit. The overall number who reported quitting over the three years was 57 or 2% of all smokers. However, given the rate of follow-up, this may represent as much as 3% of all smokers and 8% of smokers who expressed a readiness to quit.

Conclusions

Although pediatricians are well position to address smoking among parents, they are not the parents’ physician. Thus, this CHICA module supports a different type of relationship in which the pediatrician intends to impact the health behavior of a non-patient. At this stage, CHICA prompts pediatricians to give advice, but we have not suggested, for example, that the pediatricians write prescriptions for parents. Some pediatricians do so, but we have elected at this stage not to. Although parent smoking status and interventions are captured by CHICA in the child’s record, we have not yet begun recording this information in the parents’ charts. This is a challenge that will require further work.

The CHICA system provides an effective decision support environment for impacting physician behavior. However, our ability to change what physicians do is only the first step. It remains to be shown that decision support will ultimately lead to parental smoking cessation. We have demonstrated an effective way to track quit rates. The RCT we have initiated is likely to increase the effectiveness of counseling and allow us to measure whether this CDSS intervention will actually reduce ETS exposure in children.