An evidence based clinical audit on the process of management of smoking cessation in a primary care clinic

Dominic M W Lau 劉敏維

HK Pract 2005;27:212-222

Summary

Objective: To audit the process performance of smoking cessation in a government primary care clinic.

Design: Retrospective in phase 1 and prospective in phase 2.

Subjects: All adult cigarette smokers attending the clinic within a 12-month period.

Main outcome measures: Four major criteria developed from evidence based guidelines were used for process measurement. The criteria included documentation of smoking status, motivation assessment, discussion of smoking cessation, offering follow up and recommendation of nicotine replacement therapy for motivated smokers. Phase 1 data were collected from medical record review. Deficiencies were identified and changes were implemented. Phase 2 data were collected from computerized smoking registry. Phase 1 and phase 2 results were compared for improvement of performance.

Results: There were 447 smokers in phase 1 and 222 smokers in phase 2. The majority of them were male and their mean age was 45. The mean age of first smoking was 21. In phase 1, less than half of patients had been asked about smoking status and advice on quit smoking. The performance of remaining criteria was also unsatisfactory in which less than 15% reached the standard. After one year implementation of changes, there were improvements in all process measurements in phase 2 and the changes were statistically significant (p value < 0.001). More than 95% reached the standard in all the four criteria.

Conclusion: Clinical audit is effective in improving process of care in smoking cessation. There was significant positive impact on patient care. Further studies may focus on the outcome of smoking cessation rate.

Keywords: Smoking cessation, audit, primary care

摘要

目的： 對在一政府基層診所為戒煙所提供的程序進行查核。

設計： 第一期為回顧性調查和第二期為前瞻性調查。

研究對象： 所有在為期十二個月曾使用診所服務的成年吸煙人仕。

主要測量內容： 源於在實證指引所用以量度程序的四個主要標準。這些準則包括： 確定吸煙行為的記錄、動機評定、戒煙討論，為積極戒煙人仕提供跟進及推介尼古丁替代治療。 第一期，從復查病歷記錄取得資料。尋找不足，加以改善。第二期資料源自已計算機化的煙民登記冊。 將第一和第二期的表現結果作比較。

結果： 第一期和第二期分別有447位和222位吸煙人仕。多數為男性， 平均年齡為45歲。初次吸煙時的平均年齡是21歲。在第一期調查中， 少於一半的病人曾被問及抽煙習慣和建議戒煙。其餘準則的表現亦很不足， 只少於15%能達到標準。經過一年在執行上的改變後，在第二期調查時的所有程序量度得以改善。 兩者的分別已達統計學上的重要性，(P值<0.001)。在所有四個準則中，多於95%達到標準。

結論： 臨床審計能有效地改善戒煙護理的程序，令病人護理得到重要的正面影響。繼後可集中研討戒煙的成果。

詞彙： 戒煙，審計，基層醫療。

Background

Smoking is a worldwide problem. The estimated global prevalence of smoking is around 1.1 billion.¹ It is also common in Hong Kong. According to the Thematic Household Survey performed in Hong Kong 2003,² there were totally 819,700 daily smokers, accounting for 14.4% population aged 15 or above.

Tobacco is the single largest preventable cause of death and disease in the world.³ It is currently responsible for the death of one in ten adults worldwide.³ An estimated 4.9 million premature deaths were attributed to smoking.⁴ In Hong Kong, smoking kills over 5,600 people each year or 15 people per day.⁵ Tobacco causes over 40 diseases, many of them are fatal and disabling. It is one of the most potent human carcinogens in the world.

There is a large body of evidence from prospective cohort and case control studies showing that smoking related health risks can be reduced by smoking cessation. The risk of death from all causes falls when people stop smoking.⁶ The life expectancy would improve even among people who stopped smoking after age 65.⁷

Primary care physicians have extraordinary access to smokers. At least 70% of smokers see a physician each year.⁸ However, more than one third of current smokers report never having been asked about their smoking status or urged to quit.^9-10 Moreover, a population based survey found that less than 15% of smokers who saw a physician in the past year were offered assistance, and only 3% had a follow up appointment to address tobacco use.¹¹ Although there is no large scale study to address the performance of smoking cessation among primary care doctors in Hong Kong, the situation may be similar. Therefore, opportunities exist for substantial improvement in smoking cessation in general practice.¹²

The clinic of the author is one of the primary care clinics in the public sector on Hong Kong Island serving civil servants, their dependants and pensioners. Patients do not need to pay consultation fee and there is no limitation in number of consultations. After discussing the importance of smoking cessation in a clinic meeting, all staffs agreed to evaluate the process of smoking cessation and improve the performance through clinical audit. Audit is the process of critically and systematically assessing our own professional activities with a commitment to improving personal performance and ultimately, the quality and / or cost-effectiveness of patient care.¹³ Many studies have shown that audit with feedback has resulted in improved performance.¹⁴ Audit can be viewed as a framework to implement quality into practice.¹⁵

Objectives

1. To audit the process of management on smoking cessation in a primary care clinic.
2. To define the criteria and standard of care which are supported by the best current evidence.
3. To identify areas of deficiencies in the process of management on smoking cessation.
4. To identify strategies for improvement and implementation of changes.
5. To evaluate performance after the changes.

Method

There is an extensive body of literature on the subject of smoking cessation in primary care. Several evidence based international guidelines¹⁶ were used as reference for setting criteria. The major ones included guidelines from United States¹⁷, United Kingdom¹⁸, New Zealand¹⁹ and Canada.²⁰ Four audit criteria on the process of smoking cessation were identified. The level of evidence that supported each criterion from different guidelines was stated (Appendix 1 and 2). In addition, the scope of the audit was limited to adults who smoke cigarette. This is because evidence on effectiveness of primary care smoking cessation interventions in teenagers and children is lacking. Moreover, more than 99.8% daily smokers in Hong Kong were cigarette smokers.² In view of no similar local audit in primary care having been done before, no references could be compared for standard setting. A consensus on standard setting among clinic staffs was reached and Table 1 summarizes the standard for each criterion.

The audit design was retrospective in phase 1 and prospective in phase 2. The first data collection in August 2003 was a review of medical records of all current smokers including occasional smokers who attended the clinic between September 2002 and August 2003. The source of information was mainly based on cover page, progress sheet and health education sheet of medical record. There were 447 clients recruited in the first phase evaluation.

The first phase audit results were presented in the clinic meetings. Several areas of deficiencies were identified and all clinic staff (6 doctors, 6 nurses, 5 clerks and 3 workmen) realized the need for further improvement. Strategies involving changes of clinic policy, practice, staff training and smoker's attitude were implemented. Two formal clinic meetings involving all staff were held to further clarify the planned changes and provided support to clinic staff during the implementation period. A summary of areas of deficiencies and corresponding strategies implemented is shown in Table 2.

The second data collection was performed in November 2004, one year after implementation of changes. A computerized smoking registry was set up and the relevant data of all smokers attending the clinic between November 2003 and October 2004 were retrieved from the registry. There were 222 clients recruited in the second phase evaluation. The big difference in number of smokers recruited in two phases was due to sampling bias in the first phase period and will be explained in the discussion part. The author was the chief investigator to evaluate performance of the four criteria.

Statistical methods

All the data were entered and analyzed by Statistical Package for the Social Sciences version 10.0 ( SPSS Inc, Chicago [IL], United States ). The results of first phase and second phase were compared for statistically significant difference. Chi-square test was used for categorical variables. The null hypothesis is that there is no difference between first phase and second phase data. P-value of < 0.05 would be regarded as statistically significant.

Results

Characteristics of smokers

There were in total 447 and 222 smokers recruited in the first and second phase evaluation respectively. In both phases, the mean age, sex ratio and age of start smoking were similar. More smokers who smoked 10 cigarettes daily were recruited in the second phase (Table 3).

Process performance

The results of process performance in the two phases are shown in Table 4. All the performance in the second phase reached the standard and there were statistically significant improvements between first and second phase.

Discussion

Characteristics of smokers

There were in total 447 and 222 smokers recruited in first and second phase evaluation respectively. The big difference in numbers between two phases was predictable because in the first phase period, 52.1% smokers' smoking status were not documented annually. Some of them actually had quitted smoking already but their status was not updated. This could lead to potential bias of sampling during first phase evaluation.

Most of the recruited smokers were male (>84%) and the finding was compatible with the local general population in 2003 in which 86.8% were male smokers.² In both phases, the mean age of smokers was around 45 and most of the smokers belonged to age group 35 to 55. The mean age of first smoking was 21.

More smokers who smoked 10 cigarettes daily were recruited in the second phase (68.5% vs 59.4%). The mean number of cigarettes smoked daily was also higher in the second phase (12.12 vs 10.19). These were understandable because more heavy smokers would be actively recruited for quitting smoking after implementation of nicotine replacement therapy programme in the second phase period. However, this would not affect the audit result as the main objective of the audit was to assess the process and not the outcome of smoking cessation.

Generally speaking, the characteristics of smokers in the two phases were accountable.

Process performance

All the performance in the second phase reached the standard and there were statistically significant improvements between first and second phase. Concerning criterion II, one out of the 222 cases could not meet the standard. The medical record of that case was reviewed and it was found that the smoker's motivation had been assessed but the relevant information was not written down on the smoking status insert. Therefore, no data had been recorded in the smoking registry.

Impact on patient care

Following the audit, there was significant improvement in the quality of the process of smoking cessation after implementation of changes. The management of smoker was standardized and the whole process was more effective.

All the four criteria adopted in this audit focused on a same target i.e. improvement in cessation rate. Criterion I was related to documentation of smoking status and meta-analysis has shown that checking smoking status regularly significantly increases rates of clinician intervention.¹⁷ Higher rate of smoking cessation, although the finding was not statistically significant, was noticed in another meta-analysis.¹⁷

Criterion II described the assessment of motivation. Multiple studies²¹ showed that stage based intervention is effective in changing smoking behaviour. In addition, higher motivation and ready to change are associated with higher abstinence rates.¹⁷

Criterion IIIa mentioned discussing smoking cessation and systematic review found that brief advice given by physicians improved quit rates.²² There is a dose response relationship between session lengths and abstinence rate.¹⁷ On the other hand, meta-analysis has shown that multiple treatment sessions to quit smoking increase abstinence rate over those brought by one or no session.¹⁷ Therefore, offering follow up for motivated smokers (criterion IIIb) could improve cessation rate.

Nicotine replacement therapy is proven to be effective in quit smoking especially for those motivated smokers who smoke at least 10 cigarettes a day.²³ The benefit of nicotine replacement therapy is similar for men and women. As a result, fulfilling criterion IV would probably increase abstinence rate.

In conclusion, smoking cessation rate in my clinic was expected to be increased provided that the above process criteria could meet the standard. Up to October 2004, the 26 week cessation rate of nicotine replacement therapy programme in my clinic was 33%.²⁶ It means that smokers had sustained smoking cessation since recruitment into the programme and had not smoked at all in the previous 7 days. The result compared favourably with overseas programmes which generally had cessation rates between 15% and 30%.¹⁷

For the ultimate outcome measure, the morbidity and mortality rate of smoking related diseases of smokers in my clinic could be decreased and this is the most important impact on patient care.

The benefit of this audit was not only limited to patient care. Clinic staff all agreed that they had better understanding of nature of audit and realized that quality of care could be improved through this exercise. It also facilitated positive culture in the clinic so that clinic staff would identify deficiencies of the clinic and tackle problems in a systematic way.

Limitation

There were several limitations that needed to be addressed in this clinical audit project. There may be a potential sampling bias in the first phase data collection by finding active smokers through tracing their medical records retrospectively. Some of them were no more smokers during the first phase data collection period. This problem had been solved after attachment of smoking status insert to the medical record of every smoker and the setting up of a smoking registry in the intervention phase. It was because relevant data were collected prospectively and would be reviewed at least annually. In addition, there was no control group in the audit. The changes observed may be under the influence of other factors such as change of medical staff but not purely due to the intervention only.

Conclusion

A cycle of clinical audit on process performance of smoking cessation was completed systematically. Smoking cessation is one of the most important and cost effective preventive care activities in health care. The impact of this audit on patient care was positive. Clear documentation of smoking status, comprehensive motivation assessment, effective delivery of quit smoking advice and offering follow up, standardized recommendation of nicotine replacement therapy for motivated smokers all contributed to the essential elements of a successful smoking cessation programme. In addition, the smoking cessation rate, the intermediate outcome of the audit, could be increased as a result of the better process performance of smoking cessation. Eventually, the morbidity and mortality of smoking related disease could be improved provided that the above process and outcome performance could meet the standard continuously. Therefore, further studies and audits are necessary to measure the continuity of the process performance and outcome of smoking cessation.

Acknowledgement

I would like to give my sincere thank to the Health Promotion Working Group of Professional Development and Quality Assurance unit, Department of Health for continuous support throughout the audit cycle. My special thanks are to Dr. Luke Tsang and Dr. Linda Hui for their support in preparing this manuscript. I also wish to thank Department of Health for the approval to publish.

Key messages

1. Smoking kills over 5,600 people each year or 15 people per day in Hong Kong.
2. Primary care physicians have extraordinary access to smokers. However, the performance of smoking cessation is suboptimal.
3. Clear documentation of smoking status, comprehensive motivation assessment, effective delivery of quit smoking advice, offering follow up and recommendation of nicotine replacement therapy for motivated smokers have been shown to improve smoking cessation rate.
4. Clinical audit is effective in improving process of care in smoking cessation.