Developing Healthcare System Changes for Tobacco Cessation in a Non-Traditional Provider Setting: A Pilot Study

Sunday, 29 October 2017: 10:45 AM

Kelly P. Buettner-Schmidt, PhD1
Brody Maack, PharmD2
Mary F. Larson, PhD, MPH3
Becky McDaniel, MSN1
Donald R. Miller, PharmD2
Megan Orr, PhD4
Katelyn R. Mills, MPH5
(1)School of Nursing, North Dakota State University, Fargo, ND, USA
(2)School of Pharmacy, North Dakota State University, Fargo, ND, USA
(3)Department of Health, Nutrition and Exercise Science, North Dakota State University, Fargo, ND, USA
(4)Department of Statistics, North Dakota State University, Fargo, ND, USA
(5)School of Nursting, North Dakota State University, Fargo, ND, USA

Purpose: Presents the components and results of a pilot intervention engaging nontraditional healthcare providers, chiropractors, in advancing tobacco control and cessation efforts through the implementation of the best practices (CDC, 2014) and current guidelines (USPHS, 2008; CDC, 2016) in their clinics.

Methods: To develop the pilot study, first a focused review of literature was conducted. In particular, relevant chiropractic studies (Muramoto et al., 2016; Cunningham et al., 2015; Hawk, Kaeser, & Beavers, 2013), Cochrane Reviews (Boyle, Solberg, & Fiore, 2014; Carson et al., 2012; White, Rampes, Liu, Stead, & Campbell, 2014), and other related studies were reviewed. Second a focus group of chiropractors (n = 4) identified key recommendations for development of the evidenced-based intervention including, assuring that the health systems change and the interactions with their patients were easy to implement, to gain knowledge,confidence, and skills to interact with patients in a nonconfrontational manner, and recognizing the varying philosophies of chiropractors concerning pharmaceutical intervention.

Third, educational sessions were developed. Participants were recruited through mailed invitations to all chiropractors practicing within 120 miles of the university (n = 175) with follow up emails; a presentation at a state level annual chiropractic meeting, and through word of mouth. Participants were awarded 12 hours of continuing education by the chiropractic licensing agency. Participants for this pilot study completed mandatory training by the authors’ university Institutional Review Board. The educational sessions were presented in the evenings and on weekends and utilized both face-to-face and webbased learning to accommodate the chiropractors’ requests to have the learning outside of their regular scheduled clinic hours.

The sessions began with a presentation by a chiropractor on the opportunities for chiropractor engagement in evidenced based, mainstream, tobacco control in their clinics by adopting health system changes in order to address tobacco use by their patients and future possibilities for reimbursement of clinical time. More formal education included the evidence-base of epidemiology, health effects of tobacco, and principles of addiction, along with best practices for tobacco control, the Ask-Advise-Refer brief intervention method (CDC, 2014, 2016; University of California San Francisco, 2016; USPHS, 2008) and tobacco cessation treatment. Active learning occurred through sessions on motivational interviewing techniques and creating health systems change in clinics. As one aspect of creating health systems change in clinics, the participants used worksheets adapted from the American Academy of Family Physicians (2015) to evaluate their current health system and patient flow and then created plans for a new patient flow and for standardizing the new system; and developed an implementation plan with deadlines. Free resources for tobacco cessation posters, patient handouts, and Quitline referrals, along with information on how to order these items in the future were provided. Participants were encouraged first to share amongst themselves and then to share formally with the group their new patient flow, how they would standardize the new systems, and their implementation plans.

A pre-post educational assessment of the sessions was conducted. The chiropractors completed an adapted version of written questionnaires (Cunningham et al, 2015; RTI International, 2015). Analysis of the questionnaire included summarizing the differences in the distributions of responses posteducational assessment compared to pre-educational assessment for each item on the questionnaire.

Results: The items with the largest change in distribution pre- versus post-educational assessment of the responses involved training and confidence in counseling. Five of the six (83%) chiropractors agreed more strongly with the following statements post-education compared to pre-education: “I feel that I have the training and resources I need to help patients with quitting” and “I am confident in my ability to counsel a patient to quit using tobacco”. Additionally, four (67%) of the chiropractors reported being more confident post-education compared to pre-education in providing information about medications that help patients in quitting tobacco. Three (50%) of the chiropractors agreed more strongly with the statement “I am motivated to help tobacco users quit” post-education compare to preeducation with none of the chiropractors agreeing more strongly with the statement pre-education.

Three (50%) of the chiropractors also reported being more confident post-education in exploring issues related to quitting smoking, even if the patient is not interested in quitting as well as being more comfortable in talking with patients about tobacco use.

Conclusion: Chiropractors are one type healthcare provider that have not been systematically including in the education and implementation of current evidence-based recommendations for health systems change to address patients’ tobacco use during clinic visits. There is a need to include chiropractors in interdisciplinary education and expectations of including tobacco cessation interventions in their practice. Public health nurses involved in educating or providing resources for tobacco cessation for healthcare professionals should consider including chiropractors in their outreach.

This pilot study to develop an intervention to engage chiropractors included a focused literature review, a focus group of chiropractors, educational sessions, and a pre-post assessment of the educational sessions. The assessment of the educational sessions found that after completion of the sessions, chiropractors had increased motivation, comfort, and confidence to talk, help, and assist their patients with quitting, even with those patients not currently interested in cessation. Participants were also more comfortable providing information to their patients about medications for cessation. The educational sessions were able to address the recommendations of the chiropractors related to concerns of "confronting" patients about their tobacco use, concerns with providing information about medications, and the need to have increased knowledge, confidence, and skills to address their patients’ tobacco use. This pilot study will help inform the full study which will include state-wide dissemination of the program. Future studies will include an outcomes study of patients receiving tobacco cessation interventions during their chiropractic care. Another potential far reaching implication is that chiropractors should be included systematically in efforts to advance tobacco control and cessation best practices and guidelines through the implementation of health systems change in their clinics.