EHR-integrated alerts may improve referrals to quitlines, but patient use remains low
A study of 22 primary care practices in Maryland found that while adding a prompt for a smoking quitline referral to the electronic health record (EHR) helped increase referral rates, only approximately 20% of patients called the quitline.
A best practices alert (BPA) integrated into an electronic health record (EHR) increased referrals to a smoking quitline but did not affect uptake, a study found.
Researchers in Maryland conducted a waitlist-controlled, cluster-randomized trial of primary care practices to determine whether including a BPA for smoking quitline referral in the EHR and educating clinicians about quitlines would improve referrals and patient engagement. Participating sites were assigned to a new EHR-based BPA prompting electronic referral to the state-run quitline for patients with EHR-documented current tobacco use, a BPA in the EHR plus additional clinician education (a consolidated educational handout and quick-reference sheet and an offer for an additional live teaching session), or usual care. The study was conducted in two phases, from April to October 2017 and from November 2017 to May 2018, among 22 practice sites. The primary outcome was referral of patients to the quitline. Secondary outcomes included patient acceptance and enrollment in quitline services. Results were published March 8 by the Journal of General Internal Medicine.
Smoking prevalence between study sites ranged from 4.4% to 23%. In phase 1, the BPA-plus-education arm had 5,636 eligible encounters and 405 referrals to the quitline (referral rate, 7.2%), the BPA-only arm had 6,857 eligible encounters and 623 referrals (referral rate, 9.1%), and the usual-care arm had 7,434 encounters but no referrals. When the BPA-plus arm was compared to the BPA-only arm, the odds ratio for referral was 0.76 (95% CI, 0.32 to 1.80).
In phase 2, the combined BPA-plus-education sites had 8,516 eligible encounters and 475 referrals (referral rate, 5.6%) and the BPA-only sites had 9,134 eligible encounters and 470 referrals (referral rate, 5.2%), with no statistically significant difference between the study arms (odds ratio, 1.06; 95% CI, 0.52 to 2.16). An average of 19.5% of patients who were referred accepted quitline services, with similar rates across study arms.
The authors concluded that the addition of clinician education regarding smoking-cessation strategies and quitline services did not improve any of the studied outcomes. They noted that there was uneven uptake of educational visits, with some sites refusing the in-person teaching session and others receiving it months after the study launch. Barriers to providing evidence-based smoking-cessation interventions included a lack of organizational support, perceived lack of efficacy, time limitations, lack of reimbursement, and difficulty changing practices, they said.
While EHR-based methods of integrating referrals into ambulatory clinicians' workflows could improve the number of referrals to free quitline services, they remain underutilized, the authors said. “The BPA was low cost and easy to implement, suggesting it is feasible for most practices,” they wrote. “ … Ultimately, a quitline BPA with minimal education can increase referrals, but strategies to optimize BPA use by providers and quitline acceptance by primary care patients require further investigation.”