First name
Robert
Last name
Schnoll

Title

Cluster Randomized Pragmatic Clinical Trial Testing Behavioral Economic Implementation Strategies to Improve Tobacco Treatment for Patients With Cancer Who Smoke.

Year of Publication

2023

Number of Pages

JCO2300355

Date Published

07/2023

ISSN Number

1527-7755

Abstract

PURPOSE: Few cancer centers systematically engage patients with evidence-based tobacco treatment despite its positive effect on quality of life and survival. Implementation strategies directed at patients, clinicians, or both may increase tobacco use treatment (TUT) within oncology.

METHODS: We conducted a four-arm cluster-randomized pragmatic trial across 11 clinical sites comparing the effect of strategies informed by behavioral economics on TUT engagement during oncology encounters with cancer patients. We delivered electronic health record (EHR)-based nudges promoting TUT across four nudge conditions: patient only, clinician only, patient and clinician, or usual care. Nudges were designed to counteract cognitive biases that reduce TUT engagement. The primary outcome was TUT penetration, defined as the proportion of patients with documented TUT referral or a medication prescription in the EHR. Generalized estimating equations were used to estimate the parameters of a linear model.

RESULTS: From June 2021 to July 2022, we randomly assigned 246 clinicians in 95 clusters, and collected TUT penetration data from their encounters with 2,146 eligible patients who smoke receiving oncologic care. Intent-to-treat (ITT) analysis showed that the clinician nudge led to a significant increase in TUT penetration versus usual care (35.6% 13.5%; OR = 3.64; 95% CI, 2.52 to 5.24; < .0001). Completer-only analysis (N = 1,795) showed similar impact (37.7% clinician nudge 13.5% usual care; OR = 3.77; 95% CI, 2.73 to 5.19; < .0001). Clinician type affected TUT penetration, with physicians less likely to provide TUT than advanced practice providers (ITT OR = 0.67; 95% CI, 0.51 to 0.88; = .004).

CONCLUSION: EHR nudges, informed by behavioral economics and aimed at oncology clinicians, appear to substantially increase TUT penetration. Adding patient nudges to the implementation strategy did not affect TUT penetration rates.

DOI

10.1200/JCO.23.00355

Alternate Title

J Clin Oncol

PMID

37467454
Featured Publication
No

Title

A Clinical Decision Support System for Motivational Messaging and Tobacco Cessation Treatment for Parents: Pilot Evaluation of Use and Acceptance.

Year of Publication

2023

Date Published

03/2023

ISSN Number

1869-0327

Abstract

BACKGROUND: Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion.

OBJECTIVE: To assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates.

METHODS: The system was evaluated at one large pediatric practice through a single-arm pilot study from June-November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: 1) the parent remembered the motivational message, 2) the pediatrician reinforced the message, and 3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text-message counseling). We described survey response rates overall and with 95% confidence intervals (CI).

RESULTS: During the entire study period, 8488 parents completed use of the CDS: 9.3% (n=786) reported smoking, and 48.2% (n=379) accepted at least one treatment. One hundred and two parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25-34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported the pediatrician reinforced the motivational message.

CONCLUSION: A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.

DOI

10.1055/a-2062-9627

Alternate Title

Appl Clin Inform

PMID

36972687
Featured Publication
No

Title

A Clinical Decision Support System for Motivational Messaging and Tobacco Cessation Treatment for Parents: Pilot Evaluation of Use and Acceptance.

Year of Publication

2023

Date Published

03/2023

ISSN Number

1869-0327

Abstract

BACKGROUND: Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion.

OBJECTIVE: To assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates.

METHODS: The system was evaluated at one large pediatric practice through a single-arm pilot study from June-November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: 1) the parent remembered the motivational message, 2) the pediatrician reinforced the message, and 3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text-message counseling). We described survey response rates overall and with 95% confidence intervals (CI).

RESULTS: During the entire study period, 8488 parents completed use of the CDS: 9.3% (n=786) reported smoking, and 48.2% (n=379) accepted at least one treatment. One hundred and two parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25-34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported the pediatrician reinforced the motivational message.

CONCLUSION: A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.

DOI

10.1055/a-2062-9627

Alternate Title

Appl Clin Inform

PMID

36972687
Featured Publication
No

Title

Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke.

Year of Publication

2021

Number of Pages

72

Date Published

2021 Jul 15

ISSN Number

1748-5908

Abstract

<p><strong>BACKGROUND: </strong>Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care.</p>

<p><strong>METHODS: </strong>A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges.</p>

<p><strong>DISCUSSION: </strong>This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers.</p>

<p><strong>TRIAL REGISTRATION: </strong>Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.</p>

DOI

10.1186/s13012-021-01139-7

Alternate Title

Implement Sci

PMID

34266468

Title

Pediatrician Delivered Smoking Cessation Messages for Parents: A Latent Class Approach to Behavioral Phenotyping.

Year of Publication

2020

Date Published

2020 Jul 27

ISSN Number

1876-2867

Abstract

<p><strong>OBJECTIVE: </strong>Message framing can be leveraged to motivate adult smokers to quit, but its value for parents in pediatric settings is unknown. Understanding parents' preferences for smoking cessation messages may help clinicians tailor interventions to increase quitting.</p>

<p><strong>METHODS: </strong>We conducted a discrete choice experiment in which parent smokers of pediatric patients rated the relative importance of 26 messages designed to increase smoking cessation treatment. Messages varied on who the message featured (child, parent, family), whether the message was gain- or loss-framed (emphasizing benefits of engaging or costs of failing to engage in treatment), and the specific outcome included (e.g. general health, cancer, respiratory illnesses, financial impact). Participants included 180 parent smokers at 4 pediatric primary care sites. We used latent class analysis of message ratings to identify groups of parents with similar preferences. Multinomial logistic regression described child and parent characteristics associated with group membership.</p>

<p><strong>RESULTS: </strong>We identified 3 groups of parents with similar preferences for messages: Group 1 prioritized the impact of smoking on the child (n=92, 51%), Group 2 favored gain-framed messages (n=63, 35%), and Group 3 preferred messages emphasizing the financial impact of smoking (n=25, 14%). Parents in Group 2 were more likely to have limited health literacy and have a child over age 6 and with asthma, compared to Group 1.</p>

<p><strong>CONCLUSIONS: </strong>We identified 3 groups of parent smokers with different message preferences. This work may inform testing of tailored smoking cessation messages to different parent groups, a form of behavioral phenotyping supporting motivational precision medicine.</p>

DOI

10.1016/j.acap.2020.07.018

Alternate Title

Acad Pediatr

PMID

32730914

Title

Parent Preferences for Pediatric Clinician Messaging to Promote Smoking Cessation Treatment.

Year of Publication

2020

Date Published

2020 Jun 22

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Insights from behavioral economics suggests that the effectiveness of health messages depends on how a message is framed. Parent preferences for smoking cessation messaging has not been studied in pediatrics, warranting further exploration to maximize benefit. We sought to assess parents' perceptions regarding the relative importance of distinct message framings to promote their smoking cessation.</p>

<p><strong>METHODS: </strong>We conducted a cross-sectional discrete choice experiment in which parent smokers rated the relative importance of 26 messages designed to encourage them to begin cessation treatment. Messages varied on who was featured (child, parent, or family), whether the message was gain or loss framed, and what outcome was included (general health, cancer, respiratory illnesses, child becoming a smoker, or financial impact). The participants were 180 parent smokers attending primary care visits with their children at 4 diverse pediatric sites. The main outcome was the importance of smoking cessation messages based on who was featured, gain or loss framing, and the outcome emphasized.</p>

<p><strong>RESULTS: </strong>Parent smokers highly prioritized cessation messages emphasizing the impact of quitting smoking on their child versus parent or family. Messages focusing on respiratory illness, cancer, or general health outcomes consistently ranked highest, whereas messages focused on the financial benefits of quitting ranked lowest. Gain versus loss framing did not meaningfully influence rankings.</p>

<p><strong>CONCLUSIONS: </strong>Parent smokers identified smoking cessation messages that emphasized the impact on their child, with outcomes focused on respiratory health, cancer, or general health, as most important. The clinical impact of these messages should be tested in future research.</p>

DOI

10.1542/peds.2019-3901

Alternate Title

Pediatrics

PMID

32571991

Title

Implicit attribution of culpability and impact on experience of treating tobacco dependence.

Year of Publication

2019

Number of Pages

1069-1074

Date Published

2019 Dec

ISSN Number

1930-7810

Abstract

<p><strong>OBJECTIVE: </strong>Given the number of annual interactions between people who smoke and health care providers, even low-efficacy interventions would be expected to have a large cumulative effect on smoking prevalence. Efforts to improve uptake of tobacco dependence treatment guidelines have had limited success. It remains unclear whether complex social motivations influence treatment decision-making among providers, despite widespread understanding of the condition's impact on morbidity.</p>

<p><strong>METHOD: </strong>Clinicians from across the United States participated in a computer-based survey of potential explicit tobacco treatment biases, relative to care of hypertension. Items corresponded to framework domains of Weiner's causal attribution theory of social motivation (Weiner, 1993). Single-word, open-response items were used to gain insight into the frequency of spontaneous perceptions regarding treatment of each condition. Implicit association testing (IAT) measured strength of association between images of smoking and evaluation of guilt versus innocence.</p>

<p><strong>RESULTS: </strong>Significant differences in agreement scores were identified within the causal attribution, emotional response, and help investment domains. Single-word answers confirmed a significant difference in emotional response to tobacco treatment (28.1% vs. 10.5%, p = .02), and suggested the difference was driven by the frequent perception of frustration (75% vs. 0%, p = .07). IAT revealed incompatibility between images of smoking and words conveying "innocence" compared with "guilt" (latency 1,846 ms vs. 1,113 ms, p &lt; .001).</p>

<p><strong>CONCLUSIONS: </strong>Complex social motivations may be operational in the context of tobacco dependence treatment, limiting provider willingness to follow treatment guidelines. If confirmed, this represents a critical obstacle to sophisticated guideline implementation, and should be addressed in future implementation strategies. (PsycINFO Database Record (c) 2019 APA, all rights reserved).</p>

DOI

10.1037/hea0000784

Alternate Title

Health Psychol

PMID

31436440

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