Author Affiliations: Mongan Institute for Health Policy, Massachusetts General Hospital, Boston (Drs Levey, Vogeli, and Rigotti); Tobacco Research and Treatment Center, General Medicine Division, Massachusetts General Hospital, Boston (Drs Levy and Rigotti); Department of Medicine, Harvard Medical School, Boston (Drs Levy, Vogeli, and Rigotti); and Institute for Healthcare Studies, Northwestern University, Feinberg School of Medicine, Chicago, Illinois (Mr Kang).
In 2002, The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) adopted a set of publicly reported quality measures for US hospitals that included assessment of smoking cessation advice or counseling (SCA) delivered in hospitals to smokers discharged with acute myocardial infarction (AMI), congestive heart failure (CHF), or community-acquired pneumonia (CAP).1 The National Quality Forum is now considering a revised set of hospital-based smoking cessation measures developed by TJC for use in all hospitalized patients. The new comprehensive measures will track offers of smoking cessation medications, and they will track smoking cessation outcomes.2 Determining the predictors of the mature SCA measure will provide insight into issues that will arise when the new SCA measures are adopted. We present the first study, to our knowledge, of patient and hospital factors associated with SCA rates using a comprehensive sample of hospitals reporting SCA data for patients hospitalized with diagnoses of AMI, CHF, and CAP.
Patient-level data on SCA, demographic, and clinical characteristics collected under the TJC/CMS quality reporting program for 2008 were acquired from CMS.3 The patient-level outcome was receipt of SCA, defined as hospital provision of SCA to patients with a principal diagnosis of AMI, CHF, or CAP, who were smokers at some time in the 12 months prior to admission. The hospital-level outcome was the proportion of eligible patients in a hospital who received SCA. Data on patient characteristics included age, sex, race, ethnicity, insurance coverage, length of stay, comorbidities, and discharge status. Hospital characteristics came from the 2006 American Hospital Association annual survey (numbers of beds, urban location, census region, teaching status, and ownership)4 and by aggregating patient-level data to the hospital level.
We tracked condition-specific SCA rates over time, modeled hospital-level SCA rates using linear regression models (excluding hospitals with <10 smokers admitted for AMI, CHF, or CAP), and estimated multilevel logistic models (for AMI, CHF, CAP, and all patients combined) with hospital random intercepts to assess factors associated with patient receipt of SCA.
In 2008, nearly all patients received SCA (99% AMI [n = 135 142], 97% CHF [n = 131 621], and 95% CAP [n = 204 504]), though SCA rates at some hospitals were still low. The mean hospital-specific SCA rates among reporting hospitals were 88% for CAP (n = 4139), 91% for CHF (n = 3840), and 95% for AMI (n = 2813). The median hospital-specific SCA rate was 100% for smokers admitted for AMI or CHF and 98% for smokers admitted for CAP.
Private-for-profit (PFP) hospitals had SCA rates 1.03 (CHF; 95% CI, 0.12 to 1.93) to 2.72 (CAP; 95% CI, 1.76 to 3.69) percentage points higher than not-for-profit (NFP) hospitals, while public hospitals had SCA rates 2.91 (CHF; 95% CI, −4.32 to −1.49) and 4.23 (CAP; 95% CI, −5.63 to −2.82) percentage points lower than NFP hospitals. Hospitals where a minimum of 9% of patients with AMI or CHF were Medicaid recipients had SCA rates 0.92 (AMI; 95% CI, −1.44 to −0.40) and 1.09 (CHF; 95% CI, −1.79 to −0.39) percentage points lower than hospitals with fewer Medicaid patients in these diagnosis categories.
The Table presents predictors of individual patient receipt of SCA. Indicators of patient frailty (age and discharge status) were associated with lower SCA rates; patients discharged to an institution had at least 75% lower odds of receiving SCA than patients discharged home across all 3 diagnoses. Minority and Medicaid patients were generally less likely to receive SCA. Hospital-level factors including ownership type and proportion of patients on Medicaid also predicted individual receipt of SCA.
Near-universal provision of SCA in 2008 is in stark contrast to the level of SCA reported in 2002, the first year of public reporting, where the mean SCA rate at US hospitals was 67% for AMI, 42% for HF, and 37% for CAP.5 While the current high rates of SCA provision are positive steps, from a public health perspective, it is not clear that our findings necessarily reflect the delivery of effective smoking cessation interventions due to limitations inherent in the current SCA measure and the limited form of SCA it assesses.6,7 Despite very high levels of documentation of SCA provision, differences persist across hospitals and patients nationally. Particularly troubling is the evidence that SCA rates fall short for frail and minority patients as well as hospitals serving vulnerable populations.
Forthcoming updates to the SCA measures are closely tied to the smoking cessation evidence base and have real potential to improve cessation rates and health outcomes for hospitalized smokers given hospitals' high motivation to improve quality on publicly reported measures tied to pay-for-participation incentives. Nevertheless, our findings of persistently lower SCA rates in some vulnerable populations hint at a strong possibility that disparities will continue in the new smoking cessation measures, potentially becoming exacerbated in the context of their more stringent demands.
Correspondence: Dr Levy, Mongan Institute for Health Policy, Massachusetts General Hospital, 50 Staniford St, Ninth Floor, Boston, MA 02114 (firstname.lastname@example.org).
Author Contributions:Study concept and design: Levy and Rigotti. Acquisition of data: Levy, Kang, and Vogeli. Analysis and interpretation of data: Levy, Kang, and Rigotti. Drafting of the manuscript: Levy. Critical revision of the manuscript for important intellectual content: Levy, Kang, Vogeli, and Rigotti. Statistical analysis: Levy and Kang. Obtained funding: Levy. Administrative, technical, and material support: Levy and Kang. Study supervision: Levy and Rigotti.
Financial Disclosure: None reported.
Funding/Support: This work was supported by a grant from the Robert Wood Johnson Foundation Substance Abuse Policy Research Program. We acknowledge the assistance of the Illinois Foundation for Quality Health Care and the Centers for Medicare & Medicaid Services (CMS) in providing data which made this research possible.
Disclaimer: The conclusions presented are solely those of the author and do not represent those of Illinois Foundation for Quality Health Care or CMS.
Previous Presentation: This study was presented at the Academy Health Annual Research Meeting; June 27, 2010; Boston, Massachusetts.
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