Introduction: This study determined the effectiveness of the Tobacco Tactics intervention.Design/setting/participants: This was a pragmatic, quasi-experimental study conducted from 2010 to 2013 and analyzed from 2014 to 2015 in five Michigan community hospitals; three received the Tobacco Tactics intervention, and two received usual care. Smokers (N = 1,528) were identified during hospitalization, and sent surveys and cotinine tests after 6 months. Changes in pre- to post-intervention quit rates in the intervention sites were compared with usual care control sites.Intervention: The toolkit for nurses included: (1) 1 continuing education unit contact hour for training; (2) a PowerPoint presentation on behavioral and pharmaceutical interventions; (3) a pocket card entitled "Helping Smokers Quit: A Guide for Clinicians"; (4) behavioral and pharmaceutical protocols; and (5) a computerized template for documentation. The toolkit for patients included: (1) a brochure; (2) a cessation DVD; (3) the Tobacco Tactics manual; (4) a 1-800-QUIT-NOW card; (5) nurse behavioral counseling and pharmaceuticals; (6) physician reminders to offer brief advice to quit coupled with medication sign-off; and (7) follow-up phone calls by trained hospital volunteers.Main outcome measures: The effectiveness of the intervention was measured by 6-month 30-day point prevalence; self-reported quit rates with NicAlert (R) urinary biochemical verification (48-hour detection period); and the use of electronic medical record data among non-responders.Results: There were significant improvements in pre-to post-intervention self-reported quit rates (5.7% vs 16.5%, p<0.001) and cotinine-verified quit rates (4.3% vs 8.0%, p<0.05) in the intervention sites compared with no change in the control sites. Propensity-adjusted multivariable analyses showed a significant improvement in self-reported 6-month quit rates from the pre-to post-intervention time periods in the intervention sites compared to the control sites (p=0.044) and a non-statistically significant improvement in the cotinine-verified 6-month quit rate.Conclusions: The Tobacco Tactics intervention, which meets the Joint Commission standards for inpatient smoking, has the potential to significantly decrease smoking among inpatient smokers. Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Background: Administrative records are the mainstay of many national surveillance and quality assessment efforts, but the ICD-9-CM recording of diagnoses are known to be of variable validity. The Recovery After In-Hospital Cardiac Arrest: Late Outcomes & Utilization (ResCU) study looks specifically at patients who survived in-hospital cardiac arrest (IHCA). A key factor in this study is to ensure that IHCA is correctly identified in order to examine the long-term outcomes of Veteran survivors. Objective: To determine the positive predictive value of ICD-9-CM codes for IHCA as compared to a gold standard of medical record review, using a standardized Eligibility Screener Questionnaire (ESQ) conducted by Masters level researchers. Methods: ICD-9-CM codes 427.5 (cardiac arrest), 99.60 (cardiopulmonary resuscitation), and 99.63 (closed chest cardiac massage) were abstracted from the electronic medical record (EMR) of patients who were discharged from any VA Medical Center between September 1, 2013 and October 31, 2013. One hour of initial training and a second hour of detailed team review of the first dozen cases took place. Subsequently, two Masters level research assistants and the project coordinator independently reviewed the patient’s EMR to confirm eligibility. The ESQ included the following questions: (1) “Did the patient have a cardiac arrest?”; (2) “Where did the cardiac arrest take place?”; (3) “What was the presenting rhythm?”; (4) “Was the patient defibrillated during the treatment of their cardiac arrest?”; (5)”Is the patient eligible for this study?”. After individual screening, reviewers logged their answers in separate documents to determine inter-rater reliability. Furthermore, the team reviewed each case collaboratively to ensure eligibility agreement. In situations where discrepancies were present, a physician investigator reviewed the case to determine eligibility. Results: There were 324 patients discharged with an IHCA code between September 1, 2013 and October 31, 2013, of which 257 were deceased. 67 patients were therefore eligible for the inclusion in this study. Of these 67, 2 (3%) were deceased and 14 (21%) did not have an IHCA. Of these 14, 11 incorrectly coded for cardiac arrest (e.g., activation of a rapid response team, defibrillation of atrial tachyarrhythmia) and 3 had a cardiac arrest outside of a VA facility as compared to a gold standard of medical record review. Thus, the positive predictive value for these conventional IHCA codes was 76% (binomial 95% CI: 0.64-0.86). The inter-rater reliability was high (86.6%, kappa = 0.64); 3 cases required physician review due to discrepancies. Conclusion: Conventional ICD-9-CM codes for IHCA provide high but imperfect positive predictive value in Veteran survivors. Rapid review of medical records by Masters level researchers is feasible to enhance the purity of samples constructed from administrative records.

Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework.

Background The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate the volunteer telephone smoking cessation counseling follow-up program implemented as part of the inpatient Tobacco Tactics intervention in a Veterans Affairs (VA) hospital. Methods This was a quasi-experimental, mixed methods design that collected data through electronic medical records (EMR), observations of telephone smoking cessation counseling calls, interviews with staff and Veterans involved in the program, and intervention costs. Results Reach: Of the 131 Veterans referred to the smoking cessation telephone follow-up program, 19% were reached 0–1 times, while 81% were reached 2–4 times. Effectiveness: Seven-day point-prevalence 60-day quit rates (abstracted from the EMR) for those who were reached 2–4 times were 26%, compared to 8% among those who were reached 0–1 times (p = 0.06). Sixty-day 24-hour point-prevalence quit rates were 33% for those reached 2–4 times, compared to 4% of those reached 0–1 times (p < 0.01). Adoption and Implementation: The volunteers correctly followed protocol and were enthusiastic about performing the calls. Veterans who were interviewed reported positive comments about the calls. The cost to the hospital was $21 per participating Veteran, and the cost per quit was $92. Maintenance: There was short-term maintenance (about 1 year), but the program was not sustainable long term. Conclusions Quit rates were higher among those Veterans that had greater participation in the calls. Joint Commission standards for inpatient smoking with follow-up calls are voluntary, but should these standards become mandatory, there may be more motivation for VA administration to institute a hospital-based, volunteer telephone smoking cessation follow-up program. Trial registration ClinicalTrials.Gov NCT01359371.

Background: Recently, we developed and validated a model to calculate risk-standardized survival rates (RSSRs) for in-hospital cardiac arrest_a common condition occurring within hospitals. Although RSSRs can be used to determine high and low performing sites, it remains unclear if RSSRs for in-hospital cardiac arrest are stable, i.e., similar from year to year. Methods: Within the Get With The Guidelines-Resuscitation registry, we identified 21,947 patients from 240 hospitals admitted between 2012 and 2013 with an in-hospital cardiac arrest. Using hierarchical logistic regression, we separately calculated 2012 and 2013 risk-standardized RSSRs for hospitals with at least 10 cardiac arrest cases and evaluated the correlation between 2012 and 2013 RSSRs. Results: The mean hospital RSSR was 23% + 4% (median, 23% [IQR: 21%-25%]) in 2012 and 25% + 5% (median, 25% [IQR: 22%-27%]) in 2013. There was strong correlation between a hospital’s performance between the two years (r=0.50; P <0.0001; Figure ). Most hospitals with RSSRs in the top quintile in 2012 (64.2% [34/53]) remained in the top 2 quintiles in 2013, and only 13.2% (7/53) had RSSRs below the median in 2013. Conversely, most hospitals with RSSRs in the lowest quintile in 2012 (60.4% [29/48]) remained in the lowest 2 quintiles in 2013, and only 22.9% (11/48) had RSSRs above the median in 2013. Conclusion: There was good correlation in RSSRs for in-hospital cardiac arrest for 2012 and 2013. Most top performing hospitals continued to excel and most low performing hospitals continued with below average survival, although some discordance was noted. These findings have implications for identifying top performing hospitals as those that consistently excel in survival outcomes each year.

Background: Short term mortality following in-hospital cardiac arrests (IHCA) is well understood. However, little is known about long term patient-reported outcomes - such as activities of daily living, cognitive function, and depression among survivors of IHCA. Objective: To assess the patient-reported outcomes in IHCA survivors 12-months after cardiac arrest. Methods: Veteran survivors of IHCA (ICD-9-CM codes 99.60, 99.63 or 427.5) who were discharged alive from a U.S. Veterans Administration Medical Center from September 1, 2013 to October 31, 2013 were identified. After confirmation of eligibility by medical record review, they were mailed a research information packet. Those who did not opt-out were contacted by phone two weeks later. Veterans who consented were surveyed by phone or mail. The survey encompassed Katz Activities of Daily Living (ADL), Lawton Instrumental Activities of Daily Living (IADLs), self-reported depressive symptoms (via the PHQ-9) and an assessment of cognition (via the modified Telephone Interview for Cognitive Status (mTICS) as used by the Health and Retirement Study). Results: Among 50 IHCA survivors, 37 (74%) completed surveys; survey operations are detailed in another abstract. Among those 37 who completed the survey, answers to all patient-reported outcomes items were obtained from 29 (78%). Respondents’ median age was 66 years old (range 38 to 87) and 95% were male. The survivors self-reported health assessment of their health was poor, with 8% and 40% describing their health as “poor” or fair” respectively, but only 5% saying “very good” and none reporting “excellent”. Similarly, 27% reported having 4 or more health-related difficulties in their basic and instrumental activities of daily living, 24% reported 1-3, and 46% none. On the PHQ-9, 19% had scores consistent with severe depression. Of those tested for cognitive impairment, 32% were at risk for at least some cognitive impairment. Conclusion: Among survivors of IHCA, we found that few patients at 12-months reported an overall sense of good health, and a significant number of patients had high-levels of disability, cognitive impairment and depression. There is an urgent need to understand the epidemiology and trajectory of this poor health, and develop interventions to improve the long term outcomes of IHCA.

The purpose was to determine the effectiveness of the Tobacco Tactics program in three Veterans Affairs hospitals. In this effectiveness trial, inpatient nurses were educated to provide the Tobacco Tactics intervention in Ann Arbor and Detroit, while Indianapolis was the control site (N = 1,070). Smokers were surveyed and given cotinine tests. The components of the intervention included nurse counseling, brochure, DVD, manual, pharmaceuticals, 1-800-QUIT-NOW card, and post-discharge telephone calls. There were significant improvements in 6-month quit rates in the pre- to post-intervention time periods in Ann Arbor (p = 0.004) and Detroit (p < 0.001) compared to Indianapolis. Pre- versus post-intervention quit rates were 4 % compared to 13 % in Detroit, were similar (6 %) pre- and post-intervention in Ann Arbor, and dropped from 26 % to 12 % in Indianapolis. The Tobacco Tactics program, which meets the Joint Commission standards that apply to all inpatient smokers, has the potential to significantly decrease smoking among Veterans.

BACKGROUND:The objective of this study was to evaluate the effectiveness of the inpatient, nurse-administered Tobacco Tactics program for patients admitted for psychiatric conditions in two Veterans Affairs (VA) hospitals compared to a control hospital.METHODS:This is a subgroup analysis of data from the inpatient tobacco tactics effectiveness trial, which was a longitudinal, pre- post-nonrandomized comparison design with 6-month follow-up in the three large Veterans Integrated Service Networks (VISN) 11 hospitals.RESULTS:Six-month self-reported quit rates for patients admitted for psychiatric conditions increased from 3.5% pre-intervention to 10.2% post-intervention compared to a decrease in self-reported quit rates in the control hospital (12% pre-intervention to 1.6% post-intervention). There was significant improvement in self-reported quit rates for the pre- versus post-intervention time periods in the Detroit and Ann Arbor intervention sites compared to the Indianapolis control site (P=0.01) and cotinine results were in the same direction.CONCLUSION:The implementation of the Tobacco Tactics intervention has the potential to significantly decrease smoking and smoking-related morbidity and mortality among smokers admitted to VA hospitals for psychiatric disorders.

Background Web-based cessation interventions have been shown to reduce tobacco use, be more efficacious than self-help booklets, be more efficacious if they provide tailored messages, and enhance quit rates in conjunction with nicotine replacement therapy. Objective The objective of this study was to usability test and pilot test the Tobacco Tactics website for veterans. Methods Both formative and summative evaluations were used across three small successive studies to develop and test the Tobacco Tactics website for veterans, which was based on a prior face-to-face smoking cessation intervention. Once the website was developed, the research team and Web developers usability tested the website with 5 veteran smokers and former smokers. Feedback from the veterans was collected as they navigated each webpage, then used to revise the website. In pilot study 1, 9 veteran smokers were provided access to the website, and given a baseline and 30-day follow-up survey. In pilot study 2, 18 veteran smokers, who were also motivated to quit smoking, were recruited and randomized to either the Tobacco Tactics website plus nicotine replacement therapy or to the 1-800-QUIT-NOW telephone line. Results As a result of usability testing, more than 27 modifications were made to improve the website. In pilot study 1, 50% (3/6) veterans who entered the website had cut down on the number of cigarettes and 83% (5/6) found the website enjoyable, easy to read, easy to navigate, and would recommend the website to others. In pilot study 2, which included only smokers motivated to quit and also offered nicotine replacement therapy, seven-day point prevalence abstinence at 30-day follow-up was 40% (4/10) in the intervention group compared to 13% (1/8) in the control group. Conclusions These preliminary results are promising and suggest the need for wider-scale testing of the Tobacco Tactics website for veterans.

Background: Although Veterans Affairs (VA) hospitals have been smoke-free inside of buildings since 1991, smoke-free campuses have not been initiated. The purpose of this article is to describe staff attitudes regarding making the VA hospital a smoke-free campus except for the mandated smoking shelters. Methods: In 2008, a cross-sectional, anonymous survey was conducted with a convenience sample of employees at a Midwestern VA (N = 397). Results: Descriptive statistics showed that the vast number of employees were in support of a smoke-free campus (76%), relocating the smoking shelters (62%), and offering employees assistance to quit smoking (71%). Multivariate analyses showed that those who were nonsmokers, older, women, and higher educated were the greatest supporters of policies to support a smoke-free environment (p < .05). Write-in comments were generally favorable but also revealed employee resistance related to freedom, personal choice, and potential loss in productivity as smokers go further away from the building to smoke. Conclusions: VA hospitals have unique challenges in implementing smoke-free campus policies.

Recent research indicates that 35 percent of blue-collar workers in the US currently smoke while only 20 percent of white-collar workers smoke. Over the last year, we have been working with heavy equipment operators, specifically the Local 324 Training Center of the International Union of Operating Engineers, to study the epidemiology of smoking, which is 29% compared to 21% among the general population. For the current study funded by the National Cancer Institute (1R21CA152247-01A1), we have developed the Tobacco Tactics website which will be compared to the state supported 1-800-QUIT-NOW telephone line. Outcome evaluation will compare those randomized to the Tobacco Tactics web-based intervention to those randomized to the 1-800-QUIT-NOW control condition on: a) 30-day and 6-month quit rates; b) cotinine levels; c) cigarettes smoked/day; d) number of quit attempts; and e) nicotine addiction. Process evaluation will compare the two groups on the: a) contacts with intervention; b) medications used; c) helpfulness of the nurse/coach; and d) willingness to recommend the intervention to others.

AIMS AND OBJECTIVES:To test the transportability and implementation of the Tobacco Tactics intervention using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, for inpatient units at the Jesse Brown Veterans Affairs Medical Center. BACKGROUND:Smoking rates are high among veterans. While the Department of Veterans Affairs has standardised outpatient cessation clinics, inpatient cessation services, known to be efficacious, are only sporadically provided. DESIGN:This was a phase 4, pre and postimplementation study of the Tobacco Tactics intervention. METHODS:A unique convenience sample of inpatient veteran smokers was recruited both before (n = 54) and after (n = 50) implementation of the Tobacco Tactics programme. Participants completed baseline and 30-day follow-up surveys along with urine cotinine test kits. In addition, staff completed anonymous surveys during the preintervention period (n = 158) and two months after (n = 81) the Tobacco Tactics training. Bivariate analyses compared preintervention vs. postintervention patient and staff characteristics using Chi-square, Fisher's Exact or Student's t-test. p-values <0·05 were considered significant. RESULTS:Patient-reported receipt of services and satisfaction was 10% higher in the postintervention compared to the preintervention group. Quit rates were 3% higher in the postintervention than in the preintervention group. The mean number of cigarettes smoked per day increased from 13 to 15 in the preintervention group, while the mean number of cigarettes smoked per day decreased from 14 to 9 in the postintervention group. Staff's confidence in their ability to provide cessation services improved greatly posttraining (p = 0·0017) as did self-reported delivery of cessation services (p = 0·0154). CONCLUSIONS:With as little as one-hour training for nurses, the Tobacco Tactics intervention has the potential to be widely disseminated in the Department of Veterans Affairs. RELEVANCE TO CLINICAL PRACTICE:The implementation of inpatient smoking interventions has the potential to improve quit rates and decrease morbidity and mortality in the Department of Veterans Affairs.

The objectives of this smoking cessation study among hospitalized smokers are to: 1) determine provider and patient receptivity, barriers, and facilitators to implementing the nurse-administered, inpatient Tobacco Tactics intervention versus usual care using face-to-face feedback and surveys; 2) compare the effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention versus usual care across hospitals, units, and patient characteristics using thirty-day point prevalence abstinence at thirty days and six months (primary outcome) post-recruitment; and 3) determine the cost-effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention relative to usual care including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved.

Background: The purpose of this study was to describe the development and evaluation of the image-based Veterans Affairs (VA) Tobacco Tactics program logo and campaign character using principles of social marketing.Methods: Four cross-sectional surveys with open-and closed-ended questions were used to gather participant demographic information, smoking behavior, and feedback on the development and evaluation of the Tobacco Tactics program logo and campaign character.The first 3 surveys were conducted with 229 veterans, visitors, and staff to obtain feedback for the final logo and character choice.The fourth survey was conducted with 47 inpatient veteran smokers to evaluate the Tobacco Tactics manual which was illustrated with the logo and campaign character.Descriptive statistics and bivariate analyses comparing demographic characteristics and tobacco use variables to opinions about the pictures for each round of testing were computed.Results: After three rounds of testing to modify the logo and character choices based on participant feedback and survey data, the bulldog logo was chosen to represent the VA Tobacco Tactics program as it was viewed as strong and tough by the majority of participants.About 80% of the participants rated the manual highly on items such as logo, color, and pictures/illustrations.Almost 90% said they would recommend the manual to someone trying to quit smoking. Conclusion:Social marketing techniques that include consumer feedback to develop appealing tobacco cessation campaigns can increase consumer engagement and enhance the development of compelling tobacco cessation campaigns to compete with the influential marketing of tobacco companies.

While smoking, psychiatric and substance abuse disorders are high among veterans, there is considerable controversy over providing smoking cessation interventions to those suffering with psychiatric and substance abuse disorders. The objective of this study was to determine motivation to quit smoking among veterans experiencing psychiatric and substance abuse disorders. A convenience sample of patients recruited at a primarily psychiatric Veterans Affairs hospital completed a self-administered survey (N = 146). Means or frequencies were calculated for all variables. Bivariate and multivariate logistic regression models were examined to determine the association between psychiatric or substance abuse disorders and opinions about the importance of quitting smoking to health, thinking of quitting smoking in the next 30 days, and interest in receiving smoking cessation services. Psychiatric and substance abuse disorders were reported among 74% and 64% of patients, respectively. After controlling for nicotine dependence, age, race/ethnicity, and employment status, veterans with psychiatric disorders had 2.6 times greater odds of thinking that quitting smoking was very or extremely important to their health (p = 0.05) and 4.4 times greater odds of thinking of quitting using tobacco products in the next 30 days (p = 0.02) compared to those without psychiatric disorders. There were no differences in motivation to quit smoking among those with and without substance abuse disorders. Veterans with psychiatric disorders are motivated to quit smoking and should be offered cessation services. Veterans with substance abuse disorders may need interventions to enhance motivation to quit.