Education for Health,Vol. 19, No. 2, July 2006, 155 – 165
Impact of Educational Outreach Visits on SmokingCessation Activities Performed by SpecialistPhysicians: A Randomized Trial
Institute of Social and Preventive Medicine, University of Geneva,Switzerland
Objectives: To find out whether educational visits by a nurse to specialist
physicians improved their self-reporting of smoking cessation activities; whether thesevisits increased the percentage of physicians who were aware of and recommended acomputer-tailored smoking cessation program and who participated in a trainingworkshop on tobacco dependency treatment. Methods: Specialist private practice physicians (n ¼ 523) working in Geneva, Switzerlandwere randomly assigned to either receiving (n ¼ 261) or not receiving (n ¼ 262) a single40-minute visit by a trained nurse in 2003. The physicians answered a postal questionnaire5 months after the visits indicating the percentage of their patients they counselled or treatedfor tobacco dependency and we recorded whether physicians took part in the workshop. Findings: Only half (53%) of the physicians agreed to receive a visit. At follow-up morephysicians in the intervention group than in the control group were aware of thecomputer-tailored program (73% vs. 39%, p 5 0.001) and more physicians in the inter-vention group said they recommended the use of this program to more patients (20% vs. 10%, p ¼ 0.009). Among non-smoking physicians only, the proportion of patients whowere advised to quit smoking was higher in the intervention than in the control group(69% vs. 54%, p ¼ 0.019, as reported by physicians). The intervention had no impact onphysicians’ participation in the workshop. Conclusions: Visits by a nurse increased the proportion of physicians who recommendedto their patients the use of a computer-tailored smoking cessation program. Among non-smoking physicians only, the intervention increased the proportion of patients whoreceived the advice to quit smoking, as reported by physicians.
Continuing education, smoking cessation, primary prevention.
Author for correspondence: Jean-Franc¸ois Etter, PhD, MPH, Institute of Social and PreventiveMedicine, University of Geneva, CMU, 1 rue Michel-Servet, CH-1211, Geneva 4, Switzerland. Tel: þ41 22 379 59 19. Fax: þ41 22 379 59 12. E-mail: [email protected]
Education for Health ISSN 1357-6283 print/ISSN 1469-5804 online Ó 2006 Taylor & Francis
Physicians have a decisive role to play in the treatment of tobacco dependencybut many patients do not receive appropriate support to stop smoking fromtheir doctor (Dickinson et al., 1989; Humair & Ward, 1998). In particular,specialist physicians who work in private practice are less likely than generalpractitioners to treat tobacco dependency (Prignot et al., 2000). Several factorsmay explain this lack of interest in treating tobacco dependency: theperception that it is the role of general practitioners only, time constraints,lack of relevant training and lack of reimbursement or of support materials(Cornuz et al., 2000). Continued medical education and the development ofeffective self-help materials can improve this situation (Lancaster et al., 2000;Thomson O’Brien et al., 2001). Two effective programs were recentlydeveloped in Switzerland to train physicians to treat tobacco dependency(Cornuz et al., 2002) and to provide physicians with self-help materials for theirpatients (Etter & Perneger, 2001).
A Training Workshop for PhysiciansThe training workshop Vivre sans Tabac uses active learning methods to trainphysicians in the treatment of tobacco dependency (Humair & Cornuz, 2003). This workshop consists of 2 half-days and includes video clips, interactivesessions, role plays, practice with standardized patients and written materials. A randomized trial showed that patients of physicians who were trained in thisworkshop were twice as likely to stop smoking compared with patients ofuntrained physicians (Cornuz et al., 2002).
A Self-help Smoking Cessation ProgramThe ‘‘Stop-tabac.ch’’ program uses computers to provide individualized coun-selling to smokers and ex-smokers (Etter, 2002). After answering a question-naire, participants receive counselling letters tailored to their personalcharacteristics, a series of booklets and follow-up e-mails. ‘‘Stop-tabac.ch’’was listed among the 5 best smoking cessation websites (Bock et al., 2004). A randomized trial showed that this program doubled smoking cessationrates, compared with smokers who did not receive it (Etter & Perneger, 2001;Etter, 2005).
Educational Outreach VisitsEducational outreach visits are an effective strategy to ensure the continuededucation of private practitioners and to modify their behaviour regardingtobacco dependency treatment (Davis et al., 1995; Oxman et al., 1995; Loboet al., 2002; Thomson O’Brien et al., 2000, 2001). However, almost all previousstudies targeted general practitioners and volunteers, not specialists, thus thereis little information about whether educational outreach visits for smokingcessation are also effective with specialist physicians who did not volunteer for
this intervention. Targeting specialists is important because many patients mayvisit only specialists and not general practitioners.
A nurse was hired whose role it was to conduct educational outreach
visits to specialist physicians in private practice. The objective was to informthe physicians about these two programs and to motivate them to treattobacco dependency in their patients. The aim of the study was to assess theimpact of these visits on smoking prevention activities performed byphysicians.
InterventionIn 2000, a trained nurse began to visit private practice physicians in Geneva,Switzerland to inform them about available treatments for tobacco dependencyand about the two programs described above. The nurse used an interactiveapproach and spent much time answering questions from physicians. She wasalready a professional medical sales representative when hired, and thenobtained a University diploma in tobacco dependency treatment. Advice andinformation given to physicians were based on a recent guideline (Andersonet al., 2002). When necessary the nurse sent additional documents to physiciansafter her visit.
The list of private practice physicians in Geneva consisted of 1,980
addresses. The nurse started in September 2000 and visited all generalpractitioners, internists, pneumonologists, cardiologists and ENT surgeons. ByDecember 2002 almost all physicians in these specialties had either receivedor refused her visit and 523 physicians from other specialities had not yetbeen contacted. The current trial was conducted by focusing on thisconvenience sample of 523 specialist physicians to test the intervention inspecialist physicians because this category was excluded from most previousstudies (Thomson O’Brien et al., 2000) and because guidelines recommendedthat all physicians (not just general practitioners or internists) should treattobacco dependency or should at least strongly advise their patients to quitsmoking (Anderson et al., 2002).
Randomized TrialIn order to assess the effectiveness of the educational outreach visits 523physicians were randomly assigned to either receiving the visit (n ¼ 261) or to awaiting list control group and they would receive the visit only after the end ofthe study (n ¼ 262). Based on a prior survey conducted in the same population(Etter, 2003) the study was powered to detect a difference between 60% in thecontrol group and 72% in the intervention group (a relative change of þ20%)in the proportion of patients who received the advice to quit smoking, asreported by physicians (power ¼ 80%, p ¼ 0.05). Randomization was based on a
list of random numbers generated by a computer. Between January andSeptember 2003 the nurse contacted physicians in the intervention group bytelephone and visited those who agreed. Physicians in the control group werecontacted only for the follow-up survey.
Objective Outcome MeasuresThree types of objective outcome measures were recorded. First, the nurseregistered whether the physicians accepted to receive her visit after repeatedtelephone calls and the date and duration of each visit. Second, the list ofphysicians who took part in the Vivre sans Tabac training workshop wasobtained and the date of participation for each participant. Third, a list ofphysicians who ordered the ‘‘Stop-tabac’’ documents was compiled.
Survey of PhysiciansThis was a post-test only study. A follow-up survey in September 2003 wasconducted when 94% of participants in the intervention group had beencontacted and after visits had been conducted for all those who agreed toparticipate. A questionnaire was mailed to the 523 participants and up to fourreminder mailings to non-respondents. The questionnaire (in French) coveredthe elements recommended in a recent guideline (Anderson et al., 2002), whichhave been summarized in 5 As: Ask (all patients whether they smoke), Advise(all smokers to quit), Assess (motivation to quit), Assist (smokers who want toquit) and Arrange (follow-up visits). Physicians indicated by a figure between 0and 100 the proportion of their patients to whom they provided each element ofthe ‘‘5 As’’ smoking cessation intervention. They also indicated whether theyknew the ‘‘Stop-tabac’’ program, the proportion of patients to whom theyrecommended this program and the proportion of dependent smokers whowanted to quit or who recently quit smoking and to whom they prescribed NRTor bupropion (Zyban).
Statistical AnalysesT-tests were used to compare means, Mann-Whitney U-tests to comparemedians, and chi-square tests to compare proportions.
InterventionAlmost all (94%) physicians in the intervention group could be contacted bytelephone, but only 138 (53% of 261) accepted and actually received theeducational outreach visit. The average duration of the visit was 40 minutes. Inthe survey, 54% of physicians who received the visit answered ‘‘Yes’’ and 46%answered ‘‘No’’ to the question, ‘‘Did the visit motivate you to treat tobaccodependency more systematically in your patients?’’.
Participation in the Training WorkshopSix sessions of the workshop took place in Geneva in 2003 with only onephysician participating in the intervention group and no physicians partici-pating in the control group (chi-square ¼ 1.0, p ¼ 0.3).
Orders for BookletsOrders for the ‘‘Stop-tabac.ch’’ self-help materials were received from18 physicians in the intervention group (7% of 261) and 3 in the control group(1% of 262, chi-square ¼ 11.2, p 5 0.001). When they ordered the documents,physicians in the intervention group ordered a larger number (median ¼ 85documents per order) than physicians in the control group (median ¼ 30documents per order, U-test ¼ 6.0, p ¼ 0.034).
Participation in the SurveyThere were 277 returned questionnaires (53% of 523), 148 from theintervention group and 129 from the control group and the difference inresponse rates between the two groups was not statistically significant (57% vs. 49%, chi-square ¼ 2.9, p ¼ 0.09). The interval between the visit and the answerto the questionnaire was on average 5 months (mean ¼ 152 days, quartiles98, 149 and 211 days). Among respondents to the survey, there was nostatistically significant difference between the intervention and control groupsin terms of age, sex, smoking status and medical specialty. Participants werepsychiatrists (48%), surgeons (25%), ophthalmologists (8%), anaesthesiologists(8%), general practitioners or internists (7%), and other specialists (4%) – seeTable 1.
Table 1. Characteristics of physicians in the trial, based on survey responses
Smoking Cessation ActivitiesIn both study groups, according to physicians’ self-reports, a majority ofpatients were asked whether they smoked and were advised to quit smoking. However, the patients’ level of motivation to quit and level of dependencywere assessed in only a minority of smokers. Very few smokers were assisted intheir effort to quit and physicians seldom arranged follow-up appointmentsand prescribed NRT or bupropion (see Table 2).
Table 2. Impact of educational outreach visits on self-reported smoking preventionactivities performed by responding physicians
physicians knew whether they weresmokers or non-smokers
Proportion of smokers who, accordingto physicians, were:
Proportion of smokers or recentex-smokers who received. . .
Proportion of smokers or recentex-smokers who were dependenton tobacco who received. . .
Do you know the ‘‘Stop-tabac.ch’’
think that this program is increasessmokers’ chances of quittingsmoking? (% Yes)
Impact of the VisitsMore physicians in the intervention group than in the control group said theywere aware of the ‘‘Stop-tabac’’ program (see Table 2). The proportion ofpatients who, as reported by physicians, received a recommendation to use thisprogram was small but higher in the intervention than in the control group. There was no statistically significant difference between groups for the othervariables under scrutiny. In a subgroup analysis including only non-smokingphysicians (n ¼ 209), the proportion of patients who, as reported by physicians,received the advice to quit smoking was higher in the intervention group thanin the control group (69% vs. 54%, p ¼ 0.019).
This study showed that a single 40-minute educational outreach visit by anurse to specialist physicians in private practice had an impact only on non-smoking physicians, who after the intervention, more frequently advised theirpatients to quit smoking. However, in the whole study sample, theintervention had no impact on smoking cessation activities performed byspecialist physicians, except that the visit increased physicians’ awareness of aself-help, computer-tailored smoking cessation program and the frequency ofrecommending this program to their patients. The visits had no impact onphysicians’ participating in a training workshop on tobacco dependencytreatment program. It is possible that after receiving personal instructionfrom the nurse, some physicians decided that they did not also need to attendthe workshop. Most previous literature on this topic targeted generalpractitioners who volunteered for this type of intervention. This study addsto the literature by showing how difficult it is to enrol non-volunteerspecialist physicians in this type of intervention and to motivate them to treattobacco dependency.
Several factors may have attenuated the measured effect of the visits. First,
only half the physicians in the intervention group agreed to receive a visit. Itwas anticipated that specialist physicians would not be very interested intreating tobacco dependency but, nevertheless it was important to target thisgroup, because specialists have a unique opportunity to address tobaccodependency within the context of a particular disease that is a concern to thepatient.
Second, because this was a convenience sample, included were only
physicians from disciplines (mainly psychiatry, surgery, anaesthesiology, andophthalmology) who have not been traditionally involved in the treatment oftobacco dependency (Prignot et al., 2000). Surgeons and anaesthesiologistsmay not think that their role is to treat tobacco dependency, even thoughsmoking cessation improves surgery outcomes (Mo¨ller et al., 2002). Severalpsychiatrists added written comments on the questionnaire, indicating that
they avoided talking about smoking with their patients. In this case, theabsence of treatment resulted from a deliberate choice rather than fromobjective barriers. This is particularly regrettable, because psychiatrists arethe best trained to treat addictions and usually see their patients severaltimes.
In a previous study conducted in 2002 targeting general practitioners,
internists, cardiologists, and pneumonologists who had received a visit by thesame nurse, 79% of physicians agreed to the visit, much more than the 53%rate in the present study (Etter, 2003). The previous study also showed thatalmost all private practitioners who took part in the training workshop in 2002had previously received the nurse’s visit. Thus, the specialists in the presentstudy were particularly reluctant to receive the nurse’s visit, to treat tobaccodependency, and to take part in the workshop.
Third, the survey took place five months after the visits. Any effect of
the visits was probably attenuated by the passage of time, as suggested bysome (Raisch et al., 1990) but not all previous research (Stange et al., 2003). On the other hand, evaluations that take place immediately after the endof an intervention may overestimate its long-term effects (Raisch et al.,1990).
Fourth, the intervention (a single visit) may not have been intensive enough
or its content may not have been adequate. Previous research has shown thateffective educational outreach interventions were more intensive and includedadditional features such as a second visit after some time (Van Eijk et al., 2001),educational materials, audit and feedback, reminders, or patient-mediatedinterventions (Davis et al., 1995; Thomson O’Brien et al., 2000). However, theauthors of a recent review found no published direct comparison of whetherusing two or more educational outreach visits was more effective than usingonly one visit and they found no trial comparing outreach visits plus additionalinterventions versus outreach visits alone (Thomson O’Brien et al., 2000). Indirect strategies to modify physicians’ behaviour should also be tested, inparticular by targeting the patients themselves.
Fifth, any impact of the intervention would have been difficult to detect
because of a self-reporting bias on some variables. Specifically, the proportionof patients who, according to physicians, were asked whether they smoked andwere advised to quit was probably overestimated in this survey. Directobservation has shown that only 32 – 54% of smokers are identified byphysicians (Dickinson et al., 1989; Humair & Ward, 1998), which is much lessthan the self-reported figures in this study. Selection bias may also explain thehigh frequency of anti-smoking activities in this study, if respondents to thesurvey were more actively involved in treating tobacco dependency thannon-respondents.
The present response rate was similar to the average response rate of 54%
reported in a review of mail surveys of physicians (Ash et al., 1997). Since onlyabout half the intended participants answered the survey, and because only a
limited range of medical specialties were included, results may not begeneralized to all specialists. However, one strength of this study comparedwith previous studies, is that it included all physicians in a given area and didnot focus only on volunteers. Therefore, this study extends upon the existingliterature which focused on general practitioners and volunteers in particular byshowing how difficult it is to enrol non-volunteers in this intervention. It alsoshowed that outreach visits are nevertheless a good way to promote computer-tailored smoking cessation programs.
The author developed the ‘‘stop-tabac.ch’’ computer-tailored programdescribed in this paper. This program is available at no charge to smokers andthe author has no financial interest in this program.
This study was supported by grants from the Swiss National ScienceFoundation to J.-F. Etter (3233-054994.98 and 3200-055141.98). The nursewho visited physicians was paid by the Geneva Health Department (DirectionGe´ne´rale de la Sante´, De´partement de l’Action Sociale et de la Sante´). Wethank Corinne Wahl for her work in visiting physicians and Dr Jean-PaulHumair for his advice.
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