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A Cluster-Randomized Controlled Trial

Jeffrey A. Linder, MD, MPH; Nancy A. Rigotti, MD; Louise I. Schneider, MD; Jennifer H. K. Kelley, MA; Phyllis Brawarsky, MPH; Jennifer S. Haas, MD, MSPH

Arch Intern Med. 2009;169(8):781-787.

Background  To improve the documentation and treatment of tobacco use in primary care, we developed and implemented a 3-part electronic health record enhancement: (1)smoking status icons, (2) tobacco treatment reminders, and (3) a Tobacco Smart Form that facilitated the ordering of medication and fax and e-mail counseling referrals.

Methods  We performed a cluster-randomized controlled trial of the enhancement in 26 primary care practices between December 19, 2006, and September 30, 2007. The primary outcome was the proportion of documented smokers who made contact with a smoking cessation counselor. Secondary outcomes included coded smoking status documentation and medication prescribing.

Results  During the 9-month study period, 132 630 patients made 315 962 visits to study practices. Coded documentation of smoking status increased from 37% of patients to 54% (+17%) in intervention practices and from 35% of patients to 46% (+11%) in control practices (P < .001 for the difference in differences). Among the 9589 patients who were documented smokers at the start of the study, more patients in the intervention practices were recorded as nonsmokers by the end of the study (5.3% vs 1.9% in control practices; P < .001). Among 12 207 documented smokers, more patients in the intervention practices made contact with a cessation counselor (3.9% vs 0.3% in control practices; P < .001). Smokers in the intervention practices were no more likely to be prescribed smoking cessation medication (2% vs 2% in control practices; P = .40).

Conclusion  This electronic health record–based intervention improved smoking status documentation and increased counseling assistance to smokers but not the prescription of cessation medication.

Trial Registration  clinicaltrials.gov Identifier: NCT00383461

Author Affiliations: Division of General Medicine and Primary Care, Brigham and Women's Hospital (Drs Linder, Schneider, and Haas and Mss Kelley and Brawarsky), Tobacco Research and Treatment Center and General Medicine Division, Massachusetts General Hospital (Dr Rigotti), and Harvard Medical School (Drs Linder, Rigotti, Schneider, and Haas), Boston, Massachusetts.

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