Pathways to Smoking Care Implementation Project

(P-SCIP)Christine Paul, Megan Freund, Ann Dadich, Emma Sherwood,

Natalie Taylor, Fiona Day, Bettina Meiser, Megan Varlow, Rina Hui, Tim Shaw, Jane Young, John Wiggers

Background“For cancer patients… smoking status is a powerful clinical risk indicator that merits the full attention of the health care team and the patient”(US Surgeon General)

Smoking rates after diagnosis range from 20% - 50%1

Rates of assistance are low2

39% of oncologists provided cessation support (US data)Majority believed cessation support was someone else’s role

Quitting soon after diagnosis: Gain of 1.6 years median survival time over eight years3 Decreased risk of recurrence or new primary4

Decreased risk of treatment side effects5

1. NCI 2013 2. Warren 2013 2. Weber et al 2014. 3. Walter et al 2014, Parsons 2010. 4. Rugg et al 1990

Aims

To explore:Capacity of NSW hospitals to implement key aspects of system-wide smoking cessation advice

Proportion of oncology patients who report receiving smoking cessation care

Proportion of oncology medical and nursing staff who routinely deliver cessation care to patients

To pilot test the feasibility of a smoking cessation implementation strategy

Research Design

Three successive project stages to address aimsStage 1 (complete) State-wide survey of key informantsStage 2 (ongoing) Survey of cancer care staff and cancer patients* Stage 3 (ongoing) Pilot program to test feasibility of an implementation intervention

Stage 1

Stage 2

Stage 3

* Patient data not presented

Stage 1: Key Informant SurveyElectronic survey invitation sent to key informants across NSW e.g. Director Cancer Services (n=68)

Examined capacity of hospitals to:consistently record patient smoking informationShare smoking related information across cancer care providersautomate referrals for smoking careprovide pharmacotherapy

Stage 1: Key Informant Survey34 respondents, 42 unique hospitals nominated (86 total)Item – individual hospitals N (%)

Policy for smoking cessation ? - specific to cancer patients?

19 (45%)0 (0%)

Routinely record smoking status?- At admission- By doctor / nurse

16 (38%) 12 (29%)

Routinely record smoking cessation care provided?- By doctor/nurse- At admission

14 (33%)3 (7%)

How is NRT made available to inpatients? - Unsure - Hospital pharmacy

17 (41%)10 (24%)

How is NRT made available to outpatients? - Unsure- Referral letter to GP

25 (60%)4 (10%)

Stage 1: Key Informant Survey

Quit counse

lling se

rvice

s for s

taff

Resource

s specifi

cally

for c

ancer p

atients

Staff access

to free/co

st pric

e NRT

Inservi

ce plans/s

trategic

documents

Training to provid

e cessa

tion care fo

r general p

atients0

5

10

15

20

Most common strategies implemented (34 sites)

Automated referra

l to Q

L or o

ther

Patient file field w

here cessa

tion care provid

ed can be easil

y seen

Staff ince

ntives

Incorporating ce

ssation ca

re practice

s into st

aff appraisal

0

5

10

15

20

Least common strategies implemented (n=34)

Stage 2: Staff SurveyAll staff involved with care of cancer patients

Survey items:Delivery and recording of smoking cessation careSupport strategies to facilitate cessation careBeliefs regarding cessation care for cancer patients

92 surveys completed across 2/6 sites (1 site complete)17 doctors (18.5%), 51 nurses (55.4%), 24 other (26.1%)Medical oncology, radiation oncology,

surgical oncology, and allied health

Stage 2: Staff Survey (n=92)Delivery and recording of care

Survey Question Patient setting Result

What proportion of patients do you ask/confirm smoking status?

Inpatient (n=63) 47.6% (n=30) Half or less

Outpatient (n=66) 66.7% (n=44) Half or less

For patients that smoke, what proportion did you advise to quit?

Inpatient 55.6% (n=35) Half or lessOutpatient 65.2% (n=43) Half or less

Support strategies to facilitate careSurvey Question Result

Does your hospital have a policy on smoking cessation care for cancer patients?

26.1% (n=24) Yes

Are there reminders or prompts for clinical staff to ask about smoking status?

23.9% (n=22) Yes

Beliefs regarding careSurvey Question Result

Asking about smoking jeopardises my relationship with the patient 6.5% (n=6) Strongly agree/agree Is it appropriate to provide cessation care for patients with tobacco-related cancer?

85.9% (n=79) Strongly agree/agree

Stage 3 Progress: Identifying processes and points for smoking care

Interim LearningStage 1

Low preparedness / room for improvement

Stage 2 Staff reasonably willing but system weakNeed for range of strategies – no silver bullet

Stage 3Complexity of system: need for department-specific tailoring

Thank you!

We gratefully acknowledge the funding and infrastructure support provided by:

Cancer Institute NSWThe University of NewcastleHunter Medical Research InstituteHunter New England Population Health

We also would like to thank the study participants

Stage 2: Patient SurveyAdult outpatients attending medical, radiation or surgical oncology clinics

Any cancer typeEnglish speakingPreviously attended clinic

Survey items relating to:Receipt of smoking cessation careBeliefs regarding appropriateness of cessation care

Stage 2: Patient Survey163 participants across 2 sites

97 (59.5%) medical oncology, 43 (26.4%) radiation oncology, 23 (14.1%) surgical oncology86 male (52.8%), mean age 61.4 years18 (11%) current smokers, 82 (50.3%) former smokers, 62 (38%) never smokers

Patients:Believe that cancer patients should be asked about smoking (92%) and that smokers should be advised to quit (90.1%)

However…23.3% patients were not asked about their smoking38.9% of current smokers (n=18) were not offered help to quit smoking

Stage 2: Patient Survey (n=163)Receipt of Smoking Care

Survey Question Result

Did any of your doctors or nurses as whether you smoke tobacco? 23.3% (n=38) No, UnsureFOR CURRENT SMOKERS ONLY (n=18):Were you offered help to quit smoking by people involved in you cancer care?

38.9% (n=7) Not offered help

Beliefs regarding careSurvey Question Result

Health professionals in cancer care should ask people who have cancer if they smoke

92% (n=149) Strongly agree/agree

Health professionals in cancer care should advise people who have cancer and are smokers to quit smoking

90.1% (n=146) Strongly agree/agree

There is no point quitting smoking if you have cancer 11.1% (n=18) Strongly agree/agreePeople who have cancer should not be asked to quit smoking because they have enough to deal with

12.3% (n=20) Strongly agree/agree