Brief report
Clinical Faxed Referrals to a Tobacco Quitline: Reach, Enrollment, and Participant Characteristics

https://doi.org/10.1016/j.amepre.2008.12.004Get rights and content

Background

Faxed referrals from healthcare providers may provide a sustainable, low-cost mechanism for enrolling tobacco users in statewide quitlines, but few studies have evaluated implementation in real-world settings. This study evaluated the reach rates, enrollment rates, and participant characteristics of faxed referrals to the Ohio Tobacco Quit Line.

Methods

This observational study analyzed reach and enrollment rates from June 2006 to October 2007. Demographics and tobacco-use characteristics of 1616 Quit Line enrollees recruited through faxed referrals were compared to those of enrollees who were not fax-referred.

Results

A total of 6951 faxed referrals were received during the study period, increasing from an average of 68 per month before promotional initiatives to 412 per month during the study period. However, almost 60% of fax-referred individuals could not be reached for enrollment. Compared to other enrollees (n=36,273), fax-referred enrollees (n=1616) were more likely to be women, aged ≥35 years, have less than a high school education, have at least one comorbid condition, and be uninsured or publicly insured.

Conclusions

Faxed referrals from healthcare providers are widely promoted to increase quitline participation and to assist providers in implementing cessation treatment. This study found low enrollment rates from faxed referrals; substantial efforts led to relatively few patients receiving quitline services. However, faxed referrals may reach populations who traditionally have less access to cessation aids. More research is needed to determine how to efficiently and effectively solicit faxed referrals from healthcare providers and to increase quitline enrollment rates among fax-referred smokers as well as to determine the extent to which faxed referrals influence quit outcomes.

Introduction

Healthcare providers are uniquely positioned to link tobacco users with treatment services to help them quit. A majority of smokers visit a healthcare provider each year,1, 2 and physician advice is positively associated with smokers' intentions to quit.3 Clinical guidelines recommend that all healthcare providers implement the 5A's with each patient: (1) ask about tobacco use; (2) advise to quit; (3) assess willingness to make a quit attempt; (4) assist in quit attempt or (for those unwilling to quit) in increasing motivation to quit; and (5) arrange for follow-up.4

Although the ask and advise steps are implemented relatively often,5, 6 only 20%–40% of smokers report receiving assistance for tobacco cessation during a visit to their healthcare provider.1, 6, 7 Providers' barriers include lack of time, inconvenience, and lack of reimbursement for cessation services.8

A feasible and sustainable alternative is to have providers implement the first two or three steps and then refer patients to existing cessation services such as telephone counseling.9, 10, 11, 12, 13, 14 Proactive telephone counseling, such as that provided by quitlines, increases considerably the odds of quitting over self-help materials or brief advice, and, when combined with pharmacotherapy, increases the odds over pharmacotherapy alone.15

Despite the theoretical appeal of provider-faxed referrals to telephone quitlines, few studies have evaluated this implementation in real-world settings rather than experimental, clinical ones.10, 16, 17, 18, 19 Observational studies have lacked details about enrollment rates and sustainability.13, 20 The current study describes reach rates, enrollment rates, and enrollee characteristics for faxed referrals to the Ohio Tobacco Quit Line between June 2006 and October 2007.

Section snippets

Intervention

The Ohio Tobacco Quit Line began providing services statewide in September 2004. A provider-faxed referral process was introduced in the first year; by the second year, an average of 68 referrals was received per month. Starting in May 2006, the Ohio Tobacco Prevention Foundation implemented three programs to increase provider-faxed referrals: (1) a hospital-based program (Outreach) that trained staff at 43 participating hospitals; (2) a direct-marketing initiative (Fax Five) aimed at

Reach and Enrollment Rates

The Quit Line received a total of 6951 faxed referrals between June 1, 2006, and October 31, 2007. An average of 412 referrals was received per month, ranging from 147 in the first month to 419 in the last month, and peaking at 734 in May 2007. Fewer than 3% (n=205) were repeats for an individual; 15.3% were from the Fax Five program, 27.6% were from the Outreach program, 28.1% were from the Community Grants program, and 29.0% were not identified with a specific initiative.

Fewer than one fourth

Discussion

Multiple promotional strategies increased the average monthly number of faxed referrals to a state quitline from 68 to 412. Fax-referred enrollees reported lower SES (e.g., less education, lack of insurance) than nonfax-referred enrollees. In general, lower-SES smokers are less likely to use cessation aids such as pharmacotherapy23 or to receive assistance in quitting from their healthcare provider.7 The potential of faxed-referral programs to reach these smokers should be explored.

The

Conclusion

Faxing referrals to quitlines provides a convenient way for healthcare providers to assist tobacco users, an effective recruitment strategy for quitlines, and possibly a way to reach lower-SES tobacco users. Promotional activities can increase faxed referrals, although enrollment rates may be low. Additional research is needed to improve the efficiency of faxed-referral programs, confirm the extent to which they recruit harder-to-reach populations, and determine whether faxed-referral

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  • Cited by (51)

    • A comprehensive electronic health record-enabled smoking treatment program: Evaluating reach and effectiveness in primary care in a multiple baseline design

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      These barriers have led to ask-advise-refer/connect approaches that shift the task of providing cessation treatment to external services, such as tobacco quitlines (Bentz et al., 2006). Unfortunately, results show little use of such referrals by clinic staff (Adsit et al., 2014; Fiore et al., 2019; Sheffer et al., 2012) and low rates (<30%) of enrollment in quitline services among referred patients (Leuthard et al., 2015; Wadland et al., 2007; Willett et al., 2009). Electronic health record (EHR) tools can prompt primary care teams to assess smoking status and refer patients to treatment resources.

    • Quitline program utilization and cessation outcomes: A comparison of provider-referred clients by healthcare settings

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      With at least 70% of tobacco users visiting a healthcare provider annually and a majority of whom have contemplated quitting (Jamal et al., 2012); healthcare providers are uniquely positioned to leverage healthcare encounters as opportunities to assess for tobacco use and refer patients to quitline services. In an attempt to increase reach to disparate groups of smokers, quitlines support healthcare provider-referral programs as a complementary and cost-efficient model beyond traditional media marketing and self-referral models (Willett et al., 2009; Woods and Haskins, 2007). A growing body of literature examining in-program differences (e.g., medication use, number of telephone counseling sessions, quit outcomes) for callers entering quitline services by varying sources (provider-referred vs. self-referred) has yielded mixed results.

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