Implementation strategies for integrating tobacco cessation treatment in cancer care: A qualitative study

Inner Setting

The complexity of the EHR served as both a barrier and facilitator to addressing tobacco use depending on the intervention component. The EHR was a strong facilitator to screening and documentation due to availability of tools such as visit templates, prompts, and smart phrases, which allowed for easy navigation to relevant EHR modules. Participants also noted that smoking status was easy to retrieve from the EHR. Conversely, the EHR was the most discussed barrier to electronic referral. Some oncologists had trouble finding the referral order in the EHR, and four remarked that the referral order required too much information, such as the best time to call and the patient’s treatment preferences. This problem was compounded by the fact that referrals were often entered when the patient was not in the room to provide this information.

Workload was one of the few reported barriers to screening. Oncologists described how the growing patient volume combined with increasing requirements for practice and documentation, such as regulations related to prescribing narcotics, exerted pressure on oncologists and staff. Although oncologists felt that addressing tobacco use was important, it was described as “just one of a million things” they needed to complete in a visit.

In relation to the relative priority construct, screening was prioritized for new patient visits. One oncologist noted research studies requiring smoking status data also facilitated documentation to tobacco use. Oncologists explained that tobacco use screening was prioritized due to its clinical impact as well as reimbursement requirements. Most oncologists stated screening at return visits was less of a priority, though one oncologist who primarily treated lung and head and neck cancer patients stated they screened at every visit out of habit.

The compatibility of tobacco use screening with the clinic workflows also differed between new and return patient visits. Standardized workflows typically supported screening for new patient visits, but not returning patients. Oncologists described multiple screening opportunities during new patient visit workflows; however, screening at return visits was not part of routine workflows and usually not included in EHR note templates.

Outer Setting

External policies and incentives were a strong facilitator for screening and counseling due to documentation requirements for new patient visit reimbursement. Several factors related to patient needs and resources were also identified. Over half of oncologists noted distress and anxiety related to a cancer diagnosis makes patients unreceptive to counseling on tobacco cessation, and some patients do not have any interest in quitting. Oncologists recognized that the most important time for patients to quit was at diagnosis, but that patients were often not receptive to addressing tobacco use until later in the course of their treatment. Many oncologists also noted they were more likely to discuss tobacco use and other behavioral changes after treatment was complete because they had fewer competing demands and patients were more open to discussing cessation.

Characteristics of Individuals

Oncologists frequently expressed a lack of awareness related to tobacco cessation resources both within and outside the health system. All oncologists in this study were asked if they were aware of the EHR referral to the state tobacco program, with only about half replying they were familiar with the tool. Another oncologist was aware of the referral order but unsure how to use it. Many oncologists were also unfamiliar with the tobacco cessation resources available to patients in the healthcare system, although one oncologist who was familiar with the EHR referral was uninterested in knowing details, stating, “As long as it gets done, I don’t care who does it.”

Some oncologists expressed frustration or difficulty with the EHR in general, which extended to the EHR-based components of tobacco cessation treatment. Their frustration stemmed from factors such as frequent changes and updates, number of clicks required, and hard stops, which force the provider to enter data before moving to the next screen. Although oncologists acknowledged the value of the EHR, it was often described as overwhelming and difficult to navigate.

In terms of self-efficacy, some oncologists noted that while they were confident in their ability to routinely screen for tobacco use and advise patients to quit, they were less confident in their ability to provide counseling and discuss treatment options. Although tobacco use was seen as relevant to patient treatment and outcomes, engaging patients in treatment was seen by many oncologists as beyond their scope of expertise, with one noting it was an issue that would be better addressed by primary care physicians.

At return patient visits, prioritization of addressing tobacco use was described as dependent on the patient’s condition and stage of treatment. Most oncologists noted their decision to address tobacco use was often dependent on whether they felt tobacco use was relevant to the patient’s diagnosis (e.g., tobacco-related cancers), impacting the patient’s treatment, or detrimental to their quality of life. This was especially salient for surgeons, who were invested in encouraging patients to quit prior to surgery due to the negative impact of tobacco use on surgical outcomes; however, once surgery was complete, cessation was no longer a priority.

Tobacco User Registry

Reactions to the registry strategy were mixed. While oncologists acknowledged this approach would increase the reach of the intervention, they felt that effectiveness of the treatment would be decreased without oncologist involvement. One surgical oncologist stated, “…if the conversation isn’t started with the physician who’s providing the chemotherapy, it’s probably not going to be as effective as you’d think.” Another frequent concern was the issue of patient privacy. About half of oncologists expressed concerns about sharing health information or felt patients would react negatively to unsolicited contact about tobacco cessation. One noted this strategy could damage the patient-provider relationship. Proposed strategies to mitigate privacy concerns were to offer patients the opportunity to opt-in during visit check-in and to notify patients they would be contacted regarding tobacco cessation. Finally, capacity of the state-run program to handle referrals was a concern, although one suggested that resources could be conserved by using text or automated messaging.

On-site Treatment

Oncologists expressed positive responses to offering on-site treatment to patients who use tobacco. They felt that this model would increase the accessibility of tobacco treatment and enhance engagement. Several suggested that treatment should be available on demand, with one radiation oncologist explaining,

“You know, something where it’s right there in the moment, because oftentimes it’s sort of an emotional discussion of getting them ready to do it and boy, if you call them back even a day later they go, ‘Oh, I’ll think about doing it next month.’ You’ve got to really strike while the iron is hot.”

Concerns with co-located treatment generally centered on space limitations and logistical challenges. When asked about the format of counseling treatment, most oncologists noted individual counseling was more feasible than group counseling. Other suggestions included tailoring treatment by offering brief counseling sessions, performing intensive follow up, and offering prescription medications. One oncologist noted that for billing purposes, tobacco treatment should be delivered in a separate visit to generate additional reimbursement.

Clinician Proposed Strategies

In addition to comments on the proposed strategies, oncologists offered suggestions on other ways to improve tobacco cessation treatment in cancer care. Recommended strategies organized by the CFIR are presented in Table 3.

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Table 3.

Recommended strategies organized by the CFIR.

CFIR domain	CFIR construct	Strategy	Example
Intervention	Complexity	Minimize provider involvement	Shift referral and treatment to other clinical staff
		Reduce complexity of referral	Simplify the referral template
		Leverage existing EHR tools	Build tobacco screening into existing templates and order sets
			Use patient portal to facilitate screening
Inner setting	Organizational incentives and rewards	Make the business case for tobacco treatment through financial incentives or quality measures	Establish the financial case for addressing tobacco use in oncology
			Use tobacco treatment-related outcomes as quality measure
Outer setting	Patient needs and resources	Tailor treatment to meet needs of patient population	Co-locate treatment
			Offer treatment at multiple time points
			Perform intensive follow-up
			Offer telehealth treatment options
Characteristics of individuals	Self-efficacy	Train providers on how to address tobacco use	Give providers basic information on treatment options
			Conduct face-to-face training and post instructions for the EHR referral
	Knowledge and beliefs about the intervention	Build awareness of importance of cessation and providers’ role	Include tobacco treatment in medical education
			Build awareness of the importance of addressing tobacco use in cancer care
Process	Goals and feedback	Closed-loop referrals	Document and notify physicians of referral outcomes

Intervention Characteristics

Many suggestions related to methods of reducing the complexity of the tobacco treatment intervention referral process. Recommendations included leveraging existing EHR tools (e.g., order sets, patient portal) and simplifying the existing referral template. While oncologists generally felt that it was their role to encourage patients to stop using tobacco, they felt facilitating treatment could be handled by another member of the clinical team. One medical oncologist stressed the importance of minimizing oncologist involvement in the referral process, stating,

“I think you’re fooling yourself if you think, ‘Well, it’s just one click, it’s just one piece of paper to fill out. Just sign this piece of paper and it’ll be done for you.’ It won’t happen. It has to happen outside of the input from the physician.”

A recurring suggestion related to this issue was to allow more members of the clinical team to issue the referral order, rather than requiring oncologists to sign off.

Outer Setting

Physicians emphasized the need to present a financial case to the healthcare system for integrating tobacco treatment into cancer care. One oncologist suggested that addressing tobacco use could be used as a quality measure if the financial case could not be established. Another suggestion was to tailor treatment options to the patient population. Oncologists discussed how the optimal time for patients to quit is prior to treatment, but patient distress and care complexity at this stage were barriers to addressing tobacco use. In light of this tension, they indicated that tobacco treatment should be offered consistently at multiple timepoints. Given the large proportion of rural patients who travel significant distances to receive care at the healthcare system, telehealth options were also encouraged.

Characteristics of Individuals

To overcome barriers related to oncologists’ self-efficacy, brief trainings for providers with information on the electronic referral to tobacco cessation treatment options were recommended. To build awareness of the oncologist role in tobacco cessation, it was suggested that the topic should be emphasized in medical education.

Process

A frustration with referral to the state-run program was that oncologists sent the order “into the void” and did not receive information on the outcome of the referral. One radiation oncologist stated that receiving referral outcomes would “reinforce [her] good behavior.” Another oncologist emphasized the importance of receiving referral outcomes to enable assessment of clinic performance on tobacco-related measures.