Pragmatic application of the RE-AIM framework to evaluate the implementation of tobacco cessation programs within NCI-Designated Cancer Centers

Tobacco cessation after cancer diagnosis leads to better patient outcomes. However, tobacco treatment services are frequently unavailable in cancer care settings, and multilevel implementation challenges can impede uptake of new programs. The National Cancer Institute (NCI) dedicated Cancer Moonshot funding through the Cancer Center Cessation Initiative (C3I) for NCI-Designated Cancer Centers to implement or enhance the implementation of tobacco treatment services. We examined a pragmatic application of the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) to evaluate tobacco treatment programs implemented within Cancer Centers funded through C3I. Using three C3I-funded Centers as examples, we describe how each RE-AIM construct was operationalized to evaluate the implementation of a wide range of cessation services (e.g., tobacco use screening, counseling, Quitline referral, pharmacotherapy) in this heterogeneous group of cancer care settings. We discuss the practical challenges encountered in assessing RE-AIM constructs in real world situations, including using the electronic health record (EHR) to aid in assessment. Reach and effectiveness evaluation required that Centers define the setting(s) where cessation services were implemented (to determine the denominator ), enumerate the patient population, report current patient tobacco use, patient engagement in tobacco treatment, and 6-month cessation outcomes. To reduce site heterogeneity, increase data accuracy, and reduce burden, reach was frequently captured via standardized EHR enhancements that improved the identification of current smokers and tobacco treatment referrals. Effectiveness was determined by cessation outcomes (30-day point prevalence abstinence at 6-months post-engagement) assessed through a variety of data collection approaches. Adoption was measured by the characteristics and proportion of targeted cancer care settings and clinicians engaged in cessation service delivery. Implementation was assessed by examining the delivery of tobacco screening assessments and intervention components across sites, and provider-level implementation consistency. Maintenance assessments identified whether tobacco treatment services continued in the setting after implementation and documented the sustainability plan and organizational commitment to continued delivery. In sum, this paper demonstrates a pragmatic approach to using RE-AIM as an evaluation framework that yields relevant outcomes on common implementation metrics across widely differing tobacco treatment approaches and settings

Integrating the Telequit Smoking Cessation Program in the Admission Process and Analyzing Its Effect on the Rate of Utilization by Homeless Veterans Within a Federal Healthcare Facility

The use of telehealth for smoking cessation has not been consistently applied and evaluated within the hospital admission process despite the supporting evidence. Likewise, telehealth interventions have not been evaluated in the context of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. This quasi-experimental quality improvement study of two groups seeks to fill this gap by investigating the effectiveness of integrating a Telequit smoking cessation protocol for homeless veterans into the hospital admission process. The findings are expected to support incorporating Telequit e-consults into the patient admission template within the federal healthcare inpatient residential program. Currently, the Telequit consult is not offered in the admission questionnaire, which may lead to missed opportunities of offering Telequit to incoming residential patients. It is hypothesized that by incorporating the Telequit referral in the admission process, more veterans would be enrolled in the Telequit program. The null hypothesis is that it will not impact referral and engagement

Smoking cessation : a report of the Surgeon General

Tobacco smoking is the leading cause of preventable disease, disability, and death in the United States (U.S. Department of Health and Human Services [USDHHS] 2014). Smoking harms nearly every organ in the body and costs the United States billions of dollars in direct medical costs each year (USDHHS 2014). Although considerable progress has been made in reducing cigarette smoking since the first U.S. Surgeon General\u2019s report was released in 1964 (USDHHS 2014), in 2018, 13.7% of U.S. adults (34.2 million people) were still current cigarette smokers (Creamer et al. 2019). One of the main reasons smokers keep smoking is nicotine (USDHHS 1988). Nicotine, a drug found naturally in the tobacco plant, is highly addictive, as with such drugs as cocaine and heroin; acti- vates the brain\u2019s reward circuits; and reinforces repeated nicotine exposure (USDHHS 1988, 2010, 2014; National Institute on Drug Abuse [NIDA] 2018).The majority of cigarette smokers (68%) want to quit smoking completely (Babb et al. 2017). The 1990 Surgeon General\u2019s report, The Health Benefits of Smoking Cessation, was the last Surgeon General\u2019s report to focus on cur- rent research on smoking cessation and to predominantly review the health benefits of quitting smoking (USDHHS 1990). Because of limited data at that time, the 1990 report did not review the determinants, processes, or outcomes of attempts at smoking cessation. Pharmacotherapy for smoking cessation was not introduced until the 1980s. Additionally, behavioral and other counseling approaches were slow to develop and not widely available at the time of the 1990 report because few were covered under health insurance, and programs such as group counseling ses- sions were hard for smokers to access, even by those who were motivated to quit (Fiore et al. 1990).The purpose of this report is to update and expand the 1990 Surgeon General\u2019s report based on new scien- tific evidence about smoking cessation. Since 1990, the scientific literature has expanded greatly on the deter- minants and processes of smoking cessation, informing the development of interventions that promote cessa- tion and help smokers quit (Fiore et al. 2008; Schlam and Baker 2013). This knowledge and other major develop- ments have transformed the landscape of smoking ces- sation in the United States. This report summarizes this enhanced knowledge and specifically reviews patterns and trends of smoking cessation; biologic mechanisms; various health benefits; overall morbidity, mortality, and economic benefits; interventions; and strategies that pro- mote smoking cessation.Suggested citation: U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020.2020-cessation-sgr-full-report.pdf2020713

Facilitating implementation of research evidence (FIRE): A randomised controlled trial and process evaluation of two models of facilitation informed by the promoting action on research implementation in health services (PARIHS) framework

Background: The PARIHS framework proposes that successful implementation of research evidence results from the complex interplay between the evidence to be implemented, the context of implementation and the facilitation processes employed. Facilitation is defined as a role (the facilitator) and a process (facilitation strategies/methods). Empirical evidence comparing different facilitation approaches is limited; this paper reports a trial of two different types of facilitation represented in the PARIHS framework. Methods: A pragmatic cluster randomised controlled trial with embedded process evaluation was undertaken in 24 long-term nursing care settings in four European countries. In each country, sites were randomly allocated to standard dissemination of urinary incontinence guideline recommendations and one of two types of external-internal facilitation, labelled Type A and B. Type A facilitation was a less resource intensive approach, underpinned by improvement methodology; Type B was a more intensive, emancipatory model of facilitation, informed by critical social science. The primary outcome was percentage documented compliance with guideline recommendations. Process evaluation was framed by realist methodology and involved quantitative and qualitative data collection from multiple sources. Findings: Quantitative data were obtained from reviews of 2313 records. Qualitative data included over 332 hours of observations of care; 39 hours observation of facilitation activity; 471 staff interviews; 174 resident interviews; 120 next of kin/carer interviews; and 125 stakeholder interviews. There were no significant differences in the primary outcome between study arms and all study arms improved over time. Process data revealed three core mechanisms that influenced the trajectory of the facilitation intervention: alignment of the facilitation approach to the needs and expectations of the internal facilitator and colleagues; engagement of internal facilitators and staff in attitude and action; and learning over time. Data from external facilitators demonstrated that the facilitation interventions did not work as planned, issues were cumulative and maintenance of fidelity was problematic. Implications for D&I Research: Evaluating an intervention - in this case facilitation - that is fluid and dynamic within the methodology of a randomised controlled trial is complex and challenging. For future studies, we suggest a theoretical approach to fidelity, with a focus on mechanisms, as opposed to dose and intensity of the intervention