Positive reinforcement can spur physicians and health practitioners to promote tobacco cessation

University of Maryland Medical System researchers studied the effects of positive reinforcement to encourage physicians and health practitioners to promote referral to tobacco Quitline resources. The researchers observed an uptick in referrals after physicians and health practitioners received letters and certificates acknowledging their referral efforts in January 2022, indicating that positive feedback and acknowledgment may improve tobacco cessation e-referral rates.

The authors assert that providing physicians and health care providers with access to accurate EHR data can also be a valuable tool in improving clinical outcomes in vulnerable populations and that recognition of physicians' and practitioners' efforts can potentially be expanded beyond tobacco cessation to address other areas of practice.

Tobacco use is one of the most preventable causes of morbidity and mortality in the United States. In our project, positive reinforcement for tobacco cessation referrals was accomplished by recognizing physicians/practitioners across the University of Maryland Medical System (UMMS) for their commitment to tobacco cessation.

The tobacco e-referral outreach and education initiative includes the entirety of the UMMS, which spans 12 hospitals and more than 150 ambulatory clinics in 11 counties and Baltimore City.

There are more than 4,600 affiliated physicians providing primary and specialty care who can utilize the tobacco cessation e-referral within the Epic electronic health record (EHR) to refer patients who use tobacco to the Maryland Quitline, or to the on-campus Tobacco Health Practice.

Outreach and education are conducted across UMMS to physicians/practitioners to promote the use of a tobacco cessation e-referral to the Maryland Quitline or to the Tobacco Health Practice for patients who use tobacco products. Referrals to the Maryland Quitline have been demonstrated to reach the most vulnerable segments of our population. Over 500 physicians/practitioners and staff were educated across 40 presentations on how to use the e-referrals.

Educational topics include tobacco epidemiology, types of tobacco products including e-cigarettes/vape devices, tobacco cessation pharmacotherapeutics, tobacco treatment options, and EHR workflows. Education occurred via grand rounds, departmental meetings, webinars, pre-recorded presentations, Epic tip sheets, and one-on-one academic detailing.

Data from the Epic EHR were reviewed to identify the number of tobacco cessation e-referrals to the Maryland Quitline by physicians/practitioners across the UMMS in 2021. Physicians/practitioners who e-referred 10 or more patients in a 12-month period were considered "Tobacco Cessation Champions," and those who e-referred less than 10 patients were considered "Tobacco Cessation Advocates."

Each physician/practitioner received a letter and certificate via e-mail celebrating their work and inspiring them to encourage their colleagues to e-refer their patients for tobacco cessation. Letters and certificates were tailored to Champions and Advocates, respectively. In 2021, 264 physicians/practitioners e-referred patients to the Maryland Quitline.

These physicians/practitioners received a letter and certificate in January 2022. There were 203 e-referrals submitted to the Maryland Quitline in the 4th quarter of 2021 and 269 e-referrals submitted to the Maryland Quitline in the 1st quarter of 2022. There were also 443 referrals to the Tobacco Health Practice in 2021. The sustainability of this effort is supported by having developed a scalable EHR workflow and training material existing in perpetuity.

Positive reinforcement and acknowledgment of physicians'/practitioners' work to improve their patients' health may help increase tobacco cessation e-referrals. Physicians/practitioners self reported enthusiasm at being acknowledged for their effort. Access to accurate EHR data can be a valuable tool in quality improvement to improve clinical outcomes in vulnerable populations.

Recognition of physician/practitioner efforts can potentially be expanded beyond tobacco cessation to address other areas of practice. Future iterations of this effort should consider the proportion of patients who smoke and patients who do not require referral for treatment. Utilizing the rate of eligible smokers who need and are referred for treatment may produce a more accurate representation of physician/practitioner treatment efforts.

The research was published in The Annals of Family Medicine.