Participants
The final sample of chiropractors consisted of six practitioners (five men and one woman) from six practices at six clinics, with an average age of 41 years (range, 30 to 58 years). The chiropractors had been in practice for an average of 13 years (range, 3 to 33 years), and four routinely screened patients for tobacco use prior to the study. Three were solo practitioners, and three were in a group practice with a single partner. Two used only paper records, and four used a combination of paper and EHRs. Four described themselves as in a mixed style of practice, and two called themselves “evidence-based” practitioners. Finally, they had an average of 103 patients provided chiropractic care in their practice (range, 30 to 200 patients) per month, with an average of 222 patient visits per month. Compared with the population of chiropractors in the region, our study participants were more often males in small practices and more likely to be practicing in a mixed or evidence-based style. Because of the small number of participants, the study did not use a control group, and all six practitioners underwent training for systems change.
Academic detailing
Each of the six clinics received AD from the OS staff, and all AD tasks were completed. Review of each clinic’s systems change workflow and implementation plan developed during the educational session was offered, and none felt the need to review. In a review of the forms currently being used by each clinic, two clinics had started process change prior to the first AD visit and received reinforcement, and four clinics received AD assistance and education. A system to prompt the chiropractor to conduct and document AAR was discussed, with none of the clinics having chosen a preferred method prior to the initial AD visit. Clinics then chose one of the following as a prompt: an electronic system (n = 2), a paper “sticky note” system (n = 2), use of the intake form (n = 1), and a flag/color system for patient charts (n = 1). For a method of referral, five clinics chose the fax referral option and one clinic chose an online method. Three clinics were also interested in using palm cards with the quitline telephone number for patients to self-enroll. Tracking of tobacco users and referrals was discussed, with clinics choosing to use electronic/diagnosis codes, dot stickers, a spreadsheet, and sticky notes, and keeping faxed referral forms on file.
Identification of a “clinic champion” was discussed, with clinics choosing one of the following: the chiropractor as the champion (n = 3), use of a team approach (n = 1), support staff as champion (n = 1), or no champion (n = 1). An ongoing internal feedback system was discussed, with some clinics interested in incorporating either a system for chart review for AAR performance (n = 1) or AAR follow-up tracking (n = 2). No clinics were interested in incorporating a formal policy for AAR. The process for ordering and identifying new educational materials was reviewed with additional staff educated on this process. Clinics designated who would be responsible for ordering materials, as follows: the chiropractor (n = 3), the chiropractor and support staff jointly (n = 2), or designated support staff (n = 1). The OS reviewed the sample job description for staff orientation in the educational materials.
Development of a tobacco-free workplace policy was discussed with each clinic. One clinic had a statement already in place in lieu of a formal policy, and two clinics showed interest in developing a policy.
Prior to the initial AD visit, five clinics had decided on a system for the Ask component, but no other components of the AAR system were in place until after the AD discussion with the OS. Plans for incorporation of the overall AAR workflow were discussed, with clinics determining that patients would either initially complete forms asking about tobacco use via the patient intake form (n = 5) or use a separate form specifically for tobacco use (n = 1); all clinics decided that the workflow would be the same for both new and established patients. Five clinics decided to perform the Ask component at the first patient visit, and one clinic decided to do this at the second visit, with documentation directly on the patient intake form (n = 4), by use of a sticky note system (n = 1), or use of both sticky notes and the intake form (n = 1). All clinics determined that the chiropractor would perform the Advise component in the examination room at the same visit that Ask was performed, with documentation through the use of an electronic prompt, sticky note system, spreadsheet/notes, formal AAR form, intake form, or EHR. It was also decided that the Refer component would be discussed with patients by chiropractors in the examination room, using the same documentation methods as Advise. The completion of referrals would also be performed by chiropractors on the same day as the discussion. Documentation of completed referrals included filing of the fax referral form and use of patient chart notes, spreadsheet/notes, the intake form, or the EHR.
At the end of the initial AD visit, the OS completed the SPS with all chiropractors (N = 6) participating. All chiropractors “engaged” with the Standard Patient before using AAR to address tobacco use, with the level of engagement ranging from a very quick style to building a caring foundation by briefly addressing the primary reason for the visit first. All chiropractors conducted AAR with the Standard Patient, with three chiropractors referring to the intake form during the Ask. component. The style of the Advise component was individualized, with chiropractors referencing the health concerns of tobacco (n = 4), including citing the connections among tobacco use, back pain, and healing (n = 2), and using MI techniques (n = 1). Two chiropractors advised using a more indirect approach (“I’m on your side and I know you know the harmful effects”) and a softened approach (“This may come as no surprise to you, as your health care provider, I recommend you quit using tobacco”). There was more commonality in the way chiropractors referred the Standard Patient, either by providing a brief explanation of the quitline program (n = 4) or by stating a plan to continue discussing tobacco use at their next visit (n = 1). The supportive behaviors assessed by the OS using the aforementioned six-point survey revealed a median score of six (“considerably”) for all components. The OS reported that of the six participants, only one was not as confident as the other chiropractors in the delivery of AAR.
Environmental scan
Environmental scans were completed for all chiropractic offices (N = 6) pre- and post-intervention.
Number of staff and examination rooms
The number of clinic staff changed slightly between pre- and post-scan. Pre-intervention, the number ranged from two to three per clinic (mean = 2.67), with one clinic increasing staff members from three to four post-intervention (mean = 2.83). The number of examination rooms changed slightly; pre-intervention, the number ranged from two to three (mean = 2.83), with one clinic decreasing from three to two rooms (mean = 2.67) post-intervention.
State quit program products
Pre-intervention observations assessing the presence of the state quit program products found that none were present in any of the clinics. Post-intervention, four of the six clinics (66.7%) incorporated the state quit program products into their clinics, including posters (n = 4 clinics), brochures (n = 2 clinics), and tear-off sheets (n = 2 clinics). The following quitline products were not observed post-intervention in any clinic: palm cards, foldover cards, or wallet cards. None of the clinics incorporated other cessation, secondhand smoke, or ENDS educational or referral materials from the state quit program or other sources into their clinics.
Signage, ashtrays, and written policies/guidelines
Smoke-free signage was not present indoors in any of the clinics. Smoke-free signage on some or all of the doors into the buildings was present for three clinics pre- and post-intervention. Ashtrays were not present within 20 ft from any door or window of any clinic either pre- or post-intervention. Written policies or guidelines related to smoke-free clinics or AAR were not present in any clinic either pre- or post-intervention.
Evidence of systematic processes in place to conduct AAR
The baseline chart review was conducted in each of the six clinics. At baseline, two of the six clinics had evidence of a systematic method for the Ask component for NEC patients. No clinics had evidence of a systematic method for Advise or Refer, or to assess for ENDS use or exposure to secondhand smoke. By the end of the fourth month of the intervention period, processes were in place for AAR in all clinics, to assess ENDS use by 50% of the clinics, and to assess exposure to secondhand smoke by 67% of the clinics.
Evidence of AAR implementation and systems change
See Table
1 for a summary of AAR implementation at baseline and over the six-month study period.
Table 1
AAR implementation by chiropractor
1 | Baseline | 33 | 100.0 | 0 | NA | NA |
1 | 7 | 100.0 | 0 | NA | NA |
2 | 4 | 100.0 | 0 | NA | NA |
3 | 8 | 100.0 | 1 | 0.0 | 0.0 |
4 | 7 | 100.0 | 2 | 50.0 | 50.0 |
5 | 5 | 100.0 | 0 | NA | NA |
6 | 11 | 100.0 | 0 | NA | NA |
2 | Baseline | 24 | 0.0 | NA | NA | NA |
1 | 12 | 83.3 | 7 | 100.0 | 71.4 |
2 | 18 | 94.4 | 6 | 83.3 | 33.3 |
3 | 18 | 100.0 | 2 | 100.0 | 100.0 |
4 | 21 | 81.0 | 4 | 50.0 | 25.0 |
5 | 21 | 95.2 | 4 | 75.0 | 75.0 |
6 | 6 | 100. | 1 | 0.0 | 0.0 |
3 | Baseline | 40 | 100.0 | 18 | 0.0 | 0.0 |
1 | 33 | 100.0 | 5 | 0.0 | 0.0 |
2 | 21 | 100.0 | 4 | 25.0 | 0.0 |
3 | 20 | 100.0 | 2 | 50.0 | 0.0 |
4 | 30 | 100.0 | 6 | 83.3 | 0.0 |
5 | 40 | 100.0 | 6 | 16.7 | 0.0 |
6 | 26 | 100.0 | 3 | 0.0 | 0.0 |
4 | Baseline | 39 | 100.0 | 17 | 0.0 | 0.0 |
1 | 40 | 100.0 | 7 | 28.6 | 28.6 |
2 | 25 | 100.0 | 2 | 50.0 | 50.0 |
3 | 40 | 100.0 | 5 | 40.0 | 0.0 |
4 | 39 | 100.0 | 2 | 0.0 | 0.0 |
5 | 38 | 100.0 | 7 | 85.7 | 71.4 |
6 | 38 | 100.0 | 8 | 37.5 | 25.0 |
5 | Baseline | 40 | 35.0 | 6 | 0.0 | 0.0 |
1 | 29 | 37.9 | 8 | 75.0 | 0.0 |
2 | 27 | 40.7 | 2 | 100.0 | 50.0 |
3 | 10 | 100.0 | 0 | NA | NA |
4 | 12 | 100.0 | 0 | NA | NA |
5 | 9 | 100.0 | 3 | 0.0 | 0.0 |
6 | 3 | 100.0 | 0 | NA | NA |
6 | Baseline | 35 | 100.0 | 6 | 0.0 | 0.0 |
1 | 7 | 100.0 | 0 | NA | NA |
2 | 15 | 100.0 | 0 | NA | NA |
3 | 14 | 100.0 | 4 | 0.0 | 0.0 |
4 | 16 | 100.0 | 1 | 0.0 | 0.0 |
5 | 16 | 100.0 | 1 | 0.0 | 0.0 |
6 | 22 | 100.0 | 1 | 0.0 | 0.0 |
All | Baseline | 211 | 76.3 | 47 | 0.0 | 0.0 |
1 | 128 | 84.4 | 27 | 55.6 | 25.9 |
2 | 110 | 84.5 | 14 | 64.3 | 28.6 |
3 | 110 | 100.0 | 14 | 35.7 | 14.3 |
4 | 125 | 96.8 | 15 | 53.3 | 13.3 |
5 | 129 | 99.2 | 21 | 47.6 | 38.1 |
6 | 106 | 100.0 | 13 | 23.1 | 15.4 |
Ask for NEC patients
At baseline, four of the six chiropractors asked all NEC patients whose charts were assessed whether they used tobacco; thus, these four chiropractors were not eligible for a systems change in Ask, although three of them developed a more comprehensive Ask component by adding questions to the intake forms. Of the remaining two chiropractors, at baseline, one chiropractor never asked about tobacco use, and one asked 35% of NEC patients. The chiropractor who never asked at baseline reached at least 50% at month 1 and remained at ≥50% throughout the study. The chiropractor who started at 35% for Ask surpassed 50% at month 3 and remained 100% thereafter. Therefore, successful systems change in Ask occurred in both applicable instances. It is noteworthy that all clinics asked patients at 100% of NECs by month 6. The number of NECs ranged from three to the maximum of 40 per clinic per month, with a mean of 19.7 (standard deviation [SD] = 11.7).
Advise for NEC patients
At baseline, no chiropractors advised NEC patients identified as tobacco users to quit tobacco use. The number of NEC patients who were tobacco users totaled 104 over the six-month intervention period and ranged from zero to eight per month for individual chiropractors, with a mean number of 2.89 (SD = 2.64) patients. Five of the six clinics succeeded in having some months of ≥50% of NEC patients who were tobacco users being advised, and three clinics achieved the formal definition (two consecutive months ≥50%) of systems change in Advise.
Refer for NEC patients
Referrals were included when documentation was present that indicated, either “indirectly” or “directly,” that an offer of a referral occurred. Indirectly meant documentation indicating that the patient was “not interested,” was already working with a primary care physician on quitting, was currently taking cessation medication, and so forth. Two clinics did not document referral of any NEC patients who were tobacco users; the chiropractor in one of these clinics indicated he only documented Refer if the patient was interested in quitting. Four clinics met the criterion of ≥50% of users referred for at least one month post-intervention; two clinics did so for one month, one clinic did so for two nonconsecutive months, and one clinic did so for three nonconsecutive months. None of the clinics achieved the formal definition of systems change in the Refer component.