The Effect of an Inpatient Smoking Cessation Treatment Program on Hospital Readmissions and Length of Stay

Successful smoking cessation interventions result in substantial gains in health and life expectancy by reducing smoking-related illnesses and preventing premature deaths.^1,2 The Department of Health and Human Services recommends clinicians use hospitalization as “an opportunity to promote smoking cessation’’ and ‘‘to prescribe medications to alleviate withdrawal symptoms”³ because individual readiness to quit may be high during hospitalizations. A meta-analysis of 50 studies (21 from the United States) examining the efficacy of hospital-initiated smoking cessation interventions concluded that smoking cessation support programs that began in the hospital and continued for at least 1 month postdischarge significantly increase the likelihood of patients being smoke-free in the long term.⁴ The most efficacious strategies included counseling and pharmacotherapy rather than counseling alone.³ Most inpatient smoking cessation studies have focused on quit-rates or medical outcomes, while fewer studies have looked at healthcare utilization.

However, previous research has shown that smoking cessation for inpatients has relatively immediate economic and health benefits. Patients who quit smoking during hospitalizations for cardiovascular disease are less likely to be readmitted or to die during follow-up.^5,6 Patients with acute myocardial infarction (AMI), unstable angina, heart failure, and chronic obstructive pulmonary disease who received an inpatient smoking cessation intervention had reductions in inpatient readmission rates.⁷ A 1% reduction in overall smoking rates would lead to an annual reduction of 3,022 hospitalizations for stroke and 1,684 hospitalizations for AMI.⁸ One comprehensive program, the Ottawa Model for Smoking Cessation (OMSC), found that a hospital-initiated intervention increased long-term cessation rates by 15% in cardiac patients and by 11% in general hospital populations.^9,10 The applicability of this result to US healthcare systems is unknown. This paper adds to the existing literature by evaluating the impact of an inpatient smoking cessation program on healthcare utilization among patients hospitalized for any reason, rather than solely focused on those with cardiopulmonary diagnoses.

The current study focuses on an inpatient smoking cessation program at a teaching hospital in the Rocky Mountain region. The hospital implemented a smoking cessation treatment program on July 1, 2013, based on the OMSC. The goal was to identify and support inpatient adult smokers who wanted to make a quit attempt and help them remain smoke-free after discharge. The objective of the current study was to determine the effect of the program on 30-day readmission rates and length of stay (LOS) of the index hospitalization. Although the general cost effectiveness of properly structured smoking cessation programs are well established,^11-13 the healthcare utilization effects of inpatient smoking cessation programs are not well understood.

Data

The study population consists of patients over age 18 who were admitted to the hospital between July 1, 2012, and July 1, 2014. Baseline smoking status was assessed at hospital admission and recorded in Epic (Epic Systems Corporation, Verona, Wisconsin), the electronic medical records system, as a current smoker (every day and some days), former smoker, never smoker, and never assessed. To check the accuracy of recorded smoking status, a random sample of 819 inpatients was selected and contacted via telephone for verification; 93% of Epic-identified smokers confirmed that they were smokers at hospital admission.¹⁴

Intervention

The intervention, which launched July 13, 2014, modified the Epic system to automatically alert providers viewing a tobacco user’s medical record that the patient should receive standardized orders for a bedside consultation with a Tobacco Treatment Specialist (TTS) and a prescription for nicotine replacement therapy (NRT) while in the hospital.¹⁵ Previously, referrals for tobacco treatment were done on an ad-hoc basis by the physician, and NRT was not routinely available. This system-level intervention standardized and automated the referral process. For patients with a bedside consultation order, TTS used a patient-centered approach (motivational interviewing) to explore patients’ motivation to quit smoking and offered NRT to improve comfort and safety while in the hospital. Patients who chose to make a quit attempt received a free 2-week supply of NRT at discharge and 6 months of free follow-up counseling by interactive voice response (IVR) telephone technology that included (a) prerecorded advice keyed to individual patient needs, (b) a warm-transfer option to speak with a live TTS (later dropped), and (c) a collection of patient smoking and cessation treatment measures.¹⁵