Implementation of New Clinical Work-flow to Improve Enrollment Rates in Tobacco Cessation for Oncology Patients

Background: Cigarette smoking is the leading cause of preventable death in the United States (Center for Disease Control, 2020). Persistent smoking for cancer patients can cause adverse effects on their survival rates, treatment-related effects on the tumor (e.g., accelerated growth, progression, metastases, and recurrence), or on the response to treatment (i.e tumor resistance or treatment-related toxicities) (U.S. Department of Health and Human Services (USDHHS), 2014). The American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer network (NCCN) guidelines recommend tobacco treatment services be offered to all oncology patients, which include pharmacotherapy and counseling (ASCO, 2021 and NCCN, 2020). The Huntsman Cancer Institute (HCI) Tobacco Cessation Program offers standard of care tobacco treatment services, following the recommended ASCO and NCCN guidelines. Methods: A quality improvement project was implemented to increase the number of patients who are referred to the HCI Tobacco Cessation Program (HTCP). Medical assistants in a Huntsman Cancer Hospital clinic primarily serving patients with lung, cardio-thoracic, head and neck cancers were surveyed to identify their current experiences referring patients to the HTCP. An educational presentation and a patient centered tri-fold brochure were presented and a new clinical work-flow including the patient centered tri-fold brochure was implemented with feedback from the medical assistants and clinical manager. The presentation included current data on risk factors of tobacco users with a current cancer diagnosis and a review of the referral process to the HTCP including the Best Practice Act (BPA). The patient centered trifold brochure provided useful information about the HTCP. Pre-implementation and post- implementation surveys were handed to medical assistants to determine the effectiveness of the education, the usefulness of the tri-fold brochure, and feedback on the new process. In addition, the number of patients who were referred by the medical assistants to the HTCP were compared pre- and post-implementation of the new work-flow process intervention. Results: Findings confirmed that medical assistants are assessing tobacco usage 96% of the time, that they find the BPA beneficial, and 88% use the BPA at least once a month. Post-intervention found that 71% of the medical assistants who attended the training found it beneficial (n=5) and 71% of the medical assistants reported using the tri-fold brochure in their new clinical work-flow (n=5). In addition, the total average number of patients per month who were referred to the HCI Tobacco Cessation Program increased by 23% post-implementation (n=11 pre-implementation) (n=14 post-implementation). Conclusions: The educational presentation, tri-fold brochure and new clinical work-flow processes were found to be useful and valuable resources to increase awareness about the HCI Tobacco Cessation Program. This had a positive effect on the number of patients who were referred from the BPA and the total number of patients who were referred to the HCI Tobacco Cessation Program. Replication of this quality improvement project is needed to determine if similar rates are observed for other clinics and their medical assistants in an oncology setting and beyond.