COPD and pharmacotherapy for smoking cessation at the VA: Study

Kathryn WheelerSmoking cessation is the most effective intervention for patients with chronic obstructive pulmonary disease (COPD), yet many patients continue to smoke even after hospitalization for an exacerbation, and treatment rates for tobacco abuse after a hospital stay are often low.

Identifying the differences between patients who receive therapy for tobacco cessation and those who do not could help improve standards for the prescribing of post-discharge tobacco-cessation therapy.

See also: MTM essentials for COPD management, Part 1

The study

Researchers reviewed the electronic medical records in the Veterans Affairs Veterans Integrated Service Network (VISN-20) for a cohort of current smokers admitted to a hospital for a COPD exacerbation. 

Researchers identified 1,511 current smokers older than 39 years of age and hospitalized between 2005 and 2012 with a primary discharge diagnosis of COPD or an admission diagnosis indicative of a COPD exacerbation. Patients without a documented smoking status or who died during admission were excluded. 

Pharmacy records supplied information about which patients met the primary outcome, receipt within 48 hours of hospital discharge of medication approved to aid with smoking cessation.  

Each patient’s medical record was examined for possible predictors of tobacco-cessation therapy use during the index admission and for the previous year. Sensitivity analysis reviewed the use of bupropion during and after hospital admissions, and noted inclusion of COPD diagnosis as a primary discharge diagnosis. These analyses revealed no significant differences in observed effects. 

See also: MTM for COPD management, Part 2

The findings

Overall findings were similar to those of other studies: Use of tobacco-cessation therapy was low.

Only 17.5% of patients in this study received tobacco-cessation therapy as an inpatient. Of these patients, only 44.7% were dispensed such therapy after discharge from the hospital.

 A nicotine replacement patch was the most commonly prescribed outpatient therapy. 

Negative predictors

Investigators identified several factors associated with decreased odds of tobacco cessation. 

• Black patients were less likely to receive medications for tobacco cessation after discharge compared to white patients. 

• Patients with a history of psychosis, hypertension, stroke, heart failure, or coronary artery disease were less likely to receive tobacco-cessation medications after discharge. 

• Patients with a higher Charleston Score, a scoring system for comorbidities, were increasingly less likely to receive medications with each additional point scored.

• Use of steroids within the previous year served as a marker of COPD severity.  Patients who received steroids were also less likely to receive tobacco-cessation medications post-discharge.  

• Age is a significant factor as well. For every additional year of age, a patient was 4% less likely to be dispensed tobacco-cessation therapy after hospital discharge. 

Positive predictors

Researchers identified two positive predictors for receipt of tobacco-cessation therapy post-discharge. 

Patients who received treatment with a medication for tobacco cessation as an inpatient (OR 5.95, 95% CI 3.19-11.10) or who received discharge counseling about smoking cessation from nursing staff (OR 3.08, 95% CI 2.02-4.68) had improved odds of receiving tobacco-cessation therapy within 48 hours post-discharge.

Not sought and not found

Researchers did not address the reasons that smoking-cessation therapy so often went unprescribed. 

Other concerns not addressed in the study include:

• Lack of information about a patient’s use of nicotine-replacement therapies or prescription medications for tobacco cessation obtained outside the VA system

• Self-reporting of smoking status

• Lack of patient diversity (most of the patients in the study were white men)

Robust documentation

Despite these limitations, the robust documentation system employed by the VA healthcare system allows for thorough review of patient records across a variety of hospital settings for all identified smokers admitted to hospital for a COPD exacerbation. 

There is a need for further study into improvement of the delivery of smoking-cessation therapies to patients after discharge. However, the positive predictors of patient use of these therapies are rooted in interventions based in healthcare systems (e.g., discharge counseling and initiation of therapies as an inpatient where smoking is prohibited).

Implementation of systemic approaches ensuring that all smokers receive these opportunities may eliminate disparities in treatment and bolster weak treatment rates.

Source: Predictors of pharmacotherapy for tobacco use among veterans admitted for COPD: The role of disparities and tobacco control processes. Melzer AC, Feemster LC, Collins MP, et al. J Gen Intern Med. 2016 Feb 22. [Epub ahead of print]

Kathryn Wheeler is associate clinical professor, Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Conn.