Abstract
There are limited or no effective interventions for recurrence of coronary heart diseases among the patients who smoke. Smoking cessation interventions has been suggested to have little benefit; however, there is little evidence on its cost- effectiveness and efficacy of such programs for cardiac inpatients. This study describes the efficacy and cost- effectiveness of intensive smoking cessation methods for cardiac patients admitted in the hospital cardiac unit. The experimental design assesses the efficacy and cost- effectiveness of the intervention that includes face- to- face counselling in combination with the nicotine replacement therapy using 8 cardiac wards of hospitals in the local region. The baseline and follow-up data for 6 and 12 months are recorded. The patients upon admission to the cardiac unit are assessed for their smoking habits. Control group are not subjected to counselling while the test groups are subjected to face- to- face and telephonic counselling. Most affected patients enrolled in this study were male with a mean age of 57 years. The telephonic counselling was found to be more effective over the one- on- one counselling sessions. The study outcomes demonstrated that telephonic counselling is more effective among highly motivated patients while the one- on- one counselling is more effective among the less- motivated or low SES patient groups.
Problem Statement:
Smoking is a major contributor to wide ranges of diseases such as cardiovascular diseases, cancers and lung diseases. It is also associated with increased incidence of hospitalization among patients for surgical procedures. Nursing professionals currently provides care to approximately 390,000 Americans who suffer from smoking related disorders. Smoking is known to increase the risk of comorbidities post- surgery and can also cross- react with certain drugs. Sudden smoking cessation has been associated with increased risks of anxiety and discomfort among patients. Patients addicted to chronic smoking are reluctant to approach health care support with a fear of smoking cessation. Therefore, nurses are in ideal state to encourage patients to quit smoking during their hospitalization. However, there are a number of factors that acts a barrier to the smoking cessation programs. Counselling programs, in the past, has been suggested to be partially effective in smoking cessation such that nurse- mediated post- discharge counseling sessions over the phone is an effective tool to improve the cessation rates of smoking post- discharge. Therefore, it becomes important assess how one- on- one counselling can effectively encourage smoking cessation among the cardiac patients who are at higher risk of experiencing recurrence or related complications and identify the barriers to the process (Jones, 2010).
Background
Smoking has been palpably associated with the exacerbation and progression of coronary and consequently cardiac conditions. It is a growing health concern all over the globe as it increases the hospitalization rates especially concerning respiratory illness, vascular disease and cancers. Increased hospitalization due to smoking- related illness can effectively boost the receptivity to the cessation of smoking messages by enhancing the perceived vulnerability or the “teachable moment”. Such diseases force the patients to contact healthcare professionals where they can be convinced by the nursing professionals to quit smoking by making them participate in the smoking cessation programs. Smoking cessation post- first coronary episode like a myocardial infarction can significantly reduce the mortality risk, reoccurrence and hospitalisation rates. Additionally, procedures like coronary arteriography provide information of the cardiac status of the patient, which can further aid in minimizing the consequent denial of risks of cardiac issues by patients. Smoking cessation is therefore relevant to patients who have coronary heart disease. Nonetheless, approximately 50% of the patients who used to smoke prior to hospitalisation for heart disease tend to smoke even after discharge. Such patients who prolong smoking even after hospitalisation are embodied as chronic smokers with little or no intention to quit. Evidence based research has proved that imparting succinct cessation support is not helpful enough to encourage smoking cessation among cardiac patients. Therefore, more intensive smoking cessation strategies are needed for cardiac patients (Battersby, 2010).
Interventions that have been proven to promote smoking cessation rates among hospitalized cardiac smokers are promising. In comparison to the prevention benefits and reduced mortality and morbidity, the healthcare expenditure of such programs is low (Murthy, 2010). A number of hospitals restrict smoking to prevent the staff and the patients from second hand exposure to smoke by providing them a smoke- free environment. This also gives the patients an opportunity to strive abstinence of tobacco from the standard ecological nods to smoke. Therefore, hospital based tobacco dependence treatments might be an effective way to prevent patients from smoking. The coronary arterial lumen plaguing as a result of smoking results in the arterial lumen narrowing, which thereby leads to the coronary artery blockage and consequently, results in diminished cardiac output and the cardiac condition progression (Jones, 2010). In this regard, smoking cessation is pretty essential in arresting the exacerbation or progression of coronary disease after a post coronary intervention (Hanna, 2013).
Research demonstrates that behavioral counselling in combination with pharmacological treatment is an effective mean to increase smoking cessation rates. Experts recommend that smoking cessation programs should be initiated from the time of admission and should be followed- up post- discharge. Such interventions include cardiologist advices, and counselling and motivational sessions. The nicotine- replacement therapy (NRT) has been also proved to increase the smoking cessation rates and has been also proven to suppress the withdrawal symptoms among patients. Both face- to- face counseling and telephonic counselling has been predicted to be an effective method. Therefore, the significance of this study is that it assesses the effectiveness of the counselling interventions by comparing the smoking cessation and health outcomes along with its cost- effectiveness. This study aims to study the differential effects of the proposed interventions in smoking abstinence.
System Context
In order to assess the efficacy of the one- on- one counselling interventions on patients with cardiac problems, who are smokers and were admitted to the cardiac ward of the Bay area hospital. This organization is a 350- bedded hospital consisting of specific intensive care units for related disease i.e., cardiac care unit, orthopaedic care unit, respiratory care unit, etc. The cardiac care unit had the capacity of 50 patients. The organizational leaders are aware of the fact that smoking can worsen the patients health conditions especially in case of patients who have experienced a recent cardiac episode ore has undergone a surgery. Therefore, the organization offers smoking cessation interventions to the cardiac patients who are hospitalized. In order to successfully conduct or implement the proposed intervention in the organization, the organizational leaders were first educated about the intervention and permissions were seeked to commence the intervention (Zhu, 2012).
Once the permission were obtained, the stakeholders were then identified and seeked for consent for their participation. These stakeholders included registered nurses or APRNs, staff nurses, cardiologists, hospital management delegates and the patients who were regular smokers and were admitted to the hospital for cardiac issues. In order to ensure continuous support from the key stakeholders, feedback loop will be set. The cardiologists and the nursing staffs along with the APRNs were first approached prior to the commencement of the study. Each of these stakeholders was educated about the need of such programs in hospitals. The management provided the relevant resources to the cardiologists and the nursing staff and aided in kick starting the project. The nursing staff and physicians were well- training for conducting the face- to- face counselling and telephonic counselling sessions with the patients. The nurses were responsible for following- up the discharged patients post- 6 months and 12- months. The patient outcomes and project success rate were measured by tracking the patient’s self- control over smoking and the number of cigarettes smoked per day and by collecting feedbacks from the stakeholders. The feedbacks were obtained and assessed by the hospital management. This helped in identifying the changes (if needed) post- implementation. These efforts further helped in sustaining the stakeholder’s interests and their participation in the program.
Clinical, Satisfaction and Cost Outcomes Definition and Methods
The clinical outcomes comprise of the process and the outcome measures. The financer (organization) seeks for information on the clinical success of the intervention in order to formulate contract decisions and track the provider’s payment. The healthcare professionals (cardiologist and nursing staff) seek for information related to the performance and success in order to facilitate high- quality and cost- effective development and improvement in the proposed intervention. The hospital management looks for the outcomes from both the organization and the healthcare professionals in order to develop and hen implement policies on smoking cessation. The outcomes of the intervention is important as it provides information on the success rate of smoking cessation among cardiac patients and risks of re- hospitalization due to smoking related complications. In such interventions, two satisfaction outcomes are mandatorily important to assess or measured. This comprises of patient satisfaction and staff/ cardiologists satisfaction. The patient satisfaction is considered as an imperative variable that demonstrates the likelihood of the success of the proposed intervention for smoking cessation. Increased patient satisfaction with the intervention further aids the patients to adhere to the goals set by them during the intervention and sticks to the treatment regimen. On the other hand, the caregiver satisfaction is an imperative variable as it encourages the patients to quit smoking and increases their confidence and morale. This is therefore considered to have a direct influence on the patient management and thus the measurements of their satisfaction levels are also important. The cost outcomes will be measured by estimating the saved hospital charges when treating smoking- related issues in cardiac patients. The cost- outcomes will also include the cost per visit of the patient. The decrease in the cost- outcomes of per patient will ensure the clinical efficacy of the smoking cessation intervention and the satisfaction levels of both the healthcare professionals and the patients. This is because the high expenditure that can result as a result of smoking can be avoided due to the success of the program (McKenzie, 2016).
The clinical satisfaction and cost outcomes of this intervention were assessed by using pre- validated questionnaires. The point- prevalence abstinence (PPA) from smoking post 6 months (T1) and 12- month period (T2) was considered as the most valid and sensitive measure of the intervention success rate. At T1 and T2, the measured health outcomes are described as the new coronary issues and risk of re- hospitalization for coronary issues. The verification of smoking was done among the cardiac patients post- discharge by assessing their cholesterol levels, blood pressure and saliva sample, which are reliable for verifying the smoking status. To assess the cost- outcomes, the information related to economic outcomes were assessed at T1 and T2, during patients visit to the cardiologist, outpatient visit, rehospitalisation, health- related costs, QoL and informal care costs. Patient or clinical satisfaction was measured from the feedback from the patients and their personal beliefs on smoking cessation. Smoking cessation related after effects were also assessed and accordingly dealt with to enable patients to stick to their goals (Berndt, 2012).
Implications of Outcomes for Quality Management
The outcomes of the proposed intervention can effectively encourage the patients admitted in the hospital for cardiac issues to quit smoking if in case they are regular smokers. The intervention comprises of one- on- one counselling and telephonic counselling during the hospital stay and post- discharge of patients from the hospital. This intervention has earlier been suggested to be effective, however, a very less number of hospitals have been observed to implement this intervention in their organization when treating cardiac patients. The outcomes of this study has huge implications of the quality management as the quality improvement initiatives majorly focuses on doing the right thing at the right time at the first go for the vulnerable population. The study intervention majorly focuses on convincing and encouraging the patients to quit smoking and thus in order to bring out maximum benefit out of this intervention the physicians and the nurses put tremendous effort by conducting counselling sessions. The quality of care process is further managed by conducting telephonic counselling post- discharge to help patients to adhere to their goal and prevent the risks of acquiring smoking- related cardiac complications and incidence of re-hospitalization (Billings, 2012).
The outcomes of this study can be beneficial for the local, regional and national QM initiatives because it provides the healthcare agencies to figure out a way to minimize the incidence of re-hospitalization due to smoking- related complications ain cardiac patients and also aids in reducing the healthcare costs. The outcomes of this study is further beneficial because it helps the policy- makers to design and develop effective policies for encouraging smoking cessation in hospitals and minimize the patient turnover due to cardiac issues due to smoking. Implementation of smoking cessation intervention is not only effective in reducing cardiac issues in patients abut also is cost- effective and thus can reduce the economic burden of the patients, local, regional and national healthcare organizations (Drummond, 2015). The outcomes of the study also helps the health partner commissions to monitor the success rate of preventing cardiac events by using such interventions and further aids them in auditing the existing policies and guidelines to ensure quality management in every organization. This further increases both patient and healthcare professionals’ satisfaction levels.
Ethical Balance
A number of ethical challenges arise when designing a smoking cessation intervention especially for patients who have already undergone a cardiac surgery or event. These challenges need to be accurately dealt with. In order to ensure positive outcomes from the program and achieve good amount of money, the services are aptly monitored and procured such that all ethical conditions are met. Challenging ethical issues arises especially when there is a shortage of funds. This hugely affects the resources such as treatment and services that needs to be provided to the patients. Such issues further intensify when the life- expectancy of patients increases and so does their healthcare expectations. When designing this healthcare intervention, one of the most difficult choices made by the organization was to take decision whether or not to fund this program. However, the organization realized that such interventions are important as it reduces the re- hospitalization rates and reduces smoking associated complications in cardiac patients.
The ethical dilemmas also raised because imparting education for smoking cessation was given the least importance in most of the organizations i.e., irrespective of the known fact that smoking cessation can minimize the complications, yet most hospitals were found not to take an initiative to encourage patients to quit smoking. Furthermore, another challenges arises with the fact that smoking is a persons’ personal choice, thus whether interfering in patient’s (who are adults) decision ethical, as every individual has the right to chose their own lifestyle. Such issues are very difficult to be addressed and in most cases, the commissioners tend to ignore them. However, in this study, these issues were addressed and irrespective of patient’s autonomy the nurses and the cardiologists tried to put maximum effort to convince the patients to quit smoking. Furthermore, to support the planned intervention, the positive public health goals were set in order to validate the study. In this case, the positive health goal was to promote smoking cessation and reducing cardiac risks in the vulnerable population. Additionally, since the program needs participation of all stakeholders, informed consents were obtained from each of the stakeholders in order to prevent future ethical issues and each of the stakeholders were thus introduced to the program prior to obtaining the informed consent (Go, 2010).
Sustainability Plan for Translating Evidence into Practice
The translation of research evidence into policy, practice and public health enhancement is referred as a widespread adoption and dissemination of interventions, which can result in significant health benefits. Most interventions are designed with a goal to improve the health of a target population; however the accessibility and delivery of such interventions hugely depends on the health care delivery systems (HCDS), communities, government agencies and healthcare professionals. However, translation of planned and effective intervention into practice has been reported to be inconsistent and slow. This is because a number of barriers pose challenges to the implementation of the programs in the healthcare setup. One of the major barriers to the translation of evidence into practice and its sustainability in the system is the lack of faith in the programs, which hugely influences the outcome expectancies. This further prevents the implementation of the interventions or guidelines or policies in a healthcare setup. In case of adoption of smoking cessation programs in the system, lack of confidence of the nurses and the physicians hugely influences the implementation and sustainability of the program. In many cases, the healthcare professionals are reluctant to put extra effort especially when they have little expectation for the improvement. Furthermore, lack of motivation also affects the implementation (Greenberg, 2008). These are some of the most influencing factors/ barriers to the successful implementation and sustainability of a health intervention (Heckman, 2010).
However, this health intervention/ program for smoking cessation is designed such that most of the vital barriers can be easily overcome and the translation of the intervention into practice and its sustainability can be achieved. The program includes educating the physicians, healthcare providers and the patients. In the past, research has indicated that successful education can effectively encourage the stakeholders in accepting a change in the program. Therefore, imparting education to each of the stakeholders and introducing them to the benefits of the program will help in motivating them. Due to motivation, the physicians and healthcare providers will themselves volunteer for the cause without hesitation. Additionally, patient education can further help in convincing patients to adhere to their treatment goals and quit smoking. Furthermore, one- on- one counseling services help one to not only get motivated but also helps one to lead a healthy lifestyle. The telephonic counselling has been found to further encourage the patients to stick to their treatment regimen even post- discharge. Thus the program design will help the healthcare professionals to easily implement in their daily practice. The translation of this successful project into practice will bring sustainable change by ensuring reduction in recurrence of cardiac events, re-hospitalization rates and smoking- related complications.
References
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