RESEARCH PAPER
 
KEYWORDS
TOPICS
ABSTRACT
Introduction:
While initiation rates of tobacco cessation pharmacotherapy have improved both inside and outside the Department of Veteran Affairs (VA), prescribing rates remain low. The objective of this study was to examine correlation of the characteristics of providers, clinics, and facilities with initiation of tobacco cessation pharmacotherapy.

Methods:
This retrospective, observational study used VA outpatient electronic medical record data from federal fiscal year 2011. Logistic regression models estimated the adjusted odds ratio associated with provider characteristics for pharmacotherapy initiation.

Results:
For the 639507 veterans who used tobacco, there were 30388 providers caring for them. Younger (p<0.001) and female (p<0.001) providers were more likely to initiate tobacco cessation pharmacotherapy. Compared to physicians, pharmacists were 74% more likely to initiate pharmacotherapy, while all groups of nurses were 5–8% and physicians’ assistants were 12% less likely (p<0.001). Compared to those seen in primary care clinics, patients assessed in substance use treatment clinics were 16% more likely to have pharmacotherapy initiated (p<0.001), while those in psychiatry were 10% less likely (p<0.001), and those in outpatient surgery were 39% less likely to initiate pharmacotherapy (p<0.001). Compared to almost all other classes of VA facilities, patients seen in primary care community-based outpatient clinics (CBOCs) were 7–28% more likely to initiate pharmacotherapy (p<0.0001).

Conclusions:
While the VA is at the leading edge of providing tobacco cessation pharmacotherapy, targeting quality improvement efforts towards providers, clinics, and facilities with low prescribing rates will be essential to continue the declining rates of tobacco use among VA patients.

ACKNOWLEDGEMENTS
The project was supported by Merit Review Award (Number I01 HX001764) from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. We gratefully acknowledge the contribution of Adam Chow of the VA Health Economics Resource Center, Menlo Park, CA for his help in identifying tobacco use status.
CONFLICTS OF INTEREST
The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. P.G. Barnett reports that his institution received payment from Merit Review Award I01 HX001764 from the U.S. Department of Veterans Affairs Health Services Research & Development Service.
FUNDING
This work was supported by the Health Services Research and Development Service of the U.S. Department of Veterans Affairs (Proposal number IIR 14-301) awarded to SD. This funding was in the form of an unrestricted allocation. The sponsor did not directly shape the design or conduct of the study, the collection, management, analysis, and interpretation of the data, or the preparation, review, or approval of the manuscript.
ETHICAL APPROVAL AND INFORMED CONSENT
Ethical approval and informed consent were not required as all data used were from existing databases.
DATA AVAILABILITY
The data supporting this research cannot be made available for privacy reasons.
AUTHORS' CONTRIBUTIONS
ACB, SAD, MCG, RVI, HMK and PGB made substantial contributions to the conception, interpretation of analysis and findings, and critical revision for intellectual content. RVI made substantial contributions to analysis and interpretation of data. All authors read and approved the final manuscript.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
 
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