Proactive Electronic Visits for Smoking Cessation and Chronic Obstructive Pulmonary Disease Screening in Primary Care: Randomized Controlled Trial of Feasibility, Acceptability, and Efficacy

Abstract

Background: Most smokers with chronic obstructive pulmonary disease (COPD) have not yet been diagnosed, a statistic that has remained unchanged for over two decades. A dual-focused telehealth intervention that promotes smoking cessation, while also facilitating COPD screening, could help address national priorities to improve the diagnosis, prevention, treatment, and management of COPD. The purpose of this study was to preliminarily evaluate an integrated asynchronous smoking cessation and COPD screening e-visit (electronic visit) that could be delivered proactively to adult smokers at risk for COPD, who are treated within primary care.

Objective: The aims of this study were (1) to examine e-visit feasibility and acceptability, particularly as compared to in-lab diagnostic pulmonary function testing (PFT), and (2) to examine the efficacy of smoking cessation e-visits relative to treatment as usual (TAU), all within primary care.

Methods: In a randomized clinical trial, 125 primary care patients who smoke were randomized 2:1 to receive either proactive e-visits or TAU. Participants randomized to the e-visit condition were screened for COPD symptoms via the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE). Those with scores ≥2 were invited to complete both home spirometry and in-lab PFTs, in addition to two smoking cessation e-visits. Smoking cessation e-visits assessed smoking history and motivation to quit and included completion of an algorithm to determine the best Food and Drug Administration-approved cessation medication to prescribe. Primary outcomes included measures related to (1) e-visit acceptability, feasibility, and treatment metrics; (2) smoking cessation outcomes (cessation medication use, 24-hour quit attempts, smoking reduction ≥50%, self-reported abstinence, and biochemically confirmed abstinence); and (3) COPD screening outcomes.

Results: Of 85 participants assigned to the e-visits, 64 (75.3%) were invited to complete home spirometry and in-lab PFTs based on CAPTURE. Among those eligible for spirometry, 76.6% (49/64) completed home spirometry, and 35.9% (23/64) completed in-lab PFTs. At 1 month, all cessation outcomes favored the e-visit, with a significant effect for cessation medication use (odds ratio [OR]=3.22). At 3 months, all cessation outcomes except for 24-hour quit attempts favored the e-visit, with significant effects for cessation medication use (OR=3.96) and smoking reduction (OR=3.09).

Conclusions: A proactive, asynchronous e-visit for smoking cessation and COPD screening may offer a feasible, efficacious approach for broad interventions within primary care.

Trial registration: ClinicalTrials.gov NCT04155073; https://ichgcp.net/clinical-trials-registry/NCT04155073.

Keywords: COPD; EHR; acceptability; chronic obstructive pulmonary disease; diagnosis; e-visit; efficacy; electronic health record; electronic visits; feasibility; function; intervention; management; patient portal; prevention; pulmonary; screening; smoking cessation; telehealth; treatment.

Conflict of interest statement

Conflicts of Interest: JD is co-owner of Behavioral Activation Tech LLC, a small business that develops and evaluates mobile app–based treatments for depression and co-occurring disorders. MJC has received consulting honoraria from Pfizer and from Frutarom Inc. CS has grants related to chronic obstructive pulmonary disease (COPD) paid to the Medical University of South Carolina from AstraZeneca, CSA Medical, National Institutes of Health, Nuvaira, and Takeda within the past 3 years. He has consulted for Bronchus, GlaxoSmithKline, and Pulmanage, for COPD. The funding sources had no role in study design, data collection, data analysis, data interpretation, writing this report, or in the decision to submit this paper for publication.

©Jennifer Dahne, Marty S Player, Charlie Strange, Matthew J Carpenter, Dee W Ford, Kathryn King, Sarah Miller, Ryan Kruis, Elizabeth Hawes, Johanna E Hidalgo, Vanessa A Diaz. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 30.08.2022.

Figures

Figure 1

CONSORT flow diagram. CAPTURE: COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk; CO: carbon monoxide; COPD: chronic obstructive pulmonary disease; PFT: peak expiratory flow; TAU: treatment as usual.

Figure 2

e-Visit feedback.

Figure 3

Home vs. In-Lab FEV1 and Peak Flow Among Participants Who Completed Both.

Figure 4

Smoking cessation outcomes. CO: carbon monoxide; OR: odds ratio; TAU: treatment as usual.