Apr 052012

The Joint Commission (previously called "JCAHO") launched its new "Tobacco Cessation Performance Measure Set" on January 1, 2012. Like most New Years' resolutions, we all promptly ignored it. But it's time to pay attention -- your hospital might be.

Wasn't there already a smoking cessation performance measure? Yes, in 2004 hospitals were required to report the proportion of smokers who were counseled to quit after being admitted for specific conditions (myocardial infarction, pneumonia, congestive heart failure). Most institutions quickly learned how to check the box on discharge forms that smoking patients were counseled, achieving near 100% on this measure (most of you know this, since you were the ones checking the boxes). There was no evidence that anyone was quitting smoking, though, and the National Quality Forum decided this approach was useless and abandoned it as one of their recommended performance measures.

The new performance measure set mandates that hospitals make a serious attempt at treating hospitalized smokers for tobacco dependence:

  • Hospitals must identify and document smoking behaviors among all patients admitted;
  • Give evidence-based counseling on cessation AND cessation medications to any patient without a contraindication who does not opt out;
  • At discharge, make referrals for further cessation counseling and prescribe medications to support cessation, and
  • Document the patient's smoking status at 30 days after discharge.

In a NEJM editorial, Michael Fiore, Eric Goplerud, and Steven A. Schroeder argue that the JC's new performance measure is beefier and more rational. Hospitalizations are the perfect time and place to offer patients not just an offhand "you should quit smoking." The patient is captive and often tobacco abstinent, additional resources of time and staff are present, and a comprehensive approach to smoking cessation with one-on-one counseling and provision of nicotine replacement, Zyban and/or Chantix (varenicline).

What's the point? Does smoking cessation counseling even work? Actually, yes it does. And since only 30% of smokers visiting primary care clinics say they receive smoking cessation counseling, there's certainly room for improvement.

There's one possible stumbling block, though: adoption of these particular "mandates" is optional. The Joint Commission only requires hospitals report on 4 of 14 potential performance measures; hospitals can pick their own selections from the menu. With dismay, authors predict most hospitals will pass on implementing the tobacco-cessation performance measures, because they require more effort than the others (especially that bothersome and time-consuming bit about calling every smoker 30 days after discharge to see how they're doing).

Fiore MC, Goplerud E, Schroeder SA. The Joint Commission's New Tobacco-Cessation Measures — Will Hospitals Do the Right Thing? N Engl J Med 2012;366:1172-1174.

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Joint Commission launches new smoking cessation performance measures