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Study flow diagram for update 2014
Figures and Tables -
Figure 1

Study flow diagram for update 2014

Study

Smoking cessation

Guideline recommended actions

Randomized controlled trials

Bentz 2007

Guideline actions increased within the intervention clinics for smoking status (94.5% vs 88.1% p<0.05), advised to quit (71.6% vs 52.7%, p<0.001), assessed interest in quitting 65.5% vs 40.1% p<0.001), and provided assistance (20.1% vs 10.5%, p < 0.001).

Quitline referral increased in the intervention clinics (adjusted OR 1.53)

Linder 2009

Significantly more smokers in the intervention clinics were subsequently documented as nonsmokers compared to smokers in the control clinics (5.3% vs 1.9%, p < 0.001)

Significantly more smokers were referred to cessation counselling in the intervention clinics (4.5% vs 0.4% in control clinics, p<0.001), and significantly more smokers from intervention clinics made contact with a cessation counsellor (3.9% vs 0.3% in control clinics, p<0.001). No difference in the proportion of documented smokers from control or intervention clinics prescribed any cessation medication (2.0% vs 2.0%).

Rindal 2013

Significantly more smoking patients from intervention clinics versus control clinic patients reported dental provider actions: discussed interest in quitting (87% vs 70%); discussed quitting (47% vs 26%); and referral to quitline (37% vs 17%).

Sherman 2008

The average number of smokers per month referred to telephone counselling increased from 1.0 to 15.6 (p< 0.001) among intervention clinic providers, and from 0.2 to 0.7 (p<0.04) among control clinic providers.

Vidrine 2013

Patients from intervention clinics were more likely to enroll in quitline treatment compared to control clinics (15% vs 0.5%).

Vidrine 2013a

Patients from intervention clinics were more likely to enroll in quitline treatment compared to control clinics (8% vs 0.6%).

Controlled trials

Bentz 2002

Documentation of tobacco use was unchanged in the paper chart clinic, but increased from 79% to 88% in the enhanced EHR clinic.

Frank 2004

Assessment of smoking status was unchanged between intervention and control patient visits (2.0% vs 1.8%, RR 1.12 , 95% CI 0.90 to 1.39).

Szpunar 2006

Asking about tobacco use increased in the intervention clinics from 88.4% to 92.8%.

Uncontrolled trials

Adsit 2014

The proportion of patients referred to the quitline increased from <1% to 14%. 5% enrolled in quitline treatment.

Koplan 2008

The proportion of smoking patients referred to cessation counselling increased from 0.8% to 2.1% (p < 0.001); medication ordered increased from 1.6% to 2.5% (p < 0.001).

Lindholm 2010

Tobacco use status in the EHR increased from 71.6% to 78.4% (p < 0.001).

Mathias 2012

The percentage of documented smokers with a change in smoking status from active to quit during the pre‐ or postintervention period increased from 17.1% in the preintervention cohort to 20.5% in the postintervention cohort (p = .06)

In the post enhancement period, cessation medication prescribing did not change (14.4% vs. 13.4%, p = .5), but quitline referral increased from 2% to 7% (p < 0.001).

McCullough 2009

Tobacco use status increased from 71% to 84% (p < 0.001). Assessement of plan to quit increased from 25.% to 51% (p < 0.005), and smokers assessed for a plan to quit were more likely to receive cessation counselling (46% vs 14% among smokers not assessed, p < 0.001).

Ragucci 2009

Of 90 smokers in the study, 29 were quit at 6 months (32%)

Spencer 1999

Recording of tobacco use status increased from 18.4% to 80.3%.

Figures and Tables -
Analysis 1.1

Comparison 1 Study results, Outcome 1 All outcomes.

Use of electronic health records to support smoking cessation

Patient or population: People who smoke

Settings: Healthcare clinics

Intervention: Any use of an Electronic Health Record (EHR) to improve smoking status documentation or cessation assistance for patients who use tobacco, either by direct action or by feedback of clinical performance measures.

Comparison: No EHR, or EHR without support for smoking cessation intervention

Outcomes

Effect

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Smoking cessation

More intervention clinic than control clinic smokers quit (5.3% vs 1.9%, p < 0.001)

1 cluster RCT, 26 clinics

⊕⊝⊝⊝

very low1

Indirect measurement based on EHR documentation of smoking status

Guideline recommended actions

Studies typically showed positive effects on outcomes including documenting smoking status, giving advice to quit, assessing interest in quitting, and providing assistance including referral.

6 cluster RCTs, 98 clinics

⊕⊕⊕⊝

Moderate2

Studies did not all assess the same outcomes. Non randomized and uncontrolled studies also showed positive effects

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Only one study reported the outcome, and did not use direct patient report of cessation

2 Heterogeneity in the interventions and targeted behaviours

Figures and Tables -
Comparison 1. Study results

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 All outcomes Show forest plot

Other data

No numeric data

1.1 Randomized controlled trials

Other data

No numeric data

1.2 Controlled trials

Other data

No numeric data

1.3 Uncontrolled trials

Other data

No numeric data

Figures and Tables -
Comparison 1. Study results