Training for perioperative smoking cessation interventions: a national survey of anesthesiology program directors and residents

Journal of Clinical Anesthesia (2014) 26, 563–569

Original Contribution

Training for perioperative smoking cessation interventions: a national survey of anesthesiology program directors and residents☆,☆☆,★ Caleb R. Schultz MD, MPH (Resident)a,⁎, Jeffrey J. Benson MD (Resident)a , David A. Cook MD, MHPE (Professor of Medical Education and Medicine)b , David O. Warner MD, PhD (Professor of Anesthesiology)b a

Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA

b

Received 28 December 2012; revised 1 April 2014; accepted 7 April 2014

Keywords: Anesthesiology residency; Perioperative tobacco control; Residency education; Smoking cessation programs

Abstract Study Objective: To ascertain current knowledge, attitudes, and practices of anesthesiology residents regarding tobacco control, and to determine the characteristics of current residency training offered in tobacco control. Design: Electronically distributed survey instrument of anesthesiology residency program directors and residents. Setting: University medical center. Measurements and Main Results: The program director and resident response rates were 75/131 (57.3%) and 490/1182 (41.4%), respectively. Programs currently provide education regarding the perioperative consequences of smoking and, with the exception of the effect of smoking cessation shortly before surgery, resident knowledge reflected this curricular emphasis. However, the strong majority of programs did not offer education on how to ask about smoking status and advise cessation (79.5%) or help tobacco users quit before surgery (89.0%), though both program directors and residents felt these topics should be covered. A strong majority of residents (87.8%) felt the perioperative period was an effective time to assist in long-term smoking cessation, and desired education on tobacco control. Barriers to helping patients quit preoperatively included lack of time and low confidence in counseling abilities. Conclusions: A need exists for expanded formal education on perioperative tobacco cessation interventions for anesthesiology residents. Published by Elsevier Inc.

☆

Reprints will not be made available from the author. Supported by departmental funding only. ★ IRB: Mayo Clinic Office of Human Subject Protection, Institutional Review Board. Tel: 507-266-4000; IRBservice [email protected]; study deemed exempt. ⁎ Correspondence: Caleb Schultz, MD, MPH, Assistant Professor of Anesthesiology, University of Minnesota, Department of Anesthesiology, B515 Mayo Memorial Bldg., 420 Delaware St., S.E. MMC294, Minneapolis, MN 55455, USA. Tel.: + 1 612 624 9990. E-mail address: [email protected] (C.R. Schultz). ☆☆

http://dx.doi.org/10.1016/j.jclinane.2014.04.008 0952-8180/Published by Elsevier Inc.

564

1. Introduction Tobacco smoking remains a major public health threat in the United States, rivaled only by obesity-related disease. According to the Centers for Disease Control and Prevention (CDC) in 2010, 19.3% of U.S. adults (45.3 million people) smoked cigarettes [1]. The cost of tobacco use in the U.S. is estimated at $96 billion in direct medical costs and $97 billion in lost productivity annually [2]. Smoking prevalence has declined as a result of tobacco control policies, but progress has slowed in the last decade. The widespread offering of effective tobacco control interventions to cigarette smokers accelerates the decline in smoking prevalence, helping to reach the Healthy People 2020 objective to reduce smoking prevalence to ≤12% by 2020 [3]. Surgery represents an excellent opportunity to implement tobacco interventions. Smoking increases the risk for several perioperative complications, and cessation significantly decreases risk [4–10]. Furthermore, surgery offers a “teachable moment” for smoking cessation, as it may prompt abstinence even in the absence of interventions [11–14]. Indeed, approximately one in 12 of all quit events in older U.S. residents may be attributed to undergoing surgery [13]. Even smoking cessation within 12 hours of surgery is helpful from a cardiovascular standpoint, as carbon monoxide toxins in smoke and nicotine return to normal levels [5,15,16]. Annually, an estimated 10 million procedures are performed on tobacco using patients in the U.S., so systematically applied interventions yield substantial public health benefits [17–20]. However, evidence from several countries suggests that clinicians in general, and anesthesiologists in particular, do not take advantage of the opportunity to intervene in this setting [21–25]. As perioperative physicians, anesthesiologists should take a leading role in ensuring that surgical patients who use tobacco receive tobacco interventions [26]. However, most anesthesiologists have little training in, or experience with, tobacco control [21,22,25]. One strategy to increase the rate with which anesthesiologists address their patients’ tobacco use is to incorporate tobacco control training in the residency curriculum. Efforts to provide such training have proven efficacious in primary care specialties, most notably pediatrics, but have not been attempted in anesthesiology [27–32]. Formative work is needed to design such a curriculum. The aims of this study were to 1) ascertain current knowledge, attitudes, and practices of anesthesiology residents regarding tobacco control, 2) determine the characteristics of current residency training offered in tobacco control, and 3) perform a needs assessment directed towards the development of a national, residentspecific curriculum on perioperative smoking cessation.

2. Materials and methods This national survey of U.S. anesthesiology residency program directors and residents was approved by the Mayo Clinic Institutional Review Board. Survey procedures were

C.R. Schultz et al. developed in consultation with the Mayo Clinic Survey Research Center, utilizing their expertise in survey instrument design and dispersal. Response monitoring, reminders, and data collection were conducted by the Survey Center.

2.1. Participants and survey procedures Two surveys were conducted: a complete sampling frame of all program directors of U.S. Accreditation Council for Graduate Medical Education (ACGME) - accredited anesthesiology residencies and a program director-delimited sampling frame of anesthesiology residents. Both surveys were completed anonymously, and responses were not linked to individual respondents. 2.1.1. Program director survey Through the Fellowship and Residency Electronic Interactive Database Access System (FREIDA) maintained by the American Medical Association, contact information for all 131 program directors of U.S. ACGME-accredited anesthesiology residencies was obtained. Program directors were contacted via an email that described a research effort to develop an anesthesiology resident-specific tobacco control curriculum and were provided an internet link to the survey. Three reminder notifications were sent at two-week intervals. 2.1.2. Resident survey Program directors were also asked if they would be willing to participate in distributing an anesthesiology resident survey by forwarding an email to their residents. This request was made after submission of their anonymous survey and required providing a contact email address. After the close of the program directors’ survey, willing program directors were sent an introductory email letter with survey link for anesthesiology residents and asked to forward the email to residents. In addition, program directors were asked to respond directly to the study investigators with the number of residents the email was forwarded to. Methods to increase the response rate included having the survey email come from program directors rather than from an unknown study team, an incentive offer of a drawing for participants for an iPad, and interval reminder notifications as described above.

2.2. Survey instruments One set of items assessed knowledge, attitudes and beliefs, and current practices regarding tobacco control and were based on previous surveys of practicing anesthesiologists in the U.S., Japan, and China performed by one of the investigator (DOW) [21,22,25]. These items were revised by the co-investigators, Survey Center, and practice guideline updates [33]. Another set of items queried currently offered curriculum, learning preferences, and preferences regarding new curricula. These items were formulated based on research examining tobacco control curricula in other medical specialties, previous graduate

Residency smoking cessation survey medical education director survey research, and the expert input of study investigators (DOW and DAC) [34]. The surveys were implemented online using SurveyTracker software (version 5.6.2; Training Technologies, Inc., Lebanon, OH, USA). A total of 13 questions containing 26 possible responses were included in the program director survey, which fell within the following general categories: Current curriculum. These items queried the presence and characteristics of any existing tobacco control curriculum. Desired curriculum. These items ascertained interest in new curriculum, including desirable characteristics of such curriculum. Demographics. These items included practice environment and number of residents and physician faculty.

A total of 28 questions with 48 possible responses were included in the resident survey which fell within the following general categories: Current practices. These items related to the current practices of residents regarding tobacco use interventions. Attitudes and beliefs. These items queried attitudes toward and beliefs regarding tobacco use interventions. They included risks and benefits of perioperative smoking abstinence, beliefs regarding anesthesiologists’ responsibility to intervene, and attitudes towards learning about tobacco control. Knowledge about tobacco control. The items addressed knowledge of postoperative complications associated with smoking (Grouping 1), the benefit of preoperative smoking cessation (Grouping 2), and tobacco control treatments (Grouping 3). Current training and learning preferences. These items addressed current tobacco control curriculum and general learning preferences. Demographics. These items included year of training, smoking history, and other personal characteristics.

2.3. Statistical analysis Summary statistics of responses were prepared, and they represent the primary focus of this report. Chi-square and correlation analysis was performed to assess any relationship between answers to attitudes and beliefs questions and knowledge and practices questions, respectively, by postgraduate year.

3. Results 3.1. Program director survey Of the 131 surveys distributed to the program directors of U.S. ACGME-accredited anesthesiology residencies, 75 were returned for a response rate of 57%. The median number-range for both the number of residents and fellows in the programs and the number of full-time faculty was 26 to 50. Programs represented both university (public and

565 private) and non-university-based medical education systems. Half of the institutions did not have a program to provide tobacco interventions to preoperative patients. Although most program directors reported that their programs provided education regarding the risks posed by smoking and the benefits of abstinence, few provided education about tobacco control (Table 1). However, a strong majority felt that such education should be offered. For those who were providing some tobacco control education, the most common delivery method was live lectures (Table 2). Interest in adding tobacco control education into residency curriculum was high, with 91% agreeing or strongly agreeing that they would include a web-based module into their offerings if it was available. Other formats that program directors agreed or strongly agreed would be of interest included live lectures (eg, an annotated PowerPoint presentation for delivery by local faculty, 82%), portable delivery methods (eg, smartphone or tablet applications, 58%) and social media (28%). Program directors were also queried regarding preferences for hosting a web-based module; similar proportions would prefer local hosting versus hosting on a central, nationally accessible server (53% and 44%, respectively). The median time range for the preferred duration of training annually was 30 to 60 minutes (38%).

3.2. Resident survey Of the 131 program directors who were sent surveys, 58 (44%) responded that they would be willing to forward a survey to their residents. Of the 1,182 residents (representing 22% of all U.S. anesthesiology residents) who were sent the introductory email with survey link by their program director, 490 completed the survey, for a response rate of 41%. The number of programs represented in the resident responses is unknown; this information was not requested so as to maintain respondent anonymity. Of the total number of respondents, 453 were in their CA-1, CA-2, or CA-3 years; the remaining respondents were in their clinical base year or a fellowship and were excluded from analysis. The proportion of respondents in their CA-1, CA-2, and CA-3 years was 37%, 34%, and 29%, respectively; 43% were women. Most respondents (91%) had never smoked, with 9% and b 1% indicating that that they were former and current smokers, respectively. The proportions of residents reporting the availability of training in various topics related to tobacco were consistent with the offerings reported by the program directors (Table 1). Residents also felt that training in tobacco interventions should be offered. Regarding preferences for educational format, residents found that live lectures and reading materials were most helpful in the past (Table 2). The median time range for the preferred duration of training annually in tobacco control was 30 to 60 minutes (46%). Regarding their current tobacco control practices, although the majority of residents reported consistently asking about tobacco use, few practices consistently provided advice or assistance (Table 3). Nonetheless, 88% of residents strongly agreed or agreed that it was part of their responsibility as

566 Table 1

C.R. Schultz et al. Residency program formal education topics Current offerings

Tobacco use as cause of perioperative complications How preoperative smoking cessation affects risk of perioperative complications How to ask patients about tobacco use, advise them to quit How to help patients quit smoking around time of surgery

Should be offered

Program director (part of curricula)

Residents (have recd training)

Program directors

Residents

70.3 74.0

55.8 60.0

97.3 97.3

96.5 97.6

20.5 11.0

28.4 14.0

83.3 74.0

76.8 82.0

*Values are percentages (number of yes responses/number of responders).

anesthesiologists to advise their patients to quit smoking, and 73% strongly agreed or agreed that the perioperative period was an effective time to help patients quit smoking for good (Table 4). A smaller proportion (42%) strongly agreed or agreed that it was their responsibility to ensure that patients received the help they needed to quit. Interest in incorporating tobacco interventions into future practice was very high. Barriers to intervention included a lack of self-efficacy (with 39% disagreeing or strongly disagreeing that they felt confident in their ability to help patients quit smoking perioperatively) and time (with 44% agreeing or strongly agreeing that time was a barrier). Most respondents were willing to incorporate effective, brief tobacco interventions into their future practices. Chi-square analysis showed that responses to attitude and belief questions (Table 4) did not depend on year of training (CA-1 to CA-3; data not shown). Resident performance on items assessing knowledge of issues related to perioperative tobacco control was generally good, with a majority of respondents providing correct responses for all but three of the 14 items (Table 5). Weak, though statistically significant, correlations were noted when comparing resident year with knowledge (Spearman’s rho = 0.13; P = 0.006) and resident year with reported practices (Spearman’s rho = 0.11; P = 0.02).

Table 2

4. Discussion Few anesthesiology residencies offer formal training in perioperative tobacco control, although both program directors and residents agree that this is an important topic and that further training is desirable. Given that clinician-delivered tobacco interventions are efficacious and current practice guidelines recommend that all clinicians address their patients’ tobacco use, it is appropriate to address tobacco control as a part of anesthesiology residency training [33]. Resident tobacco control training is an established focus of education in primary care residency programs, including family medicine and internal medicine [30,35]. Pediatric graduate medical education provides the most recent example of a rigorous effort to develop and implement tobacco control curriculum that included assessment of resident cognitive and behavior change outcomes [27–29,31,32]. General surgery residencies are also addressing the need for tobacco control education, as many patients present with surgical needs directly related to tobacco use [23,36]. The current study represents a first step toward providing consistent training in tobacco control to anesthesiology residents, who are in a unique position to facilitate perioperative tobacco interventions.

Education formats * Program directors

Residents

Format of currently offered Previously “very” or “somewhat” Previously “not at all” helpful tobacco education helpful education format education format Live lectures Reading material Small group discussion Computer-assisted/online training/ interactive web-based Recorded lectures Simulation or demonstration Portable delivery (smartphone, tablet) Social media (eg, Facebook, YouTube)

94.3 63.3 44 6.7

93.8 95.2 87.2 74.7

6.2 4.9 12.8 25.3

6.4 2.2 NA NA

76.5 86.9 71.2 44.4

23.5 13.1 28.8 55.6

NA–not asked. * Values indicate % (No. yes / No. responding).

Residency smoking cessation survey Table 3

567

Resident current practices

How often do you…

Less than 5% of the time

5% to 25% of the time

26% to 75% of the time

More than 75% of the time

Ask patients if they use tobacco? Advise patients about how smoking affects their risks for surgical or anesthetic complications? Advise your patients who use tobacco to quit? Provide counseling, medication, or other direct assistance to help your patients quit tobacco? Refer patients who use tobacco to other services (stop smoking clinics, quit lines, etc.) to help them quit?

2.2 18.3

5.3 31.6

18.9 36.1

73.6 14

20.8 72.2

29.3 19.1

27.1 6.4

22.8 2.2

80.8

12.7

4.9

1.6

*Values indicate % (No. yes / No. responding).

In comparing this study with a previous survey of practicing U.S. anesthesiologists [22], respondents to both surveys agreed on the deleterious effects of smoking on perioperative outcomes, the benefits of smoking cessation before surgery, and the recognition that the perioperative period was an opportune time to promote permanent smoking abstinence. Unfortunately, these beliefs do not seem to translate into smoking cessation counseling or intervention for patients in either study [22]. Barriers to intervention identified in the current study were consistent with previous studies and included inadequate time and lack of confidence in the ability to counsel on smoking cessation [21,22,25]. Nonetheless, both residents and practicing anesthesiologists expressed a strong interest in learning more about perioperative smoking cessation interventions, and a willingness to intervene preoperatively if the intervention was efficacious and brief.

Table 4

This study identified important issues to address as tobacco control curriculum is developed for anesthesiology residents. Resident respondents in this survey appeared to demonstrate good knowledge of the effects of smoking on postoperative complications and the benefits of preoperative smoking cessation. A notable exception was the endorsement of, or uncertainty about, the belief shared by many practicing anesthesiologists and now shown to be inaccurate, that quitting smoking a few days before surgery significantly increases the risk of pulmonary complications [15,37–39]. It is important to address this misconception as part of the curriculum. There also appeared to be knowledge deficits regarding nicotine therapy and postoperative complications, which need to be addressed. It was encouraging that a strong majority of residents viewed the perioperative period as an opportune time to intervene, and that they were responsible for providing advice. However, because only a minority felt

Resident attitudes, barriers, and beliefs

Statement:

Strongly Agree Neutral Disagree Strongly Don't know Not applicable agree disagree

It is part of my responsibility as an anesthesiologist to advise my patient to quit smoking It is part of my responsibility as an anesthesiologist to make sure that patients get the help they need to quit smoking The perioperative period is an effective time to help patients quit smoking for good I don't have time to counsel my patients about how to quit smoking I feel confident in my ability to help patients quit smoking around the time of surgery Patients generally aren't interested in quitting smoking in the perioperative period After I enter practice, I would be willing to spend an extra 5 minutes preoperatively helping a patient who smokes to quit if it was effective in helping them After I enter practice, I would refer a patient who smokes to an effective intervention service in my practice setting if it did not require much extra time on my part

34.7

53.1

8.4

2.9

0.9

0.0

0.0

9.1

33.3

36.1

18.2

3.1

0.2

0.0

35.0

37.5

12.2

11.1

3.3

0.9

0.0

11.3

33.0

19.5

28.8

7.1

0.2

0.0

5.1

21.0

34.0

34.0

5.3

0.4

0.2

5.6

26.7

20.7

38.0

6.0

3.1

0.0

30.5

48.5

12.2

5.5

1.5

1.8

0.0

47.8

47.1

3.8

0.4

0.2

0.4

0.2

Values are percentages of respondents who answered the question.

568 Table 5

C.R. Schultz et al. Resident knowledge of issues related to perioperative tobacco control

Grouping 1. Which of the following postoperative complications are at increased risk of occurring due to smoking?

Correct

Wound infections (Yes) Pulmonary complications (eg, pneumonia) (Yes) Postoperative nausea and vomiting (No) Myocardial infarction (Yes) Urinary retention (No)

91.8 99.8 79.1 90.0 16.2

Grouping 2. According to current evidence, which of the following is/are correct regarding smoking cessation?

Correct

Quitting smoking for 6 mos or longer before surgery will significantly reduce rate of most postop complications related to smoking. (Yes) Quitting smoking a few days before surgery significantly increases the risk of pulmonary complications. (No) Asking pts if they smoke and then advising them to quit improves their chances of quitting. (Yes) Interventions to help pts quit smoking, including counseling and medications, can at least double their chances of successfully quitting. (Yes) The majority of cigarette smokers want to quit. (Yes)

97.3 48.1 73.4 90.0

Grouping 3. Accurate statements regarding medications to help smokers quit including which of the following?

Correct

Nicotine patches should never be used in surgical patients. (No) Nicotine patches should never be used in pts with coronary artery disease. (No) Nicotine patches require a prescription. (No) There are medications other than nicotine that can also help pts quit smoking. (Yes)

77.4 55.4 62.7 98.2

72.3

Values are percentages of respondents who answered the question.

that it was their responsibility to help provide assistance, the potential role of the anesthesiologist should be emphasized. Further, special curricular emphasis is likely needed on how to provide counseling, thereby improving self-efficacy in performing tobacco control interventions. Tobacco control curricula developed for residency training in other specialties often includes an emphasis on physicians directly providing assistance and follow-up as a part of tobacco interventions, which is appropriate for practice settings that feature continuity of care. Anesthesiologists typically have a single encounter with the patient, and have considerable time pressures in the busy perioperative period (as reflected by the survey results), so that direct assistance and follow-up may not be feasible. The ASA recommends an “ask-advise-refer” approach, in which the anesthesiologist refers smokers to available treatment services rather than providing extensive assistance.1 This relatively simple and brief approach is easily mastered, which could address identified deficits in selfefficacy. It also takes a relatively short time to teach, which fits within the preferences expressed for time devoted to the curriculum, and is amenable to delivery via the preferred educational formats (live lectures and reading materials). This approach also may be used in practice settings that do not provide tobacco intervention services to patients via utilization

1 American Society of Anesthesiologists Smoking Cessation Task Force. ASA Stop Smoking Initiative for Providers (www.asahq.org/stopsmoking); accessed 8/21/12.

of the national quitline resource, an important consideration given that half of the institutions surveyed had no such programs to provide intervention services. This study had limitations. Although the majority of program directors responded, less than half of the residents did so. This situation allowed considerable potential for response bias, as those most interested in tobacco control may be more likely to respond. Recall bias may also be present with regard to current practices, previous smoking-related educational exposure, and previously helpful education formats. Previous research has shown that physicians consistently overestimate their smoking cessation counseling practices [40–42]. These biases, if present, would most likely artificially inflate our estimates of perioperative smoking cessation current practices. Strengths of this study include the use of previously-described survey items, rigorous content development, and use of expert survey administration personnel. Both anesthesiology residents and anesthesiology program directors expressed considerable interest in such a curriculum. Perioperative physicians offering surgical patients smoking cessation interventions should be considered a best practice and are consistent with the ASA Smoking Cessation Task Force recommendations and perioperative Surgical Home models of care. Creation and implementation of an openaccess, national, anesthesiology resident-specific perioperative smoking cessation education module may provide further momentum to build the capacity for health institutions to promote long-term tobacco cessation in surgical patients and further diminish the impact of tobacco-related diseases on public health.

Residency smoking cessation survey

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