Ogni antibiotico è efficace in relazione a un determinato gruppo di microrganismi
comprare ciprofloxacina online in italiain caso di infezioni oculari vengono scelte gocce ed unguenti.
Ochs-13-03-29 367.374
The Ochsner Journal 13:367–374, 2013Ó Academic Division of Ochsner Clinic Foundation
Patient Tobacco Use, Quit Attempts, and Perceptions
of Healthcare Provider Practices in a Safety-Net
Healthcare System
Sarah Moody-Thomas, PhD,* Michael D. Celestin, Jr., MA, CHES, CTTS,*
Tung-Sung Tseng, DrPH, MS, CHES/MCHES,* Ronald Horswell, PhDà
*School of Public Health and
Stanley S. Scott Cancer Center, Louisiana State University Health Sciences Center, New Orleans, LA
àPennington Biomedical Research Center, Baton Rouge, LA
Results: Patient reports indicated that provider adherence to
the 5A clinical protocol increased from 2004 to 2010.
Background: Although smoking rates in the United States (US)
Significant (P<0.001) improvements were observed for theassess (39
are high, healthcare systems and clinicians can increase
% vs 72%), assist (24% vs 76%), and arrange
(8% vs 31%) treatment variables. Patient-reported quit
cessation rates through application of the US Public Health
attempts increased, along with awareness of cessation
Service tobacco treatment guideline (2000, 2008). In primary
services (from 19% to 70%, P<0.001), while use of cessation
care settings, however, guideline implementation remains low.
medications decreased (from 23% to 5%, P<0.002).
This report presents the results from an assessment of patient
Conclusion: Following implementation of the guideline,
tobacco use, quit attempts, and perceptions of provider
significant improvements were noted in patient reports of
treatment before (2004) and after (2010) guideline implemen-
provider treatment and awareness of cessation services.
tation.
Methods: By use of a systems approach, the LouisianaTobacco Control Initiative integrated evidence-based treatmentof tobacco use into patient care practices in Louisiana's public
hospital system. This prospective study, designed to collect
Tobacco use continues to lead the nation as a
data at 2 time points for the purpose of evaluating the effect of
preventable cause of morbidity and mortality.1 De-
the 5A protocol (ask, advise, assess, assist, and arrange),
spite reductions over the past 3 decades in smoking
included 571 and 889 adult patients selected from primary
among the nation's general population,2 rates of
care clinics in 2004 and 2010, respectively. Chi-square
tobacco use remain high among low-income, less-
analyses determined differences between survey administra-
educated, minority, and under- and uninsured
tions, along with direct standardization of weighted rates to
groups.3 Louisiana's smoking prevalence (22%) is
control for confounding factors.
higher than the national average (17%).4 Nationwide,smoking rates vary by insurance coverage: 16% ofthose covered by private insurance smoke, compared
Address correspondence to
to 30% of public insurance enrollees (Medicaid and
Sarah Moody-Thomas, PhD
Medicare) and 32% of uninsured residents.5 In
School of Public Health and Stanley S. Scott Cancer Center
Louisiana, a large proportion (25%) of residents is
Louisiana State University Health Sciences Center
uninsured; 34% of these smoke.6
2020 Gravier St.
Healthcare providers and delivery systems can
New Orleans, LA 70112
impact population-level cessation rates through im-
Tel: (504) 568-6038
plementation of the US Public Health Service
Fax: (504) 568-5911
(USPHS) clinical practice guideline (CPG) Treating
Email:
[email protected]
Tobacco Use and Dependence: 2008 Update thatincludes the 5A protocol: (1) ask about tobacco use,
Keywords: Guideline adherence, physician's practice patterns,
(2) advise all identified smokers to quit, (3) assess
smoking cessation
smokers' willingness to quit, (4) assist smokers in
Funding: This work was supported by the Louisiana Cancer
their quit attempt, and (5) arrange for follow-up
contact. Furthermore, the CPG delineates standards
Volume 13, Number 3, Fall 2013
Clinical Practice Guideline Effects on Tobacco Use
for quality care, endorses the effectiveness of evi-
nonpediatric primary care clinics. For each clinic, the
dence-based treatments for tobacco use, and pro-
survey was conducted during approximately 70
vides strategies for integrating screening and
operating days during the quarter; for each stratum,
treatment into routine patterns of care. Nearly 70%
2 of these operating days (a total of 44 3 2 ¼ 88) were
of smokers visit a physician at least once a year,
selected as the first-stage cluster sample. The second
providing an opportunity for intervention.7 However,
stage in 2004 involved choosing specific participants
CPG implementation in primary care settings is less
within each clinic-day combination. After further
stratifying by age and gender, subjects were selected
Patients' perceptions of their care have become
randomly from appointments scheduled for the clinic
increasingly important to health systems as many
on the selected days.
seek to improve the quality and satisfaction with
In 2010, the first-stage cluster sampling plan
treatments and to provide patient-centered care.9,10
included 7 public hospitals in the system and 29
When tobacco users receive treatment according to
nonpediatric clinics. For each clinic, a survey time was
the CPG, they report higher satisfaction with overall
assigned over a 2-week period. Each day, the
healthcare received relative to untreated tobacco
surveyors were required to visit 1 clinic for about 2
users.7 Provider treatment of tobacco use can be
hours, either in the morning or the afternoon, thus
measured by patient surveys (eg, Consumer Assess-
designating a total of 10 slots for the 2-week period
ment of Healthcare Providers and Systems, National
(10 weekdays). The second stage in 2010 included
Health Interview Survey), provider surveys, medical
participants within each clinic-day combination. In this
record reviews, and direct observation. However,
survey, all subjects presenting to the clinic during the
limitations exist for each of these and results vary.
assigned time slot were included. Because clinic
While direct observation is the standard for assessing
patient loads varied, the samples collected for each
provider treatment, healthcare systems can benefit
stratum were determined in proportion to the relative
from precise, cost-effective, and practical approaches
patient volume of each clinic.
to obtaining patient perceptions of provider interven-tion.11,12 Patient surveys are more accurate than chart
Survey Instrument
audits for assessing chronic disease advice, informa-
Both surveys contained items found in other
tion dissemination, and, in some instances, general
national surveys (eg, National Health Interview Sur-
health promotion.13
vey, Adult Tobacco Survey, Behavioral Risk Factor
In 2002, to accompany an increase in the excise tax
Surveillance System). The 2004 survey consisted of 8
on cigarettes, the Louisiana State University School of
sections: Health Status, Health Care Access, Demo-
Public Health (LSUSPH), in partnership with Louisi-
graphics, Tobacco Use, Quit Attempts and Methods
ana's safety-net healthcare system, created the To-
to Quit, Stages of Change for Quitting, Physician and
bacco Control Initiative (TCI). The TCI, described in
Health Professional Behavior, and Other Tobacco
detail elsewhere,14 employed a systems approach to
Use. The 2010 survey consisted of 3 sections:
facilitate implementation of the CPG in the LSU
Tobacco Use, Quit Attempts and Methods to Quit,
network of public hospitals. This report presents
and Physician and Health Professional Behavior.
results from an assessment of patient tobacco use,quit attempts, and perceptions of provider treatment
Survey Administration
before (2004) and after (2010) the CPG implementation
In 2004, surveys were administered by interview-
in Louisiana's safety-net healthcare system.
ers and conducted in a private area in the clinic priorto the patients' interaction with the healthcare
provider. After agreeing to take the survey, patients
completed consent procedures and were informed
In May 2004, patients ‡18 years old and using
they would be compensated $10 for their time. The
LSU as their principal source of primary care were
response rate was 95%. Participants' responses were
evaluated. Eligible participants met the condition of 1
recorded on a hard copy of the survey instrument.
or more visits to an LSU primary care clinic in the prior
Payment was mailed after the interview.
year. A follow-up survey was conducted in January
In 2010, considerations of cost and sustainability
2010. Participants were eligible in 2010 if they had
resulted in changes to the survey methodology. Self-
had 1 or more visits to an LSU primary care clinic
administered surveys were distributed to all patients
during survey administration.
presenting for a clinic visit with the request to
A stratified, 2-stage, cluster sampling plan was
complete them prior to their clinic visit. A TCI tobacco
used in 2004 and 2010. In 2004, the first stage
cessation coordinator provided clinic intake clerks
included 10 public hospitals in the system and 44
with surveys, clipboards, and pencils that were given
The Ochsner Journal
to all patients at appointment check-in. This approach
Changes in Patient Perceptions of Physician
yielded a 99% response rate. Because survey
and Health Professional Behaviors
participation was both voluntary and anonymous,
To determine if, in their interactions with smokers,
and the survey was made available to all patients, it
healthcare providers were following the CPG related
was not necessary for patients to complete an
to smoking cessation, smokers were questioned
informed consent or patient privacy form. Participants
about interactions with healthcare providers. Specif-
did not receive compensation. The study was
ically, smokers were asked about their tobacco use
approved by the Institutional Review Board of the
and whether the healthcare provider gave advice to
LSU Health Sciences Center and by the Research
quit smoking. Table 3 shows the patient-reported
Review Committee of each facility.
healthcare provider behaviors regarding the CPG 5Aprotocol: ask, advise, assess, assist, and arrange. In
2004 and 2010, 86%-90% of patients reported that
Descriptive statistics of the demographic charac-
their healthcare provider had asked and advised them
teristics of respondents were derived. For the purpose
to quit smoking in the past 12 months. In 2010,
of comparing 2004 and 2010 patients, the results
however, healthcare providers did a better job in
were standardized by the gender and age population
assessing, assisting, and arranging. Table 3 shows
distribution in 2010. All analyses were weighted to
that 72% of patients had been assessed during the
account for the complex sampling design. Chi-square
past 12 months in 2010, but only 39% of patients were
analyses were conducted to explore 2004 and 2010
assessed during the previous 12 months in 2004
differences among patients who were smokers.
(P<0.001). Similarly, 76% of patients had been
Weighting of analytical procedures was accomplished
assisted in the past 12 months in 2010, but only
with SAS 9.1 (SAS Institute, Cary, NC). To allow valid
24% of patients had been assisted in the previous 12
comparison of groups, direct standardization (or
months in 2004 (P<0.001). In addition, 31% of
adjustment) of rates was used to minimize the
patients had cessation services arranged in 2010,
influence of confounding factors.
but only 8% of patients had services arranged in 2004(P<0.001).
RESULTSChanges in Demographic Status
Changes in Patient-Reported Quit Attempts
Included in the results were 571 patients in 2004
and 889 patients in 2010, representing the 7 hospitals
Table 4 shows the quit-smoking behaviors
in the Louisiana public hospital system that partici-
reported by patients who smoked. Although the
pated in both administrations of the survey. Table 1
proportion of smokers who stopped smoking for 1
shows the demographics for the samples. About two-
day or longer was higher in 2010 (60%) vs 2004
thirds of the patients were ‡45 years old. The sample
(49%), the difference was not statistically significant
was predominantly female (82% in 2004 vs 71% in
(P¼0.120). In 2010, a significantly higher proportion
2010). In 2004, most of the patients were African-
of smokers reported being aware of assistance
American (60%). In 2010, however, more than half the
(70%) such as telephone quit lines or cessation
patients were white (54%). Most patients were lower
services at local LSU hospitals; however, only 19% of
income, with 58% of the participants reporting free
smokers were aware of such assistance in 2004
care (indigent) status in 2004 and 52% in 2010.
(P<0.001). Nearly the same percentage of those whosmoked cigarettes regularly and had stopped smok-
Changes in Tobacco Use
ing for 1 day or longer to quit smoking in the past 12
To compare patients in 2004 and 2010, the results
months (75% in 2004 and 76% in 2010, P¼0.920)
were standardized by gender and age distribution
reported that they tried to quit smoking on their own
using the 2010 population distribution. Chi-square
(cold turkey). A significant difference was found in
analyses were conducted to explore 2004 and 2010
the use of an aid to quit smoking. More smokers in
differences among patients who were smokers. Table
2004 than in 2010 stated they used a stop-smoking
2 shows the tobacco use status in 2004 and 2010. In
product such as a nicotine patch or bupropion
general, the proportion of ever smokers was similar
hydrochloride (Zyban) (23% in 2004 vs 5% in 2010,
(54% vs 49%; P¼0.083). Between 2004 and 2010, no
significant differences were found for the period oftime since ever smokers had last smoked cigarettes
(P¼0.328). However, the percentage of heavy smok-
The survey findings suggest that integrating the
ers (those who smoke more than 11 cigarettes per
USPHS CPG in a large public hospital system impacts
day) was higher in 2004 than in 2010 (P<0.001).
patient tobacco use, quit attempts and methods for
Volume 13, Number 3, Fall 2013
Clinical Practice Guideline Effects on Tobacco Use
Table 1. Demographic Status
May-Aug 2004 (n¼571)
Jan-Feb 2010 (n¼889)
Commercial insurance
Free care/indigent
Table 2. Tobacco Use in Patients Who Have Smoked at Least 100 Cigarettes in Their Lifetimes
May-Aug 2004 (n¼529)
Jan-Feb 2010 (n¼823)
Have you smoked at least 100 cigarettes
in your entire lifetime?a
Do you now smoke cigarettes every day,
some days, or not at all?a
On average, about how many cigarettes
a day do you smoke?a
1 – 10 cigarettes
11 – 20 cigarettes
21 – 35 cigarettes
40 or more cigarettes
About how long has it been since you last
smoked cigarettes regularly?a
1 to 3 months ago
3 to 6 months ago
6 to 12 months ago
5 or more years ago
The Ochsner Journal
Table 3. Physician and Health Professional Behaviors
Asked - In the past 12 months, did any health care provider at
this LSU Hospital ask if you smoke?Yes
Advised - In the past 12 months, did any health care provider
advise you to quit smoking?aYes
Assessed - During the past 12 months, did any health care
provider ask you if you were willing to make a quit attempt?aYes
Assisted - In the past 12 months, when a health care provider
advised you to quit smoking, did they do any of the following(prescribe or recommend medication, suggest setting quit date,recommend or refer to counseling, or give self-help material)?bYes
Arranged - In the past 12 months, when a health care provider
advised you to quit smoking, did they do any of the following(call and ask you about your quit attempt within one week orone month)?bYes
aSmoked cigarettes regularly in the past 12 months.
bSmoked cigarettes regularly in the past 12 months and in the past 12 months healthcare provider advised patient to quit smoking.
Note: Weighted percentages reported for all questions of the 5A protocol.
quitting, and perceptions of provider treatment be-
prevention programs and media campaigns focused
havior. In 2010, fewer respondents reported ever
on averting smoking initiation, the decrease in those
smoking and heavy smoking. While the decrease
smoking 11 or more cigarettes per day may result
among ever smokers may be attributed to statewide
from successful quit attempts either on their own or
Table 4. Quit Attempts and Methods
In the past 12 months, have you stopped smoking for one day
or longer because you were trying to quit smoking?aYes
Are you aware of assistance that might be available to help
you quit smoking at this LSU Hospital such as telephonequit lines or local health clinic services?aYes
The last time you tried to quit smoking did you quit cold
turkey (on your own)?bYes
The last time you tried to quit smoking, did you use a patch or
Zyban to help you quit?bYes
aSmoked cigarettes regularly in the past 12 months.
bSmoked cigarettes regularly and had stopped smoking for 1 day or longer to quit smoking in the past 12 months.
Note: Weighted percentages reported for all questions.
Volume 13, Number 3, Fall 2013
Clinical Practice Guideline Effects on Tobacco Use
from utilizing cessation services in the LSU Health
Respondents reported an increase in quit at-
System. Since 2004, TCI has made free group
tempts, and significantly more reported awareness
behavioral counseling, self-help material, access to
of assistance to help them quit. These increases
low-cost pharmacotherapy, and, more recently, ac-
suggest that TCI's efforts to ensure that all providers
cess to free quit-line telephone counseling available
were trained to identify and discuss best-practice
to aid patient quit attempts. Compared to 2004, more
treatment options with their patients were effective. In
respondents in 2010 reported smoking 10 ciga-
addition, TCI employed dedicated tobacco specialists
rettes per day, daily smoking, and having smoked in
to coordinate cessation services and to support
the previous month. This trend suggests an emer-
clinicians at each facility. The present results regard-
gence of differing levels of smokers and their
ing quit attempts were less favorable than results
cessation pathways: smokers who are able to quit
reported in primary care settings19 but higher than instudies among the uninsured.8
and maintain abstinence, smokers who quit and
Between 2004 and 2010, no change was seen in
relapse, and recalcitrant smokers.15 Relapsing and
respondents who reported making a quit attempt on
recalcitrant smokers are likely recycled in the health
their own (cold turkey), and fewer respondents
system16 and may need tailored services to improve
reported making a quit attempt by using a nicotine
quit attempts and abstinence rates.17 However, the
patch or Zyban. This finding suggests efforts to
smoking rate of survey participants in both 2004 and
increase quit attempts using evidence-based strate-
2010 was higher than the rates reported for patients in
gies were not equally effective. However, the de-
other primary care settings18,19 and for patients who
crease in use of a patch or Zyban may also be
explained by increased access to and availability of
Patient respondents reported an increase in all of
varenicline (Chantix) starting in 2006,24 an option that
the provider treatment measures, except advice to
was not on the 2004 survey.
quit, which remained unchanged. There was a slight
Study limitations should be noted. One limitation
increase in provider screening for tobacco use and
is that patient responses were based on their previous
significant increases in providers who assessed
clinic visit (ie, surveys were conducted before their
patient willingness to quit, assisted patients with their
current clinic visit). This delayed measurement and
quit attempts, and arranged follow-up for patients
reliance on recall may overestimate performance.12 A
after the clinic visit.
second limitation is that the results were based on a
These increases may indicate that TCI's effort to
self-report method. Further, several commonly used
galvanize the clinical and patient-level cessation
methods to assess provider cessation counseling
interventions by the LSU Health System were effec-
have limitations. Patient surveys may under-23 or
tive, and this systems-based approach may serve as a
overestimate,25,26 provider surveys may overesti-
model for future statewide intervention efforts to
mate,23,27 paper medical charts may underesti-
decrease patient tobacco use through the systematic
mate,25,26,28,29 and electronic medical records may
implementation and evaluation of the USPHS CPG for
underestimate all items on the 5A protocol, except for
treating tobacco use by healthcare providers. Identi-
asking about tobacco use.11 Direct observation, the
fication and documentation of tobacco users were
ideal method, is burdensome and costly.29 Health-
obtained from nursing assessment forms, followed by
care systems can benefit from precise, cost-effective,
TCI referral forms, and finally from electronic medical
and practical approaches to assessing treatment fortobacco use, and this type of onsite survey distribu-
records with prompts and reminders for intervention.
tion proved to be an effective strategy for data
Systemwide adoption of a tobacco treatment policy,
collection in Louisiana's public hospital system.
training to improve provider intervention skills, andprovider feedback on clinical performance via an
electronic dashboard occurred throughout the sys-
This study—which examined patient tobacco use,
tem. These multilevel cessation interventions, includ-
quit attempts and methods, and perceptions of
ing counseling and medication, have been successful
physician behavior to treat tobacco use among
in improving adherence to the USPHS CPG for
primary care patients in Louisiana's safety-net health-
treatment of tobacco use in primary care settings.21
care system—found positive changes between 2004
Although few studies have reported patient percep-
and 2010. During this time frame, practice guidelines
tions of provider adherence to the 5A approach (ask,
for the treatment of tobacco use and dependence
advise, assess, assist, arrange) in primary care
were implemented. Obviously, these results do not
settings, overall our results were more favorable than
indicate cause and effect because this study was a
those found by others in similar settings11,18,22,23 and
nonrandomized and noncontrolled observation. Other
in studies of the uninsured.8
extraneous factors may have promoted improve-
The Ochsner Journal
ments in many of the items measured; however, some
Bleich SN, Ozaltin E, Murray CK. How does satisfaction with the
differences are quite large and statistically significant.
health-care system relate to patient experience? Bull World
Therefore, these results overall indicate a positive
Health Organ. 2009 Apr;87(4):271-278.
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10. Sofaer S, Firminger K. Patient perceptions of the quality of health
care after implementation of the 5A clinical protocol.
Annu Rev Public Health. 2005;26:513-559.
11. Conroy MB, Majchrzak NE, Silverman CB, et al. Measuring
These observations have implications for eliminating
provider adherence to tobacco treatment guidelines: a
tobacco use at the population level, especially among
comparison of electronic medical record review, patient survey,
ethnic/racial minorities, those of low socioeconomic
and provider survey. Nicotine Tob Res. 2005 Apr;7(Suppl 1):S35-
status, and the under- and uninsured. Future studies
should examine the effects of implementation exper-
12. Houston TK, Richman JS, Coley HL, et al; DPBRN
imentally in a randomized-controlled trial and com-
Collaborative Group. Does delayed measurement affect patient
pare patient responses to clinician (electronic)
reports of provider performance? Implications for performance
documentation. Furthermore, tailored interventions
measurement of medical assistance with tobacco cessation: a
that target relapsed and recalcitrant smokers and
Dental PBRN study. BMC Health Serv Res. 2008 May 8;8:
the use of evidence-based strategies during quit
attempts are warranted. Decreasing tobacco use is
13. Green ME, Hogg W, Savage C, et al. Assessing methods for
measurement of clinical outcomes and quality of care in primary
a top objective of Healthy People 2020.30 Improving
care practices. BMC Health Serv Res. 2012 Jul 23;12:214.
the quality of treatment through a systems-based
14. Moody-Thomas S, Celestin M Jr., Horswell R. Use of systems
approach may impact the disproportionate use of
change and health information technology to integrate
tobacco in especially disparate populations.
comprehensive tobacco cessation services in a statewidesystem for delivery of healthcare. Open J Prev Med. 2013;
U.S. Department of Health and Human Services. How Tobacco
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Nurs. 2007 Jun;25(2):32-38.
Atlanta, GA: U.S. Department of Health and Human Services,
16. Partin MR, An LC, Nelson DB, et al. Randomized trial of an
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Garrett BE, Dube SR, Trosclair A, Caraballo RS, Pechacek TF;
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Clinical Practice Guideline Effects on Tobacco Use
25. Pbert L, Adams A, Quirk M, Hebert JR, Ockene JK, Luippold RS.
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This article meets the Accreditation Council for Graduate Medical Education and the American Board ofMedical Specialties Maintenance of Certification competencies for Patient Care, Systems-Based Practice,and Practice-Based Learning and Improvement.
The Ochsner Journal
Source: http://ochsnerjournal.org/doi/pdf/10.1043/1524-5012-13.3.367
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