and promote collaborations among facilities. The smoking-cessation lead clinician at each VA facility completed the survey. The VA PHSHCG also held a Provider Feedback Forum on smoking- and tobacco-use cessation (VA, 2007a) to ask VA front-line health-care providers about their experiences in conducting smoking- and tobacco-cessation programs for VA patients. The forum addressed the implementation of evidence-based tobacco-use cessation interventions, special populations, pharmacy issues, tobacco-free policies, and current resources and future opportunities. However, beyond the data on required brief counseling and offer of medications, VA does not appear to have any data on whether its outpatient clinics and CBOCs offer tobacco-cessation programs, what types of services or referrals are offered and to whom, or how many veterans avail themselves of these services.

The VA/DoD guideline and the 2008 PHS guideline for tobacco cessation recommend that VA health-care providers use the 5 A’s for each patient. Before 2007, performance measures for VA health-care providers were based on whether patients were asked about tobacco use and whether they were advised to quit if they were users. Over 90% of providers were in compliance with these measures. The VA Office of Quality and Performance (OQP) is responsible for implementing and monitoring performance measures for VHA health-care providers, including adherence to the use of clinical reminders to ask about tobacco use and follow-up. In 2006, VA developed new performance measures that are used by the OQP to increase the provision of tobacco-cessation treatment to outpatients. The three performance measures are: (1) how many patients were provided with brief counseling in the preceding year, (2) how many patients who used tobacco were offered medication to assist in cessation, and (3) how many patients who used tobacco were offered referral to a smoking-cessation clinic to assist in cessation. Compliance with the performance measures for FY 2008 ranged from 75% to 99% among the VISNs (VA, 2007b).

VA compliance with smoking-cessation care metrics exceeds that of the commercial sector or Medicaid for smoking-cessation counseling (89% vs. 76% vs. 70%, respectively), the offer of smoking-cessation medications (84% vs. 51% vs. 39%), and referral or use of smoking-cessation strategies (92% vs. 48% vs. 39%) (Kim Hamlett-Berry, VA, personal communication, November 10, 2008). Although VA is one of the health-care leaders in asking patients about tobacco use and has instituted electronic prompts in the patients’ medical records to ensure that patients can receive tobacco-cessation medications and referrals if they want them, there is an almost total lack of information on whether the performance measures have had an effect on tobacco-use rates, although they have improved health-provider practices.

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