Outreach with Embedded Asynchronous Care Improves Smokers’ Engagement in Physician-Assisted Quit Attempts

Abstract: As portal messaging grows, we need to understand the value of coupling patient outreach with asynchronous care (AC) to better activate patient-physician collaboration. In a field experiment targeting smoking quit attempts, we demonstrate the value of outreach and the supplemental value of embedding a link to AC to activate physician-assisted quit attempts (PAQA). We found outreach coupled with AC efficiently found smokers interested in physician assistance and engaged them in evidence-based quit attempts at significantly higher rates than treatment as usual or outreach alone. Current EMR and portal functionality were applied.

Background: Over forty million smokers reside in the United States¹. Smoking cessation is better accomplished with physician assistance yet overwhelmingly smokers try to quit on their own¹. Smoking decline has stalled in the US1. Rural and younger patients face greater barriers to PAQA because it currently occurs in face-to face visits. The potential benefit of offering these populations access to AC is tremendous. Smokers are concentrated in difficult to reach, rural populations¹ and younger patients make more quit attempts but visit the doctor less. Moreover, if smokers quit by 35-44 years of age they avoid most of the mortality risk of smoking¹. 

Methods: In a 2x2 experimental design, 250 patients were randomly assigned to one of four test conditions or control group. We tested if sender (physician or health system) and message type (outreach alone or outreach with AC) affected PAQA rates. EMR documented physician-assisted quit attempts were tracked 30 days after outreach. Salient patient traits were collected. 

Results: Digital outreach alone generated a 4% quit attempt rate. Using T-tests, outreach with a link to asynchronous care generated a significantly higher rate, 9.5% (p=0.020). 56% of patients opened the message. Among openers, outreach alone generated a 7% rate and outreach with asynchronous care link generated a significantly higher rate (p=0.014), 18%. Control group had 0 PAQAs. All patients with PAQAs opened the message. Surprisingly, physician as sender did not significantly increase open rates (p= 0.225) or quit attempt rates (p=0.827). Among openers, only age significantly predicted asynchronous care PAQA’s (p=0.0095). 

Conclusion: Outreach coupled with AC significantly improved patient-physician collaboration. Digital messaging activated difficult to reach patients (rural) and AC activated patients who arguably have the greatest benefit of quitting (younger). The program efficiently found patients interested in PAQA and delivered it outside of the clinic setting. Unlike other telemedicine innovations, AC is billable. Physicians were comfortable with the program and found it valuable. Additionally, the results suggest patients are engaged at the health system level, a positive sign indicating systems can target population health goals with AC. The effectiveness of asynchronous care is particularly impactful now during COVID-19 when need for high quality, remote care is growing.