Warm Handoff Versus Fax Referral for Linking Hospitalized Smokers to Quitlines

Abstract

Introduction: Few hospitals treat patients' tobacco dependence. To be effective, hospital-initiated cessation interventions must provide at least 1 month of supportive contact post-discharge.

Study design: Individually randomized clinical trial. Recruitment commenced July 2011; analyses were conducted October 2014-June 2015.

Setting/participants: The study was conducted in two large Midwestern hospitals. Participants included smokers who were aged ≥18 years, planned to stay quit after discharge, and spoke English or Spanish.

Intervention: Hospital-based cessation counselors delivered the intervention. For patients randomized to warm handoff, staff immediately called the quitline from the bedside and handed the phone to participants for enrollment and counseling. Participants randomized to fax were referred on the day of hospital discharge.

Main outcome measures: Outcomes at 6 months included quitline enrollment/adherence, medication use, biochemically verified cessation, and cost effectiveness.

Results: Significantly more warm handoff than fax participants enrolled in quitline (99.6% vs 59.6%; relative risk, 1.67; 95% CI=1.65, 1.68). One in four (25.4% warm handoff, 25.3% fax) were verified to be abstinent at 6-month follow-up; this did not differ significantly between groups (relative risk, 1.02; 95% CI=0.82, 1.24). Cessation medication use in the hospital and receipt of a prescription for medication at discharge did not differ between groups; however, significantly more fax participants reported using cessation medication post-discharge (32% vs 25%, p=0.01). The average incremental cost-effectiveness ratio of enrolling participants into warm handoff was $0.14. Hospital-borne costs were significantly lower in warm handoff than in fax ($5.77 vs $9.41, p<0.001).

Conclusions: One in four inpatient smokers referred to quitline by either method were abstinent at 6 months post-discharge. Among motivated smokers, fax referral and warm handoff are efficient and comparatively effective ways to link smokers with evidence-based care. For hospitals, warm handoff is a less expensive and more effective method for enrolling smokers in quitline services.

Trial registration: ClinicalTrials.gov NCT01305928.

Figure 1

EQUIP CONSORT diagram.

Figure 2

Enrollment and abstinence outcomes. Note: Participants referred via warm hand-off completed more quitline calls (mean=2.05, SD=1.40) than fax-referred patients (mean=1.23, SD=1.63) (p<0.001) Participants referred via warm hand-off were more likely to complete calls 1-3 than fax referred participants (p<0.001); there were no differences for calls 4 and 5.

Figure 3

Quitline counseling participation, by study arm.