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Insights into QuitWorks Referrals and Their Impact
Between April 1, 2002, and March 31, 2011, 32,967 tobacco users received referrals from thousands of providers statewide. Our analysis suggests that QuitWorks has had 3 phases of referrals (Figure 1).
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Figure 1.
Number of QuitWorks referrals, by month and trend by joinpoint analysis (8), April 2002 through March 2011.
During the first phase, from April 2002 through November 2005, monthly referrals increased from approximately 100 to approximately 325, an annual percentage change (APC) of 38.3% (P < .001). During the second phase, from December 2005 through January 2009, the number of referrals to QuitWorks did not change significantly (APC = −7.6%, P = .30). However, in February 2009, referrals to QuitWorks began to substantially increase (APC = 69.2%, P < .001) during the next 2.25 years. QuitWorks received 3,909 referrals in 2009, 7,067 referrals in 2010, and approximately 9,000 in 2011. The program is on pace to receive approximately 10,000 referrals in 2012. With limited funding to promote the quitline directly to consumers through a media campaign, QuitWorks provider referrals have become the primary source of quitline clients. Since November 2009, provider referrals have accounted for approximately 80% of total client volume of the Massachusetts quitline.
Our examination of referral patterns also suggests that QuitWorks has become an integral component of health care delivery over time, in part because major users have begun to incorporate referrals into their electronic health records. In addition, reflecting the evolution of the program, the sources of referrals have varied over time.
Integrating QuitWorks into Health Care Delivery
An increase in referrals built on large numbers of providers using QuitWorks just once or twice cannot be taken as evidence of integration into the health care delivery system. However, an increase in the average number of referrals per institution does document a change in practice patterns. This is the pattern seen for the top 10 referring providers and institutions during the third referral phase (February 2009 through March 2011). In this phase, the average number of monthly referrals for these institutions increased by 117%, from 14.4 to 31.2. At the same time, the proportion of total referrals accounted for by the top 10 referring institutions decreased from 54% to 37%, indicating that many new providers were trying QuitWorks even as the top referrers were increasing their average number of monthly referrals. In 2008, 704 individual providers referred patients to QuitWorks. By 2010, 1,919 individual providers referred patients to QuitWorks.
Integrating QuitWorks into Electronic Health Records
In 2008, QuitWorks was among the last paper-based systems still working with the Harvard Vanguard Medical Associates (HVMA) network. HVMA is a 17-site clinic system serving 325,000 adult patients under the large Atrius Health system umbrella. The QuitWorks paper-based system no longer fit within the streamlined HVMA workflow and required substantial HVMA staff time to manually assign patient identification information to QuitWorks referral forms and reports.
In 2010, Massachusetts launched a fully electronic version of QuitWorks in partnership with the entire Atrius Health/HVMA 21-clinic system, using an interface program that accepts referrals from any electronic health record with patient medical record identification. The interface program also has the capability to transmit feedback reports electronically to the referring provider organization. Once the fully electronic referral system was available, total referrals from Atrius Health to QuitWorks increased markedly. Before the electronic referral launch, Atrius made 279 referrals from October 2009 through March 2010. After the launch, Atrius made 605 referrals during the same 6-month October through March period (Figure 2). October 2009 through March 2011 was a period of increasing referrals to QuitWorks overall. However, the rate of increase of referrals from Atrius sites exceeded the rate of increase from all non-Atrius sites (117% vs 43%). Increases in referrals following implementation of electronic systems may vary because of many factors, including seasonality in quit attempts, a decline in the number of tobacco users over time, or other reasons.
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Figure 2.
QuitWorks referrals 6 months before launch of electronic referrals (October 2009 through March 2010) and the same period 1 year later, 21 Sites, Atrius Health.
Assessing Changes in Referral Sources
Our analysis of referrals trends shows that different types of institutions drove the growth of QuitWorks in each of the 3 periods. Hospitals always have been an important source of referrals, but the proportion of referrals coming from hospitals peaked during the second period, and use by practices expanded in the third period.
The third referral period was marked by an expansion of use to 477 practices, hospitals, clinics, community health and social service providers, and approximately 3,000 unique providers. The proportion of referrals from practices increased in this period from 2% to 13% in response to repetitive low-cost promotions announcing the availability of free nicotine patches, while the proportion of referrals from hospitals declined from 63% to 52%.
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