Smoking cessation in pregnancy: failure of an HMO pilot project to improve guideline implementation

This pilot project investigated whether a system introduced by a health maintenance organization (HMO) could encourage obstetric providers to implement smoking-cessation guidelines in their offices. Staff from participating offices was trained in cessation counseling and paid $150 for each pregnant smoker counseled. Data were collected from chart review from participating physicians and a telephone survey of all HMO members giving birth before and after program implementation. Eighteen physician practices participated, representing 27 office sites and 80 physicians. Sixty-six staff members were trained in cessation counseling. Chart review revealed that identification of smoking status increased from 90% to 96% (p=0.03), but documentation of advice to quit worsened (62% vs. 24%, p=0.03). The HMO received claims for counseling from four pregnant smokers out of the 21 identified on chart review. The telephone survey revealed a similar prevalence of current smokers in the baseline and post-intervention samples (15% vs. 13%) but more former smokers (11% vs. 22%) in the follow-up. For the HMO as a whole, fewer smokers reported being advised to quit in the follow-up survey (86% vs. 65%). Few smokers reported being counseled to quit at baseline or follow-up (11% vs. 3%). None of the smokers who received obstetric care from a pilot group physician reported awareness of the smoking-cessation benefit despite the placement of brochures in participating offices advertising the program. This pilot project to reimburse for cessation counseling did not increase smoking-cessation advice or counseling in participating physician's offices. Smoking-cessation counseling worsened across the entire HMO obstetric community during the intervention. A more comprehensive systems approach and a larger HMO market share or a partnership among multiple HMOs may be required to increase smoking-cessation guideline implementation.