Based on an audit of Wisconsin Medicaid medical records, researchers found those least likely to be asked about their smoking status were younger patients, patients who were not pregnant and those from rural areas. Just 55 percent of adolescent patients seeing a physician in a two-year period were asked about their smoking status and only five percent of patients' charts included smoking status as a vital sign, a government-backed recommendation.
"Previous studies may have overestimated interventions with adolescents because they were based on physician self report," says Tammy Sims, M.D., M.S., the study's lead author from University of Wisconsin Transdisciplinary Tobacco Use Research Center. "Through analysis of patient charts, we have found that physicians are losing a golden opportunity to intervene with current teen smokers and to dissuade potential smokers among the younger teen population."
Information for the study, published in the journal Health Services Research was gleaned from patient charts randomly selected from Wisconsin Medicaid HMO eligibility files from January 1997 to January 1999. The study, focused on individuals 11 to 21 years old, found that tobacco use was documented on 55 percent of patient charts. Of those documented, 35 percent were current tobacco users (99.3 smokers and 0.7 percent smokeless tobacco users), 8 percent were former smokers and 57 percent had never smoked.
This analysis focused on the high-risk, low-income population enrolled in the Medicaid program. Previous research has indicated that individuals with less education and lower incomes are more likely to start smoking and less likely to quit.
"We chose Medicaid recipients because, given the disproportionate burden of illness caused by tobacco use found in lower income groups, we believed it was important to know what interventions they were receiving," says Sims.
The study found that older adolescents were more likely to have their smoking status recorded than younger adolescents. In fact, the odds of having smoking status documented in their charts increased by 21 percent for every one-year increase in the patient's age. Smoking status was less likely to be recorded in charts of patients from rural areas. Patients in urban or suburban areas were almost twice as likely as rural patients to have smoking status recorded.
"We also saw a failure to address tobacco status at more than one visit," Sims says. "This coupled with their reluctance to ask younger adolescents about smoking status means that physicians were unlikely to identify early experimenters--another missed opportunity."
Pregnant patients fared better than those who were not pregnant-the charts of pregnant patients were almost 10 times more likely to have tobacco use documented than non-pregnant patients. One explanation, in addition to the greater risks associated with smoking during pregnancy, is that prenatal forms such as those from the American College of Obstetrics and Gynecology (ACOG) include reminders prompting a physician to address and document tobacco use in the patient's medical record.
The treatment picture is also somewhat better. Eighty percent of patients who said they had ever used tobacco had a detailed history of their tobacco use recorded in their medical record. Chart records indicated that 50 percent of teen smokers received physician advice to quit and were offered assistance. Counseling was the most common form of assistance offered. No prescriptions for nicotine replacement therapy were documented. Of those offered assistance, 39 percent had follow-up arranged. However, this was only 16 percent of identified smokers.
In terms of exposure to second-hand smoke, only five percent of charts had documentation about this risk. Second-hand smoke was four times more likely to be documented for pregnant patients than non-pregnant ones.
Researchers acknowledge that a gap may exist between what a physician discusses during an office visit and what is written in the patient's medical record. However, paper documentation is vital for reimbursement of services as well as for quality control and medical-legal reasons.
The University of Wisconsin Transdisciplinary Tobacco Use Research Center (TTURC) is one of seven centers funded by the National Cancer Institute and the National Institute on Drug Abuse to investigate new ways of combating tobacco use and nicotine addiction, using an innovative, integrated approach. The Robert Wood Johnson Foundation also funds the TTURCs at these institutions through the Partners with
Tobacco Use Research Centers program. The Partners program supplements the TTURC research by supporting tobacco-related policy research and communications activities.