A behavioral economic intervention to increase psychiatrist adherence to tobacco treatment guidelines: a provider-randomized study protocol

BACKGROUND: People with a psychiatric diagnosis smoke at high rates, yet are rarely treated for tobacco use. Health care systems often use a “no treatment” default for tobacco, such that providers must actively choose (opt-in) to treat their patients who express interest in quitting. Default bias theory suggests that opt-in systems may reinforce the status quo to not treat tobacco use in psychiatry. We aim to conduct a pilot study testing an opt-out system for implementing a 3As (ask, advise, assist) tobacco treatment model in outpatient psychiatry. METHODS: We will use a mixed-methods, cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists at the VA New York Harbor Healthcare System. Psychiatrists (N = 20) will be randomized 1:1 to one of the two groups: (1) opt-in treatment approach—psychiatrists will receive a reminder that encourages them to offer cessation medications and referral to cessation counseling; (2) opt-out treatment approach—psychiatrists will receive a clinical reminder that includes a standing cessation medication order and a referral to cessation counseling that will automatically generate unless the provider cancels. Prior to implementation of the reminders, we will hold a 1-h training on tobacco treatment for psychiatrists in both arms. We will use VA administrative data to calculate the study’s primary outcomes: (1) the percent of smokers prescribed a cessation medication and (2) the percent of smokers referred to counseling. During the intervention period, we will also conduct post-visit surveys with a cluster sample of 400 patients (20 per psychiatrist) to assess psychiatrist fidelity to the 3As approach and patient perceptions of the opt-out system. At 6 months, we will survey the clustered patient sample again to evaluate the study’s secondary outcomes: (1) patient use of cessation treatment in the prior 6 months and (2) self-reported 7-day abstinence at 6 months. At the end of the intervention period, we will conduct semi-structured interviews with 12–14 psychiatrists asking about their perceptions of the opt-out approach. DISCUSSION: This study will produce important data on the potential of opt-out systems to overcome the barriers in implementing tobacco use treatment in outpatient psychiatry. TRIAL REGISTRATION: Clinicaltrials.gov NCT04071795 (registered on August 28, 2019)