Background: In rural America, cigarette smoking is prevalent and health care providers lack the time and resources to help\nsmokers quit. Telephone quitlines are important avenues for cessation services in rural areas, but they are poorly integrated with\nlocal health care resources.\nObjective: The intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering\nexpert tobacco treatment at a distance: telemedicine counseling that was integrated into smokersââ?¬â?¢ primary care clinics (Integrated\nTelemedicineââ?¬â?ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes\n(Phone).\nMethods: Smokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly\nassigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling,\nsimilar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered\nthe counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both\ngroups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome\nwas verified 7-day point prevalence smoking abstinence at month 12, using an intent-to-treat analysis.\nResults: There were no significant baseline differences between groups, and the trial achieved 88% follow-up at 12 months.\nVerified abstinence at 12 months did not significantly differ between ITM or Phone (9.8%, 27/280 vs 12%, 34/286; P=.406).\nPhone participants completed somewhat more counseling sessions than ITM (mean 2.6, SD 1.5 vs mean 2.4, SD 1.5; P=.0837);\nhowever, participants in ITM were significantly more likely to use cessation medications than participants in Phone (55.9%,\n128/280 vs 46.1%, 107/286; P=.03). Compared to Phone participants, ITM participants were significantly more likely to recommend\nthe program to a family member or friend (P=.0075). From the combined provider plus participant (societal) perspective, Phone\nwas significantly less costly than ITM. Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions.\nFrom the provider perspective, counseling costs were similar between ITM (US $45.46, SD 31.50) and Phone (US $49.58, SD\n33.35); however, total provider costs varied widely depending on how the clinic space for delivering ITM was valued.\nConclusions: Findings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking.\nITM increased utilization of cessation pharmacotherapy and produced higher participant satisfaction, but Phone counseling was significantly less expensive. Future interventions could combine elements of both approaches to optimize pharmacotherapy\nutilization, counseling adherence, and satisfaction. Such an approach could commence with a telemedicine-delivered clinic office\nvisit for pharmacotherapy guidance, and continue with telephone or real-time video counseling delivered via mobile phones to\nflexibly deliver behavioral support to patients where they most need itââ?¬â?in their homes and communities.
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