a b s t r a c t

Background: Emergency Department Observation Unit (EDOU) patients with chest pain have a high prevalence of smoking, a key cardiovascular disease risk factor. While in the EDOU, there is an opportunity to initiate smoking cessation therapy (SCT), but this is not standard practice. This study aims to describe the missed opportunity for EDOU-initiated SCT by determining the proportion of smokers who receive SCT in the EDOU and within 1-year of EDOU discharge and to evaluate if SCT rates vary by race or sex.

Methods: We performed an observational cohort study of patients >=18 years old being evaluated for chest pain in a tertiary care center EDOU from 3/1/2019-2/28/2020. Demographics, smoking history, and SCT were deter- mined by electronic health record review. Emergency, Family Medicine, internal medicine, and cardiology records were reviewed to determine if SCT occurred within 1-year of their initial visit. SCT was defined as behavioral in- terventions or pharmacotherapy. Rates of SCT in the EDOU, 1-year follow-up period, and the EDOU through 1- year of follow-up were calculated. SCT rates from the EDOU through 1-year were compared between white vs. non-white and male vs. female patients using a multivariable logistic regression model including age, sex, and race.

Results: Among 649 EDOU patients, 24.0% (156/649) were smokers. These patients were 51.3% (80/156) female and 46.8% (73/156) white, with a mean age of 54.4 +- 10.5 years. From the EDOU encounter through 1-year of follow-up, only 33.3% (52/156) received SCT. In the EDOU, 16.0% (25/156) received SCT. During the 1-year follow-up period, 22.4% (35/156) had outpatient SCT. After adjusting for potential confounders, SCT rates from the EDOU through 1-year were similar among whites vs. non-whites (aOR 1.19, 95% CI 0.61-2.32) and males vs. females (aOR 0.79, 95% CI 0.40-1.56).

Conclusions: SCT was rarely initiated in the EDOU among chest pain patients who smoke and most patients who did not receive SCT in the EDOU never received SCT at 1-year of follow-up. Rates of SCT were similarly low among race and sex subgroups. These data suggest an opportunity exists to improve health by initiating SCT in the EDOU.

(C) 2023

1. Introduction

Smoking is associated with one in every five deaths in the United States (US) [1,2]. It is also associated with significant morbidity, including coro- nary heart disease (CHD), stroke, cancer, diabetes, and chronic obstructive

* Corresponding author at: Department of Emergency Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.

E-mail address: [email protected] (N.P. Ashburn).

pulmonary disease [1,2]. Each year, the US spends approximately $240 bil- lion on smoking-related Healthcare costs [3]. The US Preventive services Task Force (USPSTF) recommends that clinicians ask all adults about smoking use, advise patients who smoke to stop, and offer behavioral interventions and pharmacotherapy to support cessation efforts [4].

There are >6.5 million annual Emergency Department (ED) encoun- ters for acute chest pain, the most common presenting symptom of CHD [5,6]. Given that smoking is a key risk factor for CHD and that ED pa- tients with chest pain have a high prevalence of smoking, the ED and

https://doi.org/10.1016/j.ajem.2023.02.033

0735-6757/(C) 2023

ED-based Observation Units (EDOUs) may be well-positioned to improve health and mitigate CHD risk by offering smoking cessation therapy (SCT) [7]. Recognizing the potential public health impact of ED-based SCT, the Society for Academic Emergency Medicine and the American College of Emergency Physicians recommend that emergency providers evaluate patient smoking status and offer SCT [8-11]. ED patients with chest pain frequently receive lengthy testing in an Emer- gency Department Observation Unit (EDOU) [7,12,13]. While receiving testing to evaluate for CHD, EDOU patients may be amenable to receiv- ing Preventive care, such as SCT [14-16]. However, it is not usual prac- tice to initiate EDOU-based SCT [12,17,18]. Traditionally, EDOU-based SCT has been deferred due to the focus on acute care and the perceived lack of time for preventive care services [9,19]. Therefore, at the time of EDOU discharge, patients are typically instructed to follow-up with their primary care physician or cardiologist, with the assumption that SCT will be provided outpatient. However, it is unclear whether these patients ultimately receive SCT as an outpatient. Furthermore, non-white and female patients are less likely to receive preventive cardiovascular care services for risk factors like hyperlipidemia and hypertension [20-23]. But, it is unknown if these groups are also less likely to receive SCT.

Therefore, the goal of this study is to determine whether a missed opportunity for EDOU-initiated SCT exists among patients with chest pain and if so, to determine the magnitude of this opportunity. If pa- tients do not receive SCT in the EDOU, do they ultimately receive SCT as an outpatient? Or is the EDOU missing an opportunity to improve health by failing to initiate SCT? To address this key evidence gap, this study sought to determine the proportion of patients who receive SCT in the EDOU during their initial visit and within 1-year of EDOU dis- charge. A secondary objective was to determine if EDOU or outpatient SCT rates vary by race or sex.

1. Methods
   1. Study design

We conducted a retrospective observational cohort study of patients being evaluated for chest pain in the EDOU of a large academic medical center from 3/1/2019 to 2/28/2020. The Wake Forest University Health Sciences Institutional Review Board approved the study protocol and granted a waiver of informed consent. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines helped direct the research and reporting processes [24].

• 1. Study setting and population

This study included patients >=18 years old with chest pain receiving care in the EDOU for possible acute coronary syndrome at a single ter- tiary care center. Patients with ST-segment elevation myocardial infarc- tion, hemodynamic instability (heart rate <40 or >120 beats per minute, systolic blood pressure <90 mmHg, or SpO2% <90% on room air or normal home oxygen flow rate), high sensitivity cardiac troponin I (Beckman Coulter; Brea, CA) >=100 ng/L, or trauma were not eligible for EDOU care. The EDOU chest pain protocol is available in Supplemental Appendix 1. The EDOU in this study is a type 1, protocol-driven observa- tion unit. The EDOU is managed by emergency medicine physician as- sistants and nurse practitioners who are supervised by board-certified emergency physicians. During the study period, no formal SCT training was provided. Patients undergo serial Troponin testing, telemetry mon- itoring, and when appropriate receive Stress testing or coronary com- puted tomography angiography.

• 1. Data collection and variables

Index Encounter data (from initial ED presentation to discharge from the EDOU) through 1-year of outpatient follow-up were abstracted

from the electronic health record (EHR; Clarity-Epic Systems Corpora- tion, Verona, WI) by trained data abstractors. Outpatient follow-up in- cluded any primary care or specialty visit. Smoking status, sex, race, and medication use were self-reported by patients. Patients were con- sidered current smokers if they smoked within 90-days of their ED en- counter, regardless of packs per day. Data were entered into a Research Electronic Data CAPture (REDCap) database. Best practice guidelines for the chart review were used, including having trained data extractors, variable definitions as well as a data dictionary, digital extraction forms within REDCap, and having regular performance re- view by the principal investigator (PI) [25,26]. Training consisted of in-person instruction with the PI, where actual encounters were re- viewed to ensure familiarity with where and how to access the relevant data in the EHR and how to input the data into REDCap.

• 1. Outcomes

Consistent with USPSTF guidelines, SCT was defined as the compos- ite of any provider-to-patient smoking behavioral intervention or phar- macotherapy [4]. Behavioral interventions included EDOU or outpatient counseling, including any documented conversation regarding cessa- tion. Pharmacotherapy was defined as any of the seven US Food and Drug Administration approved agents: varenicline, bupropion, or the five forms of nicotine replacement therapy (patch, gum, lozenge, nasal spray, or inhaler) [4]. A missed opportunity for EDOU-based SCT was de- fined as a smoker who did not receive any form of SCT during the EDOU encounter or in the Outpatient setting.of any Medical specialty during the 1-year follow-up period.

• 1. Statistical analysis

Counts, percentages, and means with standard deviations were used to describe the study population. Rates of SCT during the index EDOU encounter, the 1-year outpatient follow-up period, the 1-year of follow-up period inclusive of the EDOU encounter, and the missed op- portunity for EDOU-based SCT were calculated and reported along with exact 95% confidence intervals (95% CI). For patients who received SCT, rates of counseling and pharmacotherapy were also reported. Fish- er’s exact tests were used to compare SCT rates during the index EDOU encounter, the 1-year outpatient follow-up period, and the EDOU en- counter through 1-year of follow-up between white vs. non-white and male vs. female patients. To further evaluate the association of race and sex with SCT, univariable and multivariable logistic regression was performed. Multivariable models included age (continuous), race (white vs. non-white), and sex (male vs. female). Unadjusted and adjusted odds ratios (aOR) with corresponding 95% CIs were calculated.

1. Results

During the study period, there were 649 EDOU patients who received care for chest pain. Among these, 24.0% (156/649) were cur- rent smokers, 27.6% (179/649) previously smoked, and 48.4% (314/ 649) never smoked. Of the current smokers, 51.3% (80/156) were female and 46.8% (73/156) were white, with a mean age of 54.4 +-

10.5 years. Table 1 describes the demographics of patients who did and did not receive SCT within 1-year of the EDOU encounter.

There was a missed opportunity for EDOU-based smoking cessation in 66.7% (104/156, 95% CI: 59.3-74.0%) of smokers. These patients did not receive any form of SCT in the EDOU or the 1-year outpatient follow-up period. For the 33.3% (52/156) with SCT in the EDOU or 1- year outpatient period, 86.5% (45/52) received counseling and 32.7% (17/52) pharmacotherapy. Index EDOU SCT was provided for 16.0% (25/156, 95% CI 10.7-22.7%). Among these, 64.0% (16/25) had counsel- ing and 40.0% (10/25) pharmacotherapy. During the 1-year outpatient follow-up period, 22.4% (35/156, 95% CI 16.2-29.8%) received SCT, consisting of 100% (35/35) with counseling and 20% (7/35) with

Table 1

Cohort characteristics.

Patient Characteristics

	n = 52, n (%)	n = 104, n (%)	n (%)
Age (mean +- SD) (years)	54.9 (8.7)	54.1 (11.3)	54.4 (10.5)
Sex
Female Race	29 (58.0)	51 (48.1)	80 (51.3)

Smoking Cessation Therapy within 1-Year

No Smoking Cessation Therapy within 1-Year

Total

n = 156,

1. Discussion

This analysis demonstrates that a large missed opportunity for EDOU-based SCT exists. Nearly 70% of smokers did not receive any form of SCT within 1-year of their EDOU visit. Few smokers were pro- vided SCT in the EDOU, and those who did not receive SCT in the EDOU were unlikely to receive any form of outpatient SCT within the following year. Given that ED patients who smoke are not receiving out- patient SCT, the ED may be an appropriate place to fill this gap in poten-

White	26 (50.0)	47 (45.2)	73 (46.8)	tially life-saving preventive care [27-29].
Black	24 (46.2)	49 (47.1)	73 (46.8)	Nearly 25% of our cohort of chest pain patients currently smoke,

is associated with multiple favorable health outcomes, including

Other Ethnicity	2 (3.9)	8 (7.7)	10 (6.4) which is well above the national 15% average [1,2]. Smoking cessation
Hispanic or Latino	0 (0)	6 (5.8)	6 (3.9) decreased rates of premature death and tobacco-related illnesses

Comorbidities Obesity (BMI

>=30 kg/m²)

Diabetes	13 (25.0)	31 (29.8)	44 (28.2)
Hyperlipidemia	28 (53.9)	45 (43.3)	73 (46.8)

31 (59.6) 51 (49.0) 82 (52.6)

[27-29]. Patients who quit smoking may recover up to 10 years of Life expectancy [27]. Recognizing the potential massive public health im- pact, emergency medicine professional organizations advocate for SCT in the Emergency care setting [8-10]. However, providing preventive

Hypertension	43 (82.7)	73 (70.2)	116 (74.4)	care in the ED itself may be challenging. The ED focuses on acute care
CAD	4 (7.7)	12 (11.5)	16 (10.3)	and often suffers from high volumes, Staffing shortages, budget con-
Stroke	6 (11.5)	9 (8.7)	15 (9.6)	straints, and lack of time [9,19]. To bridge this gap in care, EDOUs

SD - standard deviation, BMI - body mass index, CAD - coronary artery disease.

pharmacotherapy. At 1-year, 33.3% (52/156, 95% CI 10.7-22.7%) re- ceived SCT either in the EDOU or as an outpatient. Fig. 1 demonstrates the missed opportunity for EDOU-based SCT as well as the proportion of patients who received SCT.

Rates of SCT from the EDOU encounter through 1-year of outpatient follow-up were similar among white vs. non-white [35.6% (26/73) vs. 31.3% (26/83); OR 1.21, 95% CI 0.62-2.36; p = 0.61] and male vs. female patients [30.3% (23/76) vs. 36.3% (29/80); OR 0.76, 95% CI 0.39-1.49;

p = 0.50]. After adjustment, white and non-white patients had similar SCT rates (aOR 1.19, 95% CI 0.61-2.32) as did Males and females (aOR 0.79, 95% CI 0.40-1.56). Table 2 shows the unadjusted and adjusted ORs.

Fig. 1. Missed opportunity for EDOU-initiated smoking cessation therapy.

could be used to provide preventive care services, such as SCT [30]. The EDOU may be a quieter, more private care setting with fewer dis- tractions and time pressures than the ED.

Despite the seeming advantages of EDOU-initiated SCT, there is a paucity of data evaluating the effectiveness of SCT started in the EDOU. A single EDOU-based randomized controlled trial exists and found that a tailored intervention with motivational interviewing, tele- phone follow-up, and nicotine replacement therapy was associated with increased smoking cessation at 1-month. However, due to a high rate of relapse, this effect was not observed at 6-months [31]. ED- based SCT has been more thoroughly evaluated than EDOU-based SCT. A 2014 systematic review of 13 trials found that ED-based SCT was asso- ciated with higher cessation rates than the national average [32]. How- ever, due to high relapse rates, effectiveness conclusions were mixed. These data suggest that future EDOU- or ED-based initiated SCT programs may need to be paired with outpatient programs to continue supporting these patients, in order to achieve long-term smoking cessation.

Previous literature suggests that there may be race and sex-based disparities in SCT rates [33,34]. Historically, white patients and females use pharmacotherapy more than non-white patients and males. However, in this study, no statistical different in SCT rates was found be- tween subgroups in the EDOU or during the 1-year follow-up period. However, from the EDOU encounter through 1-year of follow-up, 5% more white patients and 6% more females received SCT. This potentially clinically significant difference may not have been detected due to lack of power given the limited sample size, suggesting the need for future, more rigorous evaluation of potential disparities.

1. Limitations

This study has limitations. It was conducted at a single site and among a select group of patients with chest pain. Therefore, results may not be generalizable to other EDOUs, care settings, or patient pop- ulations. Data were retrospectively collected using the EHR of a single healthcare system. It is possible that patients received SCT in an outside healthcare system. Therefore, this study is at risk for misclassification bias. It is also possible that SCT for smoking occurred without being doc- umented by the treating provider. It is unknown if patients stopped smoking at any point during the study period, thus prohibiting any in- ferences regarding EDOU SCT efficacy. Some forms of nicotine replace- ment therapy are available over the counter. Use of these medications may not have been recorded in the EHR. Additionally, precision and power to detect differences was limited by the sample size.

Table 2

Rates of SCT among white vs. non-white and male vs. female patients.

	White N = 73 n (%)	Non-white N = 83 n (%)	Unadjusted OR (95%CI)	Adjusted OR1 (95%CI)
Index EDOU	13 (17.8)	12 (14.5)	1.28 (0.54-3.02)	1.28 (0.54-3.03)
1-Year Outpatient Follow-up	15 (20.6)	20 (24.1)	0.82 (0.38-1.74)	0.80 (0.37-1.72)
EDOU through 1-Year of Follow-up	26 (35.6)	26 (31.3)	1.21 (0.62-2.36)	1.19 (0.61-2.32)
	Male N = 76 n (%)	Female N = 80 n (%)	Unadjusted OR (95%CI)	Adjusted OR2 (95%CI)
Index EDOU	12 (15.8)	13 (16.3)	0.97 (0.41-2.28)	0.98 (0.41-2.34)
1-Year Outpatient Follow-up	16 (21.1)	19 (23.8)	0.86 (0.40-1.82)	0.90 (0.42-1.94)
EDOU through 1-Year of Follow-up	23 (30.3)	29 (36.3)	0.76 (0.39-1.49)	0.79 (0.40-1.56)

EDOU - Emergency Department Observation Unit, OR - odds ratio.

¹ Adjusted for age (continuous) and sex (male vs. female).

² Adjusted for age (continuous) and race (white vs. non-white).

1. Conclusion

This EDOU-based analysis shows that emergency providers are missing a large opportunity to improve health because very few smokers receive SCT in the outpatient setting. Few smokers received SCT in the EDOU during their initial visit and outpatient SCT within 1- year was rare. The lack of outpatient SCT highlights the opportunity for EDOU providers to improve health and mitigate cardiovascular dis- ease risk by initiating SCT. Future investigations into patient and pro- vider receptiveness to EDOU-based SCT, determining how to best deliver SCT in the EDOU, as well as evaluating if EDOU-based SCT is effective are needed.

Funding

None.

CRediT authorship contribution statement Nicklaus P. Ashburn: Writing - review & editing, Writing - original

draft, Visualization, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptual- ization. Anna C. Snavely: Writing - review & editing, Visualization, Su- pervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Rishi R. Rikhi: Writing - review & editing, Investiga- tion, Formal analysis, Data curation, Conceptualization. Michael A. Chado: Writing - review & editing, Methodology, Investigation, Data curation. Weston B. Colbaugh: Writing - review & editing, Methodol- ogy, Investigation, Data curation. Greg R. Noe: Writing - review & editing, Investigation, Data curation. Ian J. Kinney: Writing - review & editing, Investigation, Data curation. Ryan J. Morgan: Writing - review & editing, Investigation, Data curation. Jason P. Stopyra: Writing - review & editing, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization. Simon A. Mahler: Writ- ing - review & editing, Visualization, Supervision, Resources, Project administration, Methodology, Investigation, Conceptualization.

Conflicts of interest

Dr. Ashburn receives funding from NHLBI (T32HL076132).

Dr. Snavely receives funding from Abbott and HRSA (1H2ARH399760100).

Dr. Rikhi receives funding from NHLBI (T32HL076132).

Dr. Stopyra receives research funding from NCATS/NIH (KL2TR001421), HRSA (H2ARH39976-01-00), Roche Diagnostics, Ab-

bott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici.

Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, Ortho Clinical Diagnostics, Siemens, Grifols, Pathfast, Quidel, Genetesis, Cytovale, and HRSA (1H2ARH399760100). He is a consultant for Roche, Quidel, Abbott, Genetesis, Inflammatix, Radiome- ter, and Amgen and is the Chief medical officer for Impathiq Inc.

The other authors report no conflicts.

Acknowledgements

We would like to thank Ravenna Chhabria, Benjamin Brendamour, Philip Kayser, and Alexander Ambrosini for their assistance with data collection.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2023.02.033.

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