|3. Smoking Cessation|
|Smoking-cessation intervention for active smoking in patients with PAD|
|Numerator||Patients identified as tobacco users who have received cessation intervention. |
Cessation intervention may include smoking-cessation counseling (e.g., verbal advice to quit, referral to smoking-cessation program or counselor) and/or pharmacologic therapy.⁎ The type of intervention should be explicitly captured.
|Denominator||All patients age ≥18 y at the start of the measurement period with PAD who are identified as tobacco users.|
PAD is defined as the presence of 1 or more of the following:
■ Critical limb ischemia (ischemic rest pain, nonhealing ischemic ulcers, gangrene)
■ History of vascular reconstruction, bypass surgery, or percutaneous intervention to the extremities
■ Amputation for critical limb ischemia
■ Abnormal noninvasive test (e.g., ankle brachial index, ultrasound, magnetic resonance, or computed tomography imaging demonstrating stenosis in any peripheral artery; i.e., aorta, iliac, femoral, popliteal, tibial, peroneal).
|Period of Assessment||2-y measurement period|
|Sources of Data||Prospective flow sheet, retrospective medical record review, electronic medical record|
|Tobacco smoking is the most potent modifiable risk factor for development of PAD. Continued use of tobacco affects disease progression and graft patency. Smoking status should be assessed at each encounter: patients should be strongly advised to quit, and resources to assist in quitting should be offered. (The 6 A factors should be included: ask, assess, advise, assure, arrange [a follow-up], and applaud).|
|ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (12)|
Individuals with lower extremity PAD who smoke cigarettes or use other forms of tobacco should be advised by each of their clinicians to stop smoking and should be offered comprehensive smoking-cessation interventions, including behavior modification therapy, nicotine replacement therapy, or bupropion. (Level of Evidence: B)*
|This measure should be reported by all clinicians or practices managing patients with cardiovascular disease. The level of “aggregation” (clinician versus practice) will depend upon the availability of adequate sample sizes to provide stable estimates of performance.|
|Method of Reporting|
Whether the PAD patient identified as a tobacco user, received cessation intervention, and the type of cessation intervention that was provided as documented in the medical records.
Per patient population:
Percentage of PAD patients identified as tobacco users who received cessation intervention and a breakdown of the type of cessation intervention that was provided as documented in the medical record.
|Challenges to Implementation|
|■ Lack of documentation or consistency of description of interventions in medical record.|
■ Sample size may preclude reporting of reliable performance estimates, particularly at the clinician level.
PAD indicates peripheral artery disease.
↵⁎ Recent evidence supports the use of varenicline as an adjunct therapy for smoking cessation. For purposes of this measure, use of varenicline, nicotine replacement therapy, or bupropion should all be considered pharmacologic therapy for smoking cessation.