title: Comparative and cost effectiveness of telemedicine versus telephone counseling for smoking cessation.
abstract: BACKGROUND
  In rural America, cigarette smoking is prevalent and health care providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services in rural areas, but they are poorly integrated with local health care resources.
  
  
  OBJECTIVE
  The intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering expert tobacco treatment at a distance: telemedicine counseling that was integrated into smokers' primary care clinics (Integrated Telemedicine-ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes (Phone).
  
  
  METHODS
  Smokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling, similar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered the counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both groups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome was verified 7-day point prevalence smoking abstinence at month 12, using an intent-to-treat analysis.
  
  
  RESULTS
  There were no significant baseline differences between groups, and the trial achieved 88% follow-up at 12 months. Verified abstinence at 12 months did not significantly differ between ITM or Phone (9.8%, 27/280 vs 12%, 34/286; P=.406). Phone participants completed somewhat more counseling sessions than ITM (mean 2.6, SD 1.5 vs mean 2.4, SD 1.5; P=.0837); however, participants in ITM were significantly more likely to use cessation medications than participants in Phone (55.9%, 128/280 vs 46.1%, 107/286; P=.03). Compared to Phone participants, ITM participants were significantly more likely to recommend the program to a family member or friend (P=.0075). From the combined provider plus participant (societal) perspective, Phone was significantly less costly than ITM. Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions. From the provider perspective, counseling costs were similar between ITM (US $45.46, SD 31.50) and Phone (US $49.58, SD 33.35); however, total provider costs varied widely depending on how the clinic space for delivering ITM was valued.
  
  
  CONCLUSIONS
  Findings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking. ITM 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 utilization, counseling adherence, and satisfaction. Such an approach could commence with a telemedicine-delivered clinic office visit for pharmacotherapy guidance, and continue with telephone or real-time video counseling delivered via mobile phones to flexibly deliver behavioral support to patients where they most need it-in their homes and communities.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT00843505; http://clinicaltrials.gov/ct2/show/NCT00843505 (Archived by WebCite at http://www.webcitation.org/6YKSinVZ9).
authors.affiliation: University of Kansas Medical Center, Department of Preventive Medicine and Public Health, Kansas City, KS, United States. krichter@kumc.edu.
authors.forename: Kimber P
authors.identifier: http://orcid.org/0000-0002-0351-4336
authors.initials: KP
authors.lastname: Richter
authors.forename: Theresa I
authors.identifier: http://orcid.org/0000-0001-6846-8783
authors.initials: TI
authors.lastname: Shireman
authors.forename: Edward F
authors.identifier: http://orcid.org/0000-0002-7774-2729
authors.initials: EF
authors.lastname: Ellerbeck
authors.forename: A Paula
authors.identifier: http://orcid.org/0000-0002-1423-7063
authors.initials: AP
authors.lastname: Cupertino
authors.forename: Delwyn
authors.initials: D
authors.lastname: Catley
authors.forename: Lisa Sanderson
authors.identifier: http://orcid.org/0000-0002-3345-4178
authors.initials: LS
authors.lastname: Cox
authors.forename: Kristopher J
authors.identifier: http://orcid.org/0000-0003-4099-3636
authors.initials: KJ
authors.lastname: Preacher
authors.forename: Ryan
authors.identifier: http://orcid.org/0000-0001-9396-9360
authors.initials: R
authors.lastname: Spaulding
authors.forename: Laura M
authors.identifier: http://orcid.org/0000-0003-3160-7887
authors.initials: LM
authors.lastname: Mussulman
authors.forename: Niaman
authors.identifier: http://orcid.org/0000-0001-7974-910X
authors.initials: N
authors.lastname: Nazir
authors.forename: Jamie J
authors.identifier: http://orcid.org/0000-0002-1801-2152
authors.initials: JJ
authors.lastname: Hunt
authors.forename: Leah
authors.identifier: http://orcid.org/0000-0002-7084-8942
authors.initials: L
authors.lastname: Lambart
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D001291:Attitude of Health Personnel; D040421:Cell Phone; D003362:Cost-Benefit Analysis; D003376:Counseling / Q000191:economics / Q000379:methods*; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011320:Primary Health Care; D012424:Rural Population; D012907:Smoking / Q000523:psychology / Q000628:therapy*; D016540:Smoking Cessation / Q000191:economics / Q000379:methods* / Q000523:psychology; D017216:Telemedicine / Q000191:economics / Q000379:methods*; D013689:Telephone; D061485:Tobacco Use Cessation Devices; D014029:Tobacco Use Disorder / Q000628:therapy*
keywords: Internet; primary care; rural; smoking cessation, RCT; telemedicine