title: Predictors of Pharmacotherapy for Tobacco Use Among Veterans Admitted for COPD: The Role of Disparities and Tobacco Control Processes.
abstract: Many smokers admitted for chronic obstructive pulmonary disease (COPD) are not given smoking cessation medications at discharge. The reasons behind this are unclear, and may reflect an interplay of patient characteristics, health disparities, and the receipt of inpatient tobacco control processes.
  
  
  
  We aimed to assess potential disparities in treatment for tobacco use following discharge for COPD, examined in the context of inpatient tobacco control processes.
  
  
  
  Smokers aged ≥ 40 years, admitted for treatment of a COPD exacerbation within the VA Veterans Integrated Service Network 20, identified using ICD-9 discharge codes and admission diagnoses from 2005-2012.
  
  
  
  The outcome was any tobacco cessation medication dispensed within 48 hours of discharge. We assessed potential predictors administratively up to 1 year prior to admission. We created the final logistic regression model using manual model building, clustered by site. Variables with p < 0.2 in biviariate models were considered for inclusion in the final model.
  
  
  
  We identified 1511 subjects. 16.9 % were dispensed a medication at discharge. In the adjusted model, several predictors were associated with decreased odds of receiving medications: older age (OR per year older 0.96, 95 % CI 0.95-0.98), black race (OR 0.34, 95 % CI 0.12-0.97), higher comorbidity score (OR 0.89, 95 % CI 0.82-0.96), history of psychosis (OR 0.40, 95 % CI 0.31-0.52), hypertension (OR 0.75, 95 % CI 0.62-0.90), and treatment with steroids in the past year (OR 0.80, 95 % CI 0.70-0.90). Inpatient tobacco control processes were associated with increased odds of receiving medications: documented brief counseling at discharge (OR 3.08, 95 % CI 2.02-4.68) and receipt of smoking cessation medications while inpatient (OR 5.95, 95 % CI 3.19-11.10).
  
  
  
  Few patients were treated with tobacco cessation medications at discharge. We found evidence for disparities in treatment, but also potentially beneficial effects of inpatient tobacco control measures. Further focus should be on using novel processes of care to improve provision of medications and decrease the observed disparities.
authors.affiliation: Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA. acmelzer@uw.edu.|Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA. acmelzer@uw.edu.
authors.forename: Anne C
authors.initials: AC
authors.lastname: Melzer
authors.affiliation: Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA.|Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA.
authors.forename: Laura C
authors.initials: LC
authors.lastname: Feemster
authors.affiliation: Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA.
authors.forename: Margaret P
authors.initials: MP
authors.lastname: Collins
authors.affiliation: Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA.|Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA.
authors.forename: David H
authors.initials: DH
authors.lastname: Au
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D054625:Healthcare Disparities; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D029424:Pulmonary Disease, Chronic Obstructive / Q000209:etiology / Q000628:therapy*; D012680:Sensitivity and Specificity; D012907:Smoking / Q000009:adverse effects*; D016540:Smoking Cessation / Q000379:methods* / Q000706:statistics & numerical data; D061485:Tobacco Use Cessation Devices / Q000706:statistics & numerical data*; D014029:Tobacco Use Disorder / Q000150:complications / Q000188:drug therapy; D014481:United States; D014728:Veterans / Q000706:statistics & numerical data
keywords: COPD; disparities; nicotine replacement; pharmacotherapy; processes of care; smoking; tobacco