title: Smoking Cessation Counseling Improves Quality of Care and Surgical Outcomes with Financial Gain for a Vascular Practice.
abstract: BACKGROUND
  Cigarette smoking is strongly associated with atherosclerotic disease. It is incumbent on vascular surgeons to provide smoking cessation counseling (SCC) to their patients. The objective of this study was to determine the association of SCC and improvement in quality of care.
  
  
  METHODS
  As a quality project using retrospective data, the study received institutional review board exemption status. A retrospective review of prospectively maintained database from April 2014 through March 2015 of outpatient encounters in a vascular surgery clinic was performed of current smokers. Through the quality support team, providers were encouraged to counsel smokers to quit, document the discussion, and bill specific Evaluate and Management codes (99406 and 99407). The number of outpatients by smoking status, documentation and billing of SCC, demographics of current smokers, and monetary collections were collected. Data were compared using a correlation coefficient calculated and tested for statistical significant using two-tailed t-test.
  
  
  RESULTS
  A sample of 1,077 visits by 612 currently smoking patients accounted for 24% of all outpatient vascular surgery visits. The average age was 61 years, and 64% were male. Comorbidities included 77% with hypertension, 32% with diabetes mellitus, and 14% with chronic kidney disease. Medically, 72% were on aspirin, 71% on statin, and 48% on beta blocker. A total of 208 (34%) never underwent a vascular intervention, and 183 (30%) had an intervention during the study period (44% for peripheral artery disease, 10% for carotid stenosis, 14% amputations, and 10% abdominal aortic aneurysm). Documentation improved from 65% of encounters during the first month to 89% in the peak month and 79% of total encounters. All-cause mortality rate was 2%, and this cohort demonstrated 75% SCC for 28 encounters. Fifty-five patients (9%) quit smoking for more than 30 days at the end of the study period, and this cohort had 69% of their 97 encounters with documented SCC. Increased SCC was correlated with decreased 30-day readmissions during the concurrent month (r = -0.711, P = 0.009) and the following month (r = -0.719, P = 0.008). There was a weak correlation with decreased amputations the following month (r = -0.5, P = 0.08). From a financial perspective, $1,373 was collected for 33 patients with a potential for collection of $7,460 predicted for minimum Medicare payment of 1 visit per patient.
  
  
  CONCLUSIONS
  Advising vascular patients in the arduous process of smoking cessation benefits both the patient and the health system. Proper documentation and billing decreases costs of early readmissions and increases departmental revenue.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA. Electronic address: dam9t@hscmail.mcc.virginia.edu.
authors.forename: D A
authors.initials: DA
authors.lastname: Moses
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
authors.forename: J H
authors.initials: JH
authors.lastname: Mehaffey
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
authors.forename: D V
authors.initials: DV
authors.lastname: Strider
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
authors.forename: M C
authors.initials: MC
authors.lastname: Tracci
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
authors.forename: J A
authors.initials: JA
authors.lastname: Kern
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
authors.forename: G R
authors.initials: GR
authors.lastname: Upchurch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003376:Counseling / Q000191:economics*; D016208:Databases, Factual; D005249:Fees and Charges; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D017064:Process Assessment, Health Care / Q000191:economics*; D058996:Quality Improvement / Q000191:economics*; D019984:Quality Indicators, Health Care / Q000191:economics*; D012189:Retrospective Studies; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects / Q000191:economics; D016540:Smoking Cessation / Q000191:economics* / Q000379:methods; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000175:diagnosis / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics* / Q000401:mortality