Transcript Quality Improvement

YOU QUIT, TWO QUIT:
IMPROVING THE QUALITY OF TOBACCO
SCREENING & TREATMENT FOR
WOMEN OF REPRODUCTIVE AGE
Erin McClain, MA, MPH
November 7, 2014
[email protected]
Center for Maternal and Infant Health
The University of North Carolina at Chapel Hill
Disclosures
2


I have no relevant financial relationships with the
manufacturers of any products and/or providers
of commercial services discussed in this activity.
I do not intend to discuss an unapproved or
investigative use of a commercial product/device
in my presentation.
Overview
3
Tobacco Use by Women of Reproductive Age
 Behavior Change and The 5 As
 Helping Those Who Aren’t Ready: The 5Rs
 Post-Partum Relapse Prevention
 Pharmacotherapy During Pregnancy & Lactation
 Lessons Learned from the YQ2Q Quality
Improvement Initiatives

4
Tobacco Use and Women of
Reproductive Age
Women & Tobacco Use in WV
5
Percentage

2012 BRFSS survey found that 27.6% of women in WV report current
tobacco use
 Proportion is higher among reproductive age women, low-income
women, and women with less than a high school education
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Tobacco Use During Pregnancy
6


Nationally, 8.9% of babies are born to women who
report smoking during pregnancy.
WV has the highest rate of tobacco use during
pregnancy in the US at 26.3% - over 1 in 4 babies are
born to women who smoke.
 Ranges
from a low of 15.7% (Putnam Co) to a high of
44.2% (Wirt Co)
 65% of counties (n=36) have rates that are higher than the
statewide average
Tobacco Use Causes Poor Birth & Infant Outcomes
7
Maternal/Fetal Harm From Tobacco
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Infertility
Miscarriage
Ectopic Pregnancy
Premature Birth
Low Birth Weight
Stillbirth
SIDS
Infant/Child Harm From Tobacco
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SIDS
Ear infections
Respiratory Infections
Asthma
Links with childhood
obesity, cancer,
attention disorders
Tobacco use during pregnancy is directly associated with
the top 4 causes of infant mortality
A Public Health Priority
8
Helping pregnant smokers and
women of childbearing age to
quit using tobacco products should
be a top public health priority for
all of us.
9
Behavior Change & the 5 As/5Rs
Intervention Makes A Difference
10

Brief counseling works better than simple advice to quit

Pregnancy is a particularly good time to intervene

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Brief counseling with self-help materials offered by a
trained clinician can double a smoker’s chances of
quitting for good.
Brief counseling works best for moderate smokers
(<20 cigarettes/day)
 Heavy
smokers may need more intensive assistance and/or
pharmacotherapy to quit
The 5 As: Evidence-Based, Best
Practice Intervention
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
ASK the patient about her smoking status

ADVISE her to quit smoking with personalized
messages for pregnant and parenting women

ASSESS her willingness to quit in next 30 days

ASSIST with (pregnancy- and parent-specific, if
applicable) self-help materials & social support

ARRANGE to follow-up during subsequent visits
5As Algorithm
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Step 1: Ask—1 Minute
13
Ask your pregnant clients:
Which of the following statements best describes your
cigarette smoking?
A. I have NEVER smoked or have smoked less than 100 cigarettes in
my lifetime.
B. I stopped smoking BEFORE I found out I was pregnant and am
not smoking now.
C. I stopped smoking AFTER I found out I was pregnant, and I am
not smoking now.
D. I smoke some now, but have cut down since I found out I am
pregnant.
E. I smoke about the same amount now as I did before I found out I
was pregnant.
Screening for Second-Hand Exposure
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Questions for Adults:
1) Does anyone smoke in your home?
2) Does anyone smoke in your car?
3) Is smoking allowed in your workplace?
Screening for Second-Hand Exposure
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Questions for Parents/Caretakers of Children:
1) Does the mother smoke?
If yes, in the home? In the car?
2) Does the father smoke?
If yes, in the home? In the car?
3) Is the child exposed to tobacco smoke on a
regular basis (at least once a week) by
anyone other than the parents?
Step 2: Advise —1 Minute
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Clear, strong, personalized advice to quit
Clear: “My best advice for you and your baby is for
you to quit smoking.
Strong: “I need you to know that quitting smoking is
one of the most important things you can do to
protect your baby and your own health.”
Personalized: Impact of smoking on the baby, the
family, and the patient’s well being
Step 3: Assess—1 Minute
17

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Assess the patient’s willingness to quit within the next
30 days.
If a patient responds that she would like to try to
quit within the next 30 days, move on to the Assist
step.
If the patient does not want to try to quit, use the 5
Rs to try to increase her motivation.
Step 4: Assist—3+ Minutes
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Suggest and encourage the use of problemsolving methods and skills for tobacco cessation
Provide social support as part of the treatment
Arrange social support in the patient’s
environment
Provide (pregnancy- and parent-specific, if
applicable) self-help tobacco cessation
materials
Provide a proactive fax referral to the Quitline
Step 5: Arrange—1+ Minute
19

Follow up to monitor progress and provide
support

Encourage the patient

Express willingness to help

Ask about concerns or difficulties

Invite her to talk about her success
Helping Those Who Aren’t Ready:
The 5 Rs
20

RELEVANCE: Help patient figure out the relevant reasons
to quit, based on their health, environment, individual
situation

RISKS: Encourage patient to identify possible negative
outcomes to continuing to use tobacco

REWARDS: Encourage patient to identify possible benefits
to quitting

ROADBLOCKS: Work with patient to identify obstacles to
quitting and potentially how to overcome them

REPETITION: Address the 5Rs with patients at each visit
21
Preventing Postpartum Relapse
Epidemiology
22

65-80% of women who quit smoking
during pregnancy start smoking again
before the baby is one year old
45%
at 2-3 months postpartum
60-70% at 6 months
As much as 80% at one year
Postpartum Relapse: Common Causes
23
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Return of triggers (caffeine, alcohol)
Smoking spouse, family & friends
Sleep deprivation, increased stress
Weight concerns
Less social pressure to stay quit
Underdeveloped coping strategies &
overconfidence
Time limited restriction on tobacco use during
pregnancy - not intentional behavior change
Postpartum Relapse:
Prevention Strategies
24

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Begin relapse prevention counseling and skills
building toward the end of pregnancy
Focus on benefits of quitting for the woman
Highlight harms associated with secondhand
smoke for infant
Involve pediatric providers, including well-child,
WIC, early intervention, etc.
Helpful Messages
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Information on behavioral and mental coping skills
Exercises regarding triggers to smoke
Messages preparing them for withdrawal
Reminders of why they quit
Emphasizing negative health effects for both mom
and baby, including ETS exposure
Information on weight loss in the postpartum period
Ways to spend money saved
Establishing a non-smoking support system
Focusing on new role as mother Quinn, et al Mat& Child Health 2006
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Pharmacotherapy During Pregnancy
& Lactation
FDA-Approved Pharmacotherapies
for Adults
Nicotine Replacement Products
All forms of NRT are Pregnancy Category D
•Nicotine Patch
• Nicotine Gum
• Lozenge
• Nicotine Nasal Spray
• Nicotine Inhaler
Non-Nicotine Prescription Medications
• Bupropion SR (Zyban) (Pregnancy Category C)
• Varenicline (Chantix) (Pregnancy Category C)
Public Health Service Guidelines
• Non-pregnant adults are more likely to quit when
using a combination of brief counseling and
pharmacotherapy
•Behavioral intervention is first-line treatment in
pregnant women
o Pharmacotherapy has not been sufficiently tested for
efficacy or safety in pregnant patients
•May be necessary for heavy smokers
Nicotine Replacement & Lactation
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
Nicotine Patch (non-prescription)
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Nicotine Gum/Lozenge (non-prescription)
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Constant dose
21 mg transdermal patch results in nicotine equivalent to smoking 17 cigarettes
daily passing into breastmilk
7mg & 14mg patches result in proportionately lower amounts in breastmilk
Amount of nicotine that passes into breastmilk is variable, depending on the
amount chewed/dissolved
Nicotine Inhaler (prescription only)

Maternal plasma concentrations are about 1/3 of those of smokers, so
breastmilk concentrations are probably proportionately less as well
Nicotine. LACTMED: Drug and Lactation Database. National Institutes of Health. Available from:
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~rogZ0Y:1
Bupropion and Varenicline During
Lactation
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
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Bupropion (Zyban, Wellbutrin)
 Lactation risk category: L3 – Moderately Safe
 AAP: Drugs whose effect on nursing infants is unknown but may be of concern
 Peak milk level occurs 2 hrs after a 100mg dose – this milk level provides 0.66%
of the maternal dose
 Anecdotal reports of reduction in milk supply after beginning bupropion
 Should not be used in mothers and infants prone to seizures
Varenicline (Chantix)
 Lactation risk category: L4 – Possibly Hazardous
 AAP: Not reviewed
 Very little information available
 There are concerns about its long half-life (24 hrs)
 In animal studies, the drug was transferred to nursing pups
Hale T. Medications and Mothers’ Milk 2008. Hale Publishing, 2008
Chantix Prescribing Information. Available from http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/021928s007lbl.pdf
Buproprion and Chantix. Medication and Mothers Milk Discussion Forum. Available from: http://neonatal.ama.ttuhsc.edu/cgi-bin/discus/discus.cgi
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Tobacco Use in North Carolina
Women & Tobacco Use in NC
32

50
45
40
Percentage
35
30
25
20
15
10
5
0
2012 BRFSS survey found that 19.3% of women in NC report current
tobacco use
 Proportion is higher among low-income women and women with less than
a college education
Tobacco Use During Pregnancy in NC
33
Over 1 in 10
babies in NC are
born to women
reporting tobacco
use during
pregnancy.
In some counties
over 30% of babies
are born to women
who smoked.
34
You Quit, Two Quit QI Initiative
YQ2Q: 2008-2011
35


Funded by the NC Health & Wellness Trust Fund
Worked with 4 county Health Departments to
implement tobacco use screening and cessation
counseling with any provider who came in contact
with a pregnant women or the mother of a child up to
age 1, including:
 Prenatal
 Postpartum Home Visitor
 Maternity Care
Coordinators
 Family Planning
 Child Health
 WIC
 Child Service
Coordinators
 Health educators
YQ2Q: 2011 - 2013
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

Funded by US DHHS Office of Women’s Health
With Community Care of the Lower Cape Fear,
implemented tobacco use screening & treatment
for low income women of childbearing age (incl.
pregnant and postpartum women) in a 6-county
area of southeastern NC
1
mid-sized city – Wilmington, NC, & 1 small city –
Jacksonville, NC
 Urban areas surrounded by rural countryside that
traditionally grows tobacco
Quality Improvement Approach
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

Followed a QI approach, using evidence-based
interventions as outlined in the USPHS’ Guideline Treating
Tobacco Use and Dependence – 2008 Update
Implementation model was provided by the USDHHS OWH
to test, and included the following steps:
1. Assess Current Status
6. Establish Linkages (external)
2. Identify Champion/ Leader(s)
7. Provide Training
3. Plan Data Collection and
8. Deliver Interventions
Evaluation
9. Assess/Evaluate Program
4. Determine Funding/
10. Ensure Sustainability
Reimbursement
5. Formulate Policies & Internal Links
Participating Practices
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
8 practices - 16 clinical sites
5

3


practices solely provided primary care
Internal Medicine & Family Medicine practices
provided primary care & OB care
Family Medicine & Obstetric practices
All of the practices that provided OB were designated Pregnancy Medical
Homes, and Medicaid-insured OB patients had access to RN or social work
Care Managers
Selected practices saw high numbers of uninsured
and/or Medicaid-insured women
 Included private practices, residency clinic, FQHC,
teen clinic, health department, rural health clinic

Providers Trained
39

Over 300 people trained, including:
 Clinic
Providers - MDs, DOs, NPs, PAs, RNs
 Care Managers, Social Workers, and other Behavioral
Health providers
 Office staff and other support staff

Training modalities included in-person and webbased training (webinars and self-paced training),
followed by in-person and telephonic technical
assistance
Content of the Training
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5As brief counseling intervention
Motivational interviewing techniques
Information about QuitlineNC
Pharmacotherapy, including during pregnancy and
lactation
Billing and reimbursement, including CPT codes,
reimbursement rates, and other FAQs
How to access and use tobacco cessation patient
education materials
How to help those who are not ready to quit – harm
reduction and the 5Rs
Implementation Planning
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The Local Project Coordinator – based in the CCLCF office in
Wilmington, NC – helped the practices operationalize the training
and:
 Evaluate their current screening & treatment policies and
procedures for tobacco use

None of the practices were fully implementing consistent,
coordinated screening and treatment across all providers & clinics
Determine roles and responsibilities for each staff position as
related to tobacco use screening & treatment
 Decide how best to document tobacco use and cessation
assistance


Crucial for those with EHRs or transitioning from paper charts to
EHRs
QI Initiative
42

6 months between May – December 2012

Providers agreed to:
 Screen
18-44 year old female patients using a validated,
structured question
 Treat those currently using tobacco by employing the 5As
and, where appropriate, pharmacotherapy
 Document use of the 5As and any other cessation assistance
provided
 Allow the Local Project Coordinator to conduct chart audits at
3 and 6 months.
43
QI Results
Target Population Screened &
Identified as Currently Using Tobacco
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
Non-Pregnant Reproductive Age Women (18-44 yrs)
 1,599
patients in the target population seen by the practices
 97% of target patients received documented screening for
tobacco use (n=1,548)
 50% were current tobacco users (n=776)

Pregnant Women (18-44 yrs)
 408
patients in the target population seen by the practices
 100% of target patients received documented screening for
tobacco use
 15% were current tobacco users (n=61)
Documented Cessation Counseling Provided to
Non-Pregnant Female Tobacco Users (n=776)
45
100
90
80
Percentage
70
60
50
40
30
20
10
0
Advised to Quit
Assessed for Readiness to Patient Accepted Referral
Quit
to Clinic/Community
Resources*
*Included patients not yet ready to quit
Documented Readiness to Quit –
Non-Pregnant Female Tobacco Users (n=776)
46
Not Ready to
Quit or Cut Back
(n=478)
17%
21%
Ready to Quit
(n=163)
62%
Ready to Cut
Back (n=135)
Documented Cessation Counseling Provided to
Pregnant Tobacco Users (n=61)
47
100
90
80
Percentage
70
60
50
40
30
20
10
0
Advised to Quit
Assessed for Readiness to Patient Accepted Referral
Quit
to Clinic/Community
Resources*
*Included patients not yet ready to quit
Documented Readiness to Quit –
Pregnant Tobacco Users (n=61)
48
7%
33%
Not Ready to Quit
or Cut Back (n=20)
Ready to Quit
(n=37)
60%
Ready to Cut Back
(n=4)
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Documented Assistance for
Women Ready to Quit

184 women were ready to quit at the initial
screening
 147
non-pregnant women
 37 pregnant women

98% received some form of documented assistance
(n=180). Of those:
 64%
received tailored patient education materials (n=115)
 36% Developed a written quit plan (n=65)
 34% Received proactive fax referral to Quitline (n=62)
 11% Referred for behavioral health counseling (n=19)
(Some people may have received more than one type of documented assistance.)
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Lessons Learned
Technical Assistance
51

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Technical assistance was crucial for success
Not enough to provide training – practices need assistance with
implementation to produce sustainable change
Project coordinator was a skilled clinician who was also very
experienced in QI and clinic management


She had a good handle on what was reasonable to implement in a
clinical environment, and she engendered respect from other clinicians
Intensity of TA


Initial in-person TA with on-going telephonic support was enough for
most practices
Some practices required more hands-on TA, especially if they went
through staff changes during the QI process
Electronic Health Records
52
The national shift towards electronic health records (EHRs)
was a double-edged sword

EHRs assisted with continuity of care



Allowed multiple providers to engage with a patient around tobacco
use & cessation without repeating steps
Facilitated follow-up when patients were willing to try to quit or
engage in harm reduction strategies
EHRs could make useful documentation difficult


Most canned EHRs are not set up to document more than “Screened
for tobacco use” or “Patient uses tobacco”
Each EHR system is different, requiring varied work-arounds to
enable 5As and harm reduction documentation
Working With Providers
53

Billing and reimbursement information will get you in
the door


Yet, providers are willing to do the work because they are
concerned about their patients
Providers need “credit” for harm reduction work

Tobacco cessation is a multi-stage process and providers do a lot
of work to help a patient move toward being willing to quit

Providing “credit” – both in the form of recognition of their harm
reduction work and reimbursement for counseling – enables and
encourages providers to continue to engage with patients, even if
the patient is not ready to quit
Working With Providers, cont.
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A practice- or clinic-level project champion is
essential when making these type of systems changes

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The project champion facilitates the QI process and
serves as a two-way conduit for information
A successful project champion has the authority to
make changes in staff roles and responsibilities and
has a say in documentation and office policies
Quitline Fax Referrals
55
Providers reported that Quitline fax referrals were
routinely refused by patients

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Most common comment: Patient did not have minutes
to use to engage in telephonic counseling
Other methods of providing support – such as text
and web-based support – may be more acceptable
for this population
Behavioral Health
56

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Several practices strengthened their ties to behavioral
health and other resources in their communities
Providers reported that the heaviest smokers tended to
be women with other co-morbidities and/or facing
other challenges, particularly:
 Mental
health issues
 Other substance abuse
 Unstable housing
 Intimate partner violence
This is Achievable!
57
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Providers can provide evidence-based, best practice
screening and treatment as part of normal office
flow.
Technical assistance must augment training for true
implementation.
Systems-supports, such as reimbursement for
counseling and access to community referrals, are
essential for sustainability.
Questions?
58
Contact:
Erin McClain
[email protected]
www.YouQuitTwoQuit.com