Transcript Slide 1

Systems Strategies to
Address Tobacco Use:
Utilizing EHRs to Improve
Patient Care
Ryan Reikowsky, MA, MPH
Manager, Community Development
Arizona Smokers’ Helpline (ASHLine)
Why Address Tobacco Use?
Tobacco Use is EXPENSIVE.
• Tobacco use costs the U.S. $130 billion annually in health
care costs and an additional $150 billion in lost productivity
• Comprehensive tobacco cessation programs reduce
tobacco use and lower associated healthcare costs,
providing a strong ROI
Efforts to reduce tobacco use, especially among the
uninsured and underinsured, could significantly reduce
healthcare spending.
Tobacco Use in Arizona: Quick Stats
• Adult smoking prevalence: 17.1%
• Annual health care costs directly
attributable to smoking: $2.38 billion
• Portion covered by Medicaid:
$316 million
• Smoking-attributable productivity
losses: $1.65 billion
Tobacco Use as a Health Disparity
Low socioeconomic status (SES) is one of the single greatest
predictors of tobacco use.
• Prevalence of current smoking is highest among adults with:
– Working class jobs
– Low education
– Low income
– No employment or underemployment
– Medicaid
– No health insurance
Tobacco Use as a Health Disparity
Approximately 21% of adults nationally
are current tobacco users. However,
relative to the general population:
• 34% of adult Medicaid recipients
smoke
• 32% of uninsured adults smoke
• Americans below the poverty line
are 40% more likely to smoke than
those at or above the poverty line
Health Effects of Tobacco Use
• Smoking is the leading cause of preventable disease
and death in the United States
• > 440,000 Americans die annually from smoking
• > 10 million Americans suffer from at least 1 disease
caused by smoking
• Nearly 9 out of 10 cancers are caused by smoking
• 1 out of 3 cancer deaths are tobacco-related
Good News, Bad News
Bad News
Despite decades of evidence detailing the harmful effects of tobacco use
and the health/economic costs associated with tobacco use:
• Current tobacco use is disproportionately concentrated among low
SES individuals
• U.S. spends $22 billion annually in tobacco-related Medicaid costs
(11% of all Medicaid costs)
• Only 23% of smokers on Medicaid receive practical assistance with
quitting
This represents a lost opportunity.
Good News, Bad News
Good News
• Low SES smokers express
significant interest in quitting
and benefit from treatment
• Effective treatment is available
• Consistently providing
treatment benefits both
patients and providers
Community Health Centers in Arizona
Data from the National Association for Community Health Centers for
2011 suggest:
• Only 50% of community health centers in Arizona provide tobacco
cessation counseling as a preventive service on site
Moreover, data from tobacco assessments completed by BTCD/HSAG
in 2011 suggest:
• Although tobacco use screening rates are high, post-screening
intervention rates are mixed and inconsistent
• Medication assistance is offered more consistently than behavioral
support
Treating Tobacco Use & Dependence
The U.S. Public Health Service Clinical Practice Guideline
for Treating Tobacco Use and Dependence: 2008 Update
recommends:
- Patients be consistently assessed for tobacco use at
every clinical encounter and offered assistance and
resources to quit
- Brief tobacco dependence treatment is effective
- Minimal interventions (≤3 min) are effective and should
be offered to all tobacco users
Brief Interventions
STRENGTH OF EVIDENCE: A
US PHS Clinical Practice Guideline: Treating Tobacco Use
and Dependence: 2008 Update
• Interventions lasting <3
minutes increase overall
tobacco abstinence rates
• Every tobacco user should
be offered brief intervention,
even if they are not referred
to an intensive intervention
Brief Interventions
STRENGTH OF EVIDENCE: A
US PHS Clinical Practice Guideline: Treating Tobacco Use
and Dependence: 2008 Update
• Even when patients are not
ready to make a quit
attempt, clinician-delivered
brief interventions
enhance motivation and
increase the likelihood of
future quit attempts
Intervention Models: 5A’s vs. AAR
ASK
about
tobacco
use
ADVISE
to quit
ASK
about
tobacco
use
ASSESS
willingness
to make a
quit attempt
ADVISE
to quit
ASSIST
in quit
attempt
REFER
to
ASHLine
ARRANGE
follow-up
ASHLine’s Recommended Model
Follow 3 simple steps:
Ask,
Advise,
Refer
We’ll do the rest!
Integrating Tobacco Cessation Into EHRs
Ask, Advise, Refer (AAR) can be integrated into EHRs via
templates designed to consistently prompt clinicians to:
- Screen for/assess tobacco use (including SHS exposure)
- Assess cessation interest + past quit attempts
- Encourage quitting
- Advise about smokefree environments
- Connect patients and families to cessation resources and
materials
Integrating Tobacco Cessation Into EHRs
The American Academy of Family Physicians (AAFP)
recommends tobacco treatment templates be automated
to appear during all well-patient exams, as well as when
patients present with the following symptoms:
-
Cough + upper respiratory problems
Diabetes
Ear infections
Hypertension
Depression + anxiety
Asthma
Ask
STRENGTH OF EVIDENCE: A
US PHS Clinical Practice Guideline: Treating Tobacco Use
and Dependence: 2008 Update
• Identify and document
the tobacco use status
of every patient at
every visit
• Significantly increases
rates of clinician Tx and
patient cessation
Integrating Tobacco Cessation Into EHRs
Meet Meaningful Use Criteria
Objective:
Record smoking status for patients 13 years old or older.
Measure:
More than 50% of all unique patients 13 years or older seen
by the EP have smoking status recorded.
EHR Requirement:
Must enable a user to electronically record, modify, and retrieve the smoking
status of a patient. Smoking status types must include: current every day
smoker; current some day smoker; former smoker; never smoker; smoker,
current status unknown; and unknown if ever smoked.
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Integrating Tobacco Cessation Into EHRs
What should be included in a tobacco cessation EHR template?
Tobacco use status can be documented as:
- Current every day smoker
- Current some day smoker
- Former smoker
- Never smoker
- Smoker, current status unknown
- Unknown if ever smoked
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Integrating Tobacco Cessation Into EHRs
Documenting Tobacco Use History
Type of tobacco*:
□ Cigarettes □ Pipe
□ Cigars
How many years?_______
□ Smokeless
Packs per day: _______
Brand: _____________________
Approximate date of last quit attempt: ________
*□ Electronic cigarettes
□ Other
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Integrating Tobacco Cessation Into EHRs
Documenting Tobacco Use History
Medication used in previous quit attempt:
□ Patch
□ Bupropion
□ Gum
□ Varenicline
□ Lozenge
□ None
□ Inhaler
□ Other: ______________
□ Nasal Spray
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Advise
STRENGTH OF EVIDENCE: A
US PHS Clinical Practice Guideline: Treating Tobacco Use
and Dependence: 2008 Update
• In a clear, strong, and
personalized manner,
urge every tobacco
user to quit
• Capitalize on “teachable
moments” with patients
Integrating Tobacco Cessation Into EHRs
Meet Meaningful Use Criteria
Objective:
Use certified EHR technology to identify patient-specific
education resources and provide those resources to the
patient if appropriate.
Measure:
More than 10% of all unique patients seen by the EP have
are provided patient-specific education resources.
EHR Requirement:
Must enable a user to electronically identify and provide patient-specific
education resources according to, at a minimum, the data elements included
in the patient’s: problem list; medication list; and laboratory test results; as
well as provide such resources to the patient.
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Integrating Tobacco Cessation Into EHRs
Documenting Advice
Counseled for:
□ Three minutes or less
□ 3 to 10 minutes
□ 10+ minutes
□ Counseled for secondhand smoke
Counseling notes:
______________________________________________________________________
______________________________________________________________________
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Integrating Tobacco Cessation Into EHRs
Readiness to Quit:
□ Not interested in quitting
□ Thinking about quitting at some point
□ Ready to Quit
Handouts/Education Provided:
□ Quitline card
□ Quit Smoking Brochure
□ Secondhand Smoke Brochure
□ Other
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Integrating Tobacco Cessation Into EHRs
Pharmacotherapy
Recommended OTC:
□ NRT Patch
□ NRT Gum
□ NRT Lozenge
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Integrating Tobacco Cessation Into EHRs
Pharmacotherapy
Rx Treatment:
□ NRT Nasal Spray
Dosing: 1-2 doses/hour (8-40 doses/day); one dose = one spray in each
nostril; each spray delivers 0.5mg nicotine
□ NRT Inhaler
Dosing: 6-16 cartridges/day; initially use 1 cartridge q 1-2 hours
□ Bupropion SR
Dosing: Begin 1-2 weeks prior to quit date; 150mg PO q AM x 3 days,
then increase to 150mg PO bid
Contraindications: head injury, seizures
□ Varenicline
Dosing: Begin 1 week prior to quit date; days 1-3: 0.5mg PO q AM; days
4-7: 0.5mg PO bid; weeks 2-12: 1mg PO bid.
Screen for: suicidal ideations
Source: American Academy of Family Physicians. Ask and Act Tobacco Cessation Program. 2014.
Refer
STRENGTH OF EVIDENCE: A
US PHS Clinical Practice Guideline: Treating Tobacco Use
and Dependence: 2008 Update
• Proactive telephone
counseling, group
counseling, and
individual counseling
formats are effective
and should be used in
smoking cessation
interventions
Referring to ASHLine
• A proactive referral to
ASHLine ensures we will
call your patient within
24 business hours
• ASHLine provides
ongoing, intensive clinical
intervention for you!
What is ASHLine?
Evidence-Based Service
• Behavioral support
• Medication assistance
Long-Term Success
• 7 Month Quit Rate (global): 30% (vs. 5% “cold turkey”)
• 7 Month Quit Rate (meds + coaching): 56%*
ASHLine Referral Program
 Custom QuitFax
(paper-based)
 WebQuit Account
(electronic)
 EMR or EHR Template
(hybrid)
Reporting Options
• Available by fax or e-mail
• Confirmation report (within 24 hours)
• Status report (within 10 days)
– First call within 24 business hours
– Up to 5 call attempts over 10 business days
– Notification of referral outcome (e.g. Enrolled,
Only Requested Information, Unable to Reach,
Wrong Number, etc.)
Partnering to Achieve Systems Change Makes Sense!
A systems approach to tobacco
assessment and intervention will
ensure all patients receiving
services are:
- Screened for tobacco use
- Offered a brief intervention
- Referred to services that can
help them quit successfully
Partnering to Achieve Systems Change Makes Sense!
Systematic provision of tobacco cessation services significantly improves
health outcomes for all tobacco users, especially those with chronic
disease and/or those who are members of “at risk” populations:
•
•
•
•
•
•
•
•
Cancer
Chronic Obstructive Pulmonary Disorder (COPD)
Asthma
Diabetes
Hypertension
Ischemic Vascular Disease
Congestive Heart Failure
Coronary Artery Disease
Partnering to Achieve Systems Change Makes Sense!
Tobacco use assessment and intervention are key components of
preventive health. Certified Electronic Health Records (EHRs) are built to
help health care organizations provide better care.
EHRs are powerful tools that can help you:
• Ensure patients are systematically assessed for tobacco use
• Consistently prompt clinicians to provide advice to quit (i.e. brief
interventions)
• Consistent access and transmit referrals to community-based services
for intensive tobacco treatment (e.g. ASHLine)
• Manage patient medication lists (e.g. tobacco cessation medications)
• Monitor, prevent, and manage disease
Partnering to Achieve Systems Change Makes Sense!
ASHLine’s Community Development Team is available to
partner with your organization to make tobacco systems
change an achievable goal.
Things to consider:
-
Systems change requires administrative support
-
Identifying key players to lead and implement change is critical
-
Who are the “key players” and/or decision-makers in your
organization?
-
Who should you be speaking with about partnering on systems
change?
Potential Next Steps
• Evaluate tobacco use prevalence among service recipients
to assess potential impact
• Consider policy development to address consistent
provision of brief interventions + referral for tobacco users
willing to make a quit attempt
Partnership opportunities:
–
–
–
–
Policy development, implementation, rollout
Audit ASHLine database (current locations)
Establish referral mechanism (EHR or paper)
Staff training, TA, ongoing support
Questions? Thank You!
Ryan Reikowsky, MA, MPH
Manager, Community Development
Arizona Smokers’ Helpline (ASHLine)
1-800-556-6222 x208
[email protected]