Transcript Exercise: What every provider should know

Designing a comprehensive
tobacco control program: The VA
experience
Scott E. Sherman, MD, MPH
Kim Hamlett-Berry, PhD
Tobacco control vs. tobacco use
counseling
Tobacco
control
=
Sum of all efforts at tobacco
use cessation within a health
care organization or system
Objectives
• To discuss a model for an organizational
approach to tobacco control
• To examine how an organization progresses
through this model
• (To get comments on the model)
Stages of tobacco control
• Stage 1: No system
• Stage 2: Systematic screening
• Stage 3: Systematic screening and treatment
Stages of tobacco control: The VA
experience
Stage 1: No system (VA - pre-1996)
• Haphazard approach
• Likelihood of being counseled varies dramatically
by provider and by site
• Rate of counseling 30-70%
• Relies on believers and zealots
• Organizational culture and opinion leaders make a
big difference
Characteristics of stages in tobacco control
Patient
Stage 1
Haphazard
Provider
System
Zealots
None
Data
Researchers
Transition
Guidelines
Stage 2: Systematic screening (VA 1996-2002)
• National guidelines - PHS, VA/DoD
– Process specified, structure usually not specified
• Guidelines often linked to performance measures HEDIS, VA (External Peer Review Program)
– Asking about smoking (VA)
– Advising smokers to quit (HEDIS, VA)
Systematic screening
Step 1:
Ask about
smoking
Step 2:
Advise
smokers to quit
Step 3:
Assess
interest in
quitting
Step 4:
Assist
smokers in
quitting
Step 5:
Arrange
follow-up
VHA - Asking about smoking
100
90
80
70
60
50
40
1996
1997
1998
1999
2000
2001
2002
Advice to quit:
VHA and private sector
100
90
80
70
60
50
40
1996
1997
1998
VHA - Advised to quit (chart review)
NCQA - Advised to quit (patient survey)
1999
Mandated guidelines
• Unclear how tight the link is between guideline
adherence and smoking cessation
• All VA facilities asking, advising, yet prevalence
remains high
1999 Large Health Survey of
VHA Enrollees
•
•
•
•
81% report being asked about smoking
72% report being advised to quit
28% report being treated or referred
83% report needed services to quit but did
NOT get them
n = ~33,000
2002 VA Survey of Healthcare
Experiences of Patients (SHEP)
Patients seeking services for smoking cessation
• 53% offered medications for cessation
• Varied considerably by whether primary care
provider treated or referred
Provider treats and refers - 74%
Provider treats only
- 61%
Provider refers only
- 31%
n=3,750
n=1,840
n=5,750
Draft - not to be quoted or cited
VA Pharmacy Benefits
Management database
• 1999 - 14% of attempted quitters received
medications for smoking cessation
• 2002 - 14% of smokers received
medications for smoking cessation
So what should we do…?
Smoking and Tobacco Use Cessation
Technical Advisory Group
• Role is to advise VA on policy and strategy
for smoking cessation
• Interdisciplinary, geographically diverse
• Broad-based group of experts
–
–
–
–
–
Health services research
Nicotine dependence
Education
Clinical care
Provider behavior change
How to deliver smoking
cessation care?
• Should it be primary care-based or
specialty-based?
How to deliver smoking
cessation care?
Specialty approach (referral)
Smoking cessation clinic (SCC) calculations
20,000 patients / 6,000 smokers
Typical SCC - 50 new patients/month, 600/year
120 non-smokers/year
Would take 50 years to treat entire population
How to deliver smoking
cessation care?
Primary care-based approach
– Less effective, but broader reach
– More costly (based on cost/quitter)
Medications
• Data increasingly available over last few
years that medications effective independent
of level of intensity of counseling
– NRT - Cochrane review (Silagy et al, 2002)
– Bupropion - Hall et al (Arch Gen Psych, 2002)
Characteristics of stages in tobacco control
Patient
Provider
System
Data
Transition
Stage 1
Haphazard
Zealots
None
Researchers
Guidelines
Stage 2
Advised
consistently
At least
minimal
Consistent,
not coord.
Process
measures
Patient
needs
Stage 3: Coordinated visit-based
approach (VA - 2003-present)
• Essential to know your patients, system
• Are patients interested in quitting?
• Do patients receive smoking cessation services?
–
–
–
–
Counseling
Treatment
Primary care-based vs. referral
Telephone counseling
Stage 3 (cont.)
• Goal: Ensure that within primary care,
every patient interested in quitting receives
counseling and treatment
Stage 3 (cont.)
• Change 1: Medication availability
Ensure that nicotine patches, nicotine gum,
and bupropion are available within primary
care nationwide
Stage 3 (cont.)
• Change 2: Rewrite guidelines
– Old recommendation: All patients interested in
quitting should be referred to a smoking
cessation program
– New recommendation: All patients interested in
quitting should receive counseling and
treatment, regardless of their interest in
attending a cessation program
Stage 3 (cont.)
• Change 3: Revise performance measures
1. All smokers should have their level of interest in
quitting assessed.
2. All smokers interested in quitting should be given
medications.
Characteristics of stages in tobacco control
Patient
Provider
System
Data
Transition
Stage 1
Haphazard
Zealots
None
Researchers
Guidelines
Stage 2
Advised
consistently
At least
minimal
Consistent,
not coord.
Process
measures
Patient
needs
Stage 3
Assisted
consistently
At least
moderate
Coordinated
visit-based
Process
measures,
patient data
Accurate
database
Stage 3B? - Future efforts (VA 2005-?)
• Goal: Ensure that every patient receives
appropriate, targeted intervention,
regardless of whether or not they visit the
primary care clinic
Stage 3B (cont.)
•
•
•
•
Outreach
Disease management
Telephone counseling
Other??
Characteristics of stages in tobacco control
Patient
Provider
System
Data
Transition
Stage 1
Haphazard
Zealots
None
Researchers
Guidelines
Stage 2
Advised
consistently
At least
minimal
Consistent,
not coord.
Process
measures
Patient
needs
Stage 3
Assisted
consistently
At least
moderate
Coordinated
visit-based
Stage 3B
Consistent
tailored
assistance
At least
moderate
Process
measures,
patient data
Coordinated
Process,
population- utilization,
based
HSR
Accurate
database
