Transcript Translating Evidence-based Smoking Cessation Treatment into

Translating Evidence-based
Smoking Cessation Treatment
into Primary Care Settings
Judith K. Ockene, PhD, MEd. Lori Pbert, PhD,
Beth M. Ewy MPH, CHES, Denise Jolicoeur, MPH, CHES
University of Massachusetts Medical School
Worcester, MA
In this presentation I will review:
• The importance of the primary care setting for
delivering tobacco treatment
• The evidence base for smoking cessation
treatment in primary care settings
• The key components necessary for translating
smoking cessation treatment into primary care
• Barriers and facilitators to implementing
evidence-based treatment strategies
Primary Care Physicians/Settings are
Important for Prevention and Intervention
• Provide continuity of care
• 80% of adults visit a MD/year
• Credible information source
• People are aware of their health when
visiting a MD/PC setting
• Can refer to other providers
• They are effective!
The Evidence Base:
A Clinical Practice Guideline for Treating
Tobacco Use and Dependence
U.S. Public Health Service
Agency for Healthcare Research & Quality
Issued June 2000
Major Conclusions
• It is essential that clinicians and
health care delivery systems
(including insurers and purchasers)
institutionalize the identification,
documentation and treatment of
every tobacco user.
Efficacy of Office Systems to
Identify Tobacco Users at Each
Clinical Encounter
(Meta-Analysis
No System
System
of 3 Studies)
Odds Ratio
(95% CI)
Cessation Rates
(95% CI)
1.0
3.1%
2.0
(0.8-4.8)
6.4%
(1.3-11.6)
Systematic Identification and
Documentation of Tobacco
Users
• Vital signs stamp
• Patient assessment form
• Chart stickers
• Electronic medical record prompts
Major Conclusions
•
Brief tobacco dependence
treatment is effective, and
every patient who uses
tobacco should be offered at
least brief treatment.
Brief “5A” Intervention Model
• Ask about tobacco use at every visit
• Advise all tobacco users to quit
• Assess willingness to quit
• Assist the patient in quitting
• Arrange follow-up contact
Implementation of the 5As at 2 Sites
UMMHC
Discussed smoking (some, most or every visit)
Comparison
Site
2 ( value)
92
74
9.62 (0.02)
87
81
8.31 (0.08)
81
53
9.96 (0.0016)
Asked about past experience with quitting
63
23
20.11
Discussed or recommended medications for quitting
75
18
38.53
Discussed methods and strategies for quitting, other than medications
55
19
16.96
Offered written materials or videos about quitting smoking
28
37
1.08 (0.30)
Ask to set a quit date
36
3
23.76
(0.0001)
Recommended or referred to a quit-smoking program
30
30
0.003 (0.99)
Planned a follow-up discussion to support effort to quit
27
4
12.71
Advise
Advised to quit smoking (at any visit)
Assess
Assessed interest in quitting
Assist and arrange follow-up
(0.0001)
(0.0001)
(0.0001)
(0.0004)
Possible Reasons for Greater
Implementation of 5As at UMMHC
• Periodic training sessions expose providers to the 5A model for
multiple health risk behaviors
• System for screening and documenting smoking status has been
institutionalized
• Reminder system (problem list) includes smoking
• Clinical culture supports patient-centered approach to
preventive counseling
• Patients were more likely to report being asked about interest in
quitting (81% vs. 53%); suggests clinicians more prepared to
provide cessation assistance
Major Conclusions
• There is a strong dose-response
relationship between the intensity of
tobacco dependence counseling and its
effectiveness:
The more contact, the higher the
quit rate.
Estimated Abstinence Rates by
Length of Contact (n=43 studies)
Length of
Contact
No Contact
Estimated
Estimated odds
abstinence rate
ratio
(95% C.I.)
(95% C.I.)
10.9
1.0
Counseling  3
minutes
13.4
(10.9, 16.1)
1.3
(1.01, 1.6)
Counseling 3-10
minutes
16.0
(12.8, 19.2)
1.6
(1.2, 2.0)
Counseling  10
minutes
22.1
(19.4, 24.7)
2.2
(1.5, 3.2)
Major Conclusions
• Effective pharmacotherapies for
quitting smoking now exist.
Pharmacotherapies
• Five first-line therapies have been
identified as effective:
-- Nicotine patch
-- Nicotine gum
-- Nicotine nasal spray
-- Nicotine inhaler
-- Zyban (bupropion hydrochloride)
• Nicotine lozenge added Nov. 2002
Translating Evidence-based
Strategies into the Primary
Care Setting: Key Components
Key Components of Effective
Tobacco Treatment
• Routinely screen and document tobacco use
• Prompt/cue provider to conduct intervention
• Use a method for documenting each tobacco
use cessation encounter
• Make self-help materials available
• Use a follow-up system, including referral to
internal and external resources
• Use a feedback system to staff
Example: QuitWorks
Linking:
•
Eight Massachusetts commercial and Medicaid health
plans
•
15,000 providers
•
Hospitals and health centers in Massachusetts
•
All patients who use tobacco regardless of health
insurance
•
Proactive telephone counseling @ Try-To-STOP TOBACCO
Resource Center
Supported by the health plans and the Mass. Dept. of Public Health
Example: QuitWorks
1
Identify smoker and
document smoking
status
5
Receive patient
status report and
aggregate reports
2
Talk with patients
about their
tobacco use
The
QuitWorks
Solution
3
During hospital stay or
outpatient visit, enroll patient
in QuitWorks.
Fax enrollment form
4
Prescribe
Medication
QuitWorks completes
patient assessment a nd
offers intensive counseling
options,
Post discharge,
QuitWorks calls your
patient
QuitWorks: Implementation Phases
I. Promotion to primary care practices by health
plan representatives
II. Response to interest by hospitals for inpatient
and outpatient implementation
III. Plans to tailor for use by community health
centers
Barriers and Facilitators to the
Implementation and
Maintenance of Evidencebased Treatment Strategies
Barriers to Implementation/
Maintenance
• Lack of time
• Perceived lack of skills to treat
• Lack of administrative support/Not perceived as
a priority
• Treatment not viewed as effective
• Lack of reimbursement
• Institutional lethargy
Strategies to Facilitate
Implementation
• Find and nurture a champion within your
institution
• Bring together an implementation
group with decision-making authority
• Find internal motivators such as QA reviews,
JCAHO or HEDIS
Strategies to Facilitate
Implementation (Cont.)
• Educate providers about the effectiveness of
brief interventions
• Build on previous system changes
• Develop links with internal and external
treatment resources, including quitlines,
websites, voluntary agencies, local treatment
specialists,resource or prevention centers
Training to Enhance
Implementation/Maintenance
3 Levels of Training:
1. Office staff to implement and
maintain office system
2. Health care providers to deliver brief
intervention
3. Tobacco Treatment Specialists to
provide more intensive counseling
CONSIDER ALL THREE!
Conclusions
• Tobacco dependence treatment is effective
• The primary care setting is an important
place for delivery of tobacco treatment
• Key components can be implemented to
facilitate tobacco dependence treatment
• Training should be available to clinicians and
staff
• Links need to be developed with internal and
external resources