Transcript Recommending a Strategy

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Tim McAfee, MD, MPH
[email protected]
Clinical & Behavioral Sciences
Free & Clear
206-876-2551
THE GROUP HEALTH STORY
1991 report: Decreasing Tobacco Use at
Group Health During the 1990s
• Goal: “Decrease the
prevalence of tobacco use at
Group Health by 50% from
1985 level of 25% to 12.5%
by the year 2000”
Authors:
• Sue Curry
• Sallie Dacey
• Doug Louie
• Tim McAfee
• Neal Sofian
• Larry Ziedman
1991 report: Decreasing Tobacco Use at
Group Health During the 1990s
• Objective: “A comprehensive
coordinated set of
interventions will be available
at Group Health covering all
the stages of tobacco use”
Key Partners:
• Tracy Orleans
• NCI & CDC OSH
• Michael Fiore/USPHS GL
group/ATMC
• Ed Wagner & Sue Curry (CHS)
• Robert S. Thompson (DPC)
• Bill Beery & Anne Smith (CHP)
Key Partners
• Phil Nudelman/Cheryl Scott
/Scott Armstrong (CEOs)
• Al Truscott/Louise Liang/ Hugh
Straley (Med. Directors)
• Jim Truess (CFO)
• Hundreds of VPs, managers
and directors
• Thousands of physicians,
nurses, MAs, pharmacists, etc
• Tens of thousands of patients
Adult Smoking Prevalence:
30%
25%
20%
15%
10%
5%
0%
1985 1987 1990 1993 1994 1995 1996 1997
Washington
State
GHC
1991 - COP report: 7 Strategies
1)”Identify, track and treat tobacco use with the same vigor as other
diseases with significant morbidity and mortality”
2)“Advocate for coverage of tobacco services where clinical
effectiveness has been convincingly established”
3) “Encourage adolescents to never become tobacco users, both
during clinic contacts and through school and community
outreach”
4)”Encourage and support population-based projects to decrease
tobacco use”
5)”Make tobacco a top lobbying priority of the GHC legislative affairs
office”
6) “Develop educational programs about tobacco use and services
for staff at all levels, including nursing, physician, clerical, medical
assistant and pharmacy. Encourage and support on-going
programs to decrease the prevalence of tobacco use among
employees”
7)”Treat coverage for smokers in the same manner we treat
coverage for other individuals with significant chronic diseases”
Elements of comprehensive
approach
 Reliance upon evidence
 Identifying tobacco users in primary care
 Training practice teams in brief advice
 Referral to phone and group programs
 Coverage for counseling & medications
 Integration with Prevention, Quality &
Chronic Care initiatives
 Support for community policy change
Health system opportunity:
SMOKE-FREE FITS GHC MISSION
Fits GHC’s preventive care and health
promotion mission
Supported by marketing and
communications
Issue of quarterly member magazine
Top take-home lessons
• Science is a good starting place
• It’s a product, marketing and sales
challenge!
• Hold on to the tiger’s tail
• People, systems, and measurement
make a difference
• Design for end-users
Research Collaborations
NEngJMed 9/3/98
339:673-679 Curry et al
Primary care: tobacco status
identification on all charts
100
90
80
70
60
50
40
30
20
10
0
% identified
1992 1994 1995 1996 1997* 1998 1999 2000
* > 85% in all 29 primary care clinics
Provider advice to smokers
80
70
60
50
chart doc*
pt recall*
40
30
20
*p<0.05 for both
10
0
1994
1997
1998**
1999**
** Top10% of HEDIS
Documentation of Patient Tobacco
Status using the TRF:
TOBACCO USE STATUS
(circle one)
Non-Tobacco user
Current Tobacco User
Recent Quitter <1 year
4
1
2
PROVIDER INTERVENTION
Tobacco Use Disorder
/Intervention
305.1
TRF Tobacco status identification:
100
90
80
70
60
50
40
30
20
10
0
Nov-98 Dec-98 Jan-99 Feb-99 Apr-99 Jun-99 Aug-99 Nov-99 Jan-00 Mar-00 May-00 Sep-00 Dec-00
Cessation Program Quality Improvement
Why:
Excellent program, but little impact due to low reach
(in 1992 only 180 participants/year)
Difficult to sustain clinic-based assistance/follow-up
Free & Clear improvements
• Removal of financial barriers
• Integrated pharmacotherapy:
– program assesses, generates Rx
– individualized
– ensures follow-up received
• Strong quality controls/reporting
• Promotional support
Free & Clear Participation
Group Health Enrollees
4500
Group
Phone
Total
4000
3500
3000
2500
2000
1500
1000
500
0
1992
1993
1995
1997
1998
1999
One-year quit rate: 25-30%
(30-day abstinence ~ Intent-to-Treat)
2000
Policy/population tobacco efforts
• NW Health articles
• Smoke-free campuses
• Master Settlement Agreement
• Seattle Times ad ban
• Labor and Industry worksite ban
• Access/merchant fee bill
• Defeating “Smokers Rights” bill
• Testimony/op-ed pieces
• Passage of two state initiatives
• Free & Clear external & state quit lines
I – 773 and I-901
I-773 2001 WA state initiative
• Raised tax on pack of cigarettes 60 cents
• “Guarantees” 26 million to Tobacco Control
I-901 2005 Clean Indoor Air
• 100% ban
GHC Board endorsed, contributed $$, & lobbyist/staff time for
both
“To serve the greatest number…”
Free & Clear Participation Rates
per 1000
10.0
8.1
8.0
F& C Enrollment per 1,000
8.0
7.6
6.4
6.0
5.9
4.0
2.0
0.0
n
2000
2001
2002
2003
2004
4,499
4,791
4,721
3,569
3,097
(Note: 2004 rates annualized based on first 2 quarters)
Smoking Prevalence 2003
by GHC Delivery System
Commercially Insured Adults aged 18-65 years
CNCSD
Plans
Sample
HMO
157
Alliant
47
Options
248
Total
452
%
12.1
23.4
14.5
14.6
IGP
95% CI
Sample
(7.0 , 17.2)
664
(11.3 , 35.5)
483
(10.1 , 18.9)
320
(11.3 , 16.4)
1,467
%
16.1
13.0
14.4
14.7
95% CI
(13.3 , 18.9)
(10.0 , 16.0)
(10.5 , 18.2)
(12.9 , 16.5)
(Data Source: CAHPS Adult Survey 2002-2004)
Chronic Care Model
•
•
•
•
•
•
Organization of care
Clinical information systems
Delivery system design
Decision support
Self-management support
Community resources
Glasgow RE, Orleans CT, Wagner EH. Does the Chronic Care
Model serve also as a template for improving prevention? The
Milbank Quarterly, Vol. 79, No. 4, 2001.