Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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