Translating Evidencebased Smoking Cessation Treatment into Primary Care Settings

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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

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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

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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!

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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
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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.

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Efficacy of Office Systems to Identify Tobacco
Users at Each Clinical Encounter
(Meta-Analysis of 3 Studies)
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Systematic Identification and Documentation of
Tobacco Users

• Vital signs stamp
• Patient assessment form
• Chart stickers
• Electronic medical record prompts

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Major Conclusions

• Brief tobacco dependence treatment is effective,
  and every patient who uses tobacco should be
  offered at least brief treatment.

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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

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Implementation of the 5As at 2 Sites
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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

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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.

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Estimated Abstinence Rates by Length of Contact
(n43 studies)
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Major Conclusions

• Effective pharmacotherapies for quitting smoking
  now exist.

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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

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Translating Evidence-based Strategies into the
Primary Care Setting Key Components
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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

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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 _at_ Try-To-STOP
  TOBACCO Resource Center

Supported by the health plans and the Mass. Dept.
of Public Health
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Example QuitWorks
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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
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Barriers and Facilitators to the Implementation
and Maintenance of Evidence-based Treatment
Strategies
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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

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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

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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

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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!
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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