Video Counseling For Treating Tobacco Dependence

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Video Counseling For Treating Tobacco Dependence
Kimber Richter, Ph.D., M.P.H. Genevieve Casey,
M.A. Paula Cupertino, Ph.D. University of Kansas
Medical Center Department of Preventive Medicine
and Public Health KU-MPH For more info in this
talk, contact Kim or Genevieve at
krichter_at_kumc.edu or gcasey_at_kumc.edu
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Objectives

• Understand rationale for/feasibility of video
  counseling
• How we have used it at KUMC
• Group-based video counseling
• Individual video counseling
• Grief vs Benefit
• (Briefly) How were experimentally evaluating it
• From Connect2Quit, a RCT of Telemedicine for
  Smoking Cessation in Rural Primary Care (R01,
  NHLBI, Richter P.I.)

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What is video counseling? And what should we
call it?

• Telemedicine/Telecounseling/Video
  Counseling/Webcam Counseling
• Delivery of interactive coaching/counseling in
  real time, using video/audio interface
• Made possible by low cost computers,
  international telecom standards such as ISDN, and
  affordable high-speed internet services
• But many lower income/rural smokers still dont
  have
• Telemedicine is reimbursable by Medicare and in
  Kansas by Medicaid

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Does it work?

• No data available for treating tobacco dependence
• Why were running a trial
• Other health behaviors/outcomes Cochrane review
  of telemedicine vs face-to-face patient care
• Telemedicine was as effective as face-to-face
  treatment and achieved high levels of
  satisfaction among patients and providers
  (Currell et al., 2000)
• AHRQ review of 455 Telemedicine programs
  concluded the same
• Important to examine costs, cost-effectiveness
  (Hersh, 2004)
• May 1) provide equivalent care at less cost, 2)
  deliver better care at less or equivalent cost,
  3) increase access to health care for patients
  who would otherwise not receive any care at all

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What are the potential benefits?

• Counseling quality
• Increase therapeutic alliance bond between
  counselor and client
• Increase adherence, impact
• Enhance counseling accuracy and quality by
  allowing counselor to see non-verbal cues
• Easier for counselor to remember details about
  smoker
• Draw more smokers into treatment
• Quitlines are underutilized
• Novelty factor
• Wave of the future

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What are the barriers?

• Smokers tend to have lower incomes
• Smokers tend to be less well educated
• Although many have a computer in home, isnt
  always working
• Although many areas have gtaccesslt to high-speed
  internet, many residents dont purchase it
• Only 53 of Kansans have home internet, the
  majority of which is dial-up connection with
  variable download time
• Even with high-speed internet, the bandwidth
  required for high-quality telemedicine connection
  is large
• Requires firewall exceptions and periodic updates
  that internet providers typically do not provide

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How does it work?From Connect2Quit

• Individually-based counseling
• Delivered in physician offices patients
  medical homes
• Computer/webcam typically installed in an
  examining room
• 4 sessions (Week 0, 2, 4, 8)
• Session 1/ Week 0-2 D2-21 (D14 target)
• Session 2/ Week 2-3 D14-28 (D21 target)
• Session 3/ Week 4-6 D28-48 (D35 target)
• Session 4 / Week 8-11 D56-83 (D63 target)
• Combined Motivational Interviewing/Cognitive
  Behavioral approach
• Strong focus on pharmacotherapy assistance
• Counseling/materials/assessments in Spanish and
  English
• Also have done in group format can discuss
  later

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Our equipment

• Project would not be possible without fantastic
  support from KUCTT KU Center for Telemedicine
  and Telehealth
• Technicians travel state installing/troubleshootin
  g equipment issues
• Equipment
• We provide computers/webcams/software to
  physician offices
• Counselors have widescreen monitors to view
  Polycom and other needed documents (e.g. web
  browser for pharmacotherapy assistance)
• Software Polycom PVX
• Delivers higher-quality video with less
  freeze-ups than freeware
• Costs
• PVX software is 112.00 per user 
• Cameras prices fluctuate, however 95.00 is
  average
• Permits us to show desktop to the patient

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Computer equipment requirements

• Resource Requirements
• Audio recording sessions for fidelity/ QI
• Camtasia the only program that would audio
  record Polycom
• Required a gaming soundcard (multiple channels)
• Issue with Polycom shutting down or Access
  freezing intermittently
• Multiple programs running at once uses a large
  amount of RAM
• Polycom PVX places a high demand on CPU
• Polycom PVX is graphic intensive (as are Access
  and Camtasia)
• Solution (1) shut down all programs but Polycom,
  Camtasia and Access (2) Have a paper backup in
  the case of Access freezing/ shutting down
• Connection
• Requires high-speed internet connection at both
  ends (dial up does not cut it)
• Firewall issues
• Internet bandwidth requirements
• Minimum bandwith requirements to connect
• Consider clinic use variations throughout the day

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A typical session (on an ideal day)

• Counselor makes reminder call to pt and physician
  office day prior to session (Some clinics
  prefer weekly emails)
• Patient checks in, goes straight to telemedicine
  room
• Counselor dials C2Q computer at appointed office
  time
• Counselor conducts session
• 45 mins session 1, 20 mins follow-up sessions
• Counselor faxes follow up materials (prescription
  request, quit plan) to front desk for pt to pick
  up at checkout
• Provide 2 copies of each 1 for pt, 1 for
  physician/medical record
• Counselor/pt set follow up appt with receptionist
  at checkout

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Great things about a great session

• Counseling takes place in a clinic room with few
  distractions
• Show educational materials on desktop to patient
  in session
• Face to face connection much like an in person
  session
• Counselor can pick up on important non-verbal
  cues
• It is a more personal connection than phone
• Patient receives materials that day
• Access to PCP at the clinic
• Prescription request goes to physician that day
• Pharmacy assistance needing physician signature
  can be completed right away
• Physician and staff are aware of patient goals
  and generally supportive of the program
• Patient has higher accountability to call in or
  show up to a real in person appointment

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What happens when things go wrong

• Difficulty scheduling
• Some clinics have limited hours/ room
  availability may not fit patient schedules
• Clinics need staff identified to log on to
  computer/ make appointments
• Despite reminder calls, some patients dont show
• Patient work schedules, more of a time commitment
  for patient (vs. phone)
• Patient may not have transportation to the clinic
• Less motivated patients may be less likely to
  show (vs. answer a phone call)
• Clinic technology problems
• We can not connect, or the clinic staff have to
  call us
• We can never connect because of the clinics slow
  internet connection
• Occasional connection problems result from high
  traffic times
• Firewall means the clinic always had to call out
  we can not call in
• Sound quality echoes or delays at some clinics
  (movable speakers may work)
• Sometimes the image quality is poor (pixilated)
  over time or freezes completely
• Ask the patient to move the mouse to avoid
  security lock out/ computer sleeping.
• Sometimes the connection is dropped usually we
  can call back but not always. This can happen
  more than once during a call
• Interferes with the flow of the session, though
  patients have been tolerant.

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Pros/Cons of C2Q Video versus Telephone Counseling
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Design, Connect2Quit

• Not a pure test of technology
• More a comparative effectiveness study of 2
  models of care at a distance
• Telephone Quitline condition versus
  Telemedicine integrated into Doctors office
• All participants get same number of reminder
  calls, rescheduling calls, missed appointments,
  counseling windows
• All get 4 sessions, same materials and counseling
  content
• Weekly supervision, plus sessions are digitally
  recorded /coded to ensure equal content
• Outcomes
• Biochemically verified cessation at 12 months
• Cost per quit in each condition (costs include
  patient and provider costs)

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Mechanism, Connect2Quit

• Hypothesis is that integrated telemedicine,
  compared to telephone alone, will
• Lead to higher perceived support from
  physician/counselor which will
• Lead to higher autonomous motivation and
  competence for change which will
• Lead to higher cessation rates (directly) as well
  as higher medication use, which will also lead to
  higher cessation rates
• Also, higher cessation rates will result in equal
  or lower cost per quit
• Well see!!

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Questions ?