translating science into practice lsu health care services division
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TRANSLATING SCIENCE INTO PRACTICE TRANSLATING SCIENCE INTO PRACTICE
LSU Health Care Services Division LSU Health Care Services Division Disease Management Program Quarterly MeetingDisease Management Program Quarterly Meeting
March 27,2007March 27,2007
Sarah Moody Thomas, PhDSarah Moody Thomas, PhD
Clinical LeadHCSD Tobacco Control Initiative
ProfessorLSU Health Sciences Center - School of Public Health
In collaboration withIn collaboration with
Michele Jean-Pierre Michele Jean-Pierre Ron Horswell Ron Horswell
Michael CelestinMichael Celestin Zhanying Zong Zhanying Zong
Danielle TrepagnierDanielle Trepagnier Kurt BraunKurt Braun
Krysten JonesKrysten Jones Jay BesseJay Besse
Monica LewisMonica Lewis Debbie Debbie HernandezHernandez
And…
• Debby Durapau Lucretia Young
• Tambria Hunt JoAnn Brooks
• D’Adario Conway Wendy Rhodes
• Elizabeth Sylvest Jennifer Miller
• Nakesha Auguster Betty Henry
Along with…
Members of the following:
• Tobacco Teams
• Process Redesign Team
• Research & Evaluation Team
• Health Care Effectiveness Team
• HCSD Administration
We We knowknow……
There is a body of evidence amassed from There is a body of evidence amassed from 40 years of accomplishments of tobacco 40 years of accomplishments of tobacco control:control: ResearchersResearchers AdvocatesAdvocates PractitionersPractitioners
We know…We know…
In Louisiana:In Louisiana:
• residents’ health status ranked 50residents’ health status ranked 50 th th in the nation*in the nation*• ~ 20% of population is uninsured~ 20% of population is uninsured• 1010thth highest smoking rate; ~ 23% smoke* highest smoking rate; ~ 23% smoke*• 1.5 Billion healthcare cost associated with 1.5 Billion healthcare cost associated with
tobacco usetobacco use• $663 million absorbed by Medicaid $663 million absorbed by Medicaid • Nearly 6500 adults die annually from smokingNearly 6500 adults die annually from smoking
United Health Foundation, 2006
We know…We know…
• Efficacious treatments for tobacco use & Efficacious treatments for tobacco use & dependence exist.dependence exist.
• Cost- effective treatments for tobacco use Cost- effective treatments for tobacco use and dependence are key to preventing and dependence are key to preventing disease onset, progression and disease onset, progression and exacerbation. exacerbation.
• Clinical Practice Guidelines (CPG) are Clinical Practice Guidelines (CPG) are inadequately implemented. inadequately implemented.
Fiore, M. 2000Fiore, M. 2000
We know…We know…
LSU Health Care Services Division LSU Health Care Services Division (HCSD):(HCSD):
• State’s largest and nationally the 5State’s largest and nationally the 5 th th largest largest integrated public healthcare system integrated public healthcare system – 1.5m outpatient visits, 1.5m outpatient visits, – 80,000 inpatient admissions80,000 inpatient admissions
• Well-established disease management program Well-established disease management program
• Administration committed to continuous quality Administration committed to continuous quality improvement and health systems researchimprovement and health systems research
We know …We know …
It is widely recommended that evidence-based It is widely recommended that evidence-based cessation services be integrated into cessation services be integrated into healthcare healthcare delivery systemsdelivery systems in order to obtain population- in order to obtain population-wide benefits.wide benefits.
– Robert Wood Johnson Foundation (1997; 2000) Robert Wood Johnson Foundation (1997; 2000) – US Department of Health and Human Services (2000)US Department of Health and Human Services (2000)– National Academy of Sciences, Institute of Medicine National Academy of Sciences, Institute of Medicine
(2001; 2003)(2001; 2003)– Centers for Disease Control and Prevention (2006)Centers for Disease Control and Prevention (2006)
PartnershipPartnership
2002 – HCSD started initiative to place treatment of tobacco use & 2002 – HCSD started initiative to place treatment of tobacco use & dependence at forefront of Louisiana’s public hospital systemdependence at forefront of Louisiana’s public hospital system
LSU HCSD Disease Management Program
Coordination ofresources acrossthe health caredelivery system toimprove disease outcomes
HCSD Disease Management Program
• Placed cessation services in a context:
– receptive to chronic care model; tobacco dependence could be viewed as such, requiring ongoing attention and treatment (Wagner, 1998)
– supportive of multi-component systems approach to improving the delivery and quality of health care
Goal: To increase adoption, reach and impact of evidence-based Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatmenttobacco dependence treatment
Push SciencePush Science Build CapacityBuild Capacity Boost DemandBoost Demand↔↔ ↔↔
↓ ↓↓ ↓↓ ↓↓
Translating Science into PracticeTranslating Science into Practice
Evidence based Evidence based treatment (CPGs)treatment (CPGs)
-Communicate for Communicate for wide populationswide populations
-Test/adapt in new Test/adapt in new populations and populations and settingssettings
-Research and Research and evaluate to improveevaluate to improve
Link systems– level Link systems– level tobacco supportstobacco supports
-IT to identify smokers, IT to identify smokers, prompt treatment prompt treatment
-Incorporate into broader Incorporate into broader quality assurancequality assurance
-Performance Performance measurement and measurement and reporting reporting
-Provider training and TAProvider training and TA
Policies and community Policies and community strategiesstrategies to increase to increase quitting and decrease usequitting and decrease use
-Bans, decreased cost, Bans, decreased cost, Quitline support, reflective Quitline support, reflective mediamedia
-Market programsMarket programs
-Redesign cessation services Redesign cessation services to increase appeal and useto increase appeal and use
Ultimate GoalUltimate Goal:: Reduce tobacco use &Reduce tobacco use &
health care burdenhealth care burden Orleans, CT. 2001; 2004 ; Isaacs, 2004
HCSD Tobacco Control Program
Design, implement and evaluate evidence-based cessation services in Louisiana’s public hospital system.
Goal: To increase adoption, reach and impact of evidence-based Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatmenttobacco dependence treatment
Push SciencePush Science
↓ ↓↓
Translating Science into PracticeTranslating Science into Practice
Evidence based Evidence based treatment (CPGs)treatment (CPGs)
-Communicate for Communicate for wide populationswide populations
-Test/adapt in new Test/adapt in new populations and populations and settingssettings
-Research and Research and evaluate to improveevaluate to improve
2002 – 2004: Assessments conducted to determine prevalence of tobacco use, existing services and existing organizational infrastructure
Know Your Population – Patient SurveyKnow Your Population – Patient Survey
• Purpose Purpose – Characterize prevalence, patterns of tobacco Characterize prevalence, patterns of tobacco
use and readiness to quit among patients of use and readiness to quit among patients of this “safety net” health systemthis “safety net” health system
• MethodsMethods– Patients randomly selected within calendar Patients randomly selected within calendar
days days – Survey instrument administered face-to-face Survey instrument administered face-to-face
by trained interviewersby trained interviewers
Sample InformationSample Information
• N=777N=777• Predominantly:Predominantly:
• female (82%)female (82%)• African American (60%)African American (60%)• Poor (72% reported annual family incomes Poor (72% reported annual family incomes
< $15,000)< $15,000)• Ranged in age from 18 to 84 (mean= 49, Ranged in age from 18 to 84 (mean= 49,
s.d.=13.9)s.d.=13.9)• 25% current smokers25% current smokers
Readiness to Quit: % YesReadiness to Quit: % YesDuring the past 12 months, have you stopped During the past 12 months, have you stopped smoking for 1 day or longer because you were smoking for 1 day or longer because you were trying to quit?trying to quit? 49%49%
Are you planning to stop smoking within the Are you planning to stop smoking within the next 30 days?next 30 days? 23%23%
Are you seriously considering quitting within Are you seriously considering quitting within the next 6 months?the next 6 months? 56%56%
If we talk in a year, do you think you will be If we talk in a year, do you think you will be smoking?smoking? 41%41%
Are you aware of assistance that might be Are you aware of assistance that might be available to help you quit such as telephone quit available to help you quit such as telephone quit lines or local health clinic services?lines or local health clinic services? 24%24%
Treatment PreferencesTreatment PreferencesIf you were trying to quit smoking and cost If you were trying to quit smoking and cost was not an issue, would you use…was not an issue, would you use…
% yes% yes
Use a stop smoking product like nicotine patch Use a stop smoking product like nicotine patch or Zybanor Zyban
61%61%
Go to a stop smoking class or clinicGo to a stop smoking class or clinic 61%61%
Use self-help materials like books or videosUse self-help materials like books or videos 46%46%
Call a telephone quit lineCall a telephone quit line 38%38%
Use a product like acupuncture, hypnosis or Use a product like acupuncture, hypnosis or herbsherbs
35%35%
Get information from the internetGet information from the internet 24%24%
Experience with Healthcare Experience with Healthcare Delivery SystemDelivery System
Experience with health care professionals and tobacco Experience with health care professionals and tobacco cessation in past 12 monthscessation in past 12 months
% yes% yes
In the past 12 months, has a doctor, nurse or other In the past 12 months, has a doctor, nurse or other health care professional at this clinic advised you to health care professional at this clinic advised you to quit smoking?quit smoking?
73%73%
Did they also,Did they also,
Ask if you were willing to make an attempt to quit?Ask if you were willing to make an attempt to quit? 40%40%
Assist you in your quit attempt (offer counseling, refer Assist you in your quit attempt (offer counseling, refer for treatment or prescription to help?for treatment or prescription to help?
16%16%
Arrange follow up contact about your tobacco use?Arrange follow up contact about your tobacco use? 9%9%
Science PushScience Push: Lessons Learned: Lessons Learned
• Smoking rates higher than general population; similar to Medicaid population rates; varied by facility
• Pharmacologic and counseling were most preferred treatments
• It will be important to actively promote the availability of quit assistance
Baseline FacilityBaseline Facility SurveySurvey
• Purpose: Purpose: – Assess tobacco control practices and policiesAssess tobacco control practices and policies
• Distributed to all Louisiana public hospitalsDistributed to all Louisiana public hospitals– InpatientInpatient– OutpatientOutpatient– QAQA– AdministrationAdministration
• 32 surveys representing 10 of the hospitals were 32 surveys representing 10 of the hospitals were returnedreturned
Baseline Facility SurveyBaseline Facility Survey
• Comparison of findings– Survey instrument was developed based on Survey instrument was developed based on
McPhillips-Tangum’s* survey used with McPhillips-Tangum’s* survey used with Managed Care Organizations (MCOs)Managed Care Organizations (MCOs)
– Survey instruments were distributed and Survey instruments were distributed and completed during the Fall of 2003 through the completed during the Fall of 2003 through the Spring 2004Spring 2004
**McPhillips-Tangum, 1998. Results from the first annual survey on Addressing McPhillips-Tangum, 1998. Results from the first annual survey on Addressing Tobacco in Managed Care, TC Online.Tobacco in Managed Care, TC Online.
Implementation of the Guidelines: Implementation of the Guidelines: Comparison of HCSD and MCOsComparison of HCSD and MCOs
Barriers limiting provider’s effectiveness in addressing Barriers limiting provider’s effectiveness in addressing tobacco control with patients: Comparisontobacco control with patients: Comparison
Monitoring tobacco use: ComparisonMonitoring tobacco use: Comparison
Science Push: LessonsScience Push: Lessons LearnedLearned
• Tobacco cessation has to become a higher priority
• Cessation services should be meshed with existing processes of care
• Personnel designated solely to tobacco cessation needed to facilitate consistent service delivery
Follow up Site VisitsFollow up Site Visits
• Survey results presentedSurvey results presented
• Team building- recommendations for Team building- recommendations for Tobacco Team champions and membersTobacco Team champions and members
• Recommendations for process Recommendations for process implementationimplementation
Tobacco Control Initiative (TCI)
CPGs recommended system interventions shaped program development.
Provide: – Designated staff
• Certified cessation counselors
– Standardized processes, services and data collection
– Educational resources
– 5 As approach• Delineates roles and responsibilities of clinicians involved in the
support and delivery of cessation services
– Continuous program management and evaluation
Goal: To increase adoption, reach and impact of evidence-based Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatmenttobacco dependence treatment
Build CapacityBuild Capacity↔↔
↓
↓↓
Translating Science into PracticeTranslating Science into Practice
Link systems– level Link systems– level tobacco supportstobacco supports
-IT to identify smokers, IT to identify smokers, prompt treatment prompt treatment
-Incorporate into broader Incorporate into broader quality assurancequality assurance
-Performance Performance measurement and measurement and reporting reporting
-Provider training and TAProvider training and TA
Ultimate GoalUltimate Goal:: Reduce tobacco use &Reduce tobacco use &
health care burdenhealth care burden Orleans, CT. 2001; 2004 ; Isaacs, 2004
Push SciencePush Science
2003 – 2004: Process andprogram evaluation procedures and indicators determined
2004 - 2006: Phased Program implementation
Data Sources…Data Sources…
• Data collection and analyses are integral Data collection and analyses are integral components of health systems interventionscomponents of health systems interventions
• Identify eligible participants and manage day-to-Identify eligible participants and manage day-to-day activities day activities
• Evaluate the interventionEvaluate the intervention• Unobtrusive to participants, providers and staff Unobtrusive to participants, providers and staff • Detailed to determine the extent to which Detailed to determine the extent to which
program goals are metprogram goals are met
TCI Evaluation Components and Data TCI Evaluation Components and Data SourcesSources
Quantitative MeasuresQuantitative Measures__________________________________________________________________________________________________________________
Registry/Administrative DataRegistry/Administrative DataPopulation (DMED & Registry) Population (DMED & Registry) Users+ Not w/ check against DMEDUsers+ Not w/ check against DMEDRegistry Tobacco UsersRegistry Tobacco Users Rate of tobacco useRate of tobacco useRelapse Rate/New Use rateRelapse Rate/New Use rate Non users who became usersNon users who became usersQuit RateQuit Rate Users who became non usersUsers who became non users
Program (process/outcomes)Program (process/outcomes)Referral RateReferral Rate Rate of users referredRate of users referredRx assistance rateRx assistance rate Rate of referrals getting drug interventionRate of referrals getting drug interventionCounseling rateCounseling rate Rate of referrals getting ALA type interventionRate of referrals getting ALA type interventionQuit/Relapse RatesQuit/Relapse Rates Local data/registry mixLocal data/registry mix
Program (operations)Program (operations)FTEsFTEs FTEs funded by programFTEs funded by programFTE costFTE cost Funded FTE costs to the programFunded FTE costs to the programDrugsDrugs Program/non program drug costsProgram/non program drug costsHCSD in kindsHCSD in kinds Estimate of costs born by HCSDEstimate of costs born by HCSDnon HCSD in kindsnon HCSD in kinds Estimate of costs born by those external to program & Estimate of costs born by those external to program & HCSDHCSD
Qualitative/Programmatic InformationQualitative/Programmatic Information__________________________________________________________________________________________________________________Patient FlowsPatient Flows Graphical representations of programsGraphical representations of programsProgram Quarterly NarrativesProgram Quarterly Narratives Diaries of the programs from local perspectivesDiaries of the programs from local perspectivesAnnual evaluation team reportsAnnual evaluation team reports Visit reports of annual evaluation teams w/ Visit reports of annual evaluation teams w/
recommendationsrecommendationsAll of the above to be rolled up in annual reports and updated on monthly/quarterly/annual basis on a web site.All of the above to be rolled up in annual reports and updated on monthly/quarterly/annual basis on a web site.
Data Sources…Data Sources…
Tobacco RegistryTobacco Registry
CMEDCMEDDMEDDMED
*
Balancing Participant Identification, Program Balancing Participant Identification, Program Management and EvaluationManagement and Evaluation
Cessation Management & Evaluation DatabaseCessation Management & Evaluation DatabaseTrack program processes and identify opportunities Track program processes and identify opportunities
for process improvement projectsfor process improvement projects
Disease Management & Evaluation DatabaseDisease Management & Evaluation Database
Track patient encounter dataTrack patient encounter data
Electronic identification of tobacco users system-wideElectronic identification of tobacco users system-wide
Data Sources
• Weekly conference calls– Problem solving
• Data collection• Recruitment• Clinic interfacing
– Program development– Networking– Information sharing– Team building
TCI Cessation ServicesTCI Cessation Services
• Self-help materialSelf-help material
• Referral and facilitated access to state Referral and facilitated access to state Quit LineQuit Line– Proactive phone counselingProactive phone counseling
• Behavioral counseling Behavioral counseling – Group sessions Group sessions – Bedside interventionBedside intervention
• PharmacotherapyPharmacotherapy
Out Patient Process of CareTobacco User
Yes No
Patient Given:1. Self Help/Quit-line Referral Flyer2. Advice to quit by provider3. Medication Prescription
Patient Ready to quit in 30 days
Yes NoDo you want to be called by the Quit-
line?
Yes NoPatient information
given to TCI
Referral faxed to Quit-line by TCI
Referral to TCI
Contact in 30 days and 6 months
Mail out free NRT promotion bi-annually
Referral to TCI
Invite to Cessation Classes
Attended Class
Yes NoDoes the patient
have a medication prescription?
Does the patient have a medication
prescription?
Yes NoMedication
voucher given at 3rd class
Yes No
Pharmacotherapy
Pick up NRTs from Pharmacy
Refer to facility’s MAP office/TCI
Patient only wants medication
WellbutrinChantixOther
NRT
TCI StaffProvider
Cessation Classes
1st Class: MAP eligibility forms completed3rd Class: Medication voucher given
Out Patient Services
Patient Identification
Self help materials – quit line referral• Counseling
Group
PhoneCounseling + PharmacotherapyPharmacotherapy only• Motivational intervention
0 .1 .2 .3 .4 .5 .6Fraction of Patients Using Tobacco
all patients
HIV
DIABETES
CHF
ASTHMA
Tobacco Use LevelsAll Patients & by Disease Group
Smoking Rates by Quarter*Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006
Unique Patients 97225 111439 105289 81118 90047 89089
Smokers 23591 27715 27163 23045 25945 26293 % of unique patients 24% 25% 26% 28% 29% 30%
Referrals 964 1406 935 823 988 2190 % of smokers 4% 5% 3% 4% 4% 8%
Ready to quit in 30 days 637 952 654 558 725 1319 % of referrals 66% 68% 70% 68% 73% 60%
Contacted 165 479 574 539 703 1214 % of ready to quit 26% 50% 88% 97% 97% 92%
Scheduled for class 1 64 117 191 265 318 319 % of ready to quit 10% 12% 29% 47% 44% 24%
Attended 1+ classes 61 75 74 92 113 146 % of ready to quit 10% 8% 11% 16% 16% 11%
*8/10 facilities; DMED & CMED; Q1 = Jan-Mar
Smoking Rates by Disease Group, Longitudinally*
*8 of 10 facilities (D &C MED)
Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006DiabetesUnique Patients 17574 19700 18524 14913 16370 15723Smokers 3357 4144 4206 3856 4287 4141 % of unique patients 19% 21% 23% 26% 26% 26%
CHFUnique Patients 1450 1713 1566 1291 1386 1253Smokers 318 417 415 361 428 401 % of unique patients 22% 24% 27% 28% 31% 32%
asthmaUnique Patients 1101 1340 1254 1046 1146 947Smokers 211 290 274 262 273 217 % of unique patients 19% 22% 22% 25% 24% 23%
hivUnique Patients 3265 3528 3390 2255 2652 2703Smokers 1450 1716 1713 1164 1401 1451 % of unique patients 44% 49% 51% 52% 53% 54%
0
500
1000
1500
2000
2500
3000
3500
4000
q1-05 q2-05 q3-05 q4-05 q1-06 q2-06 q3-06
Number of Smokers ReferredAmong those Visiting Clinics
0
.02
.04
.06
.08
.1
.12
.14
.16
q1-05 q2-05 q3-05 q4-05 q1-06 q2-06 q3-06
Fraction of Smokers ReferredAmong those Visiting Clinics
Referrals Over Time
0100200300400500600
# R
ecei
ving
Pre
scrip
tions
600
800
1000
1200
1400
1600
#
Rec
eivi
ng S
elf-
Hel
p M
ater
ials
q1-05 q2-05 q3-05 q4-05 q1-06 q2-06 q3-06
Self-Help Materialsand Medication Prescriptions
0
5
10
15
20
25
30
35
Q1/2005 Q2/2005 Q3/2005 Q4/2005 Q1/2006 Q2/2006 Q3/2006 Q4/2006
Yearly Quarter
Per
centa
ge
Percentage of Smokers Referred that Received a Percentage of Smokers Referred that Received a Pharmacologic PrescriptionPharmacologic Prescription
Percentage of Each Pharmacologic Prescribed
0
20
40
60
80
100
120
Q1/2005 Q2/2005 Q3/2005 Q4/2005 Q1/2006 Q2/2006 Q3/2006 Q4/2006
Yearly Quarter
Per
cen
tag
e
Wellbutrin
Chantix
Other
40
60
80
100
120
140
160
180
200
q1-05 q2-05 q3-05 q4-05 q1-06 q2-06
Number of Referred SmokersAttending at least 1 Class
0
.02
.04
.06
.08
.1
.12
.14
.16
q1-05 q2-05 q3-05 q4-05 q1-06 q2-06
Fraction of Referred SmokersAttending at least 1 Class
Class Attendance among Referred Smokers
0.05.1.15
Fra
ctio
n Q
uitti
ng
.3
.4
.5
.6
.7
.8
.9
F
ract
ion
Qui
ttin
g o
r C
uttin
g B
ack
q1-05 q2-05 q3-05 q4-05 q1-06 q2-06QUARTER
Fraction Reporting Quitting or Cutting Backamong Class Attendees
Who Participates in Behavioral Counseling?
N= 986 class attendees; April 2005 - November 2006
• 62% Caucasian 36% African-American; • 69% Female• 46% smoke > 20 cigarettes/day• 68% have been smoking > 20 years• Appear more motivated to quit than overall HCSD smoking
population (e.g., 95% say they think they will quit within the next year)
Currently investigating:– What distinguishes class attendees from other smokers? – Among class attendees, what distinguishes between those who quit
smoking and those who do not?
Goal: To increase adoption, reach and impact of evidence-based Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatmenttobacco dependence treatment
Push SciencePush Science Build CapacityBuild Capacity Boost DemandBoost Demand↔↔ ↔↔
↓ ↓↓ ↓↓ ↓↓
Translating Science into PracticeTranslating Science into Practice
Policies and community Policies and community strategiesstrategies to increase to increase quitting and decrease usequitting and decrease use
-Bans, decreased cost, Bans, decreased cost, Quitline support, reflective Quitline support, reflective mediamedia
-Market programsMarket programs
-Redesign cessation services Redesign cessation services to increase appeal and useto increase appeal and use
Ultimate GoalUltimate Goal:: Reduce tobacco use &Reduce tobacco use &
health care burdenhealth care burden Orleans, CT. 2001; 2004 ; Isaacs, 2004
Referral RatesReferral Rates
0
500
1000
1500
2000
2500
3000
Q1/2005 Q2/2005 Q3/2005 Q4/2005 Q1/2006 Q2/2006 Q3/2006 Q4/2006
Outpatient Referral Inpatient Referral
Access ServicesAccess ServicesIdentification of Current Users
“Have you used tobacco within the past 30 days?”
Tobacco Control InitiativeTobacco Control Initiative
Daily Census of In-patient Smokersprinted every morning in TCI Office
InterventionInterventionAssessment by Trained Tobacco
Cessation Counselor
Self-help MaterialSelf-help Material
Guide to Quit SmokingQuit-line pocket card
Behavioral CounselingBehavioral Counseling
Individual Session GivenGroup Session Appointment
Quit-line ReferralQuit-line Referral
Proactive Faxed ReferralPharmacotherapyPharmacotherapy
NRT & Non-NRT OptionAssistance Available
Cessation VideoCessation Video
Stages of Change DVD
AdviseAdvise
AssessAssess
AssistAssist
AskAsk
In-patient Process of CareIn-patient Process of Care
ArrangeArrange
Self-help material and quit linereferral in ALL admit packets
In Patient Process of CarePatient Admitted to
Facility
Tobacco User
Yes NoTCI Staff
Notified (at each facility)
TCI Staff Bedside Visit to Patient with Nurse Notification
Patient Consent for Bedside Consultation
Yes No
Patient Given:1. “Guide to Quit Smoking” with Verbal Explanation2. Quit-line Referral Card
Patient Given Care Options (See Option list)
Nurse Informed of: 1. Pharmacotherapy Recommendation 2. Post-Discharge Referral Option Chosen by Patient
Copy of Consultation Form Placed on Patient
Chart
Option List:1. Self Help Materials2. Bedside Consult/Counseling3. Quit-line Referral4. Smoking Cessation Classes (at each facility)5. Pharmacotherapy
Provider TCI Staff Self Help/Quit-line Referral Flyer in
All Admit Packets
TCI…TCI…
• A partnership of public, private and academic entities
• A multi-level systems approach to integrating evidence-based tobacco cessation services which include:– Self help materials– Quit line referral– Behavioral counseling (group /bedside)– Pharmacotherapy (free - low cost)
Goal: To increase adoption, reach and impact of evidence based Goal: To increase adoption, reach and impact of evidence based tobacco dependence treatmenttobacco dependence treatment
Push SciencePush Science Build CapacityBuild Capacity Boost DemandBoost Demand↔↔ ↔↔
↓↓ ↓↓ ↓↓
Translating Science into PracticeTranslating Science into Practice
Ultimate GoalUltimate Goal:: Reduce tobacco use &Reduce tobacco use &
health care burdenhealth care burden
Orleans, CT, 2001, 2004; Isaacs, SL, 2004
↓↓ ↓↓ ↓↓
Future DirectionsFuture Directions
• Refine data sources• Expand services to special populations (i.e.
pregnant women, patients with chronic illnesses)• Examine strategies to provide treatment with
patients not interfaced with TCI (e.g. NRT distribution)
• Expand cessation resources on HCSD website– Provider CME– Tool kits for implementing policies for smoke-free
campus
• Redesign processes to increase appeal and use of cessation services
CLIQCLIQ
5 A’s …5 A’s …
• The Five A’s strategyThe Five A’s strategy– Ask, Advise, Assess, Assist, ArrangeAsk, Advise, Assess, Assist, Arrange
• But, if you are too busy for all five, how But, if you are too busy for all five, how about just two?about just two?– Ask your patients about tobacco useAsk your patients about tobacco use– Advise about quittingAdvise about quitting
Quit Line Use In Tobacco Cessation
• Easy to promote
• Another option for smokers
• Available to anyone with a telephone
• Reduces barriers (i.e. transportation, job)
• Increases quit attempts
• Works with diverse populations
• It’s a minimum intervention for providersAdapted from the Smoking Cessation Leadership Center
The Quit Line and HCSD PatientsThe Quit Line and HCSD Patients
• Approximately 27 thousand HCSD patients use Approximately 27 thousand HCSD patients use tobaccotobacco– Roughly 20 thousand of these patients say they want to Roughly 20 thousand of these patients say they want to
quitquit
• Implementing the quit-line could quadruple the Implementing the quit-line could quadruple the average cessation rate, translating to roughly average cessation rate, translating to roughly 3,000 quitters 3,000 quitters
• Adding brief behavioral counseling and medication Adding brief behavioral counseling and medication can increase the average cessation rate six fold, can increase the average cessation rate six fold, translating to roughly 4,400 quitterstranslating to roughly 4,400 quitters
Adapted from the Smoking Cessation Leadership Center
We know…We know…
• Tobacco cessation is the single most Tobacco cessation is the single most effective step to lengthen and improve effective step to lengthen and improve patients’ livespatients’ lives
• Tobacco cessation has immediate and Tobacco cessation has immediate and long-term benefits and is well worth the long-term benefits and is well worth the effort, both for patient and clinicianseffort, both for patient and clinicians
• Helping patients make a quit attempt is Helping patients make a quit attempt is less time consuming than you thinkless time consuming than you think
• Many new tools exist to help patients quitMany new tools exist to help patients quit
“Knowing is not enough; we must apply. Willing is not enough; we must do.”
-Johann Wolfgang von Goethe
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