Transcript Slide 1

TRANSLATING SCIENCE INTO PRACTICE
LSU Health Care Services Division
Disease Management Program Quarterly Meeting
March 27,2007
Sarah Moody Thomas, PhD
Clinical Lead
HCSD Tobacco Control Initiative
Professor
LSU Health Sciences Center - School of Public Health
In collaboration with
Michele Jean-Pierre
Michael Celestin
Danielle Trepagnier
Krysten Jones
Monica Lewis
Ron Horswell
Zhanying Zong
Kurt Braun
Jay Besse
Debbie Hernandez
And…
•
•
•
•
•
Debby Durapau
Tambria Hunt
D’Adario Conway
Elizabeth Sylvest
Nakesha Auguster
Lucretia Young
JoAnn Brooks
Wendy Rhodes
Jennifer Miller
Betty Henry
Along with…
Members of the following:
•
•
•
•
•
Tobacco Teams
Process Redesign Team
Research & Evaluation Team
Health Care Effectiveness Team
HCSD Administration
We know…
There is a body of evidence amassed from
40 years of accomplishments of tobacco
control:
 Researchers
 Advocates
 Practitioners
We know…
In Louisiana:
•
•
•
•
residents’ health status ranked 50th in the nation*
~ 20% of population is uninsured
10th highest smoking rate; ~ 23% smoke*
1.5 Billion healthcare cost associated with
tobacco use
• $663 million absorbed by Medicaid
• Nearly 6500 adults die annually from smoking
United Health Foundation, 2006
We know…
• Efficacious treatments for tobacco use &
dependence exist.
• Cost- effective treatments for tobacco use
and dependence are key to preventing
disease onset, progression and
exacerbation.
• Clinical Practice Guidelines (CPG) are
inadequately implemented.
Fiore, M. 2000
We know…
LSU Health Care Services Division
(HCSD):
• State’s largest and nationally the 5th largest
integrated public healthcare system
– 1.5m outpatient visits,
– 80,000 inpatient admissions
• Well-established disease management program
• Administration committed to continuous quality
improvement and health systems research
We know …
It is widely recommended that evidence-based
cessation services be integrated into healthcare
delivery systems in order to obtain populationwide benefits.
– Robert Wood Johnson Foundation (1997; 2000)
– US Department of Health and Human Services (2000)
– National Academy of Sciences, Institute of Medicine
(2001; 2003)
– Centers for Disease Control and Prevention (2006)
Partnership
2002 – HCSD started initiative to place treatment of tobacco use &
dependence at forefront of Louisiana’s public hospital system
LSU HCSD Disease Management
Program
Coordination of
resources across
the health care
delivery system to
improve 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
Translating Science into Practice
Goal: To increase adoption, reach and impact of evidence-based
tobacco dependence treatment
↓↓
Push Science
↓
↔
Build Capacity
Evidence based
treatment (CPGs)
Link systems– level
tobacco supports
-Communicate for
wide populations
-IT to identify smokers,
prompt treatment
-Test/adapt in new
populations and
settings
-Incorporate into broader
quality assurance
-Research and
evaluate to improve
-Performance
measurement and reporting
-Provider training and TA
↓
↔
Boost Demand
Policies and community
strategies to increase
quitting and decrease use
-Bans, decreased cost,
Quitline support, reflective
media
-Market programs
-Redesign cessation services
to increase appeal and use
Ultimate Goal:
Reduce tobacco use &
health care burden
Orleans, CT. 2001; 2004 ;
Isaacs, 2004
HCSD Tobacco Control Program
Design, implement and evaluate evidencebased cessation services in Louisiana’s
public hospital system.
Translating Science into Practice
Goal: To increase adoption, reach and impact of evidence-based
tobacco dependence treatment
↓↓
Push Science
Evidence based
treatment (CPGs)
-Communicate for
wide populations
-Test/adapt in new
populations and
settings
-Research and
evaluate to improve
2002 – 2004: Assessments conducted to
determine prevalence of tobacco use, existing
services and existing organizational
infrastructure
Know Your Population – Patient Survey
• Purpose
– Characterize prevalence, patterns of tobacco
use and readiness to quit among patients of
this “safety net” health system
• Methods
– Patients randomly selected within calendar
days
– Survey instrument administered face-to-face
by trained interviewers
Sample Information
• N=777
• Predominantly:
• female (82%)
• African American (60%)
• Poor (72% reported annual family incomes
< $15,000)
• Ranged in age from 18 to 84 (mean= 49,
s.d.=13.9)
• 25% current smokers
Readiness to Quit: % Yes
During the past 12 months, have you stopped
smoking for 1 day or longer because you were
trying to quit?
49%
Are you planning to stop smoking within the
next 30 days?
23%
Are you seriously considering quitting within
the next 6 months?
56%
If we talk in a year, do you think you will be
smoking?
41%
Are you aware of assistance that might be
available to help you quit such as telephone quit
lines or local health clinic services?
24%
Treatment Preferences
If you were trying to quit smoking and cost
was not an issue, would you use…
% yes
Use a stop smoking product like nicotine patch 61%
or Zyban
Go to a stop smoking class or clinic
61%
Use self-help materials like books or videos
46%
Call a telephone quit line
38%
Use a product like acupuncture, hypnosis or
herbs
35%
Get information from the internet
24%
Experience with Healthcare
Delivery System
Experience with health care professionals and tobacco
cessation in past 12 months
% yes
In the past 12 months, has a doctor, nurse or other
health care professional at this clinic advised you to
quit smoking?
73%
Did they also,
Ask if you were willing to make an attempt to quit?
40%
Assist you in your quit attempt (offer counseling, refer
for treatment or prescription to help?
16%
Arrange follow up contact about your tobacco use?
9%
Science Push: 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 Facility Survey
• Purpose:
– Assess tobacco control practices and policies
• Distributed to all Louisiana public hospitals
– Inpatient
– Outpatient
– QA
– Administration
• 32 surveys representing 10 of the hospitals were
returned
Baseline Facility Survey
• Comparison of findings
– Survey instrument was developed based on
McPhillips-Tangum’s* survey used with
Managed Care Organizations (MCOs)
– Survey instruments were distributed and
completed during the Fall of 2003 through the
Spring 2004
*McPhillips-Tangum, 1998.
Results from the first annual survey on Addressing
Tobacco in Managed Care, TC Online.
Implementation of the Guidelines:
Comparison of HCSD and MCOs
69%
Not aware of or
not implemented
53%
22%
Partially
39%
MCOs
9%
Fully
HCSD
9%
0%
20%
40%
60%
80%
100%
Barriers limiting provider’s effectiveness in addressing
tobacco control with patients: Comparison
93%
Time constraints during patient visits
57%
43%
Frustration due to low success rate
36%
MCOs
21%
Lack of reimbursement for cessation
HCSD
35%
61%
Low priority
43%
0%
20%
40%
60%
80% 100%
Monitoring tobacco use: Comparison
Identify individual
patients who
smoke
61%
15%
Document
smoking status in
medical record
Document
smoking status in
computer database
0%
75%
61%
7%
11%
20%
MCOs
40%
60%
80%
HCSD
100%
Science Push: Lessons Learned
• 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 Visits
• Survey results presented
• Team building- recommendations for
Tobacco Team champions and members
• Recommendations for process
implementation
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
Translating Science into Practice
Goal: To increase adoption, reach and impact of evidence-based
tobacco dependence treatment
↓
Push Science
↓
↔
Build Capacity
Link systems– level
tobacco supports
-IT to identify smokers,
prompt treatment
-Incorporate into broader
quality assurance
-Performance
measurement and reporting
2003 – 2004: Process and
program evaluation
procedures and indicators
determined
2004 - 2006: Phased
Program implementation
-Provider training and TA
Ultimate Goal:
Reduce tobacco use &
health care burden
Orleans, CT. 2001; 2004 ;
Isaacs, 2004
Data Sources…
• Data collection and analyses are integral
components of health systems interventions
• Identify eligible participants and manage day-today activities
• Evaluate the intervention
• Unobtrusive to participants, providers and staff
• Detailed to determine the extent to which
program goals are met
TCI Evaluation Components and Data
Sources
Quantitative Measures
_________________________________________________________
Registry/Administrative Data
Population (DMED & Registry)
Registry Tobacco Users
Relapse Rate/New Use rate
Quit Rate
Users+ Not w/ check against DMED
Rate of tobacco use
Non users who became users
Users who became non users
Program (process/outcomes)
Referral Rate
Rx assistance rate
Counseling rate
Quit/Relapse Rates
Rate of users referred
Rate of referrals getting drug intervention
Rate of referrals getting ALA type intervention
Local data/registry mix
Program (operations)
FTEs
FTE cost
Drugs
HCSD in kinds
non HCSD in kinds
FTEs funded by program
Funded FTE costs to the program
Program/non program drug costs
Estimate of costs born by HCSD
Estimate of costs born by those external to program &
HCSD
Qualitative/Programmatic Information
_________________________________________________________
Patient Flows
Graphical representations of programs
Program Quarterly Narratives
Diaries of the programs from local perspectives
Annual evaluation team reports
Visit reports of annual evaluation teams w/
recommendations
All of the above to be rolled up in annual reports and updated on monthly/quarterly/annual basis on a web site.
Data Sources…
Balancing Participant Identification, Program
Management and Evaluation
Tobacco Registry
Electronic identification of tobacco users system-wide
*
DMED
Disease Management & Evaluation Database
Track patient encounter data
CMED
Cessation Management & Evaluation Database
Track program processes and identify opportunities
for process improvement projects
Data Sources
• Weekly conference calls
– Problem solving
• Data collection
• Recruitment
• Clinic interfacing
– Program development
– Networking
– Information sharing
– Team building
TCI Cessation Services
• Self-help material
• Referral and facilitated access to state
Quit Line
– Proactive phone counseling
• Behavioral counseling
– Group sessions
– Bedside intervention
• Pharmacotherapy
Out Patient Process of Care
Tobacco User
Provider
TCI Staff
Patient Given:
1. Self Help/Quit-line
Referral Flyer
2. Advice to quit by provider
3. Medication Prescription
Cessation Classes
1st Class: MAP
eligibility forms
completed
3rd Class: Medication
voucher given
Yes
No
Pharmacotherapy
Patient only wants medication
Patient Ready to
quit in 30 days
NRT
Do you want to be
called by the Quitline?
Patient information
given to TCI
Yes
No
Referral faxed to
Quit-line by TCI
Yes
No
Referral to TCI
Contact in 30 days
and 6 months
Referral to TCI
Mail out free NRT
promotion bi-annually
Invite to Cessation
Classes
Pick up NRTs from
Pharmacy
Wellbutrin
Chantix
Other
Attended Class
Does the patient
have a medication
prescription?
Medication
voucher given at
3rd class
Yes
No
Yes
No
Does the patient
have a medication
prescription?
Yes
No
Refer to facility’s
MAP office/TCI
Out Patient Services
Patient Identification
Self help materials – quit line referral
• Counseling
Group
Phone
Counseling + Pharmacotherapy
Pharmacotherapy only
• Motivational intervention
Tobacco Use Levels
All Patients & by Disease Group
ASTHMA
CHF
DIABETES
HIV
all patients
0
.1
.2
.3
.4
Fraction of Patients Using Tobacco
.5
.6
Smoking Rates by Quarter*
Q1 2005
97225
Q2 2005
111439
Q3 2005
105289
Q4 2005
81118
Q1 2006
90047
Q2 2006
89089
23591
24%
27715
25%
27163
26%
23045
28%
25945
29%
26293
30%
Referrals
% of smokers
964
4%
1406
5%
935
3%
823
4%
988
4%
2190
8%
Ready to quit in 30 days
% of referrals
637
66%
952
68%
654
70%
558
68%
725
73%
1319
60%
Contacted
% of ready to quit
165
26%
479
50%
574
88%
539
97%
703
97%
1214
92%
Scheduled for class 1
% of ready to quit
64
10%
117
12%
191
29%
265
47%
318
44%
319
24%
Attended 1+ classes
% of ready to quit
61
10%
75
8%
74
11%
92
16%
113
16%
146
11%
Unique Patients
Smokers
% of unique patients
*8/10 facilities; DMED & CMED; Q1 = Jan-Mar
Smoking Rates by Disease
Group, Longitudinally*
Q1 2005
Q2 2005
Q3 2005
Q4 2005
Q1 2006
Q2 2006
Diabetes
Unique Patients
Smokers
% of unique patients
17574
3357
19%
19700
4144
21%
18524
4206
23%
14913
3856
26%
16370
4287
26%
15723
4141
26%
CHF
Unique Patients
Smokers
% of unique patients
1450
318
22%
1713
417
24%
1566
415
27%
1291
361
28%
1386
428
31%
1253
401
32%
asthma
Unique Patients
Smokers
% of unique patients
1101
211
19%
1340
290
22%
1254
274
22%
1046
262
25%
1146
273
24%
947
217
23%
hiv
Unique Patients
Smokers
% of unique patients
3265
1450
44%
3528
1716
49%
3390
1713
51%
2255
1164
52%
2652
1401
53%
2703
1451
54%
*8 of 10 facilities (D &C MED)
Referrals Over Time
Number of Smokers Referred
Among those Visiting Clinics
Fraction of Smokers Referred
Among those Visiting Clinics
4000
.16
3500
.14
3000
.12
2500
.1
2000
.08
1500
.06
1000
.04
500
.02
0
0
q1-05 q2-05 q3-05 q4-05 q1-06 q2-06 q3-06 q1-05 q2-05 q3-05 q4-05 q1-06 q2-06 q3-06
Self-Help Materials
and Medication Prescriptions
1600
1400
1200
# Receiving Prescriptions
1000
800
600
q1-05
q2-05
q3-05
600
500
400
300
200
100
0
q4-05
q1-06
q2-06
q3-06
Percentage of Smokers Referred that Received a
Pharmacologic Prescription
35
30
Percentage
25
20
15
10
5
0
Q1/2005
Q2/2005
Q3/2005
Q4/2005
Q1/2006
Yearly Quarter
Q2/2006
Q3/2006
Q4/2006
Percentage of Each Pharmacologic Prescribed
120
Wellbutrin
Chantix
Other
100
Percentage
80
60
40
20
0
Q1/2005
Q2/2005
Q3/2005
Q4/2005
Q1/2006
Yearly Quarter
Q2/2006
Q3/2006
Q4/2006
Class Attendance among Referred Smokers
Number of Referred Smokers
Attending at least 1 Class
Fraction of Referred Smokers
Attending at least 1 Class
200
.16
180
.14
160
.12
140
.1
120
.08
100
.06
80
.04
60
.02
40
0
q1-05
q2-05
q3-05
q4-05
q1-06
q2-06 q1-05
q2-05
q3-05
q4-05
q1-06
q2-06
Fraction Reporting Quitting or Cutting Back
among Class Attendees
.9
.8
.7
.6
.5
.4
q1-05
Fraction Quitting
.3
q2-05
q3-05
q4-05
QUARTER
.15
.1
.05
0
q1-06
q2-06
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?
Translating Science into Practice
Goal: To increase adoption, reach and impact of evidence-based
tobacco dependence treatment
↓↓
Push Science
↓
↔
Build Capacity
↓
↔
Boost Demand
Policies and community
strategies to increase
quitting and decrease use
-Bans, decreased cost,
Quitline support, reflective
media
-Market programs
-Redesign cessation services
to increase appeal and use
Ultimate Goal:
Reduce tobacco use &
health care burden
Orleans, CT. 2001; 2004 ;
Isaacs, 2004
Referral Rates
3000
2500
2000
1500
1000
500
0
Q1/2005
Q2/2005
Q3/2005
Q4/2005
Outpatient Referral
Q1/2006
Inpatient Referral
Q2/2006
Q3/2006
Q4/2006
In-patient Process of Care
Self-help material and quit line
referral in ALL admit packets
Access Services
Identification of Current Users
“Have you used tobacco within the past 30 days?”
Ask
Tobacco Control Initiative
Daily Census of In-patient Smokers
printed every morning in TCI Office
Intervention
Advise
Assessment by Trained Tobacco
Cessation Counselor
Assess
Assist
Self-help Material
Behavioral Counseling
Guide to Quit Smoking
Quit-line pocket card
Individual Session Given
Group Session Appointment
Quit-line Referral
Proactive Faxed Referral
Pharmacotherapy
Cessation Video
NRT & Non-NRT Option
Assistance Available
Stages of Change DVD
Arrange
In Patient Process of Care
Provider
Patient Admitted to
Facility
TCI Staff
Self Help/Quit-line
Referral Flyer in
All Admit Packets
Tobacco User
Option List:
1. Self Help Materials
2. Bedside Consult/Counseling
3. Quit-line Referral
4. Smoking Cessation Classes (at
each facility)
5. Pharmacotherapy
TCI Staff
Notified (at each
facility)
TCI Staff Bedside
Visit to Patient with
Nurse Notification
Patient Given Care
Options (See
Option list)
Nurse Informed of:
1. Pharmacotherapy
Recommendation
2. Post-Discharge
Referral Option
Chosen by Patient
Yes
No
Patient Consent
for Bedside
Consultation
Yes
No
Copy of
Consultation Form
Placed on Patient
Chart
Patient Given:
1. “Guide to Quit Smoking” with
Verbal Explanation
2. Quit-line Referral Card
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)
Translating Science into Practice
Goal: To increase adoption, reach and impact of evidence based
tobacco dependence treatment
↓
Push Science
↓
↔
Build Capacity
↓
↔
Boost Demand
↓
Ultimate Goal:
Reduce tobacco use &
health care burden
Orleans, CT, 2001, 2004;
Isaacs, SL, 2004
Future 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
CLIQ
5 A’s …
• The Five A’s strategy
– Ask, Advise, Assess, Assist, Arrange
• But, if you are too busy for all five, how
about just two?
– Ask your patients about tobacco use
– Advise 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 providers
Adapted from the Smoking Cessation
Leadership Center
The Quit Line and HCSD Patients
• Approximately 27 thousand HCSD patients use
tobacco
– Roughly 20 thousand of these patients say they want
to quit
• Implementing the quit-line could quadruple the
average cessation rate, translating to roughly
3,000 quitters
• Adding brief behavioral counseling and
medication can increase the average cessation
rate six fold, translating to roughly 4,400 quitters
Adapted from the Smoking Cessation
Leadership Center
We know…
• Tobacco cessation is the single most
effective step to lengthen and improve
patients’ lives
• Tobacco cessation has immediate and
long-term benefits and is well worth the
effort, both for patient and clinicians
• Helping patients make a quit attempt is
less time consuming than you think
• Many 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