TRANSLATING SCIENCE INTO PRACTICE

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• 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

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In collaboration with

• Michele Jean-Pierre Ron Horswell
• Michael Celestin Zhanying Zong
• Danielle Trepagnier Kurt Braun
• Krysten Jones Jay Besse
• Monica Lewis Debbie Hernandez

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And

• Debby Durapau Lucretia Young
• Tambria Hunt JoAnn Brooks
• DAdario Conway Wendy Rhodes
• Elizabeth Sylvest Jennifer Miller
• Nakesha Auguster Betty Henry

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Along with

• Members of the following
• Tobacco Teams
• Process Redesign Team
• Research Evaluation Team
• Health Care Effectiveness Team
• HCSD Administration

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We know

• There is a body of evidence amassed from 40
  years of accomplishments of tobacco control
• Researchers
• Advocates
• Practitioners

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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
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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

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We know

• LSU Health Care Services Division (HCSD)
• States 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

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We know

• It is widely recommended that evidence-based
  cessation services be integrated into healthcare
  delivery systems in order to obtain
  population-wide 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)

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Partnership

• 2002 HCSD started initiative to place treatment
  of tobacco use dependence at forefront of
  Louisianas public hospital system

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LSU HCSD Disease Management Program
Coordination of resources across the health
care delivery system to improve disease outcomes
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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
  

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Translating Science into Practice
Goal To increase adoption, reach and impact of
evidence-based tobacco dependence treatment
?
?
?
?
?
?
Push Science
Build Capacity
Boost Demand

• Evidence based treatment (CPGs)
• Communicate for wide populations
• Test/adapt in new populations and settings
• Research and evaluate to improve

• Link systems level tobacco supports
• IT to identify smokers, prompt treatment
• Incorporate into broader quality assurance
• Performance measurement and reporting
• Provider training and TA

• 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
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HCSD Tobacco Control Program

• Design, implement and evaluate evidence-based
  cessation services in Louisianas public hospital
  system.

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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
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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

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Sample Information

• N777
• Predominantly
• female (82)
• African American (60)
• Poor (72 reported annual family incomes
• Ranged in age from 18 to 84 (mean 49, s.d.13.9)
• 25 current smokers

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Readiness to Quit Yes
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Treatment Preferences
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Experience with Healthcare Delivery System
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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

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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

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Baseline Facility Survey

• Comparison of findings
• Survey instrument was developed based on
  McPhillips-Tangums 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.
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Implementation of the Guidelines Comparison of
HCSD and MCOs
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Barriers limiting providers effectiveness in
addressing tobacco control with patients
Comparison
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Monitoring tobacco use Comparison
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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

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Follow up Site Visits

• Survey results presented
• Team building- recommendations for Tobacco Team
  champions and members
• Recommendations for process implementation

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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

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Translating Science into Practice
Goal To increase adoption, reach and impact of
evidence-based tobacco dependence treatment
?
?
?
Build Capacity
Push Science

• Link systems level tobacco supports
• IT to identify smokers, prompt treatment
• Incorporate into broader quality assurance
• Performance measurement and reporting
• Provider training and TA

2003 2004 Process and program evaluation
procedures and indicators determined
2004 - 2006 Phased Program implementation
Ultimate Goal Reduce tobacco use health care
burden
Orleans, CT. 2001 2004 Isaacs, 2004
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Data Sources

• Data collection and analyses are integral
  components of health systems interventions
• Identify eligible participants and manage
  day-to-day activities
• Evaluate the intervention
• Unobtrusive to participants, providers and staff
• Detailed to determine the extent to which program
  goals are met

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TCI Evaluation Components and Data Sources

• Quantitative Measures
• __________________________________________________
  _______
• Registry/Administrative Data
• Population (DMED Registry) Users Not w/
  check against DMED
• Registry Tobacco Users Rate of tobacco use
• Relapse Rate/New Use rate Non users who became
  users
• Quit Rate Users who became non users
• Program (process/outcomes)
• Referral Rate Rate of users referred
• Rx assistance rate Rate of referrals getting
  drug intervention
• Counseling rate Rate of referrals getting ALA
  type intervention
• Quit/Relapse Rates Local data/registry mix
• Program (operations)
• FTEs FTEs funded by program
• FTE cost Funded FTE costs to the program
• Drugs Program/non program drug costs
• HCSD in kinds Estimate of costs born by HCSD
• non HCSD in kinds Estimate of costs born by
  those external to program HCSD

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Data Sources
Balancing Participant Identification, Program
Management and Evaluation
Electronic identification of tobacco users
system-wide
Cessation Management Evaluation Database Track
program processes and identify opportunities for
process improvement projects
Disease Management Evaluation Database Track
patient encounter data
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Data Sources

• Weekly conference calls
• Problem solving
• Data collection
• Recruitment
• Clinic interfacing
• Program development
• Networking
• Information sharing
• Team building

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TCI Cessation Services

• Self-help material
• Referral and facilitated access to state Quit
  Line
• Proactive phone counseling
• Behavioral counseling
• Group sessions
• Bedside intervention
• Pharmacotherapy

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Out Patient Process of Care
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Out Patient Services

• Patient Identification
• Self help materials quit line referral
• Counseling
• Group
• Phone
• Counseling Pharmacotherapy
• Pharmacotherapy only
• Motivational intervention

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Smoking Rates by Quarter
8/10 facilities DMED CMED Q1 Jan-Mar
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Smoking Rates by Disease Group, Longitudinally
8 of 10 facilities (D C MED)
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Percentage of Smokers Referred that Received a
Pharmacologic Prescription
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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?

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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
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Referral Rates
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In-patient Process of Care
Self-help material and quit line referral in ALL
admit packets
Arrange
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In Patient Process of Care
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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)

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Translating Science into Practice
Goal To increase adoption, reach and impact of
evidence based tobacco dependence treatment
?
?
?
?
?
Push Science
Boost Demand
Build Capacity
?
?
?
Ultimate Goal Reduce tobacco use health care
burden
Orleans, CT, 2001, 2004 Isaacs, SL, 2004
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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

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CLIQ
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5 As

• The Five As 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

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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
• Its a minimum intervention for providers

Adapted from the Smoking Cessation Leadership
Center
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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
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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

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• Knowing is not enough we must apply. Willing is
  not enough we must do.
• -Johann Wolfgang von Goethe