The Smoking Intervention Program, a Provider-based Care Management Process

Smoking cessation is an important public health concern, and has been the subject of a recent Agency for Health Care Policy and Research (AHCPR) guideline, as well as a HEDIS measure.   A point prevalence study conducted with the Henry Ford Health System found a 27.4% prevalence of smoking, and an additional 38.6% former smokers.

The CCE developed a first-generation smoking-dependency clinic which was staffed by trained non-physician counselors and overseen by a physician medical director. The original intervention was a 50-minute initial evaluation and counseling visit, with nicotine replacement therapy prescribed for all patients with a high level of nicotine dependency. This intervention was subsequently updated to reflect the AHCPR recommendation that, unless contraindicated, all smoking cessation patients be prescribed nicotine replacement therapy.

Because relapse is a normal part of smoking cessation, the intervention was explicitly designed to address relapse. This was done through return visits, an optional support group, and follow-up telephone counseling calls throughout the year, as illustrated in the following figure.

The program was designed to be inexpensive and simple to execute within the clinic. This was accomplished by automating the logistics of both the intervention and the collection of outcomes measures. The Flexi-Scan System, an internally developed computer application which helps automate outcome studies and disease-management interventions was used to automate (1) data entry through a scanner, (2) prompting of follow-up calls and mailings, and (3) the generation of medical-record notes and letters to the referring physicians. A database that can be used for outcomes-data analyses is acquired as a part of this process.

As illustrated on the figure below, this first-generation program achieved a twelve-month quit rate of 25%. Such a quit rate is about twice as high as the rate achieved with brief counseling intervention.

To evaluate the cost-effectiveness of this program, a decision analytic model was constructed. This model was constructed using the Markov method.  Key assumptions of the model include the following:

  • One year quit rate for usual care (optimistically assumed to consist of brief physician advice) was 12.5%.
  • Spontaneous quit rate of 1% per year in “out years.”
  • Relapse rate for recent quitters of 10%.
  • Age, Sex distribution based on Smoking Clinic patient demographics
  • Life expectancy of smokers and former smokers by age and sex based on literature (life tables).
  • Cost of clinic intervention – $199
  • Cost of nicotine therapy Smoking Clinic – $101 (Assuming 0.9 Rx/Patient)
  • Usual Care – $33 (Assuming 0.3 Rx/Patient)
  • Future health care costs were not considered
  • Annual discount rate of 5%

The results of this model were presented at the annual meeting of the Society for Medical Decision-Making.  The model results are presented in the form a table called a “balance sheet” (a term coined by David Eddy, MD, PhD).  As shown below, the model estimated that the first-generation smoking-dependency clinic cost about $1,600 for each life year gained.

To help evaluate whether this cost-effectiveness ratio is favorable, a league table was constructed (see below).  The league table shows comparable cost-effectiveness ratios for other health care interventions.  Interpretation of the table suggests that the smoking cessation intervention is highly favorable to these other health care interventions.

League Table

Intervention Cost per Quality-adjusted Life Year Gained
Smoking Cessation Counselling $6,400
Surgery for Left Main Coronary Artery Disease for a 55-year old man $7,000
Flexible Sigmoidoscopy (every 3 years) $25,000
Renal Dialysis (annual cost) $37,000
Screening for HIV (at a prevalence of 5/1,000) $39,000
Pap Smear (every year) $40,000
Surgery for 3-vessel Coronary Artery Disease for a 55 year-old man $95,000

Although this first generation program was effective and cost-effective, it was targeted only at the estimated 16,500 smokers in the HFMG patient population who were highly motivated to quit.

The estimated 66,000 other smokers in the HFMG patient population would be unlikely to pursue an intervention that involved visiting a smoking dependency clinic. Even for the smokers who were highly motivated to quit, the smoking cessation clinic had the capacity to provide counseling to about 500 people each year, or about 3% of these highly motivated smokers.

Second Generation Smoking Intervention Program

In response to this problem, the CCE developed a “second generation” Smoking Intervention Program.” This program uses a three tiered approach which includes (1) a “front-end” process for primary care and specialty clinics to use to identify smokers and provide brief motivational advice, (2) a centralized telephone-based triage process to conduct assessment and make arrangements for appropriate intervention, and (3) a stepped-care treatment tier.

In the “front-end” process, clinic physician and support staff were trained to screen their patients from smoking status and readiness to quit and provide tailored brief advise. Each participating clinic was provided with a program “kit” including screening forms, patient brochures, and posters to assist them in implementing the program. Patients who are interested in further intervention are referred to a centralized triage counselor for further assessment and intervention. These counselors are trained, non-physician care providers. They proactively call each patient referred, conduct an assessment of the patients smoking and quitting history and triage into a stepped-care intervention program.

An important part of this intervention has been providing information to clinicians, including a quarterly report showing the number of patients they have referred to the Smoking Intervention Program, the status of those patients, the type of intervention they are receiving, and the number of patients who report not having smoked in the preceding six months.

The clinician-specific data is presented in comparison to data for the medical group as a whole. These reports have a strong motivational effect on clinicians, as evidenced by a sharp increase in Smoking Intervention Program referrals after each reporting cycle.

As shown above, the second generation program achieved a six month quit rate of about 25%. This rate is virtually identical to the first generation program.  The new program, however, has much larger capacity and lower cost per participant. Patient satisfaction with the Smoking Intervention Program is encouraging, with 85% reporting that they would refer a friend to this program.

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The Managed Care College and Pediatric Asthma Management

The Managed Care College

The Managed Care College is a comprehensive professional development program that is intended to go beyond the transfer of information. It attempts to persuade clinicians that change is necessary and desirable, to provide leadership and guidance in seeking change, to create opportunities to collaborate with colleagues in planning and implementing change, and to provide ongoing provider performance feedback to monitor change. The College is an on-site, continuous program. The notion behind the College was that continuing medical education should not be removed from everyday clinical practice, but instead should be a part of it. The College offers a variety of courses, ranging from clinical epidemiology to customer oriented service provision. There is also a series of courses directed at specific conditions.

Pediatric Asthma Management Course

One of the courses within the Managed Care College focused on the ambulatory management of pediatric patients with bronchial asthma.  Within the context of this asthma course, and with guidance from course faculty, the participants did the following:

  • Completed directed reading and received a lecture to review the epidemiology and pathophysiology of asthma,
  • Agreed on a definition of pediatric asthma, based on billing codes.  To inform this process, participants conducted a chart review from an initial computer-generated list of their own asthma patients to identify coding issues.  Based on agreed-upon definitions, a registry of asthma patients was established for each participant.
  • Studied and discussed the implications of a computer-generated list of their own patients in the asthma registry, flagging patients with a recent emergency room visits and admissions and those who had submitted no claims for inhaled steroids, a preventive treatment for asthma. The list also identified the 20% of patients who had been seen by an allergy specialist, or who had poor continuity of care by primary care clinicians.
  • Reviewed externally developed guidelines for patients with bronchial asthma. These guidelines were then discussed within the context of specific patient scenarios to evaluate the appropriateness and feasibility of adapting them within the HFHS.
  • Developed a clinical-process flowchart to identify barriers to implementation of asthma guidelines, with special focus on barriers to patient education.

With this as background information about their own clinical practices, and after having reviewed a number of externally developed guidelines, the class adapted the National Heart, Lung, and Blood Institutes guidelines for the diagnosis and management of pediatric asthma. Ultimately, after several reviews and approvals, those guidelines became the guidelines adapted by the entire HFHS. As part of these guidelines, some specific tools were developed. For example, a standardized “zone sheet” was developed, including an action plan for the patient to follow depending upon their self-measurement of peak expiratory flow rate. A peak-flow diary was also created to record results of self-monitoring.

Evaluation

As part of a formal program evaluation of the Managed Care College, pre- and post-surveys were administered to all course enrollees.

  • At the end of the course, enrollees were more likely to agree that they understood the “zone sheets.”
  • Enrollees were also more likely to indicate that home monitoring of peak expiratory flow rates was important, consistent with the practice guideline.
  • Sixty four percent of enrollees indicated that their participation in the course changed their approach to the management and treatment of patients with asthma.
  • Almost three-quarters agreed with the statement that participation in the course increased the percentage of patients for whom they recommend home monitoring of peak flows.
  • About 63% said the course increased the percentage of patients for whom they prescribed preventive or maintenance medications.
  • Just over 50% indicated that participation increased the frequency with which their patients with asthma received education.
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