coordinating tobacco treatment in a tribal healthcare...
TRANSCRIPT
Coordinating Tobacco Treatment in a Tribal Healthcare System
April 28, 2017
Leah Neff Warner Tobacco Policy Program
Session Objectives
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• Identify rationale and methods for effective, culturally relevant tobacco interventions in a clinical system
• Describe ways to overcome barriers • Discuss strategies to measure success
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Alaska Native Adult Current Smoking by Tribal Region
2010-2014 Alaska White adults (18.3%) U.S. White adults (19.0%) Alaska Native adults (36.4%)
Source: ANTHC Epidemiology Center, 2017
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Preventable Killer Tobacco use is the single greatest cause of disease and premature death in the US.
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Health Burdens and Inequities
• Smoking is linked to 6 of the top 8 causes of death among AI/AN
• While every other race has seen decreases in cancer mortality over the last two decades, some AI/AN cancer mortality rates have increased
• Other smoking-related health disparities: infant mortality, diabetes, and asthma
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20
40
60
80
100
120
140
160
180
Rat
e pe
r 100
,000
Lung Cancer Incidence Rates, Alaska Native Adults and US White Adults, Men & Women
1972-2011 AN
USW
Five year average-annual rates age-adjusted to the Census 2000 US Standard
Lung Cancer Incidence in Alaska Native adults is significantly higher than in US White adults
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94
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A Coordinated Intervention Goal: All of Alaska’s health organizations to implement the U.S. Public Health Service Clinical Practice Guidelines 1. Tobacco-free campus policy and practices 2. Ask, Advise, Refer, and health record documentation 3. Intervene to motivate patients to quit 4. The right pharmacotherapy and counseling 5. Reimbursement for eligible services
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• More than 70% of current smokers want to quit • Counseling and NRT together can more than double success
rates • Clinical brief interventions for tobacco are extremely cost
effective • Effective treatment requires repeated intervention and
multiple quit attempts
Why Does it Work?
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Efficacy Increases with Input and Time
• No clinician advising 10.8% • One clinician type advising 18.3% • Two clinician types advising 23.6%
• Dose response relationship 1-3 minutes increases chance of success by 40%
4-30 minutes increases chance of success by 90% Bonus: Smokers who receive advice and assistance with quitting report greater satisfaction with their provider
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Best Practice in Action
Ask, Advise, TREAT, Refer I. Healthcare provider training presentations II. Juneau and Sitka in-house brief counseling III. Nicotine Replacement Therapy (NRT) Access
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I. Healthcare Provider Training
• Tailored to clinician types • Demo AAR • Focus on documentation • Promote Quit Line • Solicit input
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Tobacco Brief Intervention 2As and R & ATQL Fax Referral Process
ASK all of your patients if they use tobacco at every visit
“What is your tobacco use status (current, former, or never)? How long have you been using it? Have you thought about or tried to quit?
ADVISE them to quit if they use tobacco “As your Health Care Provider, I strongly advise you to
quit tobacco. It is the best thing you can do for your health.”
If patient is READY to consider quitting:
REFER to Alaska’s Tobacco Quit Line, prescribe Nicotine Replacement Therapy (NRT), and arrange an EHR tobacco cessation consult for brief counseling
For patients NOT ready to quit:
Offer materials and encouragement; plan to address tobacco use at the next visit
Document in Electronic Health Record
Ensure Patients Get Full Support for Quitting: ATQL Fax Referral process for Patient
who wants to quit
THE ATQL OFFERS:
Complete Fax referral form with Patient Patient MUST SIGN referral form Fax completed form to 1-800-483-3114 ATQL will contact Patient within 48 hours ATQL will fax provider a Fax Outcome Report
1-800-QUIT-NOW (1-800-784-8669) or http://alaskaquitline.com/
For examples of tobacco brief interventions,
visit www.akbriefintervention.org
Free Quit Materials
Free Quit Aid Products
1-on-1 Telephone Support
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II. In-House Brief Counseling
• Juneau- Electronic Health Record (EHR) Referral
• Sitka- Brief interventions at Hospital 1. Increase motivation 2. Enroll with Quit Line 3. Encourage NRT
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III. NRT Access
• Quit Line NRT not immediate • Motivation is fragile • New at SEARHC: Pharmacists prescribe NRT • 1 month/year of patches, gum, or lozenges
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Policy Proposed: Improve NRT Access, Fully Support Quit Attempts
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Preliminary Outcomes
79
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246
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NRT Prescriptions Quit Line Referrals
Total NRT Prescriptions and Quit Line Referrals among SEARHC Tobacco Using Patients
2015 2016
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Southeast AK Quit Line Callers (n=90) April-June 2016
Sourced from Alaska’s Tobacco Quit Line Report: FY16 Quarter 4. State of Alaska Tobacco Prevention and Control Program.
Preliminary Outcomes
GPRA Measure 2015 SEARHC 2016 SEARHC Alaska Goal
Tobacco Cessation Activities*
(AI/AN) 41.6% 58.2% 49.1%
*Tobacco users who received patient education, or a prescription for cessation meds, or reported quitting smoking in the report period.
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Southeast Alaska BRFSS
72%
82%
46%
68%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2011 2014
Role of HCPs in Smoking Cessation for SE Alaska Natives
Asked
Advised
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Overcoming Challenges
• Gaps in NRT access • Provider-led interventions take time • Barriers to documentation
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Lessons Learned
• The tools and systems drive the practice • Treatment involves more than a referral • Clinic workflows are complex and unique
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What’s Next?
• Pharmacist-led counseling • Routine provider trainings • Cerner opportunities
– eReferral to Quit Line
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Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion (2016). Tobacco Prevention and Control Regional Profile: Southeast Region. Anchorage, AK: Alaska Department of Health and Social Services. http://dhss.alaska.gov/dph/Chronic/Documents/Tobacco/PDF/FY15_TPC_Southeast.pdf Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Disease Prevention and Health Promotion. Tobacco Prevention and Control Regional Profile: Southeast Region. Anchorage, AK: Alaska Department of Health and Social Services; 2015. Alaska Mission 100 Healthcare Systems Change Manual Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: US Department of Health and Human Services. Public Health Service. April 2009. Hall, N., Hipple, B., Friebely, J., Ossip, D., Winickoff, J. (2009). Addressing Family Smoking in Child Health Care Settings. Journal of Clinical Outcomes Management, 16(8), 367-376. https://www2.aap.org/richmondcenter/pdfs/addressingFamilySmoking.pdf U.S. Department of Health and Human Services (1994). Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health.
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