Ohio’s Fax Referral Initiatives

Reach, Enrollment and Participant Characteristics

Jeff Willett, PhDDirector, NYS Tobacco Control Program

March 4th and 6th, 2009

Fax Referral

• The Ohio Tobacco Quit Line began providing statewide services in September, 2004.

• Fax referral was introduced in the first year to increase health provider referral.

• An average of 68 fax referrals were received per month prior to the study period.

Fax Referral

• Goal: to reduce quit line marketing costs by establishing a sustainable, high volume referral stream from health professionals.

• Three initiatives were developed or expanded to increase health provider utilization of the fax referral. – Fax Five– Hospital Outreach– Community Promotion

Fax Five

• Direct marketing initiative aimed at health professionals.– Phase I: Promotional folder and 5 fax referral

forms placed in the May/June issue of Ohio Medicine.

– Phase II: Peer Writing Campaign utilizing the Quit Line’s Advisory Panel. Sent personal letters and 5 fax referral forms to 25,970 health professionals in March, 2007.

Hospital Outreach

• A hospital-focused outreach program funded in March, 2006.

• 51 hospitals received a small stipend to institute a fax referral process.

• Rigorous training component– Daylong in-person training– 5 one-hour training calls

Community Promotion

• Health professional training program conducted by community tobacco control grantees.

• Beginning January, 2007 all 50 OTPF community grantees were required to “Promote Ohio Quits” including distribution of and training related to health professional quit kits.

Evaluation

• Evaluation Period June ’06 – Oct. ’07

• Fax referral forms including tracking codes for each initiative

• Fax referrals not tied to study initiatives were treated as “other”

Fax Referrals ReceivedJune 2006 – October 2007

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Outreach

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Referrals ≠

Enrollments

Outcomes of fax referral call attempts by initiativeJune 2006 – October 2007 (%)

Community(n=1,956)

Hospital (n=1,916)

Fax Five(n=1,065)

Other(n=2,014)

Total(n=6,951)

Enrolled 24.4% 21.3% 28.4% 22.3% 23.6%

Information only 3.4% 3.5% 4.5% 5.6% 4.2%

Declined 13.6% 14.0% 13.2% 14.0% 13.8%

Unreachable 58.6% 61.2% 53.9% 58.1% 58.5%

Examining the “Unreachable”

Rate

3rd Call Dispositions for the April 2007 “Unreachable” Fax Referrals (N=368)

Disconnect / Wrong Number

21 5.7%

No Answer, Busy, Hang up

101 27.5%

Voice mail message

183 49.7%

Message left with household

63 17.1%

Comparing Fax and Traditional

Enrollments

Quit line enrollee characteristics, by fax referral initiative and fax referral status (%)

Fax referral status

Fax (n=1,616)

Non-fax (n=36,273)

Gender

Male 33 42

Female 67 59

Age

Less than 35 21 31

35-64 72 65

65+ 8 4

Comorbidity

One or more 60 36

Note: Bold values indicate a cell count that was higher than expected values; italicized values indicate a cell count that was lower than expected values, p<0.001.

Quit line enrollee characteristics, by fax referral initiative and fax referral status (%)

Fax referral status

Fax (n=1,616)

Non-fax (n=36,273)

Education

Less than HS 24 12

HS/GED 41 40

More than HS 35 47

Insurance Status

Private 57 78

Medicaid 11 4

Medicare 8 3

Uninsured 23 16

Note: Bold values indicate a cell count that was higher than expected values; italicized values indicate a cell count that was lower than expected values, p<0.001.

Reach

• The three initiatives dramatically increased fax referral to the Ohio Tobacco Quit Line.– 68 referrals per month during year before

initiatives– 412 referrals per month during study period– Fax Five: cost-effective, least sustainable

• Can kick-off fax referral expansion

– Community: slow growth, most sustainable

Enrollment

• 23.6% of fax referred individuals enrolled

• 18% actively declined enrollment (information only or declined all service)

• Based on one-month disposition data– An estimated 40% of fax referrals passively

decline enrollment (do not return voice mail or personal messages left by Quit Line)

• Raises questions about patients actual readiness to quit.

Participant Characteristics

• Fax referred individuals were more likely to be lower educated, to be uninsured and to have public insurance.

• Compared to non-fax enrollments driven largely by media efforts, costs per enrollment were much higher for fax referrals.

Questions?

Willett J, Hood N, Burns E, Swetlick J, Wilson S, Lang D, Levinson A. Clinical Fax Referrals to a Tobacco Quitline: Reach, Enrollment and Participant Characteristics. American Journal of Preventive Medicine;36(4):XXX–XXX; April 2009.