translating the clinical guideline for treatment of tobacco

Translating The Clinical Guideline for Treatment of Tobacco Use and Dependence into Dental Settings

Margaret M. Walsh, Ed.D.

Professor

Dept of Preventive and Restorative Dental Sciences

University of California

School of Dentistry

San Francisco

Jane Weintraub DMD, MPH, J. Ellison DDS, MPH, Joanna Hill, MA, Umo Isong DDS, Ph.D., S. Gansky DrPH, Steve

Silverstein DMD, MPH, Catherine Kavanagh, Jana Murray RN, Barbara Heckman

RDH, MS

National Advisory Board

Background• Clinical Practice Guidelines are

“systematically developed statements to assist practitioner and patient decisions about healthcare for specific clinical circumstances.” (Field et al, 1990)

• Little is known about the process and factors responsible for how practitioners change their practice methods when they become aware of a guideline.

• Provide evidence-based practical methodsProvide evidence-based practical methods • Supported by evidence from 2 systematic reviewsSupported by evidence from 2 systematic reviews

(1975 - 1994 & 1995 – Jan 1999)(1975 - 1994 & 1995 – Jan 1999)

Ask: Systematically ID all tobacco users at every visit

Advise: Strongly urge all tobacco users to quit (non-

judgmental) Assess: Determine which users are

willing to make a quit attempt

Assist: Aid the patient in quitting Arrange: Schedule follow-up contact

Ask: Systematically ID all tobacco users at every visit

Advise: Strongly urge all tobacco users to quit (non-

judgmental) Assess: Determine which users are

willing to make a quit attempt

Assist: Aid the patient in quitting Arrange: Schedule follow-up contact

Strategies for Strategies for Healthcare Providers: Healthcare Providers:

5 A’s5 A’s

Strategies for Strategies for Healthcare Providers: Healthcare Providers:

5 A’s5 A’s

•Mecklenburg RE, Christen AG, et al., 1993; Fiore MC, Bailey WC, Cohen SJ, et al., 2000

Why Dental Settings?

• 46 million adult smokers in the U.S.• 1/3 of all smokers die prematurely• 50% of smokers see a dentist during

a year• If 10% of smokers who see a dentist

annually could be influenced to quit, then 2.3 million smokers could be treated and 600,000 premature deaths avoided

Oral Health Effects of Smoking

• Oral and pharyngeal cancers(U.S.Surgeon General Report, 2004)

• Adult periodontitis (50%)(Gelsky, 1999; Tomar et al., 2000)

• Failure of periodontal therapy(Amer Acad of Perio, 1999)

• Failure of dental implants(Chuang et al., 2002)

• Impairs oral wound healing(Jones et al., 1992; Preber et al., 1990)

• Increases risk of dental caries(Tomar et al.,1999)

Are Dental Practitioners Effective Smoking Cessation

Counselors?

Dental-office RCTs, dental practitioners were effective

– Gen dental patients quit smoking (17% I vs. 8% C) (Cohen et al, 1989)

– Gen dental patients quit ST use (17% I vs. 9% C) (Stevens et al, 1995)

– Periodontal patients quit smoking (14% I vs. 5% C) (Macgregor, 1996)

1997 National Survey of Dentists

• 33% Asked most or nearly all patients

• 29% Provided some form of tobacco cessation assistance

• 14% Completed formal training

• 20% Felt well prepared to assist

Dolan et al. JADA. 1997

Studies of Barriers to Effecting Change in Dentists’ Behavior*

Among the most frequent reasons cited for not providing tobacco cessation treatment:

– “lack of training”

– “not covered by insurance”

– “lack of financial incentives”

Gerbert et al., 1989; Hayes et al., 1997; Gould et al., 1998; Dolan et al., 1997; Albert et al., 200 *Gerbert et al., 1989; Hayes et al., 1997; Gould et al., 1998; Dolan et al., 1997; Albert et al., 2002

Background

• In 2003, the NIDCR and the NIDA requested proposals to study ways to translate these guidelines into dental settings

Specific Aim

• To compare the effects of intensity of training and third-party reimbursement on general dentists’ attitudes and behaviors related to the assessment and treatment of patients’ tobacco use

Hypotheses:

At 9 mos post intervention, outcomes would be more favorable in:

• High Intensity training groups compared to Low Intensity training groups

• Reimbursement groups compared to the No Reimbursement groups

• All intervention groups compared to the

usual care group

Group-Randomized Controlled Trial

• Partnered with Delta Dental (Largest U.S. provider of dental insurance)

• 250 dental practices

• Dentist eligibility:

– Delta Dental Provider in CA, PA, or WV

– 4 days in clinical practice

Practices Randomly Selected from a Master

List of Delta Dental

Providers in CA, PA, WV

Block Randomization:

80% Int 20%

UC

Usual Care

INTERV

Recruit, Consent

Recruit, Consent

Baseline N=200 Baseline N=50

Block Randomization

HITN=50

HIT+RN=50

LITN=50

LIT+RN=50

12-Mo: Patient Report & DDS Self Report via Mailed Surveys

20% of initial sample randomly assigned to usual care pool for recruitment & baseline assessment

Remaining 80% randomly assigned to intervention arm pool for recruitment, baseline assessment, & random assignment to intervention group

Stratified Randomized Controlled Trial

Usual Care Dentist Recruitment

• A “consent-form” letter was sent from CDD asking them to participate in a baseline and 9-month follow-up survey to assess preventive services provided in their practice

• Questionnaire was included with the letter,

along with a pre-addressed, stamped envelop for return of the survey to UCSF

• $10 Incentive

Intervention Dentist Recruitment

• A “consent-form” letter sent from CDD explaining the study and highlighting the 4 intervention groups for randomized assignment.

• The letter included a pre-addressed, stamped return postcard for interested dentists to mail back to UCSF for more information.

• Upon receiving the postcard, UCSF study

staff called the dentist to answer any questions and to further describe the study. An informed consent form was sent to the dentist to sign and return ($10 incentive)

Dentist Enrollment and Recruitment Pool Given a 15%

Participation Rate

• Enrolled– Yr 1: 50 – Yr 2: 75– Yr 3: 75– Yr 4: 50– Total: 250

dentists

• Recruitment pool – Yr 1: 350– Yr 2: 500– Yr 3: 500– Yr 4: 350– Total: 1700

dentists

Patient Recruitment

• Between 7 and 12 mos post-intervention, up to 100 patients receiving target visits in each study dental practices were sent a questionnaire by California Delta Dental

• Questionnaires were sent with a consent-

form cover letter

• Questionnaires asked about preventive services they have received (with special emphasis on tobacco use assessment and treatment)

HIPA Considerations

• Delta Dental sent out – initial letters to dentist with

questionnaires/postcards but questionnaires sent back to UCSF

– Patient questionnaires. Patients returned to CDD. Names were removed and then sent on to UCSF with coded ID number for affiliated dental practice.

Systems Model of Clinical Preventive Care

Focuses on factors that promote or inhibit health care providers performance of preventive care.

– Predisposing factors (beliefs and attitudes)

– Enabling factors (skills & resources)

– Reinforcing factors (social support)

– Healthcare system organizational factors (cost, cues to action) Walsh J & McPhee S. Health Education Quarterly, 1992

5 Study GROUPS

• High Intensity, No Reimbursement

• High Intensity, Reimbursement • Low Intensity, No

Reimbursement • Low Intensity, Reimbursement • Usual Care

High Intensity Training

•

10-credit CE course (Save a Life)

Skills-based course for the entire staff

8 hrs of lec/discussion, processing discomfort through open discussionvideotapes of positive role modeling, use of scripts, role-playing with student partners to practice behaviors and to gain feedback,

Homework: work with 1 user

2-hr F/up session 4wks later

High Intensity Training

• Chart reminder and checklist system

• Practice-oriented Newsletters

• Tobacco Cessation Counseling Kit

Treatments

• Not Ready to Quit– Brief intervention (3 min or less)– Motivational interview (10 min)

• Ready to Quit – Brief intervention (15 min)– Multiple appt in-office program

Multiple Appt Treatment Protocol

• Assessment• Motivation enhancement• Setting a quit date• Choosing a plan• Coping skills training• Social support• Pharmacotherapy• Follow-up/Referral

• June 2000 Clinical Practice Guideline & Quick Reference Guide

• Post-test to receive 3 CE credits

• Cover letter to encourage 5 A’s approach and referral to tobacco use quit lines

• Chart reminder and checklist system

Low Intensity Training

Reimbursement

• $50 for at least 15 minutes of counseling

• Claim forms sent by dentists to Delta Dental

– Delta Dental billed UCSF quarterly

– Patients required to give consent for quality assurance

Outcome Measures

• Primary – Patient report of dentist’s behavior during

target visits 9 mos post- intervention by self-administered questionnaire

• Secondary – Dentist self-report of behavior based on

baseline and 9-month follow-up questionnaires

Patient Evaluation Protocol

• 9 mos post-intervention

– Advance mailing (postcard) – Patient survey + color insert

highlighting drawing for $150

Patient Questionnaire

• 30 items – 1 Tobacco use– 1 Readiness to quit– 1 Think dental offices should offer tobacco cessation services?– 2 Dentist assessment behavior items– 15 Dentist treatment behavior items– 1 Dentist follow-up behavior item– 2 Validation items– 4 Patient personal behavior items– 1 F/up item – 2 Demographic

Baseline and F/Up Dentist Questionnaire

• 106 items • 74 items related to tobacco

– 11 assessed attitudes on a 5-point scale

– 30 assessed dentists’ behavior

– 33 assessed practice characteristics

*Very Unimportant to Very Important; Strongly Disagree to Strongly Agree; or Not a Barrier to Strong Barrier

**Almost Never, Sometimes, Often, Almost Always

Data Analysis: Dentist Survey

• Compared mean positive change scores in dentists’ attitudes and behaviors using The Mann Whitney Test or Chi Square

– Intervention Groups vs. Usual Care – High Intensity vs. Low Intensity

– Reimbursement vs. No-Reimbursement

Data Analysis: Patient Survey

• Multivariate GEE models adjusted for age, gender, ethnicity, and for “thinking dental offices should offer services to help patients stop tobacco use

• Compared tobacco use assessment and treatment scores of dentists as reported by their patients

– Intervention Groups vs. Usual Care – High Intensity vs. Low Intensity

– Reimbursement vs. No-Reimbursement

RESULTS

Dentist Survey

Characteristics of Study Dentists (N=265)

Gender %

Male 86

Female 14

Ethnicity White

79Asian

10 African American 5

Hispanic 3

Native American 1

Other 2


Age Years

Mean 50Median 51Range 33-61


Location %

CA 42

PA 35

WV 23

Smoked 100+ cigarettes in lifetime 23

In practice 15+ years 74

Does Your Health History Form Ask About?

CA PA WV

% % %

Caries 57 52 61

Diabetes 96 97 100

Perio 71 66 75

Tobacco 87 88 100*

*p=0.016

Patient Education Materials Provided by State

CA PA WV

% % %

Caries 69 79 75

Diabetes 26 39 36

Perio 89 97 94

Tobacco 45 66 74* WV Dentists provide Tobacco Pt. Ed. Material more than CA or PA* P = .003

Dentists’ Baseline Attitudes (N=265)

Agreed/strongly agreed: %

Very Important as part of the Dentist’s Role to Intervene with Tobacco Use

58

I Know how to assess for tobacco use

46

I feel well-prepared to intervene

26

I am quite effective intervening

18

Dentist’s Report of 5 A’s Behaviors at Baseline (N = 265)

Behavior %

Verbally Ask about tobacco use 74

Advise to quit 78

Assess readiness to quit 19

Assist: Talk about ways to quit 39

Arrange follow-up 4

Dentist Reported Behaviors at Baseline

%

Recommend nicotine replacement 36

Provide written materials 20

Assessed previous quit attempts 20

Assessed symptoms of depression 4

Prescribe Buproprion 3

Helped set a quit date 6

Offer in-office cessation assistance 2

Refer to telephone quit line 7

Refer to other external quit program 6* Highest of five ordered categories

Dentists’ Barriers to Tobacco Cessation Counseling

(N=265)

Strong Barrier (4,5 on a 5 point Likert scale)

%

Patient Resistance 66

Insurance does not reimburse 56

Not knowing where to refer 49

Lack of time 32

Not interested 17

Practice Environment related to Tobacco Control (N=265)

Practice Environment %

Asks on health history form 90

Use of patient education materials

58

Adequate staff support (Agree 4,5 on a 5 point Likert scale)

53

Reminder system 23

Service to address tobacco use 22

Office Policy 13

OUTCOMES

Intervention Groups vs.

Usual Care

In general the attitudes and behaviors of all intervention group

dentists improved from baseline to follow-up

compared to the Usual Care group and the

results were statistically significant

Example % Positive Dentist Behavior Change Scores for All Interventions vs. Usual Care

Behavior Any % change

UC % change

OR 95% CI

Refer to a community cessation program

45 21 2.7 1.4 - 5.3

Offer in-office cessation assistance

41 15 3.2 1.6 – 6.7

Refer to telephone quit line

57 0.2 3.9 2.0 – 7.6

OUTCOMES

Reimbursement Groups vs.

No-Reimbursement Groups

There were no significant differences in dentists’ attitudes and tobacco-use assessment and treatment behaviors between the Reimbursement and No-Reimbursement Groups

Example % Positive Dentist Behavior Change Scores for Reimbursement

(R) vs. No-Reimbursement (NR) Groups

Behavior

R

% No-R %

OR 95% CI

Assess Readiness to Quit

51 52 1.1 0.59– 2.1

Ask about previous quit attempts

57 50 0.85 0.45– 1.6

Suggest ways to cope with temptation

54 48 0.89 0.46– 1.7

OUTCOMES

High Intensity Training vs.

Low Intensity Training Groups

Percent of Dentists with Positive Attitude Change in Feeling Prepared to Intervene in High vs. Low Intensity Training Groups

I feel well prepared to intervene with patients to address tobacco use.

% Pos Change

OR (95%CI)

High Intensity (n=99)

76 2.83* (1.4-6)

Low Intensity 54

(n=100) *Almost 3 times more likely to report positive change

Percent Dentists with Positive Attitude Change about Feeling that they Know How to Assess in

High vs. Low Intensity Training Groups

I know how to assess patients’ tobacco use.

% Pos Change

OR (95%CI)

High Intensity (n=99)

87 4.4* (1.8-10.6)

Low Intensity 62

(n=100) *4 times more likely to report positive change

Percent with Positive Dentist Behavior Changes in High vs. Low Intensity Training Groups

Behavior

High %

Low %

OR 95% CI

Assess Readiness to Quit

61 38 2.2 1.2 - 4.3

Ask about previous quit attempts

57 38 2.3 1.2 – 4.5

Suggest ways to cope with temptation

62 38 2.8 1.4 – 5.5

Percent with Positive Dentist Behavior Changes Between High

vs. Low Intensity Training Groups

Behavior High %

Low %

OR 95% CI

Help set a quit date

56 29 2.6 1.3 - 5.1

Screen for depression

40 21 2.6 1.3 – 5.3

Assess level of nicotine dependence

62 22 5.8 1.4 – 5.5



Behavior High %

Low %

OR 95% CI

Refer to a community cessation program

57 35 2.3 1.1 - 4.4

Offer in-office cessation assistance

53 31 2.8 1.4 – 5.7

Refer to telephone quit line

78 39 5.4 2.6–11.5



Behavior High %

Low %

OR 95% CI

Recommend NRT

65 44 2.2 1.1 - 4.4

Encourage to tell others for support

67 38 2.4 1.2 – 4.7

Provide educational materials (nrq)

72 37

4.8 2.3 – 10



Behavior High %

Low %

OR 95% CI

Ask about barriers to quitting and inform how treatment can help

55 34 2.4 1.2 - 4.6

Inform available when ready

77 37 5.9 2.8 –12.6

RESULTS

Patient Survey

Characteristics of Study Patients (N=8,435)

Gender %

Male 35

Female 65

Ethnicity White 86 Asian 5

African American 5

Hispanic 3 Native American 1 Other <1

Prevalence of Tobacco Use Among Study Patients by

State

% (n)

Pennsylvania 11 431/3886

West Virginia 8 164/2001

California 5 125/2489•

Patient Responses (N=8,435)

• 62% of respondents thought dental offices should offer services to help patients stop tobacco (n=4,765)

• 9% were current smokers (n=720)

Overall Patient Report of Dentists’ Behavior (N = 8,435)

%

Verbally asked about tobacco use 21

Among users (n =720)

Advised users to quit 36

Talked about dental problems from using tobacco

29

Asked if would like to try quit 14

Ask about roadblocks 8

Provide written materials on quitting 7

Helped set a quit date 3

Refer to telephone quit line 3

Offer in-office cessation assistance 1

* Highest of five ordered categories

OUTCOMES

Intervention Groups vs.

Usual Care

Tobacco-using Patient Report of Their Dentists’ Assessment and Treatment of

Tobacco Use in Intervention vs. Usual Care Groups

Behavior

Interv %

UC %

OR 95% CI

Advise users to quit

39 28 1.7 1.1-2.6

Assist with the quitting process (Q4 &5)

42 33 1.5 >1.0-2.3

OUTCOMES

Reimbursement vs.

No-Reimbursement Groups

There were no significant differences in patient report of dentists’ tobacco-use assessment and treatment behaviors between the Reimbursement and No-Reimbursement Groups

OUTCOMES

High Intensity Training vs.

Low Intensity Training Groups

Tobacco-using Patient Report of Their Dentists’ Assessment Behavior in High

Intensity vs. Low Intensity Training Groups

Behavior High %

Low %

OR 95% CI

Assessment

Asked about tobacco use and readiness to quit (Q1 & 6)

43

55 1.7 1.1 - 2.6

Tobacco-using Patient Report of Their Dentists’ Treatment Behavior in High Intensity vs. Low Intensity Training

Groups (n=463)

Behavior High %

Low %

OR 95% CI

Treatment

Advised to quit and talked about ways to quit (Q 4 & 5)

55

70

1.1 0.7 – 1.7

Group Comparisons of Patient Reporting “Yes” Their Dentists

Asked about Tobacco Use

Comparison Yes %

P-value

Low vs. UC(n=5210)

61 vs. 39

<.001

High vs. UC(n=5379)

57 vs. 43

0.91

High vs. Low(n=5901)

46 vs. 54

<.001

Multivariate GEE Model for Patient Report of Dentists’ Tobacco

Assessment and Treatment Behaviors for All Groups

P-value

OR 95% CI

Assessment user score*(n=662 )

Gender (female)Age (in yrs)

0.01

0.02

0.6

0.9

0.5 - 0.9

0.9 - <1.0

Treatment user score**(n=661)

Gender (female)Think

0.0004

0.02

0.6

1.5

0.4 - 0.8

1.1 – 2.1Findings indicate women and older patients were less likely to report positive dentist behavior scores; whereas those who thought dental offices should offer help for patients to stop tobacco use were more likely to report positive scores

* Scores were calculated by summing the patient reported positive dentist assessment behaviors for tobacco use

** Scores were calculated by summing the patient reported positive dentist advising and assisting behaviors for tobacco control (treatment)

Limitations

• Self-report

• 65% dentist participation rate (265/410)

• 38% patient participation rate (8,435/22,085)

Conclusions

• Positive changes in dentists’ attitudes and behaviors were significantly better in:

– the Intervention Groups compared to the Usual Care Group

– the High Intensity Groups compared to the Low Intensity Groups

• Reimbursement at the level offered made no significant difference in dentists’ attitudes and behaviors

Conclusions

• Patients whose dentists were exposed to low intensity training reported significantly more positive dentist tobacco use assessment and treatment behaviors than patients in any of the other groups

• In all groups, older patients and women were less likely to report positive tobacco assessment and treatment behaviors among their dentists.

• Further exploration of our findings is needed in these areas

Recommendations• Benefit should be offered to employee

groups for tobacco use assessment and treatment in the dental office since the majority of patients supported this activity

• All Delta Dentists should be provided with the Low Intensity Counseling Package

• High intensity courses should be selectively targeted to Delta Dentists and Periodontists who have a large proportion of patients who smoke

• Further research is needed to determine

what mediated the effectiveness of the low intensity training.

translating the clinical guideline for treatment of tobacco

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