Doctors Need to Give More Smoking Cessation Advice
The Allina Medical Clinic, a large multispecialty group practice, evaluated how to implement the U.S. Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Guideline.
A team of researchers from the University of Wisconsin's Center for Tobacco Research and Intervention helped Allina to conduct a group randomized trial to determine the effectiveness of a smoking cessation strategy based on the ACHPR guideline.
The researchers planned to compare six-month quit rates between smokers in intervention and control clinics, assess how the guidelines were implemented at the clinic level, and tabulate the total cost of guideline implementation as well as the cost per smoker.
- Through patient exit interviews, researchers discovered that patients in intervention clinics were only marginally more likely to be asked if they smoked and about as likely to receive advice to quit smoking as those in control clinics.
- No significant differences in quit rates between intervention and control clinics were detected.
- The researchers concluded that the implementation strategy lacked a key component: a performance-based physician incentive plan to promote compliance with the guidelines.
After the Grant
Based on the groundwork established under this project, Allina Health System received a $500,000 grant (ID# 036023) from the Robert Wood Johnson Foundation's (RWJF) national program, Addressing Tobacco in Managed Care. Under this grant, Allina will incorporate physician incentives, performance expectations and a patient follow-up system into its group practice.
RWJF provided a $48,171 grant to support this project.
In April 1996, the US Agency for Health Care Policy and Research (AHCPR) issued a guideline to help health care providers deliver tobacco prevention and cessation interventions as part of routine primary care.
Allina Health System (Allina), a Minneapolis-based integrated health care network with 65 clinics, 20 hospitals, and a network of 7,000 contracted providers covering more than one million people, has endorsed tobacco control as part of its mission. Policymakers at Allina, guided by research evidence on the cost-effectiveness of tobacco-control interventions in health care settings, chose tobacco control as Allina's first system-wide health improvement initiative and used the AHCPR guideline as the basis of their proposed intervention.
The Robert Wood Johnson Foundation (RWJF) expected this study to provide insight into the barriers to full-scale implementation of smoking cessation guidelines in group practice clinics, a managed care setting they regarded as understudied.
While all clinics in the Allina Medical Clinic system were encouraged to adopt the AHCPR Clinical Practice Guideline for Smoking Cessation, the study focused on 20 primary care clinics.
Since Allina has no internal research department, RWJF funds supported outside research assistance (obtained through a subcontract with the University of Wisconsin's Center for Tobacco Research and Intervention), the costs of exit surveys, salaries for trainers conducting in-service training of physicians, and salaries of Allina's survey personnel. Allina received additional support from its own Foundation (Allina Foundation), and from SmithKline Beecham, McNeil, and Glaxo Wellcome, all pharmaceutical companies.
The study, a group randomized trial, established 10 intervention and 10 control-group clinics. One intervention clinic later dropped out. Intervention and control clinics had similar patient demographics, clinic volumes, and provider types. The research sought to: (1) examine the means by which full implementation of the AHCPR guideline can be achieved in a large health care organization; and (2) assess the impact of such implementation on tobacco use.
Allina's Project QUIT (Quality Improvement in Tobacco Control) outlined four study questions:
- What changes need to be made to a health care delivery system in order to implement successful clinician-based smoking cessation strategies?
- To what degree can a health care system expect to implement the AHCPR guideline in a large group practice?
- What level of reduction in tobacco use can be expected if the guideline were to be fully implemented?
- What are the costs associated with full implementation of the guideline?
The intervention took place over a three-month period. The researchers gathered data by three means: patient exit surveys, chart audits, and analysis of administrative data.
- Patient exit surveys. Allina studied the quit rate per clinic, testing for statistical differences between intervention and control clinics. Before randomaization, approximately 600 patients from each of the 20 clinics filled out brief exit surveys ascertaining their tobacco-use status and the "advice-to-quit" information they had received from providers. About three months after guideline implementation, approximately 1,200 patients from each clinic completed a survey. A third survey was mailed six months after the intervention to patients who previously had identified themselves as smokers. (The mail survey focused only on these smokers primarily because of cost constraints.)
- Chart audits. Allina abstracted information from 50 patient records per clinic to determine the degree to which clinics documented the AHCPR smoking cessation intervention steps.
- Administrative data. Allina analyzed claims data to determine if study participants took advantage of smoking cessation services such as pharmacotherapy. Allina's research team planned to compute the total cost for full guideline implementation per tobacco-using patient and the total cost per quit.
- The exit surveys revealed that patients in intervention clinics were marginally more likely to be asked if they smoked and about as likely to receive advice to quit smoking as those in control clinics. Researchers concluded that Project QUIT had not gained sufficient physician "buy-in" to affect clinical practice patterns. Because of the pressing demands of high patient volume and substantial paperwork, clinicians were not sufficiently motivated to participate in this project, even though philosophically they supported its prevention-oriented objectives. Clinics that were successful in implementing tobacco use identification and smoking cessation advice had usually identified a "champion" who made this happen.
- No significant differences in quit rates were found between smokers in intervention and control groups in the follow-up mail survey.
- Project QUIT prompted Allina to reexamine its strategies for quality improvement. Productivity goals encouraged physicians to maximize the number of patients seen, rather than to reach clinical benchmarks for patients, and thus did not encourage physicians to take time to discuss smoking cessation with patients. In-service training alone was insufficient to alter physician behavior.
- Costs associated with implementation of the guideline ran between $100,000 and $150,000 to do in-service classes, set up training and consultation sessions, and build a quality improvement infrastructure for 20 clinics.
Allina presented its findings about the challenges of implementing a smoking cessation initiative at six conferences, including the Robert Wood Johnson Foundation's conference "Addressing Tobacco in Managed Care: Partnering for Success" in February 1998. See the Bibliography for complete information on conferences. Published findings (Tobacco Control, Suppl. 1998) are currently in press.
- Motivational strategy for physicians should be included in any comparable smoking cessation program.
- This small project benefited from a communications plan. The project, whose prevention-minded goals were in keeping with the organization's prevention objectives, needed a public relations campaign implemented from the moment the project began to render it visible and important.
AFTER THE GRANT
Project QUIT led to the development of QUIT II, "Changing Smoking Cessation Practice in a Medical Group Practice," for which the Foundation has awarded Allina $500,000 (ID# 036023) as part of its Addressing Tobacco in Managed Care national program. Various pharmaceutical companies are also providing support. Allina is redirecting its efforts to:
- Establish a clear incentive plan for physicians.
- Establish clear performance expectations, e.g., percentage of patients whose tobacco use status is identified in medical records.
- Put in place a system to follow up with the patient an acknowledgment that patients do not voluntarily come back for follow-up visits in an effort to quit smoking.
It is expected that QUIT II will be able to determine what level of reduction in tobacco use is possible with full implementation of the AHCPR smoking cessation guidelines.
GRANT DETAILS & CONTACT INFORMATION
Evaluation of the Implementation of the AHCPR Smoking Cessation Guideline
Allina Health System (Minneapolis, MN)
Dates: January 1997 to April 1998
Joachim Roski, Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Roski J. "Changing Practice Patterns as a Result of Implementing the Agency for Health Care Policy and Research Guideline in 20 Primary Care Clinics." Tobacco Control, 7(Suppl.): S19S20, 1998.
Presentations and Testimony
Jeddeloh R and Roski J. "Discussion of Specific Implementation Challenges: Focus on Primary Care," at an Allina Health System meeting, "Bridging Research and Practice: Focus on Effective Dissemination Strategies," Minneapolis, Minn., September 2627, 1997.
Roski J. "Changing Practice Patterns as a Result of the Implementation of the AHCPR Guidelines on Smoking Cessation in Twenty Primary Care Clinics," at a Robert Wood Johnson Foundation meeting, "Addressing Tobacco in Managed Care: Partnering for Success," Washington, D.C., February 24, 1998.
Werb P, Roemhild H, Jeddeloh R, Roski J, and Hoele R. "Multicenter Recruitment, Retention and Subject Accrual," poster, at the Association of Clinical Research Professionals Annual Meeting, Anaheim, Calif., April 2125, 1998.
Jeddeloh R. "Implementing the AHCPR Guidelines on Smoking Cessation in Primary Care," at an American Association of Health Plans meeting, "Building Bridges IV: Improving the Public Health Through Research Partnerships," Oakland, Calif., May 79, 1998.
Jeddeloh R. "Implementing the AHCPR Guidelines on Smoking Cessation in Primary Care," poster, at the Association for Health Services Research 15th Annual Meeting, Washington, D.C., June 2123,1998.
Jeddeloh R. "Implementing Smoking Cessation Guidelines in Primary Care," as part of the symposium, "Effectively Leveraging Managed Care's Tobacco Control Opportunities: Allina Health System's Comprehensive Approach," at the American Public Health Association 126th Annual Meeting, Washington, D.C., November 1519,1998.
Report prepared by: Barbara Finkelstein
Reviewed by: Janet Heroux
Reviewed by: Marian Bass
Program Officer: C. Tracy Orleans