Smoke Screen: Oregon Providers and Smokers Unaffected by Plan Guidelines for Smoking Cessation
Between 1998 and 2004, researchers at the State of Oregon Department of Human Resources, Health Division, Portland, Ore., evaluated the results of efforts by the Tobacco-Free Coalition of Oregon to implement the Oregon Tobacco Cessation Guidelines in the 14 managed care health plans contracting with the Oregon Health Plan.
- Researchers found no change over a two-year period in the percentage of health plan patients who reported being current smokers or in the percentage of smokers who received advice to quit from their health care providers.
- Over the same period, high baseline levels of provider-reported asking about smoking and advising smokers to quit also remained the same.
The Robert Wood Johnson Foundation (RWJF) supported this project with a grant of $328,849 between September 1998 and June 2004.
In December 1997, the medical directors of the Oregon Health Plan adopted tobacco cessation as the plan's prevention priority. The Oregon Health Plan operates under a waiver from the federal government to serve low-income people using federal Medicaid funds and is the largest purchaser of managed care in Oregon.
The Tobacco-Free Coalition of Oregon a Milwaukie, Ore.-based not-for-profit organization of businesses, organizations and individuals that advocates for policies and programs aimed at reducing the effect of tobacco use on Oregonians partnered with the Oregon Health Plan and the Oregon Health Division to promote implementation of tobacco cessation guidelines in the 14 managed care subcontractors of the Oregon Health Plan.
The coalition adapted the federal Agency for Health Care Policy and Research tobacco cessation guidelines, published in 1996, for use in the Oregon managed care environment. The guidelines emphasize four activities for primary care providers:
- Ask every patient about tobacco use and smoking.
- Advise all smokers to quit.
- Assist those who are motivated with brief counseling, self-help materials and drug therapy and those who are not with brief motivational counseling.
- Arrange follow-up for continued support and more intensive treatment if needed.
Collectively, these four activities comprise the "4 A's" of tobacco cessation addressed in this project. (An update of the federal guidelines in 2000 added a fifth "A": Assess smokers' willingness to quit.)
The 14 managed care subcontractors, in total, serve 85 percent of Medicaid recipients and 80 percent of individuals in commercial managed care plans in Oregon. Because Oregon has a low rate of residents without health insurance (less than 11 percent) and mature Medicaid and commercial managed care markets, collaboration of the health plans could have a substantial impact on the tobacco cessation services provided to nearly all Oregonians. The implementation of the guidelines across multiple health plans statewide offered an opportunity to evaluate factors that either facilitate or impede the guideline implementation process.
RWJF awarded grants to disseminate the original Public Health Service guidelines, (see Grant Results on ID#s 029389, 030329, 030520, 030375, 030525 and 030254). RWJF also supported its dissemination to organized labor (see Grant Results on ID# 029471). And RWJF has supported other projects around the guidelines:
- Development of a primary care practitioners' pocket guide (see Grant Results on ID# 029466).
- A conference and proceedings about the guidelines (see Grant Results on ID# 030465).
- An evaluation of the implementation of the guide by Allina Medical Clinic (see Grant Results on ID# 030499). This helped inform RWJF's national program Addressing Tobacco in Managed Care.
- In conjunction with other organizations, the development of a blueprint for adolescents (see Grant Results on ID#s 037525 and 041053) to form the Youth Tobacco Cessation Collaborative.
- In conjunction with other organizations, the development of a blueprint for pregnant smokers through RWJF's national program Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy, working with the National Partnership to Help Pregnant Smokers Quit (see Grant Results).
RWJF's national program Addressing Tobacco in Managed Care has sought to integrate effective tobacco treatment as part of the basic health care provided by managed care organizations.
Researchers from Program Design and Evaluation Services at the State of Oregon Department of Human Resources, Health Division, evaluated the results of efforts by the Tobacco-Free Coalition of Oregon to implement the Oregon Tobacco Cessation Guidelines in the 14 managed care health plans contracting with the Oregon Health Plan. A research advisory group, consisting of members of the Health Systems Task Force of the Tobacco-Free Coalition of Oregon, provided scientific oversight of the evaluation (see Appendix 1 for list of advisory group members). Researchers conducted the following activities:
- Evaluated the impact of statewide dissemination of the Oregon Tobacco Cessation Guidelines on patient smoking status and on the rates at which patients received proper clinical care related to tobacco cessation.
- Determined patient and health plan characteristics associated with receiving and delivering the brief cessation interventions prescribed in the guidelines.
- Determined the comparability of two sources of patient outcome data: a self-administered survey versus medical chart review.
- Evaluated change over time for physician attitudes and behaviors related to guideline implementation; described barriers to guideline implementation by physicians; and assessed associated physician characteristics.
- Described health plan, medical group and clinic readiness to provide tobacco cessation services at baseline, along with the progress made by health plans in implementing the guidelines.
An initial plan to investigate whether guideline-prescribed physician behavior was associated with health plan affiliation and/or plan characteristics proved infeasible due to the frequency of changes in provider/health plan affiliations and the common practice of individual providers being affiliated with multiple health plans.
A supplemental grant of $40,000 from the State of Oregon Anti-Tobacco Program assisted the evaluation of guideline implementation at medical groups and clinics.
Researchers collected data from patients and providers at baseline (Time 1 1999) and two years later (Time 2 2001), through self-administered surveys, medical chart reviews, in-person and telephone interviews and secondary data sources. They also collected data from health plans in 2000 and 2002. They also conducted one-time surveys of medical groups and clinics. See Appendix 2 for additional information on methodology.
Researchers reported the following findings to RWJF in 2004:
Patients' smoking status and receipt of proper clinical care related to tobacco cessation:
- There was no statistically significant change over time in the percentage of Oregon Health Plan survey respondents who reported being current smokers. Data from the Consumer Assessment of Health Plans Survey (see methodology in Appendix 2) show that at Time 1, 44 percent of respondents indicated that they were current smokers, while 43 percent reported current smoking at Time 2. Regarding the general Oregon population, Behavioral Risk Factor Surveillance System data (see Appendix 2) indicate that 21 percent were current smokers at both Time 1 and Time 2.
- There was little change over time (1999 to 2001) in the percentage of patients asked about smoking. The percentage of all patients asked about smoking rose from 57 to 60 percent. The percentage of current smokers asked about smoking dropped from 75 to 73 percent.
- For survey respondents in total, there was no change over time in the extent to which smokers received advice to quit from their health care providers. At Time 1, 71 percent received such advice, versus 69 percent at Time 2. However, differences were evident when grouping patients by health plan. Among the 12 health plans with both Time 1 and Time 2 data available, three plans indicated a significant decrease in the percentage of smokers advised to quit (a 14 percent decrease to 60 percent of smokers), three showed a moderate decrease (a 7 percent decrease to 67 percent of smokers) and six indicated an improvement of 6 percent to 75 percent of smokers receiving advice to quit.
- There was little association between a patient's demographic characteristics (age, gender, etc.) and the likelihood that his or her physician would ask about smoking or give advice to a smoker to quit. Patients were more likely to report receiving advice to quit when they felt their doctor spent enough time with them and their exam was complete and when they rated doctors and health care positively.
- Random medical chart review yielded lower percentages of smokers receiving advice to quit than reported by survey respondents, with documentation of 52 percent advised to quit at Time 1 and 48 percent at Time 2. Asking about tobacco use improved from 61 percent at Time 1 to 71 percent at Time 2. Assistance to those willing to quit, already at 78 percent at Time 1, increased to 93 percent over the period. However, neither of these changes was statistically significant.
Health plans' implementation of tobacco cessation guidelines:
- Of the 12 health plans contracting with the Oregon Health Plan at both Time 1 and Time 2, half made "good" progress (as defined by project staff) over time toward guideline implementation, five made "moderate" progress and one made no progress, based on researchers' assessment of the plans relative to a set of 10 guideline-related criteria. The criteria included the following: having prompts for providers and patients, being receptive to resources and ideas, having a written policy for tobacco cessation, having a policy related to medication coverage, paying for phone-based cessation counseling, and others. There was little correlation between health plans' assessment results and the likelihood of a patient receiving the "4 A's."
Provider behavior related to tobacco cessation guidelines:
- There was no change over time to provider-reported behavior related to tobacco cessation guidelines. Among providers, 98 percent reported usually or always asking new patients about tobacco use at both Time 1 and Time 2, and 96 percent at both times reported usually or always advising current smokers to quit. Less than half (47 percent at Time 1 and 45 percent at Time 2) indicated that their office followed the "4 A's" of tobacco cessation. Familiarity with the "4 A's" was also similar at each time point; 61 percent were "fairly" or "very" familiar at Time 1 and 58 percent at Time 2.
- There was little change in how provider offices documented patients' tobacco use, and at Time 2, no single method was used at more than 26 percent of respondents' offices. Methods used included computer reminders, chart notes, flow sheets, stamps and stickers.
- Physicians were the primary individuals assessing patients for tobacco use, with 89 percent doing so at Time 1 and 84 percent at Time 2. Use of clinic assistants for this task increased from 18 percent at Time 1 to 30 percent at Time 2, while use of nurses was 34 percent at both time points.
- The availability of counseling on-site remained the same over time; most often (79 percent) a medical provider delivered the counseling. Others providing counseling included other staff (12 percent) and/or a health educator (11 percent). Follow-up contact of a patient willing to quit decreased significantly over time. The percentage of respondents not following up increased from 22 percent to 46 percent from Time 1 to Time 2, while respondents usually or always following up decreased from 48 percent to 27 percent during the period. Availability of information and/or referrals for individual counseling or group programs also decreased from 74 percent at Time 1 to 65 percent at Time 2.
- The major barriers that prevent providers from following tobacco cessation guidelines include:
- lack of staff time (38 percent)
- lack or uncertainty of reimbursement (34 percent)
- a perception that patients do not want to hear about the topic (19 percent)
- lack of readily available appropriate materials (18 percent).
Only four percent indicated a belief that tobacco use assessment and advice do not make a difference in patients' smoking behavior.
- Physicians consider their clinic or office to have the most influence on whether and how tobacco cessation guidelines are implemented, with 58 percent saying their clinic or office had at least some influence. Other factors cited as influential were medical groups (by 47 percent of physician respondents), Oregon Health Plan coverage (48 percent) and health plans (37 percent).
- No differences by age, gender or geographic region emerged among provider respondents with regard to asking new patients about smoking or advising current smokers to quit. However, women were significantly more likely (73 percent) to report familiarity with the "4 A's" than men (52 percent) and to report that their office follows the "4 A's" (51 percent versus 42 percent of men). Providers in the Portland tri-county area were significantly more likely (65 percent) than those outside that area to report familiarity with the "4 A's" (52 percent), as were those from high-density population areas (82 percent) compared to those from mid-density (46 percent) or low-density (51 percent) areas.
Implementation of tobacco cessation guidelines by medical groups and clinics:
- Half of the medical groups surveyed in 2000 reported that they assessed how often members are questioned about tobacco use. Of those who said they assessed this, half of those groups reported that all of the adult members were asked about tobacco use. Sixty-two percent of medical groups reported that they do not assess how often smokers are advised to quit. Just over half (53 percent) of the groups provide no staff training in tobacco cessation guidelines.
- All clinics responding to the 2000/2001 clinic survey reported that new patients were usually or always asked about tobacco use; 53 percent indicated that previous patients were asked only when it was relevant to the visit. Forty-seven percent of clinic respondents reported that they always advised current smokers to quit. To assist smokers in quitting, over half of the clinics referred them to the free Oregon Quit Line telephone service, and most provided self-help materials and group counseling information. Only 21 percent arranged for follow-up contact.
The principal investigator reported that:
- The difficulty of linking health plan, provider, medical group and clinic data limited the potential for "a comprehensive evaluation of what may be influencing any observed change over time." The reorganization and disbanding of health plans and medical groups, along with changing and multiple provider affiliations, contributed to the inability to link data sets.
- The "economic downturn [in Oregon] also limited interpretation of our results. The economic climate likely had a much greater influence on health plan and provider behavior related to prevention-oriented behavior" than did disseminating tobacco cessation guidelines through the health plans. "It is not clear, therefore, to what extent to attribute the observed lack of change in outcomes to failure of the intervention to have an effect."
Project staff presented a poster of findings at the 11th World Conference on Tobacco OR Health, August 711, 2000, in Chicago, and presented findings at the Addressing Tobacco in Managed Care Conference, March 31April 2, 2004, in Miami. See the Bibliography for a list of survey instruments developed for the project.
The principal investigator offered the following conclusions in a report to RWJF:
- It may be difficult and overambitious to effect provider behavior via activities with health plans in an environment such as exists in Oregon. Providers typically have affiliations with six or more plans at once, limiting the influence that any plan might have on "their providers." Providers also report that health plans have less influence on their behavior than provider groups or clinics (with which they have a single affiliation). In addition, relationships between providers and health plans are often antagonistic. It still may be most feasible to work with health plans, however, given the sheer number of enrollees and the Oregon Health Plan's lack of contractual obligations with clinics.
- In the existing managed care environment, it is important to work at the provider level to effect behavior change. Working at the health plan level with the expectation that change will "trickle down" to the providers, is not effective. This is important for other prevention issues in addition to tobacco.
- Two important predictors of health plan involvement in tobacco prevention and cessation emerged: "(1) overall economic climate, and (2) the ability to consistently use pressure and prompts to keep plans engaged in dissemination activities. [F]or most plans, activities were not sustained without consistent external prompts, reminders and whatever coercion existed via contractual requirements."
SIGNIFICANCE TO THE FIELD
According to the principal investigator, because of this project, the Oregon Anti-Tobacco Program no longer depends on the health plans as the sole mechanism to influence provider behavior. The Anti-Tobacco Program also has developed a training program to offer to clinics and individual providers.
GRANT DETAILS & CONTACT INFORMATION
Evaluation of a Statewide Collaboration of Managed Health Plans to Address Tobacco Cessation
State of Oregon Department of Human Resources, Health Division (Portland, OR)
Dates: September 1998 to June 2004
Michael J. Stark, Ph.D.
Research Advisory Group
Edward Lichtenstein, Ph.D.
Oregon Research Institute
Jack F. Hollis, Ph.D.
Kaiser Permanente Center for Health Research
Health Care Liaison (previous position)
Oregon Department of Human Services Health Division
Charles Bentz, M.D.
Medical Director, Providence Tobacco Cessation and Prevention
Providence Health System
Randahl Kirkendall, M.P.H.
Douglas County Health Department
Sources of patient data included:
- Data collected as part of the Consumer Assessment of Health Plans Survey on about 10,000 Oregon residents, funded by the federal Agency for Health Care Policy and Research. Time 1 (1999) included 4,907 respondents and Time 2 (2001) included 2,827 respondents, all of whom were Medicaid clients of the Oregon Health Plan. These data included consumer self-reports of current smoking status and of receipt of tobacco cessation advice from health care providers.
- Additional data concerning the general Oregon population from the Behavioral Risk Factor Surveillance System sponsored by the federal Centers for Disease Control and Prevention. Through monthly telephone surveys, the survey monitors state-level prevalence among adults of major behavioral risks (such as in inadequate physical exercise, overweight and use of tobacco and alcohol) associated with leading causes of death (heart disease, cancer, stroke, diabetes and injury).
- Reviews of random samples of Oregon Health Plan medical charts (not linked with Consumer Assessment of Health Plans Survey respondents) at Time 1 (276 charts of patients with visits between April 1997 and March 1998) and Time 2 (417 charts of patients with visits between January 1999 and December 1999).
Sources of provider data included mailed surveys of primary care providers associated with respondents to the 1999 Consumer Assessment of Health Plans Survey. Time 1 included about 670 providers and Time 2 included 437 providers from the Time 1 sample. Questions addressed how often adult patients were asked or advised about tobacco use, documentation of following up with cessation services for patients willing to attempt quitting, dissemination and documentation of advice, and providers' opinions regarding possible barriers to implementation of the tobacco cessation guidelines.
Health Plan Data
Sources of health plan data included in-person and telephone surveys at the 14 health plans at Time 1 (2000) and mailed and faxed surveys at 13 (of the original 14) plans at Time 2 (2002). Tobacco cessation coordinators and other health plan staff completed the surveys. Questions addressed whether or how each plan implemented tobacco cessation guidelines.
Medical Group Data
The source of medical group data was a one-time survey sent to 50 medical groups in 2000. The response rate was just under 60 percent. Questions addressed the groups' experiences implementing, or not implementing, tobacco cessation guidelines.
The source of clinic data was a one-time survey sent in 2000 and 2001 to 46 clinics, which were on record for patients participating in the original Consumer Assessment of Health Plans Survey. The response rate was 46 percent. Questions addressed clinics' experience implementing tobacco cessation guidelines.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
"Time 1 Survey of Primary Providers on Implementation of Oregon Tobacco Cessation Guidelines." Program Design and Evaluation Services, Oregon Health Division, fielded 1999.
"Time 1 Survey of Health Plans on Implementation of Oregon Tobacco Cessation Guidelines." Program Design and Evaluation Services, Oregon Health Division, fielded 2000.
"Survey of Medical Groups on Implementation of Oregon Tobacco Cessation Guidelines." Program Design and Evaluation Services, Oregon Health Division, fielded 2000.
"Survey of Clinics on Implementation of Oregon Tobacco Cessation Guidelines." Program Design and Evaluation Services, Oregon Health Division, fielded 2000 and 2001.
"Time 2 Survey of Primary Providers on Implementation of Oregon Tobacco Cessation Guidelines." Program Design and Evaluation Services, Oregon Health Division, fielded 2001.
"Time 2 Survey of Health Plans on Implementation of Oregon Tobacco Cessation Guidelines." Program Design and Evaluation Services, Oregon Health Division, fielded 2002.
Report prepared by: Mary B. Geisz
Reviewed by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans