TRANSLATING SCIENCE INTO PRACTICE LSU Health Care Services Division

1. TRANSLATING SCIENCE INTO PRACTICE LSU Health Care Services Division Disease Management Program Quarterly Meeting March 27,2007 Sarah Moody Thomas, PhD Clinical Lead HCSD Tobacco Control Initiative Professor LSU Health Sciences Center - School of Public Health

2. In collaboration with Michele Jean-Pierre Ron Horswell Michael Celestin Zhanying Zong Danielle Trepagnier Kurt Braun Krysten Jones Jay Besse Monica Lewis Debbie Hernandez

3. And… • Debby Durapau Lucretia Young • Tambria Hunt JoAnn Brooks • D’Adario Conway Wendy Rhodes • Elizabeth Sylvest Jennifer Miller • Nakesha Auguster Betty Henry

4. Along with… Members of the following: • Tobacco Teams • Process Redesign Team • Research & Evaluation Team • Health Care Effectiveness Team • HCSD Administration

5. We know… There is a body of evidence amassed from 40 years of accomplishments of tobacco control: • Researchers • Advocates • Practitioners

6. We know… In Louisiana: • residents’ health status ranked 50th in the nation* • ~ 20% of population is uninsured • 10th highest smoking rate; ~ 23% smoke* • 1.5 Billion healthcare cost associated with tobacco use • $663 million absorbed by Medicaid • Nearly 6500 adults die annually from smoking United Health Foundation, 2006

7. We know… • Efficacious treatments for tobacco use & dependence exist. • Cost- effective treatments for tobacco use and dependence are key to preventing disease onset, progression and exacerbation. • Clinical Practice Guidelines (CPG) are inadequately implemented. Fiore, M. 2000

8. We know… LSU Health Care Services Division (HCSD): • State’s largest and nationally the 5th largest integrated public healthcare system • 1.5m outpatient visits, • 80,000 inpatient admissions • Well-established disease management program • Administration committed to continuous quality improvement and health systems research

9. We know … It is widely recommended that evidence-based cessation services be integrated into healthcare delivery systems in order to obtain population-wide benefits. • Robert Wood Johnson Foundation (1997; 2000) • US Department of Health and Human Services (2000) • National Academy of Sciences, Institute of Medicine (2001; 2003) • Centers for Disease Control and Prevention (2006)

10. Partnership 2002 – HCSD started initiative to place treatment of tobacco use & dependence at forefront of Louisiana’s public hospital system

11. LSU HCSD Disease Management Program Coordination of resources across the health care delivery system to improve disease outcomes

12. HCSD Disease Management Program • Placed cessation services in a context: • receptive to chronic care model; tobacco dependence could be viewed as such, requiring ongoing attention and treatment (Wagner, 1998) • supportive of multi-component systems approach to improving the delivery and quality of health care

13. Translating Science into Practice Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatment ↓ ↓ ↓ ↓ ↔ ↔ Push Science Build Capacity Boost Demand • Evidence based treatment (CPGs) • Communicate for wide populations • Test/adapt in new populations and settings • Research and evaluate to improve • Link systems– level tobacco supports • IT to identify smokers, prompt treatment • Incorporate into broader quality assurance • Performance measurement and reporting • Provider training and TA • Policies and community strategiesto increase quitting and decrease use • Bans, decreased cost, Quitline support, reflective media • Market programs • Redesign cessation services to increase appeal and use Ultimate Goal: Reduce tobacco use & health care burden Orleans, CT. 2001; 2004 ; Isaacs, 2004

14. HCSD Tobacco Control Program Design, implement and evaluate evidence-based cessation services in Louisiana’s public hospital system.

15. Translating Science into Practice Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatment ↓ ↓ Push Science • Evidence based treatment (CPGs) • Communicate for wide populations • Test/adapt in new populations and settings • Research and evaluate to improve 2002 – 2004: Assessments conducted to determine prevalence of tobacco use, existing services and existing organizational infrastructure

16. Know Your Population – Patient Survey • Purpose • Characterize prevalence, patterns of tobacco use and readiness to quit among patients of this “safety net” health system • Methods • Patients randomly selected within calendar days • Survey instrument administered face-to-face by trained interviewers

17. Sample Information • N=777 • Predominantly: • female (82%) • African American (60%) • Poor (72% reported annual family incomes < $15,000) • Ranged in age from 18 to 84 (mean= 49, s.d.=13.9) • 25% current smokers

18. Readiness to Quit: % Yes

19. Treatment Preferences

20. Experience with Healthcare Delivery System

21. Science Push: Lessons Learned • Smoking rates higher than general population; similar to Medicaid population rates; varied by facility • Pharmacologic and counseling were most preferred treatments • It will be important to actively promote the availability of quit assistance

22. Baseline FacilitySurvey • Purpose: • Assess tobacco control practices and policies • Distributed to all Louisiana public hospitals • Inpatient • Outpatient • QA • Administration • 32 surveys representing 10 of the hospitals were returned

23. Baseline Facility Survey • Comparison of findings • Survey instrument was developed based on McPhillips-Tangum’s* survey used with Managed Care Organizations (MCOs) • Survey instruments were distributed and completed during the Fall of 2003 through the Spring 2004 *McPhillips-Tangum, 1998. Results from the first annual survey on Addressing Tobacco in Managed Care, TC Online.

24. Implementation of the Guidelines: Comparison of HCSD and MCOs

25. Barriers limiting provider’s effectiveness in addressing tobacco control with patients: Comparison

26. Monitoring tobacco use: Comparison

27. Science Push: LessonsLearned • Tobacco cessation has to become a higher priority • Cessation services should be meshed with existing processes of care • Personnel designated solely to tobacco cessation needed to facilitate consistent service delivery

28. Follow up Site Visits • Survey results presented • Team building- recommendations for Tobacco Team champions and members • Recommendations for process implementation

29. Tobacco Control Initiative (TCI) CPGs recommended system interventions shaped program development. Provide: • Designated staff • Certified cessation counselors • Standardized processes, services and data collection • Educational resources • 5 As approach • Delineates roles and responsibilities of clinicians involved in the support and delivery of cessation services • Continuous program management and evaluation

30. Translating Science into Practice Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatment ↓ ↓ ↔ Push Science Build Capacity • Link systems– level tobacco supports • IT to identify smokers, prompt treatment • Incorporate into broader quality assurance • Performance measurement and reporting • Provider training and TA 2003 – 2004: Process and program evaluation procedures and indicators determined 2004 - 2006: Phased Program implementation Ultimate Goal: Reduce tobacco use & health care burden Orleans, CT. 2001; 2004 ; Isaacs, 2004

31. Data Sources… • Data collection and analyses are integral components of health systems interventions • Identify eligible participants and manage day-to-day activities • Evaluate the intervention • Unobtrusive to participants, providers and staff • Detailed to determine the extent to which program goals are met

32. TCI Evaluation Components and Data Sources Quantitative Measures _________________________________________________________ Registry/Administrative Data Population (DMED & Registry) Users+ Not w/ check against DMED Registry Tobacco Users Rate of tobacco use Relapse Rate/New Use rate Non users who became users Quit Rate Users who became non users Program (process/outcomes) Referral Rate Rate of users referred Rx assistance rate Rate of referrals getting drug intervention Counseling rate Rate of referrals getting ALA type intervention Quit/Relapse Rates Local data/registry mix Program (operations) FTEs FTEs funded by program FTE cost Funded FTE costs to the program Drugs Program/non program drug costs HCSD in kinds Estimate of costs born by HCSD non HCSD in kinds Estimate of costs born by those external to program & HCSD Qualitative/Programmatic Information _________________________________________________________ Patient Flows Graphical representations of programs Program Quarterly Narratives Diaries of the programs from local perspectives Annual evaluation team reports Visit reports of annual evaluation teams w/ recommendations All of the above to be rolled up in annual reports and updated on monthly/quarterly/annual basis on a web site.

33. Data Sources… Balancing Participant Identification, Program Management and Evaluation Electronic identification of tobacco users system-wide Disease Management & Evaluation Database Track patient encounter data Cessation Management & Evaluation Database Track program processes and identify opportunities for process improvement projects

34. Data Sources • Weekly conference calls • Problem solving • Data collection • Recruitment • Clinic interfacing • Program development • Networking • Information sharing • Team building

35. TCI Cessation Services • Self-help material • Referral and facilitated access to state Quit Line • Proactive phone counseling • Behavioral counseling • Group sessions • Bedside intervention • Pharmacotherapy

36. Out Patient Process of Care

37. Out Patient Services Patient Identification • Self help materials – quit line referral • Counseling • Group Phone • Counseling + Pharmacotherapy • Pharmacotherapy only • Motivational intervention

39. Smoking Rates by Quarter* *8/10 facilities; DMED & CMED; Q1 = Jan-Mar

40. Smoking Rates by Disease Group, Longitudinally* *8 of 10 facilities (D &C MED)

43. Percentage of Smokers Referred that Received a Pharmacologic Prescription

47. Who Participates in Behavioral Counseling? N= 986 class attendees; April 2005 - November2006 • 62% Caucasian 36% African-American; • 69% Female • 46% smoke > 20 cigarettes/day • 68% have been smoking > 20 years • Appear more motivated to quit than overall HCSD smoking population (e.g., 95% say they think they will quit within the next year) Currently investigating: • What distinguishes class attendees from other smokers? • Among class attendees, what distinguishes between those who quit smoking and those who do not?

48. Translating Science into Practice Goal: To increase adoption, reach and impact of evidence-based tobacco dependence treatment ↓ ↓ ↓ ↓ ↔ ↔ Push Science Build Capacity Boost Demand • Policies and community strategiesto increase quitting and decrease use • Bans, decreased cost, Quitline support, reflective media • Market programs • Redesign cessation services to increase appeal and use Ultimate Goal: Reduce tobacco use & health care burden Orleans, CT. 2001; 2004 ; Isaacs, 2004

49. Referral Rates

50. In-patient Process of Care Self-help material and quit line referral in ALL admit packets Arrange