Vermont Department of Health Changing to the Minimum Data Set for Evaluation of Quit Line Services

1. Vermont Department of HealthChanging to the Minimum Data Setfor Evaluation of Quit Line Services Presented By: Todd Hill, LiCSW, LADC Public Health Tobacco Specialist As designed by the American Cancer Society: Dr. Vance Rabius

2. The Vermont Department of Health provides free Quit Line services to all smokers living in Vermont through a grant to the American Cancer Society, using funds from the Master Settlement Agreement. • Quit Line Services have been in place since March of 2001. • In that time, Quit Line has received more than 7200 calls from Vermonters either personally quitting tobacco or calling for information.

3. Vermont’s Process for making changes to the MDS: • Creation of the VT Tobacco Evaluation and Review Board (VTERB) • VT Statute: “There is created and established, within the office of the secretary, a body to be known as the Vermont tobacco evaluation and review board, an independent state board created to work in partnership with the agency of human services and the department of health in establishing the annual budget, program criteria and policy development, and review and evaluation of the tobacco prevention and treatment programs”. • American Cancer Society provided a list of how they proposed implementing the changes from the current survey to the MDS. • The Vermont Department of Health convened a meeting with the VTERBs Evaluation Committee. • The Evaluation Committee made recommendations that I reported to ACS. • ACS then sent to the Evaluation Committee a draft of the proposed script that would be used for intake and follow up calls for final approval.

4. Members of the VTERB Evaluation Committee Dr. John Hughes, MD – Dr. Hughes is on the facility of the Medical School at the University of Vermont. He is a medically trained psychiatrist. Dr. Hughes is a world renown researcher in many aspects of tobacco control. Dr. Theodore Marcy, MD, MPH – Dr. Marcy is also a member of the Facility at the University of Vermont Medical School. Dr. Marcy splits his time between being a practicing pulmonary physician and conducting tobacco control research, funded by grants from the National Cancer Institute. Dr. Laura Solomon, Ph.D. – Dr. Solomon is on the facility of the School of Psychology at the University of Vermont. She has been conducting research on Quit Lines and best practices for cessation among pregnant women for 15 years.

5. Areas of Evaluation of Vermont’s callers Not Affected by MDS Gender: “I need to verify if you are male or female?” Age: “What is your date of birth?” Geographic Location: “What is your postal or zip code?” Smoking (Tobacco) Intensity: “How many cigarettes, pipes, pouches do you use per day/week?”

6. Questions at Intake Affected by MDS • Health Insurance • Ethnicity • Education • Age of Onset • Readiness • Awareness

7. Health Insurance VT CURRENT: Health Insurance information only collected if client wanted to know about the Nicotine Replacement subsidy program. MDS CHANGES: Asks everyone, “Do you have health insurance?” FINAL DECISION: Adopt MDS question. COMMENTS: Vermont has also decided that it is important for us to have insurance provider information for all callers. We intend to add a follow up question to gather this information.

8. Ethnicity VT CURRENT: “Which of these groups would you say best describes you?” MDS CHANGES: “Are you Hispanic or Latino(a)?” FINAL DECISION: Adopt MDS question. COMMENTS: ACS warns that this change may cause in increased reporting in Hispanic callers.

9. Education VT CURRENT: “What is the highest level of education you have completed?” Categories - No school, 1-5 some grade school, 6-8 some junior high school, 9-11 some high school, GED, HS Grad, Some college, Trade school grad, College Grad, Graduate School, Refused. MDS CHANGES: “What is the highest level of education that you have completed?” Categories - (USA) Less than grade 9, grade 9-11 (no degree), GED, HS Grad, Some college, Trade or Tech school, College or University Degree. FINAL DECISION: Keep current question. Comments: We will keep old question to preserve historical data. Will take responses and recode into MDS categories.

10. Age of Smoking Onset VT CURRENT: “How long have you been smoking?” Categories - <6 months, 6mo to 1 year, 1 to 5 years, 6 to 10 years, >10 years. MDS CHANGES: “At what age did you start smoking?” FINAL DECISION: Adopt MDS question. COMMENTS: With this open text question we are able to go back and recode data for historical comparisons if needed.

11. Readiness to Quit VT CURRENT: “Are you willing to make a serious quit attempt in the next 30 days.” (yes or no) MDS CHANGES: “Do you intend to quit in the next 30 days?” (Yes, no, don’t know) FINAL DECISION: Adopt MDS question. COMMENTS: According to Dr. Hughes, the verb “intend” represents a lesser commitment than “willing”. This may contribute to some false positives. Additionally, with the MDS the “no” answers may not be comparable to historical data, with the addition of “don’t know”.

12. Awareness of Quitline VT CURRENT: “How did you hear of this phone number?” Categories – Newspaper story, newspaper ad, tv news story, tv ad, radio news story, radio ad, MD, DDS, Pharmacist, Nurse, other health care provider, flyer from school, flyer from work, flyer from community, friend/relative, internet/website, ACS office, Transfer from NCIC. MDS CHANGES: “How did you hear about the Quitline?” Categories – Mass media, other paid advertising, referrals, other. FINAL DECISION: Keep current question. COMMENTS: The Board’s committee was concerned about keeping a historical comparison with this question. Our question allows us to be able to recode the data into the MDS categories. ACS also has an open text field that allows intake workers to enter responses they do not know how to code, in order to recode later.

13. Questions asked at Intake and also at the 7 month follow-up callaffected by MDS • Type of Tobacco • Level of Addiction

14. Type of Tobacco Used VT Current: Please select caller’s reason for call: Personally quitting cigarettes, personally quitting smokeless, already quit (cigarettes/smokeless), family/friend of current smoker, other (examples: doctors, teachers, community orgs, cigar/pipe smokers) MDS CHANGES: “Do you currently smoke cigarettes?” (USA) – everyday, somedays, not at all. If yes – “How many do you smoke per day?” If no – “When was the last time you smoked or used any other tobacco products?” Ask for all other types of tobacco, cigars, pipes, chew, snuff, ect.

15. Type of Tobacco Used (Continued) FINAL DECISION: Keep current question and Adopt MDS question. COMMENTS: We were concerned about the respondent burden here, having to go through all the tobacco types. For practical purposes we decided to adopt the MDS question and looked to cut length of intake in other areas.

16. Level of Addiction VT CURRENT: “Do you have a cigarette within the first 15 minutes after you wake up?” MDS CHANGES: “How soon after you wake up do you smoke your first cigarette?” (OPEN RESPONSE) Interviewer codes – within 5 minutes, 6-30 minutes, 31-60 minutes, greater than 60 minutes. FINAL DECISION: Adopt MDS question. COMMENTS: We requested ACS not to have interviewer recode responses. We want the raw data, and will recode on our end. This will help preserve historical data.

17. Questions asked at the 7 month follow-up call affected by MDS • Client Satisfaction • Quit Attempts • Reduction of Tobacco Use • Switching • Use of pharmaceuticals • Quit Rates

18. Client Satisfaction VT CURRENT: We are asking 18 client satisfaction questions. Many based on a 10 point scale. Satisfaction questions are only asked during the first follow-up period in which we contact someone. This could be at 3, 6, or 12 months. MDS CHANGES: Only one, optional satisfaction question is asked. “Overall how satisfied were you with the service you received from the quitline?” Callers are asked to rate their response using a Likert scale. (i.e. very satisfied, mostly satisfied, satisfied, ect) FINAL DECISION: Adopt MDS question. COMMENTS: Due to respondent burden, the Board’s committee recommended dropping all other satisfaction questions, except this one. Considerations here included, difficulty of historical comparisons, as well as ACS concern that satisfaction scores become higher using Likert scales.

19. Quit Attempts VT CURRENT: “Since your last contact with the Quitline, have you quit smoking for at least 24 hours?” MDS CHANGES: “Since you first called the Quitline on (Date of First Contact), 7 months ago, did you quit using tobacco for 24 hours or longer?” FINAL DECISION: Adopt MDS question. COMMENTS: We did not choose to add the optional question, “How many times did you quit for 24 hours or longer?”

20. Reduction in the Amount of Tobacco Use VT CURRENT: “On average, how many cigarettes do you smoke per day?” MDS CHANGES: MDS asks also about cigars, pipes, and smokeless. FINAL DECISION: Adopt MDS changes. COMMENTS: The Board is concerned about respondent burden here, as switching is such a limited phenomenon.

21. Switching Forms of Tobacco and Switching From Daily to Occasional Use. VT CURRENT: “Have you smoked at all in the last 48 hours?” If no – “Have you smoked at all?” If yes – “How many days did you go without smoking?” - “On average how many cigarettes do you smoke a day?” MDS CHANGES: “At the current time, how many cigarettes do you smoke per day?” Also the MDS asks for pipe, cigars, and smokeless. Additionally, they calculate the number of smokers switch to another form, and the number of people that switch to becoming occasional smokers. FINAL DECISION: Adopt MDS questions. COMMENTS: Dr. Hughes, in his research, has found that switching is a limited phenomenon. The Board’s committee is concerned about the respondent burden to get at a potentially limited range of behaviors.

22. Use of Pharmaceuticals to Help Quit VT CURRENT: “Did you take any medications to help you quit smoking?” (yes, no, refused) “If so, which ones?” (list) “Any other medications?” (list) Also there is an open text field available to interviewer if medication is not listed. MDS CHANGES: “Since your call to the quitline on (Date of First Contact), 7 months ago, have you used nicotine replacement (gum or patch) or pills (Zyban) to help you quit?” (Yes, no, refused, don’t know) FINAL DECISION: Adopt MDS question. COMMENTS: We also kept the question from our current survey where a list of NRT products plus Zyban are read to the caller for them to endorse.

23. Quit Rates VT CURRENT: We use the lead in question of “Since your last contact with the quitline, have you quit smoking for at least 24 hours?” Then we ask, “Have you smoked within the last 48 hours?” and follow up with “Have you smoked at all?” MDS CHANGES: Have you smoked any cigarettes, cigars, pipes or used chewing tobacco or snuff in the last 7days?” and follow up with “…in the last 30 days?” (Yes, no, don’t know, refused) Also interviewer codes a response for each tobacco use. FINAL DECISION: Adopt MDS question. COMMENTS: In order to preserve historical data, we have added the question from the current survey, “When was the last day that you smoked?” We can obtain any type of point prevalence using this question. This will also be helpful in preserving data for the yet to be determined continuous abstinence question.

24. Lessons Learned • The process will take longer than you plan for. • It is a good exercise to review the entire body of questions in order to make sure you are getting the data you think you are. • Try to look for ways to either keep your original questions and roll them up into MDS answers or adopt the MDS questions and be able to roll them up into your historical categories. • Remember this is a minimum data set, so you can continue to look at your original questions, and coding the data after the survey can help you save historical categories as well.