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David A. Albert, DDS, MPH daa1@columbia.edu 212-304-7172

Systems-Level Innovations to Promote Tobacco Treatment in Health Care Settings- Columbia University/ Aetna Dental "Tobacco and the Dental Office: Encouraging Patients to Quit". David A. Albert, DDS, MPH daa1@columbia.edu 212-304-7172. Funded by the Robert Wood Johnson Foundation.

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David A. Albert, DDS, MPH daa1@columbia.edu 212-304-7172

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  1. Systems-Level Innovations to Promote Tobacco Treatment in Health Care Settings-Columbia University/ Aetna Dental"Tobacco and the Dental Office: Encouraging Patients to Quit" David A. Albert, DDS, MPH daa1@columbia.edu 212-304-7172 Funded by the Robert Wood Johnson Foundation

  2. Columbia University / Aetna Inc. Addressing Tobacco in Managed Care Dr. David A. Albert – Columbia University Dr. Donald Sadowsky – Columbia University Dr. Daniel Seidman – Columbia University Ms. Angela Ward – Columbia University Ms. Laura Akers – Deschutes Research Institute Dr. Judy Andrews – Deschutes Research Institute Mr. Steven Christiansen – InterVision Dr. Judith Gordon – Deschutes Research Institute Dr. Herb Severson – Deschutes Research Institute Dr. Thomas D. Gotowka – Aetna Dental Mr. Alan Hirschberg – Aetna Dental Ms. Dawn Romberg – Aetna Dental

  3. The Dental Profession and Managed Care • The Dental Managed Care Organization can serve as a facilitator for patient tobacco cessation advice and assimilation of tobacco cessation techniques into routine dental policies and procedures. • Improved health outcomes can be understood as contributing to lower total health costs and to an augmentation of quality by the MCO. • The Agency for Health Care Policy and Research Guideline #18(April 1996) recommends that insurers support tobacco user identification systems, support cessation treatment through staff education and training, and provide for reimbursement for tobacco-dependence treatment

  4. Prevention in the Dental Office • Why conduct tobacco cessation in the dental office? • oral entry way • leukoplackic changes • bad breath • cosmetic defects • periodontal disease • oral cancer • not a candidate for prosthetics, implants

  5. Tobacco Cessation: Are dentists ready? • Support from the American Dental Association • National Dental Association • American Academy of General Dentistry • NCI Dental Tobacco Steering Committee • AHCPR/ PHS Guidelines • Dental School Curriculum

  6. Setting Aetna Dental • One of the largest dental insurance companies in the US • Market leader in the Dental HMO business • Top 3 dental player by total membership (13 million covered dental members) • DMO product serves approximately three million members • 7,100 DMO GP locations • Presence in 50 States

  7. Managed Care Commitment to Tobacco Cessation • Commitment of Resources • Network Managers, supervisory personnel • Regional Dental Directors, National Dental Director • Quality Assurance • Dental Provider education and enhanced reimbursement • Patient education

  8. Specific Aims ("Tobacco and the Dental Office: Encouraging Patients to Quit”) • To stimulate tobacco cessation behaviors by subject-dentists • To incorporate systems-based strategies including tobacco user identification systems, education, financial incentives, and feedback • To determine whether a CD-ROM based educational intervention can increase the prevalence of cessation activities within the MCO dental practices • To evaluate the cost-effectiveness of the intervention

  9. Intervention Components • Continuing medical education via CD-ROM • Enhanced payment system for tobacco cessation in the dental office • Interactive electronic detailing sessions

  10. System Change Development and Implementation • The CD-ROM includes branding as an Aetna Dental product • The cover art on the CD-ROM case and on the CD-ROM label were developed in close conjunction with Aetna Dental • The introductory segment of the CD-ROM contains video of the Head of Aetna Dental

  11. System Change Development and Implementation • The incentive plan was developed and disseminated to participating dentists in the intervention arm • The incentive plan builds upon lessons learned in the Columbia/ Aetna Dental ATMC 1 project • Aetna Dental provided the dentist with $10 for each Aetna DMO® enrolled patient who received tobacco cessation counseling and completed the Columbia University Survey of Dental Patients during the enrollment period • Dentists were informed of the compensation program when the patient surveys and materials were sent to them and via electronic detailing (e-mail)

  12. System Change Development and Implementation • Aetna Dental implemented an updated quality assurance system incorporating tobacco cessation questions into their periodic in-office reviews • The modified system was implemented in the 29 States where dental offices are included in the study

  13. Study Design General practitioner offices in Aetna/DMO (n=6,822) Offices with more than 200 Aetna DMO adult patients (n=1508) Eligible offices (computer, CD-ROM, and Internet access) (n=501) Recruitment of Sample (224 met all eight inclusion criteria) 184 enrolled in program and randomly assigned to Usual Care (82) vs. CD-ROM-based training program (102)

  14. Eligibility Criteria

  15. Dissemination Vehicle

  16. Minimum Requirements

  17. DDS Baseline Data During the past month, approximately what % of the time did you ask about patient’s tobacco use? (N=133) 39.1% 27.1% 15.8% 6.8% 6.8% 4.5%

  18. DDS Baseline Data During the past month, approximately what % of the time did you record information in patient’s chart about their tobacco use? (N=133) 29.3% 28.6% 23.3% 12% 5.3% 1.5%

  19. DDS Baseline Data The extent to which discussion of setting specific quit dates and specific strategies for quitting are a part of your tobacco cessation activities for patients who use tobacco products. 71.6% 28.4% (N=134)

  20. DDS Baseline Data The extent to which referral of patients to cessation clinics/programs is a part of your tobacco cessation activities for patients who use tobacco products. (N=135) 76.3% 23.7%

  21. DDS Baseline Data Overall, how would you rate your knowledge about helping people stop using tobacco? (N=178) 36% 27% 19.1% 14% 3.9%

  22. Patient Baseline Data - Tobacco Users How many times during the past 12 months have you seriously tried to quit? 51.2% 22.7% 15% 11%

  23. Patient Baseline Data - Tobacco Users How confident are you that you will be able to stop using tobacco? 47.6% 21.5% 19.1% 11.8%

  24. Patient Baseline Data - Tobacco Users Indicate where you are in your thinking about quitting tobacco products. 19.9% 16.8% 14.1% 10.4% 9.1% 9.7% 0 - not ready to quit, 10 - ready to quit now

  25. Patient Baseline Data - Tobacco Users Over the past 12 months, how many visits did you make to the dental office? 18.1% 34.4% 15.8% 31.7%

  26. Patient Baseline Data - Tobacco Users Has anyone in your dentist’s office encouraged you to set a quit date? If yes, who? 21.4% 71.5% 1% 52% 28.5% 18.4% 7.1%

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