Video Counseling For Treating Tobacco Dependence

1. Video Counseling For Treating Tobacco Dependence Kimber Richter, Ph.D., M.P.H. Genevieve Casey, M.A. Paula Cupertino, Ph.D. University of Kansas Medical Center Department of Preventive Medicine and Public Health KU-MPH For more info in this talk, contact Kim or Genevieve at krichter@kumc.edu or gcasey@kumc.edu

2. Objectives • Understand rationale for/feasibility of video counseling • How we have used it at KUMC • Group-based video counseling • Individual video counseling • Grief vs Benefit • (Briefly) How we’re experimentally evaluating it • From Connect2Quit, a RCT of Telemedicine for Smoking Cessation in Rural Primary Care (R01, NHLBI, Richter P.I.)

3. What is video counseling? And what should we call it? • Telemedicine/Telecounseling/Video Counseling/Webcam Counseling • Delivery of interactive coaching/counseling in real time, using video/audio interface • Made possible by low cost computers, international telecom standards such as ISDN, and affordable high-speed internet services • But many lower income/rural smokers still don’t have • “Telemedicine” is reimbursable by Medicare and in Kansas by Medicaid

4. Does it work? • No data available for treating tobacco dependence • Why we’re running a trial • Other health behaviors/outcomes: Cochrane review of telemedicine vs face-to-face patient care • Telemedicine was as effective as face-to-face treatment and achieved high levels of satisfaction among patients and providers (Currell et al., 2000) • AHRQ review of 455 Telemedicine programs concluded the same • Important to examine costs, cost-effectiveness (Hersh, 2004) • May 1) provide equivalent care at less cost, 2) deliver better care at less or equivalent cost, 3) increase access to health care for patients who would otherwise not receive any care at all

5. What are the potential benefits? • Counseling quality • Increase therapeutic alliance – bond between counselor and client • Increase adherence, impact • Enhance counseling accuracy and quality by allowing counselor to see non-verbal cues • Easier for counselor to remember details about smoker • Draw more smokers into treatment • Quitlines are underutilized • Novelty factor • Wave of the future

6. What are the barriers? • Smokers tend to have lower incomes • Smokers tend to be less well educated • Although many have a computer in home, isn’t always working • Although many areas have >access< to high-speed internet, many residents don’t purchase it • Only 53% of Kansans have home internet, the majority of which is dial-up connection with variable download time • Even with high-speed internet, the bandwidth required for high-quality telemedicine connection is large • Requires firewall exceptions and periodic updates that internet providers typically do not provide

7. How does it work?From Connect2Quit • Individually-based counseling • Delivered in physician offices – patients’ medical homes • Computer/webcam typically installed in an examining room • 4 sessions (Week 0, 2, 4, 8) • Session 1/ Week 0-2 = D2-21 (D14 = target) • Session 2/ Week 2-3 = D14-28 (D21 = target) • Session 3/ Week 4-6 = D28-48 (D35 = target) • Session 4 / Week 8-11 = D56-83 (D63 = target) • Combined Motivational Interviewing/Cognitive Behavioral approach • Strong focus on pharmacotherapy assistance • Counseling/materials/assessments in Spanish and English • Also have done in group format – can discuss later

8. Our equipment • Project would not be possible without fantastic support from KUCTT – KU Center for Telemedicine and Telehealth • Technicians travel state installing/troubleshooting equipment issues • Equipment • We provide computers/webcams/software to physician offices • Counselors have widescreen monitors to view Polycom and other needed documents (e.g. web browser for pharmacotherapy assistance) • Software: Polycom PVX • Delivers higher-quality video with less freeze-ups than freeware • Costs: • PVX software is $112.00 per user  • Cameras prices fluctuate, however $95.00 is average • Permits us to “show desktop” to the patient

9. Computer equipment requirements • Resource Requirements • Audio recording sessions for fidelity/ QI • Camtasia – the only program that would audio record Polycom • Required a gaming soundcard (multiple channels) • Issue with Polycom shutting down or Access freezing intermittently • Multiple programs running at once – uses a large amount of RAM • Polycom PVX places a high demand on CPU • Polycom PVX is graphic intensive (as are Access and Camtasia) • Solution: (1) shut down all programs but Polycom, Camtasia and Access (2) Have a paper backup in the case of Access freezing/ shutting down • Connection • Requires high-speed internet connection at both ends (dial up does not cut it) • Firewall issues • Internet bandwidth requirements • Minimum bandwith requirements to connect • Consider clinic use variations throughout the day

10. A typical session (on an ideal day…) • Counselor makes reminder call to pt and physician office day prior to session (Some clinics prefer weekly emails) • Patient checks in, goes straight to telemedicine room • Counselor dials C2Q computer at appointed office time • Counselor conducts session • 45 mins session 1, 20 mins follow-up sessions • Counselor faxes follow up materials (prescription request, quit plan) to front desk for pt to pick up at checkout • Provide 2 copies of each – 1 for pt, 1 for physician/medical record • Counselor/pt set follow up appt with receptionist at checkout

12. Great things about a great session • Counseling takes place in a clinic room with few distractions • Show educational materials on desktop to patient in session • Face to face connection – much like an in person session • Counselor can pick up on important non-verbal cues • It is a more personal connection than phone • Patient receives materials that day • Access to PCP at the clinic • Prescription request goes to physician that day • Pharmacy assistance needing physician signature can be completed right away • Physician and staff are aware of patient goals and generally supportive of the program • Patient has higher accountability to call in or show up to a real in person appointment

13. What happens when things go wrong… • Difficulty scheduling • Some clinics have limited hours/ room availability – may not fit patient schedules • Clinics need staff identified to log on to computer/ make appointments • Despite reminder calls, some patients don’t show • Patient work schedules, more of a time commitment for patient (vs. phone) • Patient may not have transportation to the clinic • Less motivated patients may be less likely to show (vs. answer a phone call) • Clinic technology problems • We can not connect, or the clinic staff have to call us • We can never connect because of the clinic’s slow internet connection • Occasional connection problems result from high traffic times • Firewall means the clinic always had to call out we can not call in • Sound quality: echoes or delays at some clinics (movable speakers may work) • Sometimes the image quality is poor (pixilated) over time or freezes completely • Ask the patient to move the mouse to avoid security lock out/ computer sleeping. • Sometimes the connection is dropped – usually we can call back but not always. This can happen more than once during a call • Interferes with the flow of the session, though patients have been tolerant.

14. Pros/Cons of C2Q Video versus Telephone Counseling

15. Design, Connect2Quit • Not a pure test of technology • More a comparative effectiveness study of 2 models of care at a distance • Telephone “Quitline” condition versus Telemedicine integrated into Doctor’s office • All participants get same number of reminder calls, rescheduling calls, missed appointments, counseling “windows” • All get 4 sessions, same materials and counseling content • Weekly supervision, plus sessions are digitally recorded /coded to ensure equal content • Outcomes • Biochemically verified cessation at 12 months • Cost per quit in each condition (costs include patient and provider costs)

16. Mechanism, Connect2Quit • Hypothesis is that integrated telemedicine, compared to telephone alone, will: • Lead to higher perceived support from physician/counselor which will • Lead to higher autonomous motivation and competence for change which will • Lead to higher cessation rates (directly) as well as higher medication use, which will also lead to higher cessation rates • Also, higher cessation rates will result in equal or lower cost per quit We’ll see!!

18. Questions ?