Disseminating Best Practices: Tobacco Dependence Treatment in Wisconsin

1. Disseminating Best Practices: Tobacco Dependence Treatment in Wisconsin Lezli Redmond, MPH Director Statewide Outreach Programs Assistant Director, UW-CTRI NIATx Meeting Orlando Wednesday, January 27, 2010

2. Goals • Describe the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) and the Outreach Program • Describe our experience with the “how to” of disseminating best practices across a state • Discuss a national collaborative that serves as a learning community to support our work • Outline challenges and future plans

3. Advancing Tobacco Treatment Science at UW-CTRI • Established in 1992 • Lead UW-Madison entity charged with reducing the harms from tobacco use • Research focuses on counseling, medications and health system changes to help smokers quit • $50 million in external grant funding over 15 years (primarily NIH)

4. Three SuccessiveNIH P50 Center Grants 1999-2004 Relapse: Linking Science and Practice $10 million 2004-2009 Tobacco Dependence: Treatment and Outcomes $9 million 2009-2014 Engineering Effective Interventions for Tobacco Use: A Translational Laboratory $9 million

5. United States Public Health Service (PHS) Guidelines • 1996 - Initial Guideline published • Literature from 1975 -1995 • Approx. 3,000 articles • 2000 - Revised Guideline published • Literature from 1975 -1999 • Approx. 6,000 articles • 2008 - Updated Guideline published • Literature from 1975 – 2007 • Approx. 8,700 total articles

6. UW-CTRI Cessation Outreach Programs

7. UW-CTRI Cessation Outreach Program 2000-2010 • Train primary care clinicians and other clinic staff • Provide technical assistance on systems change to integrate evidence-based tobacco dependence treatment into healthcare delivery systems • Reduce barriers to tobacco dependence treatment • Increase insurance coverage for treatment • Integrate the Wisconsin Tobacco Quit Line

8. Some Process Outcomes 2000-2010 Trained over 10,000 clinicians and clinic staff Provided on-site training and technical assistance to 920 clinics and hospitals; 26 healthcare systems in Wisconsin Over 31,000 clinicians earned CME/CE The UW-CTRI website averages over 2,000,000 hits per year with over 2,000 unique visitors each week More than 150,000 callers to Wisconsin Tobacco Quit Line; 110,000 received treatment services (~15% of Wisconsin Smokers) Approximately 20% of callers referred by clinicians, 10,000 came in through Fax to Quit Integrated tobacco dependence treatment with EMRs at four health systems and several hospitals Insurance coverage for tobacco dependence treatment increased significantly

9. Long-term Outcomes • Increased quit attempts and decreased smoking rates • Smokers making serious quit attempts went from 46% in 2003 to 59% in 2008. Nationally the rate stayed at approximately 45%. • Between 2001 and 2007 adult tobacco use rates decreased from 24% to 19.7%.

10. Dissemination vs. Diffusion • Dissemination is active rather than passive • It’s a collaborative process • An organization must be “ready” and have the capacity to make the change • Involves formal and informal leaders at all levels of the organization

11. Active Dissemination Methods • Train the trainer • Media campaigns • Educating opinion leaders • Collaborative planning (take them where they’re at and work from there) • Encourage systems-level change implementation

13. Disseminating Innovations in Health Care • Find sound innovations • Find and support “innovators” • Invest in “early adopters” • Trust and enable “reinvention” • Make early adopter activity observable Donald Berwick, MD, MPP 2003

14. Levers For Change • Partnerships(consistent messages; follow through; commitment; in it for the long haul) • Leadership (champions on all levels; tobacco dependence can be treated successfully; we will show you how; everyone can save money and do the right thing) • Innovations (be a leader; demonstrate success; HMOs competitive; connection with state-of-the art tobacco dependence treatment) • Finances (cost-saving, return on investment)

15. Tobacco Treatment is a Team Effort

16. UW-CTRI Outreach Lessons • Continue to make the “why” compelling and the “how” clear, do-able and tailored • “Spread” requires social interaction and constant, multi-faceted communications • Recognize, cultivate and celebrate champions and successful organizations • Use a systems approach • Demonstrate results and provide feedback

17. Why and How? for clinicians • It’s the most important thing you can do for the health of your patient • It will only take a few minutes of your time • It’s effective • We’ll show you and your colleagues how, and give you scripts for exactly what to say

18. Why and How? for Administrators • Per member per month (PMPM) cost for tobacco dependence treatment $0.20 to $0.80 PMPM • America’s Health Insurance Plans (AHIP) and the Center for Health Research (CHR) demonstrated that investments in smoking cessation save money • It’s effective and evidence-based • We’ll provide valuable resources to help you do this (technical assistance and experience)

19. “Spread” Requires Social Interaction • Face-to-face best but not always possible • Supplement with website, email, distance learning, new technologies • Obtain communications expertise if possible • Present (or have successful innovators present) at conferences

20. “Spread” via Partnerships • Who could have a stake in the change? • Professional organizations • Quality improvement groups • Policy-makers • Coalitions • Provider groups and networks • Other networks, formal and informal • Client groups

21. Help Partners Tell Their Stories

22. Create or Join a Learning Community Mission: Facilitate sustainable changes in health care systems to reduce tobacco use and prevalence Methods: Share knowledge and practices, document emerging and best practices at the state level, work with national partners for national change www.multistatecessationcollaborative.org

23. Use A Systems Approach • Typically, interventions target smokers or clinicians • Systems-level approaches implemented throughout the healthcare delivery system • Strategies ensure tobacco use is systematically addressed and treated at every clinical encounter, creating a new standard of care • Power of “institutionalizing” treatment of tobacco dependence

24. Systems Thinking Small events can create large changes in complex systems

25. Why A Systems Approach? • Efforts directed only to tobacco users have been disappointing and expensive • Efforts directed only to healthcare providers not sufficient • Population-based is the key • We want to make BIG changes that are sustainable and integral • We can NOT create change alone

26. Results and Feedback • With a best practice you don’t need to “prove” effectiveness • Data is critical though often hard to collect • Data can take you from “adoption” to full implementation • Quality improvement staff can help • Feedback is powerful and can change individual and organizational behavior

27. Challenges to UW-CTRI Outreach • Funding cuts to our program and overall tobacco control • Less ability to do face-to-face academic detailing • Loss of “champions” • Less political support (other priorities) • Sustainability

28. www.ctri.wisc.edu