dentist and tobacco cessation
TRANSCRIPT
Systems-Level Innovations to Promote Tobacco Systems-Level Innovations to Promote Tobacco Treatment in Health Care Settings-Treatment in Health Care Settings-Columbia University/ Aetna DentalColumbia University/ Aetna Dental
"Tobacco and the Dental Office: Encouraging Patients to Quit""Tobacco and the Dental Office: Encouraging Patients to Quit"
David A. Albert, DDS, MPHDavid A. Albert, DDS, MPH
[email protected]@columbia.edu
212-304-7172212-304-7172
Funded by the Robert Wood Johnson Foundation
Columbia University / Aetna Inc. Addressing Columbia University / Aetna Inc. Addressing Tobacco in Managed CareTobacco in Managed Care
Dr. David A. Albert – Columbia UniversityDr. David A. Albert – Columbia University
Dr. Donald Sadowsky – Columbia UniversityDr. Donald Sadowsky – Columbia University
Dr. Daniel Seidman – Columbia UniversityDr. Daniel Seidman – Columbia University
Ms. Angela Ward – Columbia UniversityMs. Angela Ward – Columbia University
Ms. Laura Akers – Deschutes Research Institute Ms. Laura Akers – Deschutes Research Institute
Dr. Judy Andrews – Deschutes Research InstituteDr. Judy Andrews – Deschutes Research Institute
Mr. Steven Christiansen – InterVisionMr. Steven Christiansen – InterVision
Dr. Judith Gordon – Deschutes Research InstituteDr. Judith Gordon – Deschutes Research Institute
Dr. Herb Severson – Deschutes Research InstituteDr. Herb Severson – Deschutes Research Institute
Dr. Thomas D. Gotowka – Aetna DentalDr. Thomas D. Gotowka – Aetna Dental
Mr. Alan Hirschberg – Aetna DentalMr. Alan Hirschberg – Aetna Dental
Ms. Dawn Romberg – Aetna DentalMs. Dawn Romberg – Aetna Dental
The Dental Profession and Managed CareThe Dental Profession and Managed Care
The Dental Managed Care Organization can serve as a facilitator for The Dental Managed Care Organization can serve as a facilitator for patient tobacco cessation advice and assimilation of tobacco patient tobacco cessation advice and assimilation of tobacco cessation techniques into routine dental policies and procedures. cessation techniques into routine dental policies and procedures.
Improved health outcomes can be understood as contributing to lower total Improved health outcomes can be understood as contributing to lower total health costs and to an augmentation of quality by the MCO. health costs and to an augmentation of quality by the MCO.
The Agency for Health Care Policy and Research Guideline The Agency for Health Care Policy and Research Guideline #18(April 1996) recommends that insurers support tobacco user #18(April 1996) recommends that insurers support tobacco user identification systems, support cessation treatment through staff identification systems, support cessation treatment through staff education and training, and provide for reimbursement for tobacco-education and training, and provide for reimbursement for tobacco-dependence treatmentdependence treatment
Prevention in the Dental OfficePrevention in the Dental Office
Why conduct tobacco cessation in the dental Why conduct tobacco cessation in the dental office?office?oral entry wayoral entry way leukoplackic changesleukoplackic changesbad breathbad breathcosmetic defectscosmetic defectsperiodontal diseaseperiodontal diseaseoral canceroral cancernot a candidate for prosthetics, implantsnot a candidate for prosthetics, implants
Tobacco Cessation: Tobacco Cessation: Are dentists ready?Are dentists ready?
Support from the American Dental AssociationSupport from the American Dental Association National Dental AssociationNational Dental Association American Academy of General DentistryAmerican Academy of General Dentistry NCI Dental Tobacco Steering CommitteeNCI Dental Tobacco Steering Committee AHCPR/ PHS GuidelinesAHCPR/ PHS Guidelines Dental School Curriculum Dental School Curriculum
SettingSetting
Aetna DentalAetna Dental
One of the largest dental insurance companies in One of the largest dental insurance companies in the USthe US
Market leader in the Dental HMO businessMarket leader in the Dental HMO business Top 3 dental player by total membership (13 Top 3 dental player by total membership (13
million covered dental members)million covered dental members) DMO product serves approximately three million DMO product serves approximately three million
membersmembers 7,100 DMO GP locations7,100 DMO GP locations Presence in 50 StatesPresence in 50 States
Managed Care Commitment to Tobacco Managed Care Commitment to Tobacco CessationCessation
Commitment of ResourcesCommitment of ResourcesNetwork Managers, supervisory personnelNetwork Managers, supervisory personnelRegional Dental Directors, National Dental DirectorRegional Dental Directors, National Dental DirectorQuality Assurance Quality Assurance
Dental Provider education and enhanced Dental Provider education and enhanced reimbursementreimbursement
Patient educationPatient education
Specific Aims (Specific Aims ("Tobacco and the Dental Office: "Tobacco and the Dental Office: Encouraging Patients to Quit”)Encouraging Patients to Quit”)
To stimulate tobacco cessation behaviors by subject-dentistsTo stimulate tobacco cessation behaviors by subject-dentists
To incorporate systems-based strategies including tobacco To incorporate systems-based strategies including tobacco user identification systems, education, financial incentives, user identification systems, education, financial incentives, and feedbackand feedback
To determine whether a CD-ROM based educational To determine whether a CD-ROM based educational intervention can increase the prevalence of cessation intervention can increase the prevalence of cessation activities within the MCO dental practicesactivities within the MCO dental practices
To evaluate the cost-effectiveness of the interventionTo evaluate the cost-effectiveness of the intervention
Intervention ComponentsIntervention Components
Continuing medical education via CD-ROMContinuing medical education via CD-ROM
Enhanced payment system for tobacco cessation in Enhanced payment system for tobacco cessation in the dental officethe dental office
Interactive electronic detailing sessions Interactive electronic detailing sessions
System Change Development and System Change Development and ImplementationImplementation
The CD-ROM includes branding as an Aetna The CD-ROM includes branding as an Aetna Dental productDental product
The cover art on the CD-ROM case and on the CD-The cover art on the CD-ROM case and on the CD-ROM label were developed in close conjunction with ROM label were developed in close conjunction with Aetna DentalAetna Dental
The introductory segment of the CD-ROM contains The introductory segment of the CD-ROM contains video of the Head of Aetna Dentalvideo of the Head of Aetna Dental
System Change Development and System Change Development and ImplementationImplementation
The incentive plan was developed and disseminated to The incentive plan was developed and disseminated to participating dentists in the intervention armparticipating dentists in the intervention arm
The incentive plan builds upon lessons learned in the Columbia/ The incentive plan builds upon lessons learned in the Columbia/ Aetna Dental ATMC 1 projectAetna Dental ATMC 1 project
Aetna Dental provided the dentist with $10 for each Aetna DMOAetna Dental provided the dentist with $10 for each Aetna DMO®® enrolled patient who received tobacco cessation counseling and enrolled patient who received tobacco cessation counseling and completed the Columbia University Survey of Dental Patients completed the Columbia University Survey of Dental Patients during the enrollment period during the enrollment period
Dentists were informed of the compensation program when the Dentists were informed of the compensation program when the patient surveys and materials were sent to them and via electronic patient surveys and materials were sent to them and via electronic detailing (e-mail)detailing (e-mail)
System Change Development and System Change Development and ImplementationImplementation
Aetna Dental implemented an updated quality Aetna Dental implemented an updated quality assurance system incorporating tobacco cessation assurance system incorporating tobacco cessation questions into their periodic in-office reviewsquestions into their periodic in-office reviews
The modified system was implemented in the 29 States The modified system was implemented in the 29 States where dental offices are included in the studywhere dental offices are included in the study
Study DesignStudy 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)
Eligibility CriteriaEligibility Criteria
12.0%87.1%Does this computer have at least128 MB RAM?
11.8%87.2%Does this computer have a CD-ROM drive?
20.6%78.6%Are you able to hear audio andwatch video on this computer?
19.4%80.0%Did you purchase this computerafter 1998?
22.6%76.8%Do you use email on thiscomputer?
12.4%87.6%Do you have internet access onthis computer?
10.2%89.8%Do you have access to a personalcomputer?
NoYesQuestion
Dissemination VehicleDissemination Vehicle
Minimum RequirementsMinimum Requirements
DDS Baseline DataDDS Baseline Data During the past month, approximately what During the past month, approximately what % of the time did you ask about patient’s % of the time did you ask about patient’s tobacco use? (N=133) tobacco use? (N=133)
6.8%
39.1%
6.8%
15.8%
4.5%
27.1%
DDS Baseline DataDDS Baseline Data During the past month, approximately what During the past month, approximately what % of the time did you record information in % of the time did you record information in patient’s chart about their tobacco use? (N=133) patient’s chart about their tobacco use? (N=133)
1.5%
12%
23.3%
5.3%
29.3%28.6%
DDS Baseline DataDDS Baseline Data The extent to which discussion of setting specific quit The extent to which discussion of setting specific quit dates and specific strategies for quitting are a part of dates and specific strategies for quitting are a part of your tobacco cessation activities for patients who use your tobacco cessation activities for patients who use tobacco products. tobacco products.
Discussion of setting specific quit dates
A partNot a part
Count
100
90
80
70
60
50
40
30
28.4%
71.6%
(N=134)
DDS Baseline DataDDS Baseline Data The extent to which referral of patients to cessation The extent to which referral of patients to cessation clinics/programs is a part of your tobacco cessation clinics/programs is a part of your tobacco cessation activities for patients who use tobacco products. (N=135) activities for patients who use tobacco products. (N=135)
23.7%
76.3%
DDS Baseline DataDDS Baseline Data Overall, how would you rate your knowledge about Overall, how would you rate your knowledge about helping people stop using tobacco? (N=178) helping people stop using tobacco? (N=178)
19.1%
14%
27%
3.9%
36%
Patient Baseline Data - Tobacco UsersPatient Baseline Data - Tobacco Users How many times during the past 12 months How many times during the past 12 months have you seriously tried to quit? have you seriously tried to quit?
51.2%
22.7%
11%15%
Patient Baseline Data - Tobacco UsersPatient Baseline Data - Tobacco Users How confident are you that you will be able How confident are you that you will be able to stop using tobacco? to stop using tobacco?
21.5%
47.6%
19.1%
11.8%
Patient Baseline Data - Tobacco UsersPatient Baseline Data - Tobacco Users Indicate where you are in your thinking Indicate where you are in your thinking about quitting tobacco products. about quitting tobacco products.
0 - not ready to quit, 10 - ready to quit now
16.8%
14.1%
9.1%9.7%
10.4%
19.9%
Patient Baseline Data - Tobacco UsersPatient Baseline Data - Tobacco Users Over the past 12 months, how many visits Over the past 12 months, how many visits did you make to the dental office? did you make to the dental office?
4 or more
3
2
1
18.1%
15.8%
31.7%
34.4%
Has anyone in your dentist’s office Has anyone in your dentist’s office encouraged you to set a quit date?encouraged you to set a quit date?
More than one answer
Front Desk/Reception
Dental Hygienist
Dental Assistant
Dentist
If yes, who?
Patient Baseline Data - Tobacco Users
Has anyone encouraged you to set a quit date?
NoYes
Count
300
200
100
0 7.1%
18.4%
1%
21.4%
71.5%
28.5%
52%