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

daa1@columbia.edudaa1@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%