Systems Change: Treating Tobacco Use and Dependence

Based on the Public Health Service (PHS) Clinical Practice Guideline—2008 Update

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Systems change describes specific strategies that health care administrators, managed care organizations, and purchasers of health plans can implement to treat tobacco dependence. These strategies include implementing a tobacco-user identification system; providing training, resources, and feedback; dedicating staff to provide tobacco dependence treatments and assessing delivery of treatment in staff performance evaluations; and promoting hospital policies that support and provide tobacco dependence services.

These strategies for systems change were extracted from information in Chapters 5 and 6 of the 2008 Guideline Update.

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Contents

Introduction
Systems Change: Background
Systems Change: Strategies
Systems Change: Recommendations
Systems Change: Evidence
Systems Change: Cost Effectiveness

Introduction

Sponsored by the Public Health Service, the 2008 Update to the Clinical Practice Guideline presents evidenced-based guidelines for clinicians to use when treating their patients who use tobacco. The expert panel that developed this Guideline recognized that health professionals need the support of the health care systems in which they work in order for these treatment recommendations to be fully utilized.

The Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update, on which this Systems Change narrative is based, was developed by a multidisciplinary, non-Federal panel of experts, in collaboration with a consortium of tobacco cessation representatives, consultants, and staff. The Guideline Panel also reviewed and analyzed literature about health care-system support to clinicians. The following information is based on the conclusions and recommendations reached by the Guideline Panel.

Note: Citation numbers in the text refer to References in the Guideline Update on which this information is based. Table numbers refer to Tables of the Guideline Update.

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Systems Change: Background

For the guideline's recommendations to be fully realized, changes are needed in health care systems to support clinician interventions. Efforts to integrate tobacco intervention into the delivery of health care require the active involvement of clinicians, health care systems, insurers and purchasers of health insurance. Such integration represents an opportunity to increase rates of delivering tobacco dependence treatments, quit attempts, and successful smoking cessation.²⁰¹

In contrast to strategies that target only the clinician or the tobacco user, systems strategies are intended to ensure that tobacco use is systematically assessed and treated at every clinical encounter. Importantly, these strategies are designed to work synergistically with clinician- and patient-focused interventions, ultimately resulting in informed clinicians and patients interacting in a seamless way that facilitates the treatment of tobacco dependence.^202-204

Several considerations argue for the adoption of systems-level tobacco intervention efforts. First, such strategies have the potential to substantially improve population abstinence rates. Levy et al. estimated that, over time, widespread implementation of such strategies could produce a 2-to-3.5-percent reduction in smoking prevalence rates.²⁰⁵ Second, despite recent progress in this area, many clinicians have yet to use evidence-based interventions consistently with their patients who use tobacco.^23,48,51 Some evidence indicates that institutional or systems support (e.g., adequate clinician training or automated smoker identification systems) improves the rates of clinical interventions.^206-208 Finally, agents such as administrators, insurers, employers, purchasers, and health care delivery organizations have the potential to craft and implement supportive systems, policies and environmental prompts that can facilitate the delivery of tobacco dependence treatment for millions of Americans. For example, managed care organizations and other insurers influence medical care through formularies, performance feedback to clinicians, specific coverage criteria and marketing approaches that prompt patient demand for particular services.^139-209 Purchasers have also begun to use tobacco measures in pay-for-performance initiatives in which managed care organizations, clinics, and individual physicians receive additional reimbursement by achieving specific tobacco treatment-related goals. Indeed, research clearly shows that systems-level changes can reduce smoking prevalence among enrollees of managed health care plans.^210-212

Unfortunately, potential benefits of a collaborative partnership amongst health care organizations, insurers, employers and purchasers have not been fully realized. For example, treatments for tobacco use (both medication and counseling) are not provided consistently as paid services for subscribers of health insurance packages.^213-215 Although substantial progress has been made since the publication of the first Guideline in 1996,^1,216-218 neither private insurers nor state Medicaid programs consistently provide comprehensive coverage of evidence-based tobacco interventions.^206,214,219

Findings such as these resulted in the Healthy People 2010 objective:

Increase insurance coverage of evidence-based treatment for nicotine dependency to 100 percent ²²⁰

In sum, without supportive systems, policies, insurance coverage and environmental prompts, the individual clinician will likely not assess and treat tobacco use consistently. Therefore, just as clinicians must assume responsibility to treat their patients for tobacco use, so must health care administrators, insurers, and purchasers assume responsibility to craft policies, provide resources, and display leadership that results in a health care system that delivers consistent and effective tobacco use treatment.

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Systems Change: Strategies

Five specific strategies will help ensure that tobacco intervention is consistently integrated into health care delivery:

1. Implement a Tobacco-User Identification System in Every Clinic.
2. Provide Education, Resources, and Feedback to Promote Provider Intervention.
3. Dedicate Staff to Provide Tobacco Dependence Treatment and Assess Its Delivery in Staff Performance Evaluations.
4. Promote Hospital Policies That Support and Provide Inpatient Tobacco Dependence Services.
5. Include Tobacco Dependence Treatments (Both Counseling and Medication) Identified As Effective in the Guideline, as Paid or Covered Services in All Subscribers or Members of Health Insurance Packages.

Systems Strategy 1. Implement a Tobacco-User Identification System in Every Clinic

Action

Strategies for implementation

Implement an office-wide system that ensures that for every patient at every clinic visit, tobacco-use status is queried and documented.

Office system change: Expand the Vital Signs to include tobacco use or implement an alternative universal identification system. Responsible staff: Nurse, medical assistant, receptionist, or other individual already responsible for recording the vital signs. These staff must be instructed regarding the importance of this activity and serve as nonsmoking role models. Frequency of utilization: Every visit for every patient regardless of the reason for the visit.a System implementation steps: Routine smoker identification can be achieved by modifying electronic medical record data collection fields or progress note in paper charts to include tobacco use status as one of the vital signs. Vital Signs Blood Pressure: ______________________ Pulse: _______ Weight: _________ Temperature: ________________________ Respiratory Rate: _____________________ Tobacco Use (circle one): Current Former Never

^aRepeated assessment is not necessary in the case of the adult who has never used tobacco or not used tobacco for many years, and for whom this information is clearly documented in the medical record.

Systems Strategy 2. Provide Education, Resources, and Feedback to Promote Provider Intervention

Action

Strategies for implementation

Health care systems should ensure that clinicians have sufficient training to treat tobacco dependence, clinicians and patients have resources, and clinicians are given feedback about their tobacco dependence treatment practices.

Educate all staff. On a regular basis, offer training (e.g., lectures, workshops, inservices) on tobacco dependence treatments and provide continuing education (CE) and/or other incentives for participation. Provide resources such as ensuring ready access to tobacco quit lines (e.g., 1-800-QUIT-NOW) and other community resources, self-help materials, and information about effective tobacco use medications (e.g., establish a clinic fax-to-quit service, place medication information sheets in examination rooms). Report the provision of tobacco dependence interventions on report cards or evaluative standards for health care organizations, insurers, accreditation organizations and physician group practices (e.g., HEDIS, The Joint Commission, and Physician Consortium for Performance Improvement). Provide feedback to clinicians about their performance, drawing on data from chart audits, electronic medical records, and computerized patient databases. Evaluate the degree to which clinicians are identifying, documenting, and treating patients who use tobacco.

Systems Strategy 3. Dedicate Staff to Provide Tobacco Dependence Treatment and Assess Its Delivery in Staff Performance Evaluations

Action

Strategies for implementation

Clinical sites should communicate to all staff the importance of intervening with tobacco users and should designate a staff person (e.g., nurse, medical assistant, or other clinician) to coordinate tobacco dependence treatments. Nonphysician personnel may serve as effective providers of tobacco dependence interventions.

Designate a tobacco dependence treatment coordinator for every clinical site. Delineate the responsibilities of the tobacco dependence treatment coordinator (e.g., ensuring the systematic identification of smokers, ready access to evidence-based cessation treatments [e.g., quitlines], and scheduling of follow-up visits). Communicate to each staff member (e.g., nurse, physician, medical assistant, pharmacist, or other clinician) his or her responsibilities in the delivery of tobacco dependence services. Incorporate a discussion of these staff responsibilities into training of new staff.

Systems Strategy 4. Promote Hospital Policies That Support and Provide Inpatient Tobacco Dependence Services

Action

Strategies for implementation

Provide tobacco dependence treatment to all tobacco users admitted to a hospital.

Implement a system to identify and document the tobacco use status of all hospitalized patients. Identify a clinician(s) to deliver tobacco dependence inpatient consultation services for every hospital and reimburse them for delivering these services. Offer tobacco dependence treatment to all hospitalized patients who use tobacco. Expand hospital formularies to include FDA-approved tobacco dependence medications. Ensure compliance with The Joint Commission regulations mandating that all sections of the hospital be entirely smoke-free and that patients receive cessation treatments. Educate hospital staff that first-line medications may be used to reduce nicotine withdrawal symptoms, even if the patient is not intending to quit at this time.

Systems Strategy 5. Include Tobacco Dependence Treatments (Both Counseling and Medication) Identified as Effective in This Guideline as Paid or Covered Services for All Subscribers or Members of Health Insurance Packages

Action

Strategies for implementation

Provide all insurance subscribers, including those covered by managed care organizations (MCOs), workplace health plans, Medicaid, Medicare, and other government insurance programs, with comprehensive coverage for effective tobacco dependence treatments, including medication and counseling.

Cover effective tobacco dependence treatments (counseling and medication) as part of the basic benefits package for all health insurance packages. Remove barriers to tobacco treatment benefits (e.g., co-pays, utilization restrictions). Educate all subscribers and clinicians about the availability of covered tobacco dependence treatments (both counseling and medication) and encourage patients to use these services.

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Systems Change: Recommendations

Health care delivery administrators, insurers, and purchasers can promote the treatment of tobacco dependence through a systems approach. Purchasers (often business entities or other employers, State or Federal units of government, or other consortia that purchase health care benefits for a group of individuals) should make tobacco assessment and coverage of treatment a contractual obligation of the health care insurers and/or clinicians who provide services to them.

In addition to improving the health of their employees or subscribers, providing coverage for tobacco dependence treatment will result in lower rates of absenteeism^229-230 and lower utilization of health care resources.^229,231 Health care administrators and insurers should provide clinicians with assistance to ensure that institutional changes promoting tobacco dependence treatment are implemented universally and systematically. A number of institutional policies would facilitate these interventions such as:

• Implementing a tobacco-user identification system in every clinic (Systems Strategy 1).
• Providing adequate training, resources, and feedback to ensure that providers consistently deliver effective treatments (Systems Strategy 2).
• Dedicating staff to provide tobacco dependence treatment and assessing the delivery of this treatment in staff performance evaluations (Systems Strategy 3).
• Promoting hospital policies that support and provide tobacco dependence services (Systems Strategy 4).
• Including tobacco dependence treatments (both counseling and medication) identified as effective in this Guideline, as paid or covered services for all subscribers or members of health insurance packages (Systems Strategy 5).

These strategies are based on the evidence described in Chapter 6 of the Guideline Update as well as on panel opinion.

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Systems Change: Evidence

System Recommendations and Evidence presents the information considered by the Guideline Panel, the results of meta-analyses for research studies, and the Panel recommendations. These recommendations cover:

Clinician Training and Reminder Systems
Cost Effectiveness of Tobacco-Dependence Interventions
Tobacco-Dependence Treatment as Part of Assessing Health are Quality
Providing Treatment for Tobacco Use and Dependence as a Covered Benefit

Clinician Training and Reminder Systems

Recommendation: All clinicians and clinicians-in-training should be trained in effective strategies to assist tobacco users willing to make a quit attempt and to motivate those unwilling to quit. Training appears to be more effective when coupled with systems changes. (Strength of Evidence = B)

Meta-analyses were conducted to analyze the effects of clinician training and other systems changes. It was necessary to include studies in these analyses in which higher level units (clinicians or clinical sites) served as units of randomization. This strategy was adopted because relatively few studies in this area of research randomized individual patients to treatment or intervention conditions. Studies randomized at higher level units were considered for the analyses only if the study's analytic plan accounted for the dependency of data nested under such units or if the outcome, such as providing advice to quit, was analyzed at the same level as the randomization (e.g. clinician or clinic level). In fact, however, the few studies that analyzed data at the level of the clinician or clinic shared no common outcomes so they could not be used in the meta-analysis.

Table 6.31 depicts meta-analytic results for studies that examined the effects of training on abstinence outcomes. Only two studies, somewhat heterogenous, were available for this analysis. Thus, although the meta-analysis showed a significant effect of training, the panel elected to assign this recommendation a "B" strength of evidence.

Table 6.31. Meta-analysis (2008): Effectiveness and estimated abstinence rates for clinician training (n = 2 studies).

Intervention	Number of arms	Odds Ratio (95% C.I.)	Estimated abstinence rate (95% C.I.)
No intervention	2	1.0	6.4
Clinician training	2	2.0 (1.2-3.4)	12.0 (7.6-18.6)

Select for articles used in the Update's meta-analysis.

Clinician training and other systems changes are intended to increase rates of tobacco use assessment and intervention. Therefore, additional meta-analyses were conducted to ascertain the effects of systems changes on outcomes such as clinician assessment of smoking status ("Ask"), provision of treatment ("Assist"), and arranging for treatment followup ("Arrange"). Thus, these meta-analyses focused on systems change impact on specific clinician behaviors. In the analyzed studies, clinician behavior was assessed via patient report or chart review (not via clinician report). Analyses of such clinician behaviors are of public health significance because of evidence that the provision of treatment has been shown to lead to higher tobacco cessation rates.

As noted in Table 6.32, training clinicians increases the percentage of smokers who receive treatment, such as a discussion of benefits/obstacles to quitting or strategies to prevent relapse, medication and provision of support. Further, combining clinician training with a charting system, such as chart reminder stickers or treatment algorithms attached to the chart, increases rates of tobacco use assessment (Table 6.33), setting a quit date (Table 6.34), providing materials (Table 6.35), and arranging for followup (Table 6.36). Thus, clinician training, especially when coupled with other systems changes such as reminder systems, increases the rates at which clinicians engage in tobacco interventions that reliably boost tobacco cessation. The Guide to Community Preventive Services⁹² found insufficient evidence to recommend provider education systems as stand alone interventions, separate from other system changes, but does recommend provider education when part of other system changes such as reminder systems.

Table 6.32. Meta-analysis (2008): Effectiveness of clinician training on rates of providing treatment ("Assist") (n = 2 studies)

Intervention	Number of arms	Odds Ratio (95% C.I.)	Estimated abstinence rate (95% C.I.)
No intervention	2	1.0	36.2
Clinician training	2	3.2 (2.0-5.2)	64.7 (53.1-74.8)

Select for articles used in the Update's meta-analysis.

Table 6.33. Meta-analysis (2008): Effectiveness of clinician training combined with charting on asking about smoking status ("Ask") (n = 3 studies)

Intervention	Number of arms	Odds Ratio (95% C.I.)	Estimated rate (95% C.I.)
No intervention	3	1.0	58.8
Clinician training	3	2.1 (1.9-2.4)	75.2 (72.7-77.6)

Select for the articles used in the Update's meta-analysis.

Table 6.34. Meta-analysis (2008): Effectiveness of training combined with charting on setting a quit date ("Assist") (n = 2 studies)

Intervention	Number of arms	Odds Ratio (95% C.I.)	Estimated rate (95% C.I.)
No intervention	2	1.0	11.4
Clinician training	2	5.5 (4.1-7.4)	41.4 (34.4-48.8)

Select for the articles used in the Update's meta-analysis.

Table 6.35. Meta-analysis (2008): Effectiveness of training combined with charting on providing materials ("Assist") (n = 2 studies)

Intervention	Number of arms	Odds Ratio (95% C.I.)	Estimated rate (95% C.I.)
No intervention	2	1.0	8.7
Clinician training	2	4.2 (3.4-5.3)	28.6 (24.3-33.4)

Select for the articles used in the Update's meta-analysis.

Table 6.36. Meta-analysis (2008): Effectiveness of training combined with charting on providing materials ("Assist") (n = 2 studies)

Intervention	Number of arms	Odds Ratio (95% C.I.)	Estimated rate (95% C.I.)
No intervention	2	1.0	6.7
Clinician training	2	2.7 (1.9-3.9)	16.3 (11.8-22.1)

Select for the articles used in the Update's meta-analysis.

These meta-analyses support the finding that clinician training increases the delivery of effective tobacco use treatments. Training elements provided in these interventions included didactic presentation of material, group discussions and role playing. These studies also examined a range of clinician training, from formal training during residency to on-site clinician training within the community.

Training should be directed at both clinicians-in-training as well as practicing clinicians. Training should be reinforced throughout the clinicians' education and practice.^363-368 Such training has been shown to be cost-effective.³⁶⁹ For clinicians-in-training, most clinical disciplines currently neither provide training nor require competency in tobacco use interventions,³⁷⁰ although this is improving slowly.^371-372 One survey of U.S. medical schools found that most medical schools (69%) did not require clinical training in tobacco dependence treatment.³⁷³ The National Cancer Institute's Prevention and Cessation Education in Medical Schools (PACE) reported that, in 2004, about 36% of medical school courses offered about 10 hours of tobacco-related teaching over 4 years³⁷⁴ and PACE has developed competencies for graduating medical students.³⁷⁵

Similarly, the American Dental Education Association has guidelines recommending tobacco use cessation clinical activities (TUCCA) education for dental and dental hygiene students and, in 1998, 51% of dental schools reported clinical training in this area.³⁷⁶ Tobacco-related curricula may be taught as part of a preventive medicine or substance abuse course or as a class by itself. Similar recommendations would be relevant to virtually all other clinical disciplines. Training in tobacco use interventions should not only transmit essential treatment skills (Chapter 3) but also inculcate the belief that tobacco dependence treatment is a standard of good clinical practice.^130,208,250

Several factors would promote the training of clinicians in tobacco intervention activities:³⁷⁰

• Inclusion of education and training in tobacco dependence treatments in the required curricula of all clinical disciplines.
• Evaluation of effective tobacco dependence treatment knowledge and skills in licensing and certification exams for all clinical disciplines.
• Adoption by medical specialty societies of a uniform standard of competence in tobacco dependence treatment for all members.

Finally, clinicians who currently use any tobacco product should participate in treatment programs to stop their own tobacco use permanently. Clinicians are important role models for their patients, and those who use tobacco are probably less likely to counsel their patients to quit.³⁷⁴ Therefore, it is heartening that many types of clinicians have dramatically decreased their own tobacco use over the past 40 years,³⁷⁸ although this has not been universal.

Future Research

The following topics regarding clinician training require additional research:

• Effectiveness of training programs for other health disciplines such as nursing, psychology, dentistry (including hygienists), social work, and pharmacy.
• Effective elements in successful training programs (e.g., continuing medical education, interactive components).
• Combined effect of multiple systems changes, such as clinician training, reminder systems, clinician feedback, incentive payments, and recruitment of opinion leaders.

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