Tobacco dependence program: a multifaceted systems approach to reducing tobacco use among kaiser permanente members in northern california

Evaluating the Impact of Eliminating Copayments for Tobacco Cessation Pharmacotherapy

OBJECTIVES

We examined the impact of the Affordable Care Act-mandated elimination of tobacco cessation pharmacotherapy (TCP) copayments on patient use of TCP, overall and by income.

METHODS

Electronic health record data captured any and combination (eg, nicotine gum plus patch) TCP use among adult smokers newly enrolled in Kaiser Permanente Northern California (KPNC). KPNC eliminated TCP copayments in 2015. We included current smokers newly enrolled in the first 6 months of 2014 (before copayment elimination, N=16,199) or 2015 (after elimination, N=16,469). Multivariable models estimated 1-year changes in rates of any TCP fill, and of combination TCP fill, and tested for differences by income (<$50k, $50≥75k, ≥$75k). Through telephone surveys in 2016 with a subset of smokers newly enrolled in 2014 (n=306), we assessed barriers to TCP use, with results stratified by income.

RESULTS

Smokers enrolled in KPNC in 2015 versus 2014 were more likely to have a TCP fill (9.1% vs. 8.2%; relative risk, 1.19; 95% confidence interval, 1.11-1.27), and combination TCP fill, among those with any fill (42.3% vs. 37.9%; relative risk, 1.12; 95% confidence interval, 1.02-1.23); findings were stronger for low-income smokers. Low-income patients (<$50k) were less likely to report that clinicians discussed smoking treatments with them (58%) compared with higher income smokers ($50≥75k, 67%; ≥$75k, 83%), and were less aware that TCP was free (40% vs. 53% and 69%, respectively, P-values<0.05).

CONCLUSIONS

The Affordable Care Act's copayment elimination was associated with a modest increase in TCP use and a greater effect among low-income smokers. Uptake may have been enhanced if promoted to patients directly and via providers.

Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Evaluation of a Pilot Perioperative Smoking Cessation Program: A Pre-Post Study

BACKGROUND

Surgical clinic and perioperative settings are critical touchpoints for treating smoking, yet health care systems have not typically prioritized smoking cessation among surgical patients. We evaluated the implementation of a pilot smoking cessation intervention integrated into standard perioperative care.

MATERIALS AND METHODS

English-speaking adult smokers undergoing elective surgery in Kaiser Permanente San Francisco before (2015) and after (2016-2017) the implementation of a smoking cessation intervention were included. Provider outcomes included counseling referrals, cessation medication orders (between surgery scheduling and surgery), and preoperative carbon monoxide testing. Patient outcomes included counseling and medication use, smoking status at surgery and 30 d after discharge, and surgical complications. Multivariable logistic regression analyses examined pre-to-post intervention changes in outcomes using electronic health record data and 30-d postdischarge telephone surveys.

RESULTS

The sample included 276 patients (70% male; 59% non-Hispanic white; mean age = 50 y). There were significant pre-to-post increases in tobacco cessation counseling referrals (3% to 28%, adjusted odds ratio [AOR] = 11.12, 95% confidence interval [CI] = 3.78-32.71) and preoperative carbon monoxide testing (38% to 50%, AOR = 1.83, 95% CI = 1.10-3.06). At ∼30 d after discharge, patients in the postintervention period were more likely to report smoking abstinence in the previous 7 d (24% pre, 44% post; AOR = 2.39, 95% CI = 1.11-5.13) and since hospital discharge (18% pre, 39% post; AOR = 3.20, 95% CI = 1.42-7.23). Cessation medication orders and patient use of counseling and medications increased, whereas surgical complications decreased, but pre-to-post differences were not significant.

CONCLUSIONS

A perioperative smoking cessation program integrated into standard care demonstrated positive smoking-related outcomes; however, larger studies are needed to evaluate the effectiveness of these programs.

Adverse Childhood Experiences and Mental and Behavioral Health Conditions During Pregnancy: The Role of Resilience

INTRODUCTION

Little is known about how exposure to adverse childhood experiences (ACEs) and protective factors, such as resilience, influence prenatal mental and behavioral health. This study examined associations between exposure to ACEs and mental and behavioral health during pregnancy overall and among women with high versus low levels of resilience.

MATERIALS AND METHODS

Women in two Kaiser Permanente Northern California medical centers were screened for ACEs and resilience during prenatal care (∼14-23 weeks of gestation; N = 355). Multivariable logistic regression analyses examined associations between ACEs and prenatal mental and behavioral health conditions overall and for women with low (≤32) versus high (>32) resilience on the 10-item Connor-Davidson Resilience Scale.

RESULTS

Overall, 54% of women reported 0 ACEs, 28% 1-2 ACEs, and 18% 3+ ACEs. Relative to women with 0 ACEs, those with 1-2 ACEs had higher odds of an anxiety or depressive disorder and intimate partner violence (IPV) (odds ratios [ORs] 2.42-3.12, p < 0.05), and those with 3+ ACEs had higher odds of an anxiety or depressive disorder, depression symptoms, and IPV (ORs 3.08-4.71, p < 0.05). In stratified analyses by high (56%) and low (44%) resilience, having one or more ACEs (vs. 0 ACEs) was only associated with worse mental and behavioral health in women with low resilience.

CONCLUSIONS

ACEs predicted mental and behavioral health conditions among pregnant women, and associations were the strongest among women with low levels of current resilience. Longitudinal research is needed to understand the causal mechanisms underlying these associations.

Documentation of e-cigarette use and associations with smoking from 2012 to 2015 in an integrated healthcare delivery system

It is unclear whether use of electronic nicotine delivery systems (ENDS) precedes cigarette smoking initiation, relapse, and/or quitting. Healthcare systems with electronic health records (EHRs) provide unique data to examine ENDS use and changes in smoking. We examined the incidence of ENDS use (2012-2015) based on clinician documentation and tested whether EHR documented ENDS use is associated with twelve-month changes in patient smoking status using a matched retrospective cohort design. The sample was Kaiser Permanente Northern California (KPNC) patients aged ≥12 with documented ENDS use (N = 7926); 57% were current smokers, 35% former smokers, and 8% never-smokers. ENDS documentation incidence peaked in 2014 for current and former smokers and in 2015 for never-smokers. We matched patients with documented ENDS use to KPNC patients without documented ENDS use (N = 7926) on age, sex, race/ethnicity, and smoking status. Documented ENDS use predicted the likelihood of smoking in the following year. Among current smokers, ENDS use was associated with greater odds of quitting smoking (OR = 1.17, 95%CI = 1.05-1.31). Among former smokers, ENDS use was associated with greater odds of smoking relapse (OR = 1.53, 95%CI = 1.22-1.92). Among never-smokers, ENDS use was associated with greater odds of initiating smoking (OR = 7.41, 95%CI = 3.14-17.5). The overall number of current smokers at 12 months was slightly higher among patients with (N = 3931) versus without (N = 3850) documented ENDS use. Results support both potential harm reduction of ENDS use (quitting combustibles among current smokers) and potential for harm (relapse to combustibles among former smokers, initiation for never-smokers).

Association of the Affordable Care Act With Smoking and Tobacco Treatment Utilization Among Adults Newly Enrolled in Health Care

OBJECTIVES

To examine rates of smoking and tobacco treatment utilization by insurance coverage status (Medicaid, commercial, exchange) among newly enrolled patients in the post Affordable Care Act (ACA) era.

METHODS

We examined new members who enrolled in Kaiser Permanente Northern California through Medicaid, the California exchange, or nonexchange commercial plans (N=122,298) in the first 6 months of 2014 following ACA implementation. We compared these groups on smoking prevalence and tested whether smokers in each group differed on sociodemographic characteristics and in their utilization of tobacco treatment (pharmacotherapy and counseling) in 2014.

RESULTS

Smoking prevalence was higher among Medicaid (22%) than exchange (13%) or commercial (12%) patients (P<0.0001). Controlling for key sociodemographic and clinical characteristics, Medicaid (odds ratio, 1.49; 95% confidence interval, 1.29-1.73) smokers had greater odds of tobacco treatment use than commercial smokers. Other groups at risk for underuse included men, younger patients, Asians, and Latinos.

CONCLUSIONS

In this cohort of newly enrolled patients after ACA implementation, Medicaid patients were more likely to be smokers compared with exchange and commercial patients, but they were also more likely to use tobacco treatment. Low tobacco treatment use among exchange and commercial plan smokers, as well as younger men, Asians and Latinos poses a significant obstacle to improving public health and additional targeted outreach strategies may be needed to engage these patients with available health services.

Telephone-Based Coaching

PURPOSE

Many Americans continue to smoke, increasing their risk of disease and premature death. Both telephone-based counseling and in-person tobacco cessation classes may improve access for smokers seeking convenient support to quit. Little research has assessed whether such programs are effective in real-world clinical populations.

DESIGN

Retrospective cohort study comparing wellness coaching participants with two groups of controls.

SETTING

Kaiser Permanente Northern California, a large integrated health care delivery system.

SUBJECTS

Two hundred forty-one patients who participated in telephonic tobacco cessation coaching from January 1, 2011, to March 31, 2012, and two control groups: propensity-score-matched controls, and controls who participated in a tobacco cessation class during the same period. Wellness coaching participants received an average of two motivational interviewing-based coaching sessions that engaged the patient, evoked their reason to consider quitting, and helped them establish a quit plan.

MEASURES

Self-reported quitting of tobacco and fills of tobacco cessation medications within 12 months of follow-up.

ANALYSIS

Logistic regressions adjusting for age, gender, race/ethnicity, and primary language.

RESULTS

After adjusting for confounders, tobacco quit rates were higher among coaching participants vs. matched controls (31% vs. 23%, p < .001) and comparable to those of class attendees (31% vs. 29%, p = .28). Coaching participants and class attendees filled tobacco-cessation prescriptions at a higher rate (47% for both) than matched controls (6%, p < .001).

CONCLUSION

Telephonic wellness coaching was as effective as in-person classes and was associated with higher rates of quitting compared to no treatment. The telephonic modality may increase convenience and scalability for health care systems looking to reduce tobacco use and improve health.

Barriers to the provision of smoking cessation assistance: a qualitative study among Romanian family physicians

BACKGROUND

Smoking cessation is the most effective intervention to prevent and slow down the progression of several respiratory and other diseases and improve patient outcomes. Romania has legislation and a national tobacco control programme in line with the World Health Organization Framework for Tobacco Control. However, few smokers are advised to quit by their family physicians (FPs).

AIM

To identify and explore the perceived barriers that prevent Romanian FPs from engaging in smoking cessation with patients.

METHODS

A qualitative study was undertaken. A total of 41 FPs were recruited purposively from Bucharest and rural areas within 600 km of the city. Ten FPs took part in a focus group and 31 participated in semistructured interviews. Analysis was descriptive, inductive and themed, according to the barriers experienced.

RESULTS

Five main barriers were identified: limited perceived role for FPs; lack of time during consultations; past experience and presence of disincentives; patients' inability to afford medication; and lack of training in smoking cessation skills. Overarching these specific barriers were key themes of a medical and societal hierarchy, which undermined the FP role, stretched resources and constrained care.

CONCLUSIONS

Many of the barriers described by the Romanian FPs reflected universally recognised challenges to the provision of smoking cessation advice. The context of a relatively hierarchical health-care system and limitations of time and resources exacerbated many of the problems and created new barriers that will need to be addressed if Romania is to achieve the aims of its National Programme Against Tobacco Consumption.

The US Public Health Service "treating tobacco use and dependence clinical practice guidelines" as a legal standard of care

BACKGROUND

The important factors in evaluating the role of clinical practice guidelines (CPGs) in medical malpractice litigation have been discussed for several years, but have focused on broad policy implications rather than on a concrete example of how an actual guideline might be evaluated. There are four items that need to be considered in negligence torts: legal duty, a breach of that duty, causal relationship between breach and injury, and damages.

OBJECTIVE

To identify the arguments related to legal duty.

RESULTS

The Treating Tobacco Use and Dependence (revised 2000) CPG, sponsored by the US Public Health Service, recommends effective and inexpensive treatments for nicotine addiction, the largest preventable cause of death in the US, and can be used as an example to focus on important considerations about the appropriateness of CPGs in the judicial system. Furthermore, the failure of many doctors and hospitals to deal with tobacco use and dependence raises the question of whether this failure could be considered malpractice, given the Public Health Service guideline's straightforward recommendations, their efficacy in preventing serious disease and cost-effectiveness.

CONCLUSION

Although each case of medical malpractice depends on a multitude of factors unique to individual cases, a court could have sufficient basis to find that the failure to adequately treat the main cause of preventable disease and death in the US qualifies as a violation of the legal duty that doctors and hospitals owe to patients habituated to tobacco use and dependence.