Systems-Level Innovations to Promote Tobacco Treatment in Health Care Settings- Columbia University/ Aetna Dental "Tobacco and the Dental Office: Encouraging Patients to Quit" David A. Albert, DDS, MPH Funded by the Robert Wood Johnson Foundation

Columbia University / Aetna Inc. Addressing Tobacco in Managed Care Dr. David A. Albert – Columbia University Dr. Donald Sadowsky – Columbia University Dr. Daniel Seidman – Columbia University Ms. Angela Ward – Columbia University Ms. Laura Akers – Deschutes Research Institute Dr. Judy Andrews – Deschutes Research Institute Mr. Steven Christiansen – InterVision Dr. Judith Gordon – Deschutes Research Institute Dr. Herb Severson – Deschutes Research Institute Dr. Thomas D. Gotowka – Aetna Dental Mr. Alan Hirschberg – Aetna Dental Ms. Dawn Romberg – Aetna Dental

The Dental Profession and Managed Care  The Dental Managed Care Organization can serve as a facilitator for patient tobacco cessation advice and assimilation of tobacco cessation techniques into routine dental policies and procedures.  Improved health outcomes can be understood as contributing to lower total health costs and to an augmentation of quality by the MCO.  The Agency for Health Care Policy and Research Guideline #18(April 1996) recommends that insurers support tobacco user identification systems, support cessation treatment through staff education and training, and provide for reimbursement for tobacco-dependence treatment

Prevention in the Dental Office  Why conduct tobacco cessation in the dental office?  oral entry way  leukoplackic changes  bad breath  cosmetic defects  periodontal disease  oral cancer  not a candidate for prosthetics, implants

Tobacco Cessation: Are dentists ready?  Support from the American Dental Association  National Dental Association  American Academy of General Dentistry  NCI Dental Tobacco Steering Committee  AHCPR/ PHS Guidelines  Dental School Curriculum

Setting Aetna Dental  One of the largest dental insurance companies in the US  Market leader in the Dental HMO business  Top 3 dental player by total membership (13 million covered dental members)  DMO product serves approximately three million members  7,100 DMO GP locations  Presence in 50 States

Managed Care Commitment to Tobacco Cessation  Commitment of Resources  Network Managers, supervisory personnel  Regional Dental Directors, National Dental Director  Quality Assurance  Dental Provider education and enhanced reimbursement  Patient education

Specific Aims ("Tobacco and the Dental Office: Encouraging Patients to Quit”)  To stimulate tobacco cessation behaviors by subject-dentists  To incorporate systems-based strategies including tobacco user identification systems, education, financial incentives, and feedback  To determine whether a CD-ROM based educational intervention can increase the prevalence of cessation activities within the MCO dental practices  To evaluate the cost-effectiveness of the intervention

Intervention Components  Continuing medical education via CD-ROM  Enhanced payment system for tobacco cessation in the dental office  Interactive electronic detailing sessions

System Change Development and Implementation  The CD-ROM includes branding as an Aetna Dental product  The cover art on the CD-ROM case and on the CD- ROM label were developed in close conjunction with Aetna Dental  The introductory segment of the CD-ROM contains video of the Head of Aetna Dental

System Change Development and Implementation  The incentive plan was developed and disseminated to participating dentists in the intervention arm  The incentive plan builds upon lessons learned in the Columbia/ Aetna Dental ATMC 1 project  Aetna Dental provided the dentist with $10 for each Aetna DMO ® enrolled patient who received tobacco cessation counseling and completed the Columbia University Survey of Dental Patients during the enrollment period  Dentists were informed of the compensation program when the patient surveys and materials were sent to them and via electronic detailing ( )

System Change Development and Implementation  Aetna Dental implemented an updated quality assurance system incorporating tobacco cessation questions into their periodic in-office reviews  The modified system was implemented in the 29 States where dental offices are included in the study

Study 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 Criteria

Dissemination Vehicle

Minimum Requirements

DDS Baseline Data During the past month, approximately what % of the time did you ask about patient’s tobacco use? (N=133) 6.8% 39.1% 6.8% 15.8% 4.5% 27.1%

DDS Baseline Data During the past month, approximately what % of the time did you record information in patient’s chart about their tobacco use? (N=133) 1.5% 12% 23.3% 5.3% 29.3% 28.6%

DDS Baseline Data The extent to which discussion of setting specific quit dates and specific strategies for quitting are a part of your tobacco cessation activities for patients who use tobacco products. 28.4% 71.6% (N=134)

DDS Baseline Data The extent to which referral of patients to cessation clinics/programs is a part of your tobacco cessation activities for patients who use tobacco products. (N=135) 23.7% 76.3%

DDS Baseline Data Overall, how would you rate your knowledge about helping people stop using tobacco? (N=178) 19.1% 14% 27% 3.9% 36%

Patient Baseline Data - Tobacco Users How many times during the past 12 months have you seriously tried to quit? 51.2% 22.7% 11% 15%

Patient Baseline Data - Tobacco Users How confident are you that you will be able to stop using tobacco? 21.5% 47.6% 19.1% 11.8%

Patient Baseline Data - Tobacco Users Indicate where you are in your thinking 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 Users Over the past 12 months, how many visits did you make to the dental office? 18.1% 15.8% 31.7% 34.4%

Has anyone in your dentist’s office encouraged you to set a quit date? If yes, who? Patient Baseline Data - Tobacco Users 7.1% 18.4% 1% 21.4% 71.5% 28.5% 52%