1. HEALTHCARE Treatment Delivery: HEALTHCARE Susan Swartz, MD, MPH Center for Tobacco Independence Portland, Maine

2. Product Wide variety of professionals can –Deliver social support, counseling, medications There is significant variation –Basic knowledge and skills, beliefs about their role –Perception of smoking patients Limitations –See quitting as an event, not a process –The encounter outcome is about the relationship Strengths –Professionals want to do the right thing –Training can affect treatment use, improve outcomes

3. Populations 70% smokers seen by provider –Less ‘usual care’ in groups with the highest smoking rates: younger, male, uninsured More provider intervention with smokers –Younger, poorer health (Quinn et al), or ask for help –Having a chronic condition (Thorndike et al) –Primary care providers vs. specialists Providers drive use of accessible treatment in ME. –Medicaid Rx: 1996-99 rose across age/sex groups More Rx in age 35-55 –  Health professional referral to Quit Line High use among uninsured, age 45-64

4. Place Acute care model –‘ tyranny of visit’ -- for any chronic, proactive care Competing demands –Hours to deliver guideline recommendations Talk Therapy in a medical model? –5 A’s at odds with Diagnose & Treat Paradigm Opportunities –Care Model: Teams, office systems –Expand: dental, CAM professionals, hospitals, worksite –Quality Measurement, QI ‘wave’ Pay-for-Performance –Communicate outside the Visit

5. Price Provider perception: –Tobacco talk creates tense encounter –Smokers don’t really want to quit; are ‘weak’ –Smoker efforts not recognized Smoker perception: –Health worker will nag me (esp. pregnant) Evidence –Preventive care increases patient satisfaction –Partnering improves trust, outcomes

6. Promotion Promoting to Health Workers –Must fit into their day (different, not harder) –Seen to generate benefit, incl. short-term –Viable approach for smokers not ready Promoting Treatment to Patients –Patients trust providers (>plans, >>employers) –Need to leverage patient motivation –Must be OK to access treatment –Must be BETTER to access treatment

7. Policies Professional –Curriculum, requirements for licensing (ACGME) Health Plans –No treatment coverage - little utilization But coverage doesn’t guarantee use –Diagnosis of tobacco → Won’t reimburse Visit New CMS benefit (brief provider intervention) Health systems –Quality Improvement include tobacco (2 A’s) State programs –Improve access to treatments –But create disincentive to enhance coverage

9. No-Nag Zone Seek the Best Methods to Quit…

10. Opportunities Help Health Workers Think Differently –Tobacco is the problem vs. the Smoker is problem –Partnering vs. Paternalistic –Greater satisfaction vs. conflict Make Treatment the Best Thing to do –Credible [uncover the ‘black box’] –Beneficial –Accessible