Smoking cessation in Leumit Health Fund

Transcription

1 Smoking cessation in Leumit Health Fund Country: Israel Partner Institute: The Myers-JDC-Brookdale Institute, Jerusalem Survey no: (13) 2009 Author(s): Kitai E., Vardy D., Margalit A., Brami J., Matz E., Kahan N. and R. Gross Health Policy Issues: Public Health, New Technology, Access Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract Leumit Health Fund has initiated and implemented a computerized behavioral prescription for smoking cessation. Physicians' access is through patients' electronic medical record. The prescription provides physicians with an easyto-use patient-oriented tool for encouraging smoking cessation which can be used in the framework of a regular 10 min. office visit. It is expected to increase success rates in smoking cessation, improve the health of members and consequently reduce costs of care. 2. Purpose of health policy or idea The purpose of the program is to increase success rates of smoking cessation treatments. Characteristics: The idea is based on the Behavioural Psychology approach. Patients who express an interest in smoking cessation receive a behavioural prescription from their primary care physician. The prescription is computerized and the physician accesses it through the patients' medical record (when noting that the patient is a smoker). This prescription is also a "tailor made" contract between doctor and patient who negotiate the smoking cessation process (when to begin, practical tips, pace etc.) and jointly decide on the terms. Both patient and doctor sign the contract and receive a copy. A follow-up table is a part of this prescription to be used by patient and physician in subsequent consultations. Main objectives To increase success rates of smoking cessation treatments Type of incentives The behavioural prescription provides physicians with an easy to use tool for encouraging smoking cessation among their patients, which can be used in the framework of a regular office visit. This is expected to increase physicians' self-efficacy and thus promote their motivation for counselling on smoking cessation. Also, physicians receive immediate positive feedback from patients for the time and attention they receive in the process, which also increases their motivation for continued engagement in this process. Patients sign a contract with their doctor which creates a psychological commitment to the smoking cessation process. The contract includes a structured process for smoking cessation and encouragement from the physician - 1 -

2 which creates motivation and hope for success. The incentive for Leumit Health fund to invest resources in this program is the potential for higher success rates in smoking cessation which will improve the health of their members and consequently reduce costs of care. Groups affected 1. Physicians receive a tool for counselling which increases self-efficacy and motivation, 2. Patients engage in a process of smoking cessation with a higher probability of success, 3. Families of smokers will benefit from smoking cessation; they may try to stop smoking too 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral Innovation - The behavioural prescription for smoking cessation is an innovative tool which has not been implemented before in primary care settings in Israel. There are only a few reports on similar initiatives abroad. Degree of controversy - There is wide consensus regarding implementation. Both the administrative and medical directors of the Health Fund support it. Physicians are not expected to object as this is an optional tool which they can choose to use or not to use. Systemic impact - Using the behavioural prescription will somewhat change the practice patterns of physicians in counselling on smoking cessation. Counselling will become more patient-centred, more structured and possibly more frequent. Public visibility - This project has had no media exposure at this stage so the public is unaware of its existence, except for a few patients (yet) who have been approached. Transferability - This tool is highly transferable to other systems, as the prescription can be translated and implemented easily in the physicians' office. 4. Political and economic background Leumit Health Fund, established in 1933, is the smallest health fund in Israel, with 700,000 members and a market share of about 9% of the population. Leumit employs 2,500 medical and administrative staff and operates 370 medical centers dispersed throughout Israel. The family medicine centers are designed to provide primary medical care including: family care, pediatrics, and gynecology. The medical centers provide both primary medical care and professional medical services (orthopedics, surgery, cardiology, etc.). The multi-disciplinary medical centers supply primary medical care and comprehensive professional medicine needs. The primary focus and vision of Leumit Health Fund is to promote and to provide the most advanced and personalized health services and health education for the Israeli community. The behavioral prescription for smoking cessation is in - 2 -

3 line with Leumit's vision and mission emphasizing health promotion and health education for its members ( In addition, smoking cessation is a national goal included in the "Healthy Israel 2020" program initiated by the Ministry of Health. The program sets national health targets with strategies for achieving them for the year The program was initiated as part of Israel's commitment, as a member of the WHO region, to develop a Health for All program, and the interest of the Ministry of Health leadership in increasing the attention given to the health of the population, health promotion and disease prevention. (See Laura Rosen, Elliot Rosenberg and Bruce Rosen. "Healthy Israel 2020: National Health Targets". Health Policy Monitor, May Available at Change based on an overall national health policy statement "Healthy Israel 2020" 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea The origin of the idea is the behavioral psychology approach of Short-Term Family Therapy in Ambulatory Medicine (SFATAM). This approach stipulates that some tools used in short-term psychotherapy, including CBT strategic & solution focused psychotherapy, family interventions and hypnotherapy as well as other psychological therapies can be adapted and used in primary care, within the limits of a 10 minute office encounter. Dr. Margalit, a family physician, together with Dr. Eshet, a medical psychologist, published a textbook (1997) in which they describe several tools that can be adapted to various situations encountered by primary care physicians. The behavioral prescription for smoking cessation is based on the ideas presented in this book, which draw on the principles of behavioral psychology. There was a small scale attempt to introduce the program in another health fund which did not succeed because of internal organizational problems as well as inadequate infrastructure for absorption of the prescription into the computerized medical record (which is necessary for facilitating utilization). This attempt was evaluated internally. Fourty two Primary Care Physicians received 4 kinds of behavioral prescription packs and 15 attempted to use this method. They gave prescriptions to some 419 patients over a period of 2 months (mean age 54 years, mean body weight 63kg, mean blood pressure 154/93). All patients were interviewed by phone 1 and 6 months following the first behavioral prescription. Out of 126 patients who received the physical activity prescription, 44.4% changed their activity, after one month and 26.2% after 6 months. Out of 162 patients who received a smoking cessation prescription, 26% quit smoking after a month and 18% were free of cigarettes after 6 months. 11.1% reduced the number of cigarettes. Out of 85 patients who received the healthy diet prescription, 26% changed diet and 14% lost weight after 6 months. Out of 46 patients who received the relaxation prescription, 28.3% used some relaxation technique after 6 months. In order to successfully implement the behavioral prescription in Leumit, the prescription was inserted into the computerized medical record. This facilitates use as the physician is reminded of its existence whenever she/he encounters a smoking patient; the prescription is easily printed (similar to pharmaceutical prescriptions). Dr. Margalit presented the idea to his colleague, Prof. Vardy, Leumit's Medical Director who was impressed with the potential of this tool. Prof. Vardy and the Senior Staff of the Medical Division, with the support of the CEO of Leumit and the Information Technology Division were the driving forces behind implementation of this initiative in all primary care facilities. They have invested resources in designing the tool, computerizing it and providing access from all patients' medical records. A campaign to introduce it to all primary care physicians and to encourage utilization is planned to take place in

4 The main reason for promoting the behavioral prescription is the belief in the potential of this tool to effectively increase success rates of smoking cessation treatments. The expectation is that this will improve the health of Leumit members and consequently reduce the costs of care in the long term. Initiators of idea/main actors Providers Patients, Consumers Approach of idea The approach of the idea is described as: renewed: There was a previous attempt to implement the behavioural prescription for smoking cessation in another health fund in Stakeholder positions Medical Directorand CEO of Leumit - Support the program as they believe in its potential to increase success rates of smoking cessation treatments, which will improve the health of health fund members as well as reduce costs in the long term. The program also presents Leumit as an innovative health fund, concerned for the well-being of their members and actively supporting the Ministry of Healths' health promotion targets ("Healthy Israel 2020"). Information Technology Division- supported the program as they identified with the organization's mission of health promotion and health education. As the electronic medical record in Leumit was developed in-house, and is webbased, computerizing the behavioral prescription was an easy process which did not require much time and effort. Primary care physicians - support the initiative as they can voluntarily choose to use the behavioral prescription. They are not pressured to use it and there is no monitoring. Thus, their autonomy and discretion in medical care are not compromised. They support the program as it provides a tool for helping patients who want to stop smoking, it is easy to use and is not time consuming. Patients who wish to stop smoking can voluntarily choose to participate in the program and receive the behavioral prescription. They too are not pressured in any way and they define the terms of the smoking cessation process with their doctor. The prescription is perceived as a voluntary tool to help them in the process of smoking cessation. They also appreciate the interaction with the physician who provides encouragement and support in the process. Actors and positions Description of actors and their positions Providers CEO of Leumit Health Plan very supportive strongly opposed Medical Director Leumit Health Plan very supportive strongly opposed Information Technology Division very supportive strongly opposed Leumit Health Plan Primary care physicians at Leumit very supportive strongly opposed Health Plan Patients, Consumers Patients who wish to stop smoking very supportive strongly opposed Influences in policy making and legislation Not applicable - 4 -

5 Legislative outcome Actors and influence Description of actors and their influence Providers CEO of Leumit Health Plan very strong none Medical Director Leumit Health Plan very strong none Information Technology Division very strong none Leumit Health Plan Primary care physicians at Leumit very strong none Health Plan Patients, Consumers Patients who wish to stop smoking very strong none Positions and Influences at a glance Adoption and implementation The program was presented to the Medical Director of Leumit in He saw the potential and began the implementation process which was completed within 6 months. The behavioral prescription was computerized and included in the computerized medical record. The EMR in Leumit was developed in-house and allows for easy modifications such as adding the behavioral prescription to the other forms used in the primary care encounter. The EMR is centralized and web-based and maintained by Leumits IT division which facilitates the ability to adapt it to changing needs. Computerizing the prescription was perceived as the best way to encourage utilization because physicians see this option whenever they note that a patient is a smoker. The prescription can be easily printed during the encounter. All primary care physicians were notified through an electronic message window in the CMR, as well as announced - 5 -

6 through the organizational hierarchy which encouraged its use. To date, the behavioral prescription for smoking cessation is not yet widely used by physicians. An intensive dissemination plan within the organization is scheduled to begin at the end of 2009 after baseline data on the effectiveness of the treatment is gathered (see evaluation below). To that end, the behavioural prescription will be introduced to district management who will be held responsible for encouraging physicians to use it. District management will also be required to report utilization rates, and success rates in smoking cessation. Possible obstacles to extensive utilization of the behavioral prescription include lack of awareness of existence of this tool, low motivation to invest the effort, low self-efficacy, as well as perceived lack of time by the primary care physician during the encounter. Therefore, other strategies for changing physicians' behaviour and encouraging them to give high priority to smoking cessation efforts using this tool may be considered in the future. Among them: 1) sessions within the structured CME activities to raise physicians' awareness to the prescription, motivate and train them in using it. These may include simulation of encounters with patients so that physicians will gain proficiency in this activity and realize its feasibility within the short (10 minute) visit. 2) Material incentives could encourage physicians to use the new tool. For example, the Health Fund could declare a competition between physicians with a prize for those with highest success rates in helping patients to quit smoking. Monitoring and evaluation A structured evaluation is planned in order to assess the effectiveness of the behavioral prescription. The Director of Research at Leumit is the principle investigator of this study. Forty physicians will be recruited and requested to participate for three weeks and keep a journal in which they register all patients who have agreed to participate in the study and have signed an informed consent form. Physicians will be asked to identify smoking patients and inquire if they want to stop smoking. We expect each physician to recruit 10 patients a week for the study. In the first week, the patients recruited will be given the regular treatment (i.e. encouragement and informal advice). In the second week the patients recruited will receive a brochure on smoking cessation with written information and advice. In the third week the patients recruited will receive the behavioral prescription. All patients in the study will be called by phone after one and three months and asked by a research assistant about their smoking status and number of daily cigarettes (outcome variable). The comparison between the three groups will be conducted controlling for socio-demographic and health variables which will be retrieved from their medical files. The evaluation is scheduled to begin in the second half of 2009 after the study is approved by the Helsinki committee. Review mechanisms Mid-term review or evaluation Dimensions of evaluation Outcome Results of evaluation No results yet

7 6. Expected outcome It is too early yet to assess the effectiveness of the behavioral prescription. Theoretically this tool is expected to increase success rates in smoking cessation among patients who want to try (as explained above). The tool is also expected to increase physicians' awareness of the importance of smoking cessation counseling and to increase their self-efficacy in counseling. Thus, we can also expect a more pro-active approach of the physician towards smoking patients. We will be better able to assess the de-facto effectiveness of this tool (when implemented in the clinical setting) after the evaluation is completed. The extent to which this tool affects overall smoking cessation rates in Leumit is also dependent on the extent to which it will be utilized by practicing physicians. Thus, even if the tool is effective, the overall outcome is dependent on physicians' adherence in using it regularly. If the behavioral prescription is indeed effective in clinical settings and widely used we expect it to achieve its objectives - increase smoking cessation rates and consequently reduce smoking related costs of medical care. Furthermore, families of smokers may benefit as they will be less exposed to secondary smoking and their health will consequently improve. Based on Dr. Margalit's experience, we also expect that some family members will want to join the project if they see that the prescription was indeed successful. This program is not expected to have undesirable effects because it is voluntary and physicians have discretion in choosing to use it with their patients. Even in this early stage we see that Leumit management is enthusiastic about the potential of behavioral prescriptions and is considering designing similar prescriptions for physical activity, stress management and dietary counseling after successful implementation of the prescription for smoking cessation. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high Quality of care - Encouraging physicians to counsel patients and giving them a tool for effective counselling on smoking cessation will improve the quality of health promotion which is an important component of the primary care service. Level of equity - Will increase as physicians will have a tool for counselling on smoking cessation provided without fee. Therefore this tool is accessible to all population groups and thus will increase equity. Other existing tools (e.g. group counselling, psychological counselling and medications) are provided for a fee. Financial barriers prevent vulnerable groups (which have higher smoking rates) from receiving help in smoking cessation efforts. Cost Efficiency - Is expected to increase if the tool will indeed prove to be effective in increasing success rates of smoking cessation. The cost of administering the prescription is low. 7. References Sources of Information Margalit A, Eshet I. "SFAT-AM" - A Biopsychosocial Handbook for Primary Care Providers. Heiliger Tel-Aviv (in Hebrew) Kitai E, Gross R, Vardy D, Kahan N, Metz E, Barami JL, Sherman B, Margalit A Research proposal to evaluate the effect of a behavioural prescription for smoking cessation

8 Macaran A. Baird MD, MS & Alon A.P. Margalit, MD, PhD. "Family Interviewing and Assessment". Chapter 9.3, Vol. 1 In: Oxford Textbook of Primary Medical Care. Jones, Britten, Culpepper, Gass, Grol, Mant and Silagy (Eds). New York: Oxford University Press Inc Margalit Alon P. A., Glick Shimon M., Benbassat Jochanan & Cohen Ayala. Effect of a Biopsychosocial Approach on Patient Satisfaction and Patterns of Care. Journal of General Internal Medicine 19 (5p2), Margalit Alon P. A., Glick Shimon M., Benbassat Jochanan, Cohen Ayala & Katz Michael. Promoting a Biopsychosocial Orientation in Family Practice - Effect of two teaching programs on the knowledge and attitudes of practicing primary care physicians. Medical Teacher 27: Author/s and/or contributors to this survey Kitai E., Vardy D., Margalit A., Brami J., Matz E., Kahan N. and R. Gross Suggested citation for this online article Kitai E., Vardy D., Margalit A., Brami J., Matz E., Kahan N. and R. Gross. "Smoking cessation in Leumit Health Fund". Health Policy Monitor, April Available at -