Healthcare provider cessation practices in Ontario Alexey Babayan Knowledge Exchange Forum June 18, 2014
What we know Tobacco cessation interventions by healthcare providers (physicians, nurses, dental professionals, etc) are effective (Fiore et al., 2008; Gorin&Heck 2004) Many smokers visit a healthcare provider each year (e.g. physician:83%, dentist:70%; CTUMS 2008-2010) 5A s is a recommended model for tobacco cessation treatment (Fiore et al., 2008)
What we learned The potential of health professionals engagement in cessation is far from being realized in Ontario The current incentive system appears to be inadequate for engagement Access to training and cessation resources is likely to improve engagement Practitioner- and organizational-level barriers are critical to engagement Ontario Tobacco Research Unit
Current cessation practice in Ontario: Physicians Source: Study of Physicians Uptake of OHIP Billing Codes, OTRU 2011 Method: analysis of administrative data (OHIP) analysis of survey data (CTUMS) interviews with physicians (n=21) Ontario Tobacco Research Unit
Uptake of billing codes On average, 5,157 physicians billed for initial discussion at least once per year, 2006-2010 ( 50% of physicians in Ontario) The number of patients billed by a physician varies greatly (range: 1 to 1,278 patients per year) 50% of physicians billed for <18 patients Ontario Tobacco Research Unit
Billing data vs. population level survey estimates, Ages 15+ 611, 690 smokers received at least one initial cessation discussion (Q041 and E079), 2006-2010 Source: Canadian Tobacco Use Monitoring Survey Ontario Health Insurance Plan
Patients Billed for Initial and Follow-up Cessation Counseling Source: Ontario Health Insurance Plan
Current cessation practice in Ontario: Dental professionals Source: Provision of Smoking Cessation by Ontario Dental Health Professionals, OTRU 2012 Method: Web-based survey of dentists, dental hygienists and dental assistants (n=1966, 9% response rate) Interviews with dental professionals (n=23)
Provision of 5 A s by dental professionals, n=1966 (to all or most patients who smoke) Ask Advise Assess Overall, (n=1966), % Dentist (n=217) % Dental Hygienist (n=432) % Dental Assistants (n=1317) % Ask patients about their smoking status 40.6 52.1 b 55.6 c 33.3 Advise patients to stop smoking 33.7 47.7 b 49.7 c 25.8 Assess patients readiness to quit 26.3 29.7 a,b 49.5 c 17.4 Offer self-help resources 11.8 9.0 a 17.9 c 10.2 Assist Recommend NRT 10.3 7.1 a 16.0 c 8.8 Refer to external resources 11.0 12.6 b 18.1 c 8.1 Arrange Arrange follow-up 5.5 2.3 a 9.2 c 4.7 a Significant differences between dentists and dental hygienists, p < 0.05 b Significant differences between dentists and dental assistants, p < 0.05 c Significant differences between dental hygienists and dental assistants, p < 0.05
Dental professionals confidence to provide services
Current cessation practice in Ontario: Nurses Source: Evaluation of the 2011-2012 RNAO Nursing Best Practice Cessation Initiative, OTRU 2013 Method: Baseline and follow-up surveys of nurses (n=400) Case-studies of practice settings (review of documents, interviews) Ontario Tobacco Research Unit
RNAO Nursing Best Practice Smoking Cessation Initiative
Provision of 5 A s by Nurses, n=400 (to all or most patients who smoke) Ask Advise Assess Ask patients about their smoking status Baseline, % 6-month follow-up, % P 32.5 63.6 <0.001 Advise patients to stop smoking 25.2 51.0 <0.001 Assess patients readiness to quit 30.5 47.0 0.13 Offer self-help resources 23.2 39.1 0.01 Assist Recommend NRT 15.2 29.8 0.04 Refer to external resources 17.2 29.8 0.06 Arrange Arrange follow-up 8.6 15.9 0.11
Nurses confidence to provide cessation services Baseline, % 6-month follow-up, % Confident 37.5 85.4 <0.001 P Not confident 74.1 14.6 Ontario Tobacco Research Unit
KEY FACTORS AFFECTING SERVICE PROVISION Ontario Tobacco Research Unit
Key Factors Patient interest in quitting Time Organizational policies/practices Buy-in/support from management Cessation service provision Confidence Training Billing rules Remuneration Awareness and access to cessation services and resources
Conclusion Smoking cessation practices (5As) are not performed routinely Fee codes do not appear to provide sufficient incentive to engage in smoking cessation Perceived patient interest in quitting (or lack of it) is a critical factor for providing cessation services Ontario Tobacco Research Unit
Conclusion Improving access to training opportunities is important More dissemination activities to increase awareness of evidence-based guidelines, cessation resources and referral services Implementing a team care approach and systemlevel policies/practices is important Ontario Tobacco Research Unit
Thank You! Ontario Tobacco Research Unit