Implementing tobacco interventions in the real world of managed care
Implementing tobacco interventions in the real world of managed care
复制标题
DOI：
10.1136/tc.9.suppl_1.i18
复制
发表时间：
2000-01-01
期刊：
影响因子：
5.2
通讯作者：
Lichtenstein, E
中科院分区：
文献类型：
--
作者：
Hollis, JF;Bills, R;Lichtenstein, E
多年来，我们一直致力于开发，测试和实施烟草控制干预措施，作为Kaiser Permanente日常护理的一部分。我们的大部分工作都在Kaiser Permanente位于俄勒冈州波特兰的西北部门进行，但我们也在其他几个部门实施了类似的方法，包括俄亥俄州、夏威夷和格鲁吉亚。我将首先描述我们的一般方法，我们称之为TRAC模式（“烟草减少、评估和护理”），然后分享我们的进展和我们在整个卫生保健系统中尝试实施该计划时遇到的一些真实的困难。在常规护理期间提供简短的烟草干预的基本原理对于那些从事戒烟工作的人来说是熟悉的。1烟草仍然是可预防疾病的最重要原因。我们知道，大多数吸烟者经常看临床医生，这些访问创造了可教的时刻，当病人接受建议和干预。当我们经常忽视这些干预机会时，我们正在让我们的患者失望。事实上，来自卫生保健政策和研究机构（AHCPR）临床指南2的荟萃分析表明，简短的建议和支持可以对戒烟产生适度但一致的长期影响。我们还知道，在我们常规使用的所有医疗程序中，简短的烟草干预是最具成本效益的。3 4正是由于这些原因，健康计划雇主数据信息集（HEDIS）和其他质量监测小组要求卫生保健系统负责解决临床护理期间的烟草问题。然而，对我来说，提供戒烟建议和帮助的最重要原因是我们的患者想要、需要和期待这种支持。作为一个国家，我们如何在医疗访问期间提供戒烟建议？图1显示了来自美国劳工统计局的全国家庭访问调查6 -8和当前人口调查的时间趋势数据5。[5]这两项调查都使用全国概率样本来估计前一年就诊的吸烟者中报告医生曾建议他们戒烟的比例。早在1974年，很少有吸烟者报告接受过戒烟建议。到1986年，建议率急剧上升，并在20世纪90年代中期继续缓慢改善。在其他地方，我预测了我们目前的临床医生建议率可能对每年看医生的3500万吸烟者中的戒烟率产生的影响。我假设有3%的自发戒烟率，并且初级保健干预措施，当他们被提供时，主要包括简单的戒烟建议。[9]我们可以称之为2A模式（“询问和建议”），而不是美国国家癌症研究所（NCI）和AHCPR推荐的4A模式（“询问、建议、协助和安排”）。来自AHCPR临床指南2的荟萃分析估计，1至3分钟简单简短建议的戒烟优势比为1.2。在全国范围内，每年向60%的看过临床医生的吸烟者提供简短的建议，可能会产生大约126000名额外的戒烟者，超过自发率。如果我们将简单建议率提高到90%，我们将增加大约189000名临床医生产生的戒烟者，这将是一个巨大的成就。但是假设，每年一次，临床医生建议90%的吸烟者，并且对于这些吸烟者中至少有一半在任何给定时间考虑戒烟（Prochaska模型中的“戒烟者”），临床医生或他们的staV也提供了10分钟的实际戒烟咨询和帮助。AHCPR ...
Over the years we have been working to develop, test, and implement tobacco control interventions as a part of routine care within Kaiser Permanente. Most of our work has been in Kaiser Permanente’s northwest division, based in Portland, Oregon, but we have also implemented similar approaches in several other divisions, including Ohio, Hawaii, and Georgia. I will first describe our general approach, which we call the TRAC model (“tobacco reduction, assessment, and care”), and then share both our progress and some very real diYculties we have encountered in trying to implement the program throughout the health care system. The rationale for delivering brief tobacco intervention during routine care is familiar to those who work in cessation. 1 Tobacco remains the most important cause of preventable disease. We know that most smokers see clinicians frequently, and that these visits create teachable moments when patients are receptive to advice and intervention. When we routinely ignore these intervention opportunities, we are, in eVect, failing our patients. Indeed, metaanalyses from the Agency for Health Care Policy and Research (AHCPR) clinical guideline2 show that brief advice and support lead to modest but consistent long term eVects on smoking cessation. We also know that brief tobacco interventions are among the most cost eVective of all medical care procedures we routinely oVer. 3 4 It is for these reasons that the Health Plan Employer Data Information Set (HEDIS) and other quality monitoring groups are holding health care systems accountable for addressing tobacco during clinical care. For me, however, the most important reasons to oVer cessation advice and assistance are that our patients want, need, and expect this kind of support. How are we doing as a nation in delivering cessation advice during medical care visits? Figure 1 displays time trend data5 from the National Household Interview Survey6–8 and the Current Population Survey from the US Bureau of Labor Statistics. 5 Both surveys use national probability samples to estimate the percent of smokers with visits in the preceding year who report that a physician has ever advised them to quit smoking. Back in 1974, few smokers reported ever receiving cessation advice. Advice rates rose sharply by 1986 and have continued to slowly improve up through the mid 1990s.Elsewhere, I have projected what impact our current clinician advice rate might have on smoking cessation rates5 among the 35 million smokers who see a clinician each year. I assumed a 3% spontaneous quit rate and that primary care interventions, when they are delivered at all, largely consist of simple advice to quit. 9 We might call this the 2A model (“ask and advise”), as opposed to the 4A model (“ask, advise, assist, and arrange”) recommended by the National Cancer Institute (NCI) and the AHCPR. Meta-analyses from the AHCPR clinical guideline2 estimate that the cessation odds ratio for one to three minutes of simple brief advice is 1.2. Delivering brief advice to 60% of the smokers who see a clinician each year across the country might generate about 126 000 additional quitters over and above the spontaneous rate. If we increase the simple advice rate to 90%, we would produce something like 189 000 additional clinician generated quitters, which would be a substantial achievement. But suppose, once each year, clinicians advised 90% of smokers and that, for the half of these smokers who are at least considering quitting at any given time (“contemplators” in Prochaska’s model), clinicians or their staV also provided 10 minutes of actual cessation counselling and assistance. The AHCPR …