ASSIST: Assessment of Medicaid policy on Smoking Cessation Assistance and Surgical Outcomes

项目总结 吸烟与各种不良健康影响有关，包括术后伤口增加。 手术患者的愈合时间、伤口感染和心血管并发症。协会 手术前戒烟和手术结果的改善之间的关系导致外科医生和医院 实施要求患者在择期手术前戒烟的政策。鉴于较高的 在社会经济弱势人群中吸烟，在医疗补助中的吸烟率更高- 保险手术患者，这些政策将不成比例地影响较低社会经济地位的患者 (S)。2017年，俄勒冈州实施了美国第一项要求医疗补助的全州政策- 参保患者在广泛的择期手术前戒烟作为支付 由州医疗补助计划进行的手术。这项政策为帮助患者戒烟创造了一个合适的时机。 手术前吸烟(即“可教的时刻”)和支持手术后继续戒烟 就诊；因此，这项政策可能会导致以下患者获得更高的戒烟协助和戒毒率 更低的SES，潜在地缓解了长期存在的与吸烟有关的差异，并为 在支付者和医疗保健系统中实施类似的政策。也就是说，一些人认为，如果 这些患者不接受戒烟帮助，也因为无法戒烟而被拒绝接受手术。 政策将加剧那些已经存在的与吸烟和手术相关的差异 在社会经济上处于不利地位。这些政策对吸烟和手术相关结果的影响 在SES较低的患者中，SES较低的患者尚不清楚。为了解决这一知识差距，我们将进行一项准 实验研究采用序贯混合法设计。我们将链接电子健康记录(EHR)数据 到俄勒冈州148个社区卫生中心(CHC)的医疗补助申请，以检查吸烟的变化- (戒烟辅助率和戒烟率)和手术-(手术和手术并发症率)相关 在1/1/2014-12/31/2016年1月1日至2016年12月31日期间寻求择期骨科手术的患者的结果 2017年1月1日-2019年12月31日(政策实施后)。根据我们的量化分析，我们将进行 对卫生保健负责人、初级保健临床医生、整形外科医生和患者进行半结构化采访， 和调查护理协调组织领导人探讨组织工作流程和相关协议 这项政策(例如，增加戒烟协助)，以及对该政策的看法和经验 以及意外的后果。这项创新的研究将提供严谨、可操作的证据，以告知 各国和政策制定者在多大程度上这项政策导致了预期的变化。

PROJECT SUMMARY Smoking is associated with a variety of adverse health effects, including increased postoperative wound healing time, wound infections, and cardiovascular complications among surgery patients. The associations between pre-operative smoking cessation and improved surgical outcomes have led surgeons and hospitals to implement policies that require patients to quit smoking prior to elective surgeries. Given the high rate of smoking among socioeconomically disadvantaged populations and the even higher rate among Medicaid- insured surgery patients, these policies will disproportionately impact patients of lower socioeconomic status (SES). In 2017, Oregon implemented the first statewide policy in the United States that requires Medicaid- insured patients to quit smoking prior to a broad range of elective surgeries as a condition of payment for surgery by the state Medicaid program. This policy creates an opportune time to assist patients in quitting smoking pre-surgery (i.e., a “teachable moment”) and to support continued abstinence during post-operative visits; thus, this policy could result in higher rates of cessation assistance and cessation among patients of lower SES, potentially mitigating long-standing smoking-related disparities and providing support for implementation of similar policies among payers and health care systems. That said, some suggest that if patients do not receive cessation assistance and are denied surgery because they were unable to quit, these policies will exacerbate already existing smoking- and surgery-related disparities among those who are socioeconomically disadvantaged. The impact of these policies on smoking- and surgery-related outcomes among patients of lower SES are unknown. To address this knowledge gap, we will conduct a quasi- experimental study using a sequential mixed methods design. We will link electronic health record (EHR) data to Medicaid claims from 148 Oregon community health centers (CHCs) to examine changes in smoking- (cessation assistance and quit rates) and surgery- (rates of surgery and surgery complications) related outcomes among patients seeking elective orthopedic surgeries between 1/1/2014-12/31/2016 (pre-policy) and 1/1/2017-12/31/2019 (post-policy implementation). Informed by our quantitative analyses, we will conduct semi-structured interviews with health care leaders, primary care clinicians, orthopedic surgeons, and patients, and survey Care Coordination Organization leaders to explore organizational workflows and protocols related to this policy (e.g., increased cessation assistance), and perceptions and experiences of the policy on intended and unintended consequences. This innovative study will provide rigorous, actionable evidence to inform states and policy makers of the extent to which this policy results in the desired changes.