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New forms, training increase cessation counseling
As at most clinics and doctors’ offices, physicians at Fallon Community Health Plan in Worcester, MA, didn’t routinely and persistently encourage their patients to stop smoking. Those that did advise their patients to quit weren’t likely to record those comments in the medical record.
But with a quality improvement project that provided physician education, new documentation tools, and feedback on performance, Fallon improved both counseling and documentation during routine visits from 18% to about 50%.
After training physicians on counseling techniques and revamping the documentation tool, Fallon increased the documented counseling of smokers during routine visits from 18% to about 50%. One clinic site — an OB/GYN office — made a commitment to the project and achieved a documented counseling rate of 100%. The project encompasses the Fallon Clinic, with 275 physicians at 33 sites, and the affiliated University of Massachusetts Group Practice, with about 400 physicians. Fallon Community Health Plan also has a network of 3,000 affiliated physicians.
"By chipping away at this, we expect to impact the prevalence of smoking and ultimately to save the system a lot of money," says Christine Micklitsch, FACMPE, MBA, director of physician education and services, citing statistics that show $750 per year in excess medical costs for smokers.
There’s another incentive as well. The HEDIS effectiveness of care indicators of the National Committee for Quality Assurance in Washington, DC, which accredits health plans, includes a measure on physician counseling on smoking cessation. In 1998, Fallon had the highest rate nationwide of members who said they had been counseled by physicians on smoking, says Micklitsch.
Are they ready to change?
Changing behavior is a challenge, both for patients and their physicians. Despite years of health warnings, smoking remains pervasive. A 1997 survey of adult members of the Fallon health plan found that 39.5% said they smoke "every day or some days" and 32.3% smoke every day. Nationally, the prevalence of adult smokers is 23.5%.
The Fallon program focuses on stages of change — providing patients with information based on their readiness to change.
"The basic theory is that in order to change any behavior you have to be ready to change," says Emily Eaton, MEd, physician education specialist at Fallon. We all have things we know we should change, but we’re not ready to. That means we’re precontemplative."
For example, a precontemplative patient may say, "I know smoking’s bad for my health, but I enjoy it too much to quit." A contemplative patient may say, "I’ve thought about it. I know I should quit, but I’m not ready now."
"We want physicians to give different messages at the different stages," says Eaton. "The goal is to move them to the next stage. You are never going to get a precontemplative person to quit smoking. If you get them to change stages, that’s a major accomplishment."
A physician may provide a brochure with smoking cessation information and may tell a precontemplative patient: "I know you’re not ready. However, you need to know you should quit. If you’ll read this information, we’ll talk about it the next time you come in."
Without the tools and training on stages of change, physicians can become discouraged about their potential influence on patients’ smoking habits, says Eaton. "I think physicians are uncomfortable [talking about smoking cessation] because it’s a very difficult conversation to have." Eaton was a smoking cessation counselor for many years.
How do patients feel about being gently nagged by their doctors to give up smoking? Not bad at all, Fallon found in a telephone survey that asked patients how they felt about their doctor’s questions and comments about smoking.
"People were very pleased about being asked by their doctors about their smoking stages," says Micklitsch. "The evidence we got from that telephone survey helped us to tell [physicians] that it wasn’t something that would be an annoyance to patients, but that patients saw it as a positive thing that physicians should be doing."
The intervention itself can be brief and still have significant impact, says Eaton. One study found that physician counseling raised the one-year quit rate from 2.5% to 4%.
What should doctors say?
Yet physicians themselves need resources. Fallon revised the progress notes sheet placed on medical charts to include checkoff boxes that ask "smoking vital sign" information, including smoking status, whether the patient has tried to quit, and if the physician provided smoking cessation counseling. Based on the question, "Have you considered quitting?" the physician can mark the patient’s stage as precontemplative, contemplative, or action (ready to quit).
"Now it’s in front of them all the time," says Micklitsch. "It’s just like blood pressure, height, weight. If it’s in front of you, you feel obligated to do it."
During the pilot project, physicians received regular reminders and feedback on their documentation rates every five or six weeks. Once that level of feedback slackened, so did the documented counseling. The overall rate dropped to about 40%, and the internal medicine department even dropped to 27%.
Fallon now has a tobacco advisory council that includes physicians, nursing managers, and administrators. It is drafting a practice guideline on counseling for smoking cessation. With a guideline in place, the push for greater counseling gains a new importance. Continuous monitoring and feedback also accompanies guidelines, says Eaton.
Meanwhile, the Fallon Community Health Plan patient satisfaction survey now includes a question about counseling on smoking cessation. That item, among others, will be linked to a performance incentive plan, says Micklitsch.
"We’re trying to tie all the pieces together," she says. "We give them to tools to use, we teach them how to use them, then we reward them for using them. The patients get the benefit."