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Tim McAfee, MD, MPHtim.mcafee@freeclear.comClinical & Behavioral SciencesFree & Clear206-876-2551

THE GROUP HEALTH STORY

1991 report: Decreasing Tobacco Use at Group Health During the 1990s

• Goal: “Decrease the prevalence of tobacco use at Group Health by 50% from 1985 level of 25% to 12.5% by the year 2000”

Authors:• Sue Curry• Sallie Dacey• Doug Louie• Tim McAfee• Neal Sofian• Larry Ziedman

1991 report: Decreasing Tobacco Use at Group Health During the 1990s

• Objective: “A comprehensive coordinated set of interventions will be available at Group Health covering all the stages of tobacco use”

Key Partners:• Tracy Orleans• NCI & CDC OSH• Michael Fiore/USPHS GL

group/ATMC• Ed Wagner & Sue Curry (CHS)• Robert S. Thompson (DPC)• Bill Beery & Anne Smith (CHP)

Key Partners• Phil Nudelman/Cheryl Scott

/Scott Armstrong (CEOs)• Al Truscott/Louise Liang/

Hugh Straley (Med. Directors)• Jim Truess (CFO)• Hundreds of VPs, managers

and directors• Thousands of physicians,

nurses, MAs, pharmacists, etc• Tens of thousands of patients

0%

5%

10%

15%

20%

25%

30%

1985 1987 1990 1993 1994 1995 1996 1997WashingtonStateGHC

Adult Smoking Prevalence:Adult Smoking Prevalence:

1991 - COP report: 7 Strategies

1)”Identify, track and treat tobacco use with the same vigor as other diseases with significant morbidity and mortality”

2)“Advocate for coverage of tobacco services where clinical effectiveness has been convincingly established”

3) “Encourage adolescents to never become tobacco users, both during clinic contacts and through school and community outreach”

4)”Encourage and support population-based projects to decrease tobacco use”

5)”Make tobacco a top lobbying priority of the GHC legislative affairs office”

6) “Develop educational programs about tobacco use and services for staff at all levels, including nursing, physician, clerical, medical assistant and pharmacy. Encourage and support on-going programs to decrease the prevalence of tobacco use among employees”

7)”Treat coverage for smokers in the same manner we treat coverage for other individuals with significant chronic diseases”

Elements of comprehensive approach

● Reliance upon evidence● Identifying tobacco users in primary care● Training practice teams in brief advice● Referral to phone and group programs● Coverage for counseling & medications● Integration with Prevention, Quality &

Chronic Care initiatives● Support for community policy change

Health system opportunity:

SMOKE-FREE FITS GHC MISSION

Fits GHC’s preventive care and health promotion mission

Supported by marketing and communications

Issue of quarterly member magazine

Top take-home lessons

• Science is a good starting place• It’s a product, marketing and

sales challenge!• Hold on to the tiger’s tail• People, systems, and

measurement make a difference• Design for end-users

AdviseAsk

Refer

Research Collaborations

NEngJMed 9/3/98 339:673-679 Curry et al

Primary care: tobacco status identification on all charts

0102030405060708090

100

1992 1994 1995 1996 1997* 1998 1999 2000

% identified

* > 85% in all 29 primary care clinics

Provider advice to smokers

0

10

20

30

40

50

60

70

80

1994 1997 1998** 1999**

chart doc*

pt recall*

*p<0.05 for both

** Top10% of HEDIS

Documentation of Patient Tobacco Status using the TRF:

TOBACCO USE STATUS(circle one)

Non-Tobacco user 4Current Tobacco User 1Recent Quitter <1 year 2

PROVIDER INTERVENTION

Tobacco Use Disorder 305.1/Intervention

TRF Tobacco status identification:

0

10

20

30

40

50

60

70

80

90

100

Nov-98 Dec-98 Jan-99 Feb-99 Apr-99 Jun-99 Aug-99 Nov-99 Jan-00 Mar-00 May-00 Sep-00 Dec-00

Cessation Program Quality Improvement

Why: Excellent program, but little impact due to low reach(in 1992 only 180 participants/year)

Difficult to sustain clinic-based assistance/follow-up

Free & Clear improvements

• Removal of financial barriers• Integrated pharmacotherapy:

– program assesses, generates Rx– individualized – ensures follow-up received

• Strong quality controls/reporting• Promotional support

Free & Clear ParticipationGroup Health Enrollees

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1992 1993 1995 1997 1998 1999 2000

GroupPhoneTotal

One-year quit rate: 25-30% (30-day abstinence ~ Intent-to-Treat)

Policy/population tobacco efforts

• NW Health articles

• Smoke-free campuses

• Master Settlement Agreement

• Seattle Times ad ban

• Labor and Industry worksite ban

• Access/merchant fee bill

• Defeating “Smokers Rights” bill

• Testimony/op-ed pieces

• Passage of two state initiatives

• Free & Clear external & state quit lines

I – 773 and I-901

I-773 2001 WA state initiative

• Raised tax on pack of cigarettes 60 cents • “Guarantees” 26 million to Tobacco Control

I-901 2005 Clean Indoor Air • 100% ban

GHC Board endorsed, contributed $$, & lobbyist/staff time for both

“To serve the greatest number…”

Free & Clear Participation Ratesper 1000

8.0

5.9

6.4

8.1

7.6

0.0

2.0

4.0

6.0

8.0

10.0

2000 2001 2002 2003 2004

F&

C E

nro

llm

en

t p

er

1,0

00

4,7914,499 3,0974,721 3,569n

(Note: 2004 rates annualized based on first 2 quarters)

Smoking Prevalence 2003by GHC Delivery System

(Data Source: CAHPS Adult Survey 2002-2004)

Commercially Insured Adults aged 18-65 years

Plans Sample % Sample %HMO 157 12.1 (7.0 , 17.2) 664 16.1 (13.3 , 18.9)Alliant 47 23.4 (11.3 , 35.5) 483 13.0 (10.0 , 16.0)Options 248 14.5 (10.1 , 18.9) 320 14.4 (10.5 , 18.2)Total 452 14.6 (11.3 , 16.4) 1,467 14.7 (12.9 , 16.5)

CNCSD IGP

95%CI 95%CI

Chronic Care Model

• Organization of care• Clinical information systems• Delivery system design• Decision support• Self-management support• Community resources

Glasgow RE, Orleans CT, Wagner EH. Does the Chronic Care Model serve also as a template for improving prevention? The Milbank Quarterly, Vol. 79, No. 4, 2001.