Tobacco and Tobacco and Population Health Population Health

in in Medical SchoolMedical School

Getting beyond the 5 A’sGetting beyond the 5 A’s

Kimber Richter, Edward EllerbeckKimber Richter, Edward Ellerbeck

University of Kansas Medical Center, University of Kansas Medical Center, KCKC

In Kansas, some address tobacco In Kansas, some address tobacco and some don’t and some don’t

0

10

20

30

40

50

60

70

80

90

* percent of dr/pt interactions in which tobacco was discussed

38 physician practices

Clinical know-how necessary but Clinical know-how necessary but not always sufficientnot always sufficient

Many factors outside the examining Many factors outside the examining room impact medical careroom impact medical care

True for tobacco, true for other issuesTrue for tobacco, true for other issues AAMC, ACGM objectives require medical AAMC, ACGM objectives require medical

schools to teach population medicineschools to teach population medicine We teach population medicine concepts We teach population medicine concepts

and skills through and skills through Health of the PublicHealth of the Public Formal lectures and student projects Formal lectures and student projects

incorporate tobacco in population healthincorporate tobacco in population health

AAMC Objectives – Informatics, AAMC Objectives – Informatics, Population HealthPopulation Health

Retrieve and analyze informationRetrieve and analyze information Employ effective communicationEmploy effective communication Measure performance in populationsMeasure performance in populations Able to effect changeAble to effect change Apply quality improvement methodsApply quality improvement methods Understand physicians role in Understand physicians role in

systems of medical caresystems of medical care

Medical informatics and population health. Report II of the Medical School Objectives Project. Acad Med 1999; 74:130-141.

ACGME and the ‘Outcome ACGME and the ‘Outcome Project’Project’

ACGME – Accreditation Council for ACGME – Accreditation Council for Graduate Medical EducationGraduate Medical Education

ACGME has just announced it will require ACGME has just announced it will require residencies in all specialties to show that residencies in all specialties to show that residents meet six competencies:residents meet six competencies: Provide appropriate & effective patient careProvide appropriate & effective patient care Demonstrate knowledge of medicineDemonstrate knowledge of medicine Interpersonal communication skillsInterpersonal communication skills Professionalism & sensitivity to diversityProfessionalism & sensitivity to diversity

Sound Familiar?Sound Familiar?

But that was only four…But that was only four…

Practice-based learning and Practice-based learning and improvementimprovement analyze practice experience and perform practice-based analyze practice experience and perform practice-based

improvement activities improvement activities locate, appraise, and assimilate evidence from scientific locate, appraise, and assimilate evidence from scientific

studiesstudies obtain and use information about their population of pts. obtain and use information about their population of pts. apply knowledge of study designs and statistical apply knowledge of study designs and statistical

methods to the appraisal of clinical studiesmethods to the appraisal of clinical studies use information technology to manage and access use information technology to manage and access

informationinformation

And the sixth…And the sixth… Systems-Based PracticeSystems-Based Practice

understand how their practices affect other health care understand how their practices affect other health care professionals, the health care organization, and the larger professionals, the health care organization, and the larger society and how these elements of the system affect their society and how these elements of the system affect their own practice own practice

know how types of medical practice and delivery systems know how types of medical practice and delivery systems differ from one another, including methods of controlling differ from one another, including methods of controlling health care costs and allocating resources health care costs and allocating resources

practice cost-effective health care and resource allocation practice cost-effective health care and resource allocation that does not compromise quality of care that does not compromise quality of care

advocate for quality patient care and assist patients in advocate for quality patient care and assist patients in dealing with system complexities dealing with system complexities

know how to partner with health care managers and health know how to partner with health care managers and health care providers to assess, coordinate, and improve health care providers to assess, coordinate, and improve health care and know how these activities can affect system care and know how these activities can affect system performanceperformance

Health of the PublicHealth of the Public

Covers AAMC informatics, pop healthCovers AAMC informatics, pop health Prepares students for ACGME Prepares students for ACGME

practice-based learning, systems-practice-based learning, systems-based practicebased practice

44thth year required 4-week clerkship year required 4-week clerkship Selected lectures in Population Health Selected lectures in Population Health

CONCEPTSCONCEPTS Workshops in Population Health Workshops in Population Health SKILLSSKILLS 50% of time and grade for Capstone Project50% of time and grade for Capstone Project

Course ObjectivesCourse Objectives

Define populationsDefine populations Develop, implement, and evaluate Develop, implement, and evaluate

population-based approaches to population-based approaches to health carehealth care

Recognize and address population-Recognize and address population-wide forces in health carewide forces in health care

Develop core knowledge and skills in Develop core knowledge and skills in occupational and environmental occupational and environmental medicinemedicine

Course ThemesCourse Themes

Population-based medicine*Population-based medicine* Health Care FinanceHealth Care Finance Quality of and Access to Medical Quality of and Access to Medical

Care*Care* Systems of Medical Care*Systems of Medical Care* Injury, Occupational, and Injury, Occupational, and

Environmental MedicineEnvironmental Medicine Capstone*Capstone***These sections are particularly relevant to tobaccoThese sections are particularly relevant to tobacco

Population-Based Medicine Population-Based Medicine General ConceptsGeneral Concepts

Transition from thinking about Transition from thinking about individual pts to commonalities individual pts to commonalities among groups of patients*among groups of patients*

Four stepsFour steps define populationsdefine populations assess needsassess needs interveneintervene EvaluateEvaluate

*Also incorporates concepts from Community-Oriented Primary Care*Also incorporates concepts from Community-Oriented Primary Care

Population-Based Medicine Population-Based Medicine SkillsSkills

Using PubMed to search medical Using PubMed to search medical literatureliterature Sophisticated search methodsSophisticated search methods

Critical appraisal of literature (journal Critical appraisal of literature (journal club)club)

Epi-biostat refresherEpi-biostat refresher Using Excel to analyze clinic dataUsing Excel to analyze clinic data

Quality of and Access to Quality of and Access to Medical CareMedical Care

Quality measurementQuality measurement StructureStructure Process – HEDIS, CMS Process – HEDIS, CMS Outcome –Hard to get! Outcome –Hard to get!

Quality improvementQuality improvement Oversight of quality Oversight of quality

Systems of Medical CareSystems of Medical Care

Quality improvementQuality improvement Office organizationOffice organization Disease managementDisease management Specific issuesSpecific issues

Diabetes disease managementDiabetes disease management Chronic care modelChronic care model

CCM Component Traditional Primary Care Care in the Disease Management Program*

Organization of Care

Physician responsible for all smoking cessation activities.

Trained counselors will work under the supervision of smoking cessation experts and coordinate pharmacotherapy with physicians.

Clinical Information System

Notes are handwritten by the physician. Many charts will not indicate if the patient is a smoker.30

An electronic registry of smokers will be created with quarterly updates on cessation attempts and readiness to quit. The database will store patient-specific data on contraindications to bupropion and NRT.Delivery System

DesignPhysician is responsible for advice, assistance, and follow-up for smoking cessation. Care is dependent upon the patient coming in for an office visit.

Trained counselors will provide proactive, telephone-based counseling utilizing principles of motivational interviewing. . Physicians will receive feedback on patient progress.

Decision Support Textbook in the doctor’s office. Health counselors will follow counseling protocols. Computerized algorithms will support decisions on pharmacotherapy.

Self-management Support

Physician may provide brief advice to quit with 1-2 minutes of ‘counseling’.

Patients receive MI-based telephone counseling, written cessation and relapse prevention tips, periodic reminders on the availability of free pharmacotherapy, and follow-up support calls after a quit attempt.*Community

ResourcesUnknown or unavailable in rural communities.

Free NRT or bupropion for a smoking cessation attempt.

HOPHOP

The Capstone ProjectThe Capstone Project

Capstone puts it all togetherCapstone puts it all together

To provide a small practical To provide a small practical experience in population health careexperience in population health care

Students choose topic, work in teamsStudents choose topic, work in teams HOP Mentor/Site MentorHOP Mentor/Site Mentor 20 hrs/Week on Project20 hrs/Week on Project Verbal/Poster presentation at endVerbal/Poster presentation at end

Capstone Projects: Capstone Projects: Research or ServiceResearch or Service

Quality of CareQuality of Care Smoking and interest in quitting among parents of Smoking and interest in quitting among parents of

pediatric patients at KUMCpediatric patients at KUMC Health CommunicationsHealth Communications

Reducing passive smoking in a Spanish pediatric Reducing passive smoking in a Spanish pediatric populationpopulation

Secondary Data AnalysisSecondary Data Analysis Gender differences in health issues among Kansas Gender differences in health issues among Kansas

caregivers using 2000 BRFSScaregivers using 2000 BRFSS Curriculum DevelopmentCurriculum Development

Developing a medical school smoking cessation Developing a medical school smoking cessation curriculumcurriculum

Health AdvocacyHealth Advocacy Medical student support for a primary seat belt law in Medical student support for a primary seat belt law in

KansasKansas

Population-based health carePopulation-based health care

Identify a populationIdentify a population

Ascertain needsAscertain needs

Intervene to address needsIntervene to address needs

Evaluate impactEvaluate impact

Health Communication: Health Communication: Passive Passive Smoking at Cabot ClinicSmoking at Cabot Clinic

Eric Vaughan and Josh TimockEric Vaughan and Josh TimockUniversity of Kansas School of MedicineUniversity of Kansas School of MedicineHealth of the Public, November 2002Health of the Public, November 2002

Health Communication: Health Communication: Passive Passive Smoking at Cabot ClinicSmoking at Cabot Clinic

Population:Population: Patients attending Cabot Patients attending Cabot Westside Clinic, 82% HispanicWestside Clinic, 82% Hispanic

Needs: Needs: Knowledge, skills regarding Knowledge, skills regarding passive smoking and children’s passive smoking and children’s healthhealth

Intervention:Intervention: Bilingual brochure Bilingual brochure

Evaluation: Evaluation: nonenone

Health Communication: Health Communication: Passive Passive Smoking at Cabot ClinicSmoking at Cabot Clinic

▶ A A preliminary needs assessmentpreliminary needs assessment was performed via telephone conversations and personal was performed via telephone conversations and personal interviews with clinicians.interviews with clinicians.

▶ A A literature reviewliterature review was conducted regarding pediatric morbidity and mortality due to passive was conducted regarding pediatric morbidity and mortality due to passive smoking and past employed and existing interventional strategies.smoking and past employed and existing interventional strategies.

▶ Various Various health communication formatshealth communication formats were considered: poster vs. brochure vs. postcard. were considered: poster vs. brochure vs. postcard.

▶ A A bilingual, color, tri-fold brochurebilingual, color, tri-fold brochure was produced incorporating the health belief model and was produced incorporating the health belief model and principles of health communication.principles of health communication.

▶ Working modelsWorking models were produced and critiqued by the faculty mentor and clinic staff and revised. were produced and critiqued by the faculty mentor and clinic staff and revised.

▶ A A final versionfinal version was published and distributed with the financial support of the Block Foundation. was published and distributed with the financial support of the Block Foundation.

Health Communication: Health Communication: Passive Passive Smoking at Cabot ClinicSmoking at Cabot Clinic

Perceived Perceived SusceptibilitySusceptibility

How vulnerable one feels How vulnerable one feels regarding a condition.regarding a condition.

Cited prevalence of ETS in the Cited prevalence of ETS in the Hispanic pediatric population. Hispanic pediatric population.

Photograph of smoking child.Photograph of smoking child.

Perceived SeverityPerceived Severity How seriously one regards How seriously one regards a condition.a condition.

Outlined incidence of ETS Outlined incidence of ETS associated morbidity.associated morbidity.

Photograph of ill teenager.Photograph of ill teenager.

Perceived BenefitsPerceived Benefits How one feels regarding How one feels regarding efficacy of the intervention.efficacy of the intervention.

Outlined importance of positive Outlined importance of positive role modeling behavior. role modeling behavior.

Photograph of healthy child.Photograph of healthy child.

Perceived BarriersPerceived Barriers The obstacles viewed as The obstacles viewed as impeding the intervention.impeding the intervention.

Addressed “what if” scenarios Addressed “what if” scenarios and provided simple strategies to and provided simple strategies to overcome barriers.overcome barriers.

Cues to ActionCues to Action Activate readiness to act Activate readiness to act and stimulate overt and stimulate overt behavior.behavior.

Provided “how to” information Provided “how to” information regarding home interventions. regarding home interventions.

Self-EfficacySelf-Efficacy How confident one is in How confident one is in personal ability to take personal ability to take action.action.

Provided Spanish smoking Provided Spanish smoking cessation telephone line and cessation telephone line and other resources.other resources.

Health Communication: Health Communication: Passive Smoking Passive Smoking at Cabot Clinic - Panel 5at Cabot Clinic - Panel 5

What if I’m having trouble What if I’m having trouble quitting?quitting?

Talk with a doctor about treatments Talk with a doctor about treatments and methods that can and methods that can helphelp you quit. you quit.

What if someone does smoke What if someone does smoke in my home?in my home?

Make it Make it clearclear that smoking is that smoking is notnot allowed in your home.allowed in your home.

  

What if my childrens’ care What if my childrens’ care provider smokes?provider smokes?

  

Ask them Ask them not to smokenot to smoke around your around your children, or find a new care provider.children, or find a new care provider.

YOU CAN DO IT! BUT WHAT IF…

Population Health Population Health Communication: Communication:

Don’t Choke on SmokeDon’t Choke on Smoke

D. Brendan RiceD. Brendan Rice

Muhammad NashatizadehMuhammad Nashatizadeh

Health of the Public Health of the Public (PMED960)(PMED960)

Population Health Communication: Population Health Communication: Don’t Choke on SmokeDon’t Choke on Smoke

Survey DevelopmentSurvey Development form-based webpage for elementary school form-based webpage for elementary school

teachersteachers Survey QuestionsSurvey Questions

1) 1) Is there anything you do not understand about the handout?Is there anything you do not understand about the handout?

2) 2) What is your FAVORITE part of the handout?What is your FAVORITE part of the handout?

3) 3) What is your LEAST FAVORITE part of the handout?What is your LEAST FAVORITE part of the handout?

4) Would you take this handout home to share with family and 4) Would you take this handout home to share with family and friends? If NO, please explain why not:friends? If NO, please explain why not:

5) Did the handout help you understand more about the 5) Did the handout help you understand more about the dangers of smoking? What did you learn?dangers of smoking? What did you learn?

Population Health Population Health Communication: Communication:

Don’t Choke on Smoke – What Don’t Choke on Smoke – What did you learn? did you learn?

Chemicals

General Facts

Smoking Diseases

Rank the Killers

Nothing

Lung Pathology

• Selected quotes:

–I didn’t know there are 4700 chemicals in each cigarette

–The deadly stuff in cigarettes. Yuck! (and a lot more stuff)

–That when you take a deep breath and let it out halfway, it is called a emphysema.

–I learned smoking kills more people than guns.

–That it kills more people than AIDS, guns, pneumonia, accidents combined

–What lungs look like when you smoke

Needs Assessment, Smoking Needs Assessment, Smoking Cessation Program for Cessation Program for Parents of Newborns at Parents of Newborns at

KUMCKUMC

Jason Eppler, Matt Jason Eppler, Matt Haverkamp, Haverkamp,

Marc LarsenMarc LarsenHealth of the Public

April 17, 2003

Needs Assessment, Needs Assessment, Postpartum Smoking CessationPostpartum Smoking Cessation

Assess the need for a postpartum Assess the need for a postpartum smoking cessation program for smoking cessation program for mothers of newborn babies at the mothers of newborn babies at the University of Kansas Medical University of Kansas Medical CenterCenter ““Need” based on :Need” based on :

Mothers who smokeMothers who smoke Desire to quitDesire to quit Relapse rate of smoking after deliveryRelapse rate of smoking after delivery

Needs Assessment, Needs Assessment, Postpartum Smoking CessationPostpartum Smoking Cessation

Population: Population: Former smokers Former smokers delivering at KUMC.delivering at KUMC.

Needs: Needs: Smoking cessation, Smoking cessation, maintenance of cessationmaintenance of cessation

Intervention:Intervention: Survey will evaluate Survey will evaluate need for interventionneed for intervention

Evaluation: Evaluation: NoneNone

Needs Assessment, Needs Assessment, Postpartum Smoking CessationPostpartum Smoking Cessation

Bilingual survey looked at:Bilingual survey looked at: Demographics of mothers of Demographics of mothers of

newbornsnewborns Mothers current smoking habitsMothers current smoking habits Smoking status of others living in the Smoking status of others living in the

househouse Mothers/others desire to quitMothers/others desire to quit Desire to participate in smoking Desire to participate in smoking

cessation programcessation program

Mothers’ Smoking HistoryMothers’ Smoking History

53%

37%

10%

0%

10%

20%

30%

40%

50%

60%

Non-Smoker Ex-Smokers Current Smoker

Needs Assessment, Needs Assessment, Postpartum Smoking CessationPostpartum Smoking Cessation

Among mothers:Among mothers: 44% of ever smokers stated pregnancy 44% of ever smokers stated pregnancy

played a role in decision to quitplayed a role in decision to quit 47% had smoked at one period in their 47% had smoked at one period in their

lifelife Of these, 22% currently smokeOf these, 22% currently smoke

100% of current smokers indicated they 100% of current smokers indicated they would be interested in a smoking would be interested in a smoking cessation programcessation program

Tobacco and Population HealthTobacco and Population Health

Medical students and GMEs need to Medical students and GMEs need to know population health to be know population health to be effective clinicianseffective clinicians

Health of the Public teaches Health of the Public teaches population approaches with tobacco population approaches with tobacco in numerous examplesin numerous examples

Community-oriented primary care Community-oriented primary care also an important perspective that also an important perspective that HOP addressesHOP addresses