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  • 1. Systems-Level Innovations to Promote Tobacco Treatment in Health Care Settings- Columbia University/ Aetna Dental "Tobacco and the Dental Office: Encouraging Patients to Quit" David A. Albert, DDS, MPH [email_address] 212-304-7172 Funded by the Robert Wood Johnson Foundation
  • 2. Columbia University / Aetna Inc. Addressing Tobacco in Managed Care Dr. David A. Albert – Columbia University Dr. Donald Sadowsky – Columbia University Dr. Daniel Seidman – Columbia University Ms. Angela Ward – Columbia University Ms. Laura Akers – Deschutes Research InstituteDr. Judy Andrews – Deschutes Research Institute Mr. Steven Christiansen – InterVision Dr. Judith Gordon – Deschutes Research Institute Dr. Herb Severson – Deschutes Research Institute Dr. Thomas D. Gotowka – Aetna Dental Mr. Alan Hirschberg – Aetna Dental Ms. Dawn Romberg – Aetna Dental
  • 3. The Dental Profession and Managed Care
    • The Dental Managed Care Organization can serve as a facilitator for patient tobacco cessation advice and assimilation of tobacco cessation techniques intoroutine dental policies and procedures.
      • Improved health outcomes can be understood as contributing to lower total health costs and to an augmentation of quality by the MCO.
    • The Agency for Health Care Policy and Research Guideline #18(April 1996) recommends that insurers support tobacco user identification systems, support cessation treatment through staff education and training, and provide for reimbursement for tobacco-dependence treatment
  • 4. Prevention in the Dental Office
    • Why conduct tobacco cessation in the dental office?
      • oral entry way
      • leukoplackic changes
      • bad breath
      • cosmetic defects
      • periodontal disease
      • oral cancer
      • not a candidate for prosthetics, implants
  • 5. Tobacco Cessation:Are dentists ready?
    • Support from the American Dental Association
    • National Dental Association
    • American Academy of General Dentistry
    • NCI Dental Tobacco Steering Committee
    • AHCPR/ PHS Guidelines
    • Dental School Curriculum
  • 6. Setting
    • Aetna Dental
          • One of the largest dental insurance companies in the US
          • Market leader in the Dental HMO business
          • Top 3 dental player by total membership (13 million covered dental members)
          • DMO product serves approximately three million members
          • 7,100 DMO GP locations
          • Presence in 50 States
  • 7. Managed Care Commitment to Tobacco Cessation
    • Commitment of Resources
      • Network Managers, supervisory personnel
      • Regional Dental Directors, National Dental Director
      • Quality Assurance
    • Dental Provider education and enhanced reimbursement
    • Patient education
  • 8. Specific Aims ( "Tobacco and the Dental Office: Encouraging Patients to Quit”)
    • To stimulate tobacco cessation behaviors by subject-dentists
    • To incorporate systems-based strategies including tobacco user identification systems, education, financial incentives, and feedback
    • To determine whether a CD-ROM based educational intervention can increase the prevalence of cessation activities within the MCO dental practices
    • To evaluate the cost-effectiveness of the intervention
  • 9. Intervention Components
    • Continuing medical education via CD-ROM
    • Enhanced payment system for tobacco cessation in the dental office
    • Interactive electronic detailing sessions
  • 10. System Change Development and Implementation
    • The CD-ROM includes branding as an Aetna Dental product
      • The cover art on the CD-ROM case and on the CD-ROM label were developed in close conjunction with Aetna Dental
      • The introductory segment of the CD-ROM contains video of the Head of Aetna Dental
  • 11. System Change Development and Implementation
    • The incentive plan was developed and disseminated to participating dentists in the intervention arm
      • The incentive plan builds upon lessons learned in the Columbia/ Aetna Dental ATMC 1 project
      • Aetna Dental provided the dentist with $10 for each Aetna DMO ®enrolled patient who received tobacco cessation counseling and completed the Columbia University Survey of Dental Patients during the enrollment period
        • Dentists were informed of the compensation program when the patient surveys and materials were sent to them and via electronic detailing (e-mail)
  • 12. System Change Development and Implementation
    • Aetna Dental implemented an updated quality assurance system incorporating tobacco cessation questions into their periodic in-office reviews
      • The modified system was implemented in the 29 States where dental offices are included in the study
  • 13. Study Design General practitioner offices in Aetna/DMO (n=6,822) Offices with more than 200 Aetna DMO adult patients (n=1508) Eligible offices (computer, CD-ROM, and Internet access) (n=501) Recruitment of Sample (224 met all eight inclusion criteria) 184 enrolled in program and randomly assigned to Usual Care (82) vs. CD-ROM-based training program (102)
  • 14. Eligibility Criteria
  • 15. Dissemination Vehicle
  • 16. Minimum Requirements
  • 17. DDS Baseline Data During the past month, approximately what% of the time did you ask about patient’stobacco use? (N=133) 6.8% 39.1% 6.8% 15.8% 4.5% 27.1%
  • 18. DDS Baseline Data During the past month, approximately what% of the time did you record information inpatient’s chart about their tobacco use? (N=133) 1.5% 12% 23.3% 5.3% 29.3% 28.6%
  • 19. DDS Baseline Data The extent to which discussion of setting specific quitdates and specific strategies for quitting are a part ofyour tobacco cessation activities for patients who usetobacco products. 28.4% 71.6% (N=134)
  • 20. DDS Baseline Data The extent to which referral of patients to cessationclinics/programs is a part of your tobacco cessationactivities for patients who use tobacco products. (N=135) 23.7% 76.3%
  • 21. DDS Baseline Data Overall, how would you rate your knowledge abouthelping people stop using tobacco? (N=178) 19.1% 14% 27% 3.9% 36%
  • 22. Patient Baseline Data - Tobacco Users How many times during the past 12 monthshave you seriously tried to quit? 51.2% 22.7% 11% 15%
  • 23. Patient Baseline Data - Tobacco Users How confident are you that you will be ableto stop using tobacco? 21.5% 47.6% 19.1% 11.8%
  • 24. Patient Baseline Data - Tobacco Users Indicate where you are in your thinkingabout quitting tobacco products. 0 - not ready to quit,10 - ready to quit now 16.8% 14.1% 9.1% 9.7% 10.4% 19.9%
  • 25. Patient Baseline Data - Tobacco Users Over the past 12 months, how many visitsdid you make to the dental office? 18.1% 15.8% 31.7% 34.4%
  • 26. Has anyone in your dentist’s office encouraged you to set a quit date? If yes, who? Patient Baseline Data - Tobacco Users 7.1% 18.4% 1% 21.4% 71.5% 28.5% 52%
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    Dentist and Tobacco Cessation

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    • 1. Systems-Level Innovations to Promote Tobacco Treatment in Health Care Settings- Columbia University/ Aetna Dental "Tobacco and the Dental Office: Encouraging Patients to Quit" David A. Albert, DDS, MPH [email_address] 212-304-7172 Funded by the Robert Wood Johnson Foundation
  • 2. Columbia University / Aetna Inc. Addressing Tobacco in Managed Care Dr. David A. Albert – Columbia University Dr. Donald Sadowsky – Columbia University Dr. Daniel Seidman – Columbia University Ms. Angela Ward – Columbia University Ms. Laura Akers – Deschutes Research InstituteDr. Judy Andrews – Deschutes Research Institute Mr. Steven Christiansen – InterVision Dr. Judith Gordon – Deschutes Research Institute Dr. Herb Severson – Deschutes Research Institute Dr. Thomas D. Gotowka – Aetna Dental Mr. Alan Hirschberg – Aetna Dental Ms. Dawn Romberg – Aetna Dental
  • 3. The Dental Profession and Managed Care
    • The Dental Managed Care Organization can serve as a facilitator for patient tobacco cessation advice and assimilation of tobacco cessation techniques intoroutine dental policies and procedures.
      • Improved health outcomes can be understood as contributing to lower total health costs and to an augmentation of quality by the MCO.
    • The Agency for Health Care Policy and Research Guideline #18(April 1996) recommends that insurers support tobacco user identification systems, support cessation treatment through staff education and training, and provide for reimbursement for tobacco-dependence treatment
  • 4. Prevention in the Dental Office
    • Why conduct tobacco cessation in the dental office?
      • oral entry way
      • leukoplackic changes
      • bad breath
      • cosmetic defects
      • periodontal disease
      • oral cancer
      • not a candidate for prosthetics, implants
  • 5. Tobacco Cessation:Are dentists ready?
    • Support from the American Dental Association
    • National Dental Association
    • American Academy of General Dentistry
    • NCI Dental Tobacco Steering Committee
    • AHCPR/ PHS Guidelines
    • Dental School Curriculum
  • 6. Setting
    • Aetna Dental
          • One of the largest dental insurance companies in the US
          • Market leader in the Dental HMO business
          • Top 3 dental player by total membership (13 million covered dental members)
          • DMO product serves approximately three million members
          • 7,100 DMO GP locations
          • Presence in 50 States
  • 7. Managed Care Commitment to Tobacco Cessation
    • Commitment of Resources
      • Network Managers, supervisory personnel
      • Regional Dental Directors, National Dental Director
      • Quality Assurance
    • Dental Provider education and enhanced reimbursement
    • Patient education
  • 8. Specific Aims ( "Tobacco and the Dental Office: Encouraging Patients to Quit”)
    • To stimulate tobacco cessation behaviors by subject-dentists
    • To incorporate systems-based strategies including tobacco user identification systems, education, financial incentives, and feedback
    • To determine whether a CD-ROM based educational intervention can increase the prevalence of cessation activities within the MCO dental practices
    • To evaluate the cost-effectiveness of the intervention
  • 9. Intervention Components
    • Continuing medical education via CD-ROM
    • Enhanced payment system for tobacco cessation in the dental office
    • Interactive electronic detailing sessions
  • 10. System Change Development and Implementation
    • The CD-ROM includes branding as an Aetna Dental product
      • The cover art on the CD-ROM case and on the CD-ROM label were developed in close conjunction with Aetna Dental
      • The introductory segment of the CD-ROM contains video of the Head of Aetna Dental
  • 11. System Change Development and Implementation
    • The incentive plan was developed and disseminated to participating dentists in the intervention arm
      • The incentive plan builds upon lessons learned in the Columbia/ Aetna Dental ATMC 1 project
      • Aetna Dental provided the dentist with $10 for each Aetna DMO ®enrolled patient who received tobacco cessation counseling and completed the Columbia University Survey of Dental Patients during the enrollment period
        • Dentists were informed of the compensation program when the patient surveys and materials were sent to them and via electronic detailing (e-mail)
  • 12. System Change Development and Implementation
    • Aetna Dental implemented an updated quality assurance system incorporating tobacco cessation questions into their periodic in-office reviews
      • The modified system was implemented in the 29 States where dental offices are included in the study
  • 13. Study Design General practitioner offices in Aetna/DMO (n=6,822) Offices with more than 200 Aetna DMO adult patients (n=1508) Eligible offices (computer, CD-ROM, and Internet access) (n=501) Recruitment of Sample (224 met all eight inclusion criteria) 184 enrolled in program and randomly assigned to Usual Care (82) vs. CD-ROM-based training program (102)
  • 14. Eligibility Criteria
  • 15. Dissemination Vehicle
  • 16. Minimum Requirements
  • 17. DDS Baseline Data During the past month, approximately what% of the time did you ask about patient’stobacco use? (N=133) 6.8% 39.1% 6.8% 15.8% 4.5% 27.1%
  • 18. DDS Baseline Data During the past month, approximately what% of the time did you record information inpatient’s chart about their tobacco use? (N=133) 1.5% 12% 23.3% 5.3% 29.3% 28.6%
  • 19. DDS Baseline Data The extent to which discussion of setting specific quitdates and specific strategies for quitting are a part ofyour tobacco cessation activities for patients who usetobacco products. 28.4% 71.6% (N=134)
  • 20. DDS Baseline Data The extent to which referral of patients to cessationclinics/programs is a part of your tobacco cessationactivities for patients who use tobacco products. (N=135) 23.7% 76.3%
  • 21. DDS Baseline Data Overall, how would you rate your knowledge abouthelping people stop using tobacco? (N=178) 19.1% 14% 27% 3.9% 36%
  • 22. Patient Baseline Data - Tobacco Users How many times during the past 12 monthshave you seriously tried to quit? 51.2% 22.7% 11% 15%
  • 23. Patient Baseline Data - Tobacco Users How confident are you that you will be ableto stop using tobacco? 21.5% 47.6% 19.1% 11.8%
  • 24. Patient Baseline Data - Tobacco Users Indicate where you are in your thinkingabout quitting tobacco products. 0 - not ready to quit,10 - ready to quit now 16.8% 14.1% 9.1% 9.7% 10.4% 19.9%
  • 25. Patient Baseline Data - Tobacco Users Over the past 12 months, how many visitsdid you make to the dental office? 18.1% 15.8% 31.7% 34.4%
  • 26. Has anyone in your dentist’s office encouraged you to set a quit date? If yes, who? Patient Baseline Data - Tobacco Users 7.1% 18.4% 1% 21.4% 71.5% 28.5% 52%
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