PDAs and Practice Extenders: Integration of 5-A Tobacco Use Intervention

1. PDAs and Practice Extenders: Integration of 5-A Tobacco Use Intervention Alabama Practice Based Research Network (APBRN) Myra A. Crawford, PhD T. Michael Harrington, MD Toya V. Russell, PhD  Brenda K. Baumann, MD The University of Alabama at Birmingham

2. Problem National clinical practice guidelines for the treatment of tobacco use and dependence have existed for over a decade, but have not been widely integrated into routine practice. Public awareness of the dangers of tobacco use has increased dramatically since the first US Surgeon General’s report was released 40 years ago, yet the national adult smoking prevalence rate remains at 23%.

3. Physicians & Tobacco Use • Over half of all medical office visits in the US are to primary care physicians. • Most visits for common chronic illnesses – including those attributable to smoking - take place in primary care practices. • Primary care physicians cite tobacco use among their top patient care concerns. • Just 3 minutes of counseling can increase quit rates by 30% and evidence shows that even 1 minute may be effective.

4. Patients & Tobacco Use • Over 70% of people who smoke want to quit. • Seven out of ten smokers visit a physician each year. • Most report that they value their physicians’ advice regarding tobacco use. • Physician advice has been cited as the single most important motivator in encouraging cessation. • Behavioral therapies can increase and sustain cessation. When combined with pharmacotherapy, the likelihood of success more than doubles.

5. Yet, only 50% of patients who use tobacco report ever being advised to quit by a physician.* * Integration of health behavior counseling in routine medical care. Washington, DC: Center for the Advancement of Health, 2001.

6. Why ? • Primary care physicians often address multiple, complex or chronic problems within extremely short office visits • Patients rarely present with tobacco use as their chief complaint • Scheduling constraints / lack of time • Lack of reimbursement for preventive services • Doubts about effectiveness of intervening • Lack of training in appropriate counseling methods

7. Solution Using the guidelines’ 5-A model, develop a PDA-based tobacco use assessment and counseling tool for use in routine care. Field test and evaluate the tool among members of the Alabama Practice Based Research network (APBRN) – a voluntary consortium of primary care physicians conducting practice-based research in Alabama

8. APBRN Study Sites & Membership • AHRQ Smoking Study • 16 MDs, 13 Practices, 11 Counties •  Baldwin  Chambers  Coosa • DeKalb  Etowah Jefferson • Lawrence  Madison  Shelby •  Talladega  Tallapoosa P4H Smoking Study 8 MDs, 5 Practices, 2 Counties  Jefferson  Shelby • APBRN Membership(As of 4/1/04) • 40 MDs, 30 Practices, 21 Counties •  Baldwin  Calhoun  Chambers •  Coosa  Covington  Conecuh •  DeKalb  Etowah  Hale •  Jefferson  Lawrence  Lowndes •  Madison  Marion/Winston  Marshall •  Mobile  Montgomery  Shelby •  Talladega  Tallapoosa  Tuscaloosa

9. Purpose To explore the feasibility of using . . . • PDAs to guide physicians through an evidence-based 5-A tobacco use intervention at the point of care(AHRQ) and • Practice Extenders (PEs) to augment the assist and arrange steps by providing: • motivation / support • resources • feedback to physicians (P4H)

10. Research Questions • Can the guideline be translated into a simple, but effective, PDA program for clinical use?( AHRQ ) • Can PDA-based interventions be easily integrated into routine care?( AHRQ ) • Can research data collection occur simultaneously?( AHRQ ) • Is a system of electronic data collection and transfer from multiple remote sites possible and practical?( AHRQ ) • Can Practice Extenders (PEs) effectively augment the Assist and Arrange steps?( P4H)

11. The 5-As Clinical Practice Guideline, p. 26

12. The 5-Rs Clinical Practice Guideline, p. 32-33

13. Funding Support Phase I:Building the Alabama Practice Based Research Network US Agency for Healthcare Research and Quality(AHRQ) # 1 R21 HS13529 9/30/02 – 9/29/04 Phase II:Testing PDA-based Interventions for Smoking and Unhealthy Diet / “Prescription for Health” (P4H) The Robert Wood Johnson Foundation (with AHRQ) # 637046  7/1/03 – 10/31/04

14. Objectives Phase I -AHRQ 1)Create PDA program to guide MDs through brief intervention 2)Increase number of patients receiving “best practice” care 3)Test feasibility of PDA program to guide intervention as a means of Integrating guidelines into routine care and Translating research into practice Phase II -P4H 1) Evaluate the revised PDA intervention protocol 2)Establish a system of MD referral to Practice Extenders via PDA 3)Test feasibility / effectiveness of PEs to augment Assist & Arrange

15. Methods - PDAs • MDs provided with PDAs ( Palm OS ) • 5-A intervention simplified • PDA program created using Pendragon software • Web-based server links / permissions established • Provider representative visited participating sites • Installed software • Established server connectivity • Trained MDs in study protocol • MDs delivered PDA-based interventions to patients

16. Methods - MDs • PDA protocol guided MDs through 5-A intervention at point of care • Patients indicating readiness to quit at Assess informed of availability of PE services • Consent to PE contact obtained by MD and entered on PDA • Data collected during interventions automatically transferred to secure off-site server when MD synchronized PDA at desktop PC • Data retrieved at APBRN Coordinating Center; communicated to PEs (PDA as referral mechanism) • MDs had option of referring patients by fax

17. Methods - PEs • PEs - research assistants - one assigned to each practice • Received specialized training in: • tobacco use, including addiction and cessation • health intervention and counseling methods • study protocol • On initial telephone contact, confirmed consent and helped patients develop quit plans • Mailed personalized packets containing printout of plan, self-help materials, and info on free or low-cost resources to aid quit attempt • Followed up by phone 1 week and 1 month post quit date; available for phone support between scheduled contacts • After one month follow up, provided progress reports to physicians

18. PDA ProtocolPhase IAHRQApril 2003( Pendragon iForms v. 3.2 )

19. Phase I - Methods • 5-A intervention simplified • PDA program created using Pendragon software • Web-based server links / permissions established • MDs provided with PDAs ( Palm OS ) • Provider representative visited participating sites • Installed software • Established server connectivity • Trained MDs in study protocol • MDs delivered PDA-based interventions to patients

20. Ask Fields 3-5: Demographics(Age, Gender, Ethnicity)

21. Advise & Assess CONTINUE Fields 10, 11: Not Ready (Identify Barriers) END

22. Assist CONTINUE

23. Arrange END

24. Phase IResults

25. Phase IResults

26. Phase IResults

27. PDA ProtocolPhase IIP4H*March 2004( Pendragon Forms v. 4.0 ) *Prescription for Health( RWJF / AHRQ )

28. Phase II = P4H * • PDA Protocols revised in response to MD feedback • Added features allowed for greater personalization: • Info on risks and resistance to change (5 Rs) • Fagerstrom score calculator and pharmacotherapy info • Info on physical, behavioral and social aspects of tobacco use added, as well as practical suggestions / tips for patients • Practice Extender (PE) component added to augment Assist and Arrangesteps • PDAs served triple function: 1) guide 5-A intervention 2) data collection tool 3) referral mechanism *Prescription for Health (AHRQ / RWJF)

29. Phase II - Methods • PDA protocols revised in response to MD feedback • Added features allowed for greater personalization: • Info on risks and resistance to change (5 Rs) • Fagerstrom score calculator and pharmacotherapy info • Info on physical, behavioral and social aspects of tobacco use added, as well as practical suggestions / tips for patients • Practice Extender (PE) component added to augment Assist and Arrangesteps

30. Outcome Measures • Physician adherence to study protocol • Patient consent to PE contact • Delivery of PE assistance • Patients’ self-reported behavior change • End-of-study qualitative review with MDs and PEs also provided insights on • feasibility, utility, sustainability and • potential to affect patient outcomes

31. Ask optional

32. Fagerstrom ScoreGuides Counseling Advise optional continue

33. Assess optional optional continue

34. Optional Info continue

35. Augmented by Practice Extenders Assist & Arrange optional

36. Phase IIResults

37. Phase IIResults

38. Phase IIResults

39. Protocol Flow 1MD delivers PDA-based intervention. 2 MD syncs PDA. Data sent to server. 3 Coordinating Center (CC) retrieves data. P4HAt Assess patients told of PE services. Consent & contact info entered on PDA. P4H 4 PE contacts patient. Sends personalized materials. Follows up by phone 1 wk & 1 mo post change date + available for support between scheduled contacts. 5 PE faxes feedback to MD on status of patient’s behavior change. Informs future MD-Patient interaction. AHRQCC solicits feedback from MDs  Answers research questions related to utility / feasibility Informs future research 1 MD PDA Patient 2 MD syncs PDA 3 CC retrieves data Secure Offsite Server 5 PE MD 4 PE Patient P4HReferral info toPE AHRQfromMD informs future research informs future interaction

40. Conclusions • PDA protocols may be cost-effective, easy to use tools for promoting healthy behaviors that can be easily integrated into routine care. • In communities where cessation programs are not readily available, Practice Extenders may fill the void.

41. Conclusions Making it easy for busy physicians to integrate evidence-based interventions into clinical practice is an important first step toward improving health care and outcomes for patients who use tobacco. Assisting them in doing so – by using PDAs or PEs – is an important second step.

42. A consortium of primary care physicians conducting practice-based research in Alabama www.apbrn.net T. Michael Harrington, MD  Director Myra A. Crawford, PhD  Co-Director APBRN Coordinating Center UAB Family & Community Medicine Division of Research 930 South 20th Street, Room 307 Birmingham, AL 35205 Phone: (205) 934-9376  Email: jwhite@fms.uab.edu