Get documents about "PowerPoint Presentation
Document Sample
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
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%.
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.
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.
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.
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
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
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
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)
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 )
The 5-As
Ask Identify and document tobacco use status for every
patient at every visit.
Advise In a clear, strong, personalized manner urge every
tobacco user to quit.
Assess Is tobacco user willing to make a quit attempt?
Assist If willing, use counseling & pharmacotherapy.
If unwilling, address resistance (5-Rs)
Arrange Schedule follow-up contact within 1 week after quit date.
Clinical Practice Guideline, p. 26
The 5-Rs
Relevance Indicate how / why quitting is personally relevant. Motivational
info has greatest impact if relevant to disease status / risk,
family or social situation, or other personal characteristics.
Risks Identify consequences of tobacco use.
Suggest / highlight those most relevant.
Rewards Identify benefits of stopping tobacco use.
Suggest / highlight those most relevant.
Roadblocks Identify barriers to quitting. Note treatment elements (problem
solving, pharmacotherapy) to address.
Repetition Repeat motivational intervention at each clinic visit.
Encourage continued efforts to quit.
Clinical Practice Guideline, p. 32-33
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
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
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
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
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
PDA Protocol
Phase I
AHRQ April 2003
( Pendragon iForms v. 3.2 )
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
Ask
Fields 3-5:
Demographics (Age,
Gender, Ethnicity)
Advise & Assess
CONTINUE
Fields 10, 11: Not Ready
(Identify Barriers)
END
Assist
CONTINUE
Arrange
END
Phase I Results
MDs 21 enrolled; 16 completed (76%)
9 rural, 7 urban / suburban
Time: Orientation to protocol 15 min
Intervention delivery 3.5 min
Tech Issues: Slow internet, firewall, PDA crash, individual PCs /
computer systems
#1 Barrier: MDs forgetting to sync PDA
#1 Facilitator: Provider Representative (on site training / assistance)
Phase I Results
PDAs “Reminded” MDs to deliver intervention
Aided MDs in more effectively delivering the intervention
MDs learned about resources for patients, took CME
One started an after-hours support group for patients
Patients responded positively to MD use of PDA
MDs felt PDA intervention positively impacted patients
Phase I Results
Patients 639 received intervention
431 (67%) willing to discuss quit attempt
180 (42%) of those willing to set quit date
(28% of all patients receiving intervention)
Need More detailed info
Prompts for personalizing intervention
Means of implementing and following up on
Assist & Arrange steps
PDA Protocol
Phase II
P4H* March 2004
( Pendragon Forms v. 4.0 )
* Prescription for Health ( RWJF / AHRQ )
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 Arrange steps
PDAs served triple function:
1) guide 5-A intervention * Prescription for Health
2) data collection tool (AHRQ / RWJF)
3) referral mechanism
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 Arrange steps
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
Ask
optional
Fagerstrom Score
Advise Guides Counseling
optional
continue
Assess
optional
optional
continue
Optional Info
continue
Assist & Arrange
Augmented by
Practice Extenders
optional
Phase II Results
MDs 8 MDs in 5 urban-suburban practices
Competing practice demands / incentives took priority
Purpose of study misunderstood / forgotten over time
( integrate intervention; PDAs for referral; role of PEs )
Forgetting to sync / charge PDA
Once 5-As memorized, PDA not used/data not entered
Phase II Results
PDAs Navigability of program (no back button)
No record retention
Added info accessed infrequently:
Risks: 41 times 5Rs: 14 times
Physical: 65 times Behavioral: 20 times
Social: 26 times Pharmacotherapy: 26 times
Phase II Results
Patients 110 received intervention
81% were willing to quit
79% of those willing to quit elected PE contact / services
Inaccurate representation of stage of change / readiness
to quit (desire to please MD?)
Inaccurate contact info provided
PEs Both MDs and patients felt PEs were effective
Reported benefits / appreciation for PE efforts
Having “someone who cared” especially meaningful
Protocol Flow
1 MD delivers PDA-based intervention. P4H At Assess patients told of PE services.
2 MD syncs PDA. Data sent to server. Consent & contact info entered on PDA.
3 Coordinating Center (CC) retrieves data. P4H 4 PE contacts patient. Sends personalized
materials. Follows up by phone 1 wk &
AHRQ CC solicits feedback from MDs 1 mo post change date + available for
Answers research questions support between scheduled contacts.
related to utility / feasibility 5 PE faxes feedback to MD on status of
Informs future research patient’s behavior change.
Informs future MD-Patient interaction.
1 2 Secure 3 4 5
MD MD syncs Offsite CC P4H Referral info to PE PE PE
PDA PDA Server retrieves AHRQ from MD Patient MD
Patient data
informs future research
informs future interaction
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.
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.
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
Related docs
Other docs by HC111209224042
