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Article Excerpt
Tobacco use remains the leading cause of preventable death and disability in the United States (McGinnis and Foege 1993; Mokdad et al. 2004). Recent studies rank smoking cessation treatment as the most cost-effective preventive service due to its potential impact on public health and economic savings (Maciosek et al. 2006; Solberg et al. 2006). However, while health services such as tobacco screening and counseling have been thoroughly supported by evidence reviews and are highly recommended by the U.S. Preventive Services Task Force (USPSTF), significant gaps persist between recommended and usual care (Fiore et al. 2000; Hopkins et al. 2001; USPSTF 2005).
Best practices as outlined in the Public Health Service (PHS) Clinical Practice Guideline." Treating Tobacco Use and Dependence (Fiore et al. 2000) recommends the following "5As" approach: (1) ask about tobacco use at every visit, (2) advisesmokers to quit, (3) assesssmokers' readiness to quit, (4) assist quit attempts through counseling and pharmacotherapy, and (5) arrange follow-up to prevent relapse. The guideline provides strong evidence that brief advice combined with additional assistance such as counseling and pharmacotherapy can double quit rates (Fiore et al. 2000). Despite this evidence, there is inconsistent adherence to the guideline. Rates for cessation advice range from 30 to 75 percent, with actual treatment ranging from 2 to 38 percent for pharmacotherapy to < 10 percent for referral and follow-up (Denny et al. 2003; Quinn et al. 2005; Schroeder 2005; Ferketich, Kahn, and Wewers 2006).
The 5As are targeted to audiences such as primary care providers who are uniquely positioned to interact with smokers. More than 70 percent of smokers are seen by a primary care clinician at least once a year with an average of over three visits annually (Centers for Disease Control and Prevention 1993). Furthermore, many smokers report wanting their physician to discuss cessation with them and report greater satisfaction with the visit when their tobacco use is addressed (Fiore et al. 2000; Quinn et al. 2005). While primary care clinics are strategic venues for delivering cessation services, guideline awareness and dissemination alone are insufficient for routine application in busy care settings (Solberg et al. 2000).
This research examines the potential for the chronic care model (CCM), a systems-level quality improvement framework, to enhance 5As delivery by primary care providers. Studies of the CCM to date have typically focused on improving the care of patients with chronic illnesses including diabetes, hypertension, congestive heart failure, asthma, and depression (Wagner et al. 2001a, b; Bodenheimer, Wagner, and Grumbach 2002a, b; Bonomi et al. 2002; Kilbourne et al. 2004; Sperl-Hillen et al. 2004; Mangione-Smith et al. 2005; Pearson et al. 2005; Stroebel et al. 2005; Parchman et al. 2007). Beyond this, the model has also been preliminarily explored as a template for primary prevention and for delivery of services that address health risk behaviors (Glasgow et al. 2001; Hung et al. 2007). The current research builds on this work in prevention by specifically targeting tobacco use and examining how implementation of the CCM might improve provider adherence to treatment guidelines.
Methodologically, this study also builds on the existing CCM literature by using multilevel modeling techniques to estimate both organizational- and individual-level effects on provider delivery of health services. This approach indicates the extent to which provider delivery of the 5As may be attributed to clinic implementation of the CCM, adjusting for provider covariates and clustering. Thus, this study will: (1) describe the prevalence of CCM features tailored for treating tobacco use in urban primary care clinics; (2) examine relationships between provider 5As delivery and clinic implementation of each CCM element; and (3) examine associations between the degree of CCM integration in clinics and provider delivery of 5A services.
CONCEPTUAL FRAMEWORK
The health systems and organization of health care element of the CCM refers to organizational or system values, structures, and mechanisms that facilitate high-quality care (Improving Chronic Illness Care [ICIC] 2008). Prior research found that a common feature among successful prevention programs was the existence of program directors who reported a strong commitment to preventive care (Glasgow et al. 2001). Practices with organizational cultures valuing quality improvement also offered a greater variety of preventive services for behavioral modification (Hung et al. 2007). Examples of this CCM element in studies of chronic disease management include policies for systems change, support from senior leaders, and incentives or rewards for achieving care delivery goals (Wagner et al. 2001a, b; Bodenheimer, Wagner, and Grumbach 2002a, b; Bonomi et al. 2002; Pearson et al. 2005).
Decision support describes interventions or activities that improve the knowledge and skills of health care providers, and that facilitate care consistent with scientific evidence (ICIC 2008). While treatment decisions based on evidence are important starting points, guidelines may not be as effective unless they are integrated into routine practice (Woolf et al. 1999). Common examples of decision support in prior studies include provider education, integration of clinical guidelines through reminder systems, and distribution of pocket cards to reference clinical information (Solberg et al. 2000; Bonomi et al. 2002; Pearson et al. 2005).
Enhanced delivery system designs assure that the needs of patient populations are met in a proactive and timely manner (Wagner et al. 2001a). This involves regular and well-planned care, not just spontaneous treatment of acute problems (Bodenheimer, Wagner, and Grumbach 2002a). Features of enhanced delivery systems include clearly defined provider roles, appropriate use of specialized health professionals, case management for more complex patients, and planned interactions such as group visits (Wagner 2000; Wagner et al. 2001a; Bodenheimer et al. 2002; Pearson et al. 2005).
Clinical information systems are an essential component of effective care management processes (Wagner et al. 1999); Rundall et al. 2002; Casalino et al. 2003). Such systems provide timely access to both patient and population data, and enable routine documentation of clinical activity and patient care needs. Information systems include disease registries to monitor patient populations, as well as either paper-based or electronic medical records to manage individual patient data (Wagner et al. 2001b; Bonomi et al. 2002; Pearson et al. 2005).
The self-management support element of the CCM supports patient roles in becoming informed, active participants in their own care (Wagner, Austin, and Von Korff 1996). The goal of self-management support is to activate patients by providing them with necessary information and tools to facilitate self-efficacy, i.e., the ability to carry out behaviors in order to reach their health goals (Bodenheimer et al. 2002). A core feature of effective self-management support is the routine application of patient-centered behavior change strategies such as the 5As (Bodenheimer et al. 2002; Glasgow et al. 2004; Wagner et al. 2005).
The final CCM element is that of community resources. This element expands care for patients and may include community programs, local or state health policies, insurance benefits, and advocacy groups (ICIC 2008). An important function of quality care includes leveraging community resources by referring patients to effective programs (Institute of Medicine [IOM] 2001). Thus, the community can play an important role especially in supporting cessation and quit attempts outside of the clinical setting (Barr et al. 2003).
Integration of CCM Elements
The CCM is a multicomponent model outlining six major elements in the organization, health system, and community. Owing to practical limitations, interventions may tend to focus oil only one or two components that are viewed as most conducive to change. For this reason, relationships between each CCM component and 5As delivery will be examined. However, the CCM is ideally conceptualized as a holistic combination of all six elements that work together to foster quality improvement (Wagner et al. 2001a). While it is useful to consider individual aspects of the CCM, little is known about the extent to which care processes are affected by the degree of CCM implementation as a whole. To explore this question, associations between clinic integration of the CCM and provider delivery of 5A services will also be examined.
METHODS
Data Sources
This study used cross-sectional survey data collected from approximately 500 primary care providers in 60 community clinics located throughout New York City. The vast majority of these sites were located in areas serving low-income, minority patient populations. Sites were affiliated with major teaching hospitals, owned by the NYC public health system, and in some cases were part of a private nonprofit entity or a private medical practice.
Two self-administered surveys were used to collect data at both the organizational level and individual provider level. A clinic survey was distributed to 70 sites, and was completed by a medical director or practice administrator at 60 of the sites (85.7 percent clinic response rate). This survey obtained a description of the organization including practice type, staffing patterns, and clinic structures or processes in place for addressing tobacco use. A provider survey was distributed to all clinical staff members at the 60...
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