Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin "Medicaid covers it" campaign.

PURPOSE: Smoking prevalence among Medicaid enrollees is higher than among the general population, but use of evidence-based cessation treatment is low. We evaluated whether a communications campaign improved cessation treatment utilization. DESIGN: Quasi-experimental. SETTING: Wisconsin. SUBJECTS: Enrollees in the Wisconsin Family Medicaid program. The average monthly enrollment during the study period was approximately 170,000 individuals. INTERVENTION: Print materials for clinicians and consumers distributed to 13 health maintenance organizations (HMOs) serving Wisconsin Medicaid HMO enrollees. MEASURES: Wisconsin Medicaid pharmacy claims data for smoking cessation medications were analyzed before and after a targeted communications campaign. HMO enrollees were the intervention group. Fee-for-service enrollees were a quasi-experimental comparison group. Quit Line utilization data were also analyzed. ANALYSIS: Pharmacotherapy claims and number of registered Quit Line callers were compared precampaign and postcampaign. RESULTS: Precampaign, cessation pharmacotherapy claims declined for the intervention group and increased slightly for the comparison group (t  =  2.29, p  =  .03). Postcampaign, claims increased in both groups. However, the rate of increase in the intervention group was significantly greater than in the comparison group (t  =  -2.2, p  =  .04). A statistically significant increase was also seen in the average monthly number of Medicaid enrollees that registered for Quit Line services postcampaign compared to precampaign (F [1,22]  =  7.19, p  =  .01). CONCLUSION: This natural experiment demonstrated statistically significant improvements in both pharmacotherapy claims and Quit Line registrations among Medicaid enrollees. These findings may help inform other states' efforts to improve cessation treatment utilization.

A decade of experience promoting the clinical treatment of tobacco dependence in Wisconsin.

BACKGROUND: The University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) is the designated lead agency at the University of Wisconsin-Madison charged with the responsibility of reducing the harms from tobacco use in Wisconsin and beyond. In 2000, the UW-CTRI, with funding from the state of Wisconsin, launched a population-wide effort--the Wisconsin Cessation Outreach Program (Program)--to increase the availability and use of evidence-based clinical treatments for tobacco dependence. This paper describes the Program's strategies, outcomes, and impact on the clinical treatment of tobacco dependence in Wisconsin. PROGRAM STRATEGIES: The Program was designed to change the standard of health care in Wisconsin, so that primary care professionals, and the health systems in which they work, universally identified and intervened with tobacco users. Five primary strategies were used to accomplish its goal: (1) deliver clinic-based and Web-based training and technical assistance for clinicians, including free continuing medical education (CME); (2) provide technical assistance to accomplish health systems' change to support the routine provision of tobacco-dependence treatment; (3) include evidence-based cessation treatment as a covered insurance benefit and reduce other barriers to cessation treatment such as co-pays; (4) provide telephonic tobacco cessation quit line services to all state residents and integrate it with routine medical services; and (5) reduce tobacco-related disparities by increasing access to and use of evidence-based treatment by priority populations. OUTCOMES: In the 10 years since the Program was initiated, progress has been achieved in a number of tobacco use parameters in Wisconsin, including higher rates of Wisconsin smokers making a quit attempt; increased insurance coverage for cessation counseling and medications; higher rates of discussion of cessation treatment options by clinicians; and integration of the Wisconsin Tobacco Quit Line (WTQL) into routine primary care, with almost 100,000 Wisconsin smokers using the WTQL. Nearly half of all WTQL callers were uninsured or Medicaid enrollees. Additionally, smoking rates in Wisconsin have fallen by almost 20% during this period, from about 24% of all adults in 2000 to <20% today.

The Wisconsin Tobacco Quit Line's Fax to Quit program: participant satisfaction and effectiveness.

OBJECTIVE: The purpose of this study was to assess the Wisconsin Tobacco Quit Line's (WTQL) clinic-based Fax to Quit (FTQ) provider referral program in terms of participant satisfaction and short-term quit outcomes, and to compare those findings to a non-FTQ provider referral group. METHODS: A sample of 432 WTQL callers completed a telephone survey approximately 3 months after they received WTQL services. Of these, 265 contacted the WTQL based on a clinic referral and served as the basis for analyses. Of these 265, 158 FTQ respondents were compared to 107 non-FTQ respondents in terms of satisfaction with the WTQL as well as quit attempts and tobacco abstinence. RESULTS: Overall, survey respondents reported high levels of satisfaction with the WTQL (FTQ = 96.8%, non-FTQ = 92.7%). Other measures of satisfaction (cultural sensitivity, respondent needs and concerns understood) showed similarly high levels of respondent satisfaction for both groups. FTQ respondents reported a statistically significantly higher 30-day abstinence rate (46.8%) compared to non-FTQ respondents (32.7%). CONCLUSIONS: Participants expressed high levels of satisfaction with WTQL services and demonstrated high short-term quit rates. FTQ-referred WTQL users reported higher rates of tobacco cessation than non-FTQ-referred WTQL users. These findings suggest that fax referral has potential to successfully link smokers visiting primary care clinics to the WTQL, an evidence-based cessation option.

Creating a perfect storm to increase consumer demand for Wisconsin's Tobacco Quitline.

BACKGROUND: Telephone quitlines are a clinically proven and cost-effective population-wide tobacco-dependence treatment, and this option is now available in all 50 states. Yet, only 1% of the smoking population accesses these services annually. This report describes a series of policy, programmatic, and communication initiatives recently implemented in Wisconsin that resulted in a dramatic increase in consumer demand for the Wisconsin Tobacco Quitline (WTQL). INTERVENTION: In 2007, the Wisconsin legislature voted to increase the state cigarette excise tax rate by $1.00, from $0.77/pack to $1.77/pack effective January 1, 2008. In preparation for the tax increase, the Wisconsin Tobacco Prevention and Control Program, the University of Wisconsin Center for Tobacco Research and Intervention, which manages the WTQL, and the state's quitline service provider, Free & Clear, Inc., collaborated to enhance quitline knowledge, availability, and services with the goal of increasing consumer demand for services. The enhancements included for the first time, a free 2-week supply of over-the-counter nicotine replacement medication for tobacco users who agreed to receive multi-session quitline counseling. A successful statewide earned media campaign intensified the impact of these activities, which were timed to coincide with temporal smoking-cessation behavioral patterns (i.e., New Year's resolutions). RESULTS: As a result, the WTQL fielded a record 27,000 calls during the first 3 months of 2008, reaching nearly 3% of adult Wisconsin smokers. CONCLUSIONS: This experience demonstrates that consumer demand for quitline services can be markedly enhanced through policy and communication initiatives to increase the population reach of this evidence-based treatment.

A demonstration project for using the electronic health record to identify and treat tobacco users.

BACKGROUND: While the majority of smokers visit a primary care physician each year, only a small proportion of them receive evidence-based tobacco dependence treatment. The electronic health record (EHR) provides an opportunity to prompt clinicians to deliver tobacco dependence treatment in primary care. METHODS: Over 1 year, Dean Health Systems worked with the University of Wisconsin School of Medicine and Public Health to modify the existing Dean EHR system (Epic Systems Corp, Verona, Wisconsin) to improve identification and treatment of adult smokers visiting primary care clinics. Modifications included evidence-based prompts that helped guide medical assistants to identify smokers and clinicians to deliver a brief tobacco cessation intervention (medication and Wisconsin Tobacco Quit Line referral). Eighteen primary care clinics provided data 1 year before and 1 year after implementing the EHR modifications. RESULTS: A higher percentage of adult patients had their tobacco use status identified after EHR modification compared to pre-implementation (71.6% versus 78.4%, P < .001). During the post-implementation year, 6.3% of adult smokers were prescribed tobacco cessation medication, 2.5% of adult smokers had documentation of counseling, and 1.5% of adult smokers had counseling billed (pre-implementation data not available). CONCLUSIONS: This demonstration project showed that a large health care system can increase the delivery of tobacco dependence treatment interventions (increased identification of smokers and relatively high rates of delivering specific tobacco dependence clinical interventions) building on an existing EHR platform. The project demonstrated that brief, evidence-based tobacco dependence interventions can be incorporated into primary care, especially when the EHR is used to improve clinic workflow.

Changing clinical practice, helping people quit: the Wisconsin Cessation Outreach model.

Six University of Wisconsin-Center for Tobacco Research and Intervention (UW-CTRI) Regional Outreach Specialists, based in 5 regions across the state, provide training and technical assistance on evidence-based tobacco cessation interventions to clinics, hospitals, health systems, insurers, community organizations and worksites through academic detailing methods. The core of this approach involves individualized training on the U.S. Public Health Service Clinical Practice Guideline, "Treating Tobacco Use and Dependence" as well as follow-up technical assistance to achieve sustainable system changes and a reduction in barriers to tobacco cessation services. The program's scope includes health systems, managed care organizations, hospitals, worksites, and community organizations. The program also links organizations and the communities they serve to the Wisconsin Tobacco Quit Line and related cessation services. Since 2001, over 10,000 health care providers in over 500 clinics and 26 health systems and managed care organizations have received Guideline-based cessation training through the Outreach program. This paper examines research supporting this Cessation Outreach Model, describes its operation, discusses key outcomes, and reviews future directions and applications.