Dissemination of Addiction Research: An integrated knowledge to action framework for tobacco dependence treatment

Transcription

1 Dissemination of Addiction Research: An integrated knowledge to action framework for tobacco dependence treatment Authors: Selby P, MBBS,Dragonetti R, MSc, Herie, M, PhD, RSW & Zawertailo L, PhD Doctor Addiction therapist Social Work Pharmacologist

2 Disclosures Funding provided by the Government of Ontario and Government of Canada. Medications are purchased from Pharmaceutical companies at a discounted rate through a tendering process. All authors have received honoraria and or grant funding from manufacturers of stop smoking medications as Dr. Selby has served on advisory boards for these manufacturers. All studies have been registered at Clinicaltrials.gov

3 Objectives Understand the story of how we need to marry practice, research, KT and policy in one unit to promote better outcomes for patients with addictions Nicotine Dependence Clinic at CAMH within the Addictions Program ( 13 services, inpatient, outpatient~8000 unique clients per year) Replication in other services within the Addictions Program

4 2 million smokers in Ontario, Canada Health Care is a provincial responsibility 2 Ministries Health Promotion and Sport Health and Long Term Care Fragmentation SFO- smoke free legislation, taxation, denormalization, prevention But what about a clinical response? Background

5 RESEARCH PRACTICE There are therefore 2 major disconnects between research and practice: research may not translate expeditiously to everyday practice, and clinical problems encountered in everyday practice are often under-investigated. (Tierney et al., 2007)

6 Theoretical framework - Knowledge to Action- Graham et al. Pathmans Precede framework- Davis et al Diffusion of innovation- Greenhalgh,2004 Social networking- medical sociology Evaluation: REAIM ( R. Glasgow) adapted by Selby (REAIM/Time and Money) Adapted from Greenhalgh, 2004: Help it happen Let it happen Make it happen

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8 Model: increase the number of ex-smokers in Ontario by addressing barriers at various levels CAMH Increased access to treatment for smokers Direct to smokers (behavioural and pharmacotherapy) Increased access to treatment for special populations Increased capacity of HCPs and systems Indirect interventions through healthcare Intermediaries in a variety of ambulatory settings All models are wrong, but some are useful George Box, Robustness in Statistics, Academic Press, Increased quit attempts by smokers Decreased smoking by demand reduction (increased exsmokers)

9 Translating Research to Practice Practitioner-identified gaps in knowledge Guidelines used in practice Relevant research produced New evidence incorporated into dynamic guidelines Is A SINGLE CYCLE ENOUGH?

10 MAKE THE KNOWLEDGE SOCIALLY INFECTIOUS CHANGING HEARTS AND MINDS OF LEARNERS

11 RESEARCH PRACTICE Knowledge generator ( primary or secondary) implementer User/tester UNIFIED VISION

12 Methods 1. To develop an interprofessional, integrated clinical, research, policy and knowledge translation clinic in Ontario, Canada to increase quit attempts by facilitating the adoption of evidence based/informed interventions by smokers and health care providers. 2. To integrate clinical and public health approaches to maximize reach while reducing health disparities.

13 Setting(s) Hub: The Centre for Addiction and Mental Health, University of Toronto Participants Health care practitioners, tobacco control researchers, administrators, educators, and smokers.

14 CAMH Nicotine Dependence Tobacco Research, Education, Practice and Policy STOP Study Intervention Studies Experimental Studies Cells to Society OTRU- Roberta Ferrence Tony George Rachel Tyndale Bernard Lefoll Usoa Busto TEACH Nicotine Dependence Clinical Services Research Clinicians Graduate training Researchers Practice Education Policy Smoke Free Policy Cessation System Design Advocacy across fields PREGNETS CANADAPTT

15 indicators: does this work? A case study Number and types of smokers treated and outcomes Clinic data SMI paper, pharmacoextinction paper, Quit rates at end of treatment and 6 month follow up. STOP with REAIM Number and types of health professionals trained. TEACH Follow up Spread Number and type of health professionals participating in smoking cessation guideline development. Canadaptt Number of graduate and clinical trainees TUSP: Fellows in NDC- charl els, Wajid Ahmed, Pamela Kaduri

16 PRACTICE

17 Nicotine Clinic Smokers Combination of Evidence based and Evidence informed practice- active and passive interventions. In 5 years, 4,570 unique clients and over 32,300 visits Avg age is 50 Max age is 96 and the min was 14 63% Males 37% Females Administrative data sets are poor. Lots of missing data

18 Nicotine Clinic Smokers The clinic focuses on those with disparity or comorbidity Subsidized meds Groups Tailored treatment 50% unemployed 41% high school or less

19 RESEARCH

20 Case control of those with SMI (55) versus other mental illness/addiction (110) No difference in quit rates at end of treatment Males did better More sessions attended (>12) associated with quitting

21 Clinic implications Even though most of our clients have psychiatric/addiction co-morbidities they are able to achieve abstinence by: Individualized approach to treatment- MI trained staff Continued support for as long as they want ( alumni groups) Combination pharmacotherapy at reduced cost Multi-disciplinary clinical team

22 Clinical Studies stimulated by observations in the clinic: Smoking following methadone administration significantly increased ratings of euphoria and drug liking and decreased opioid withdrawal scores (Elkader et al, J Clin Psychopharmacol 2009) Smoking concurrently with NRT; titration to effect increasing patch dose over 10 weeks resulted in corresponding decrease in CPD, CO and cuereactivity (Selby et al, in preparation) Depressed smokers show increased prefrontal brain activation in response to smoking cues as a function of depression severity (Kushnir et al, Int J Neuropsychopharmacol 2010) Varenicline in drinker/smokers heavy drinkers show decreased cueinduced craving for alcohol after 2 weeks of varenicline compared to placebo treatment (Staios et al, in preparation) Candidate gene studies in STOP sample show association between CART, ANKK1, NRNX1 variants and early age-at-onset of daily smoking and severity of tobacco dependence (Lobo, Zawertailo et al, in preparation)

23 Population based interventions

24 The STOP Study: Transforming cessation across the province In 2005 to Study Program How do you increase the reach of evidence based smoking cessation interventions with limited funding? Can we do to pharmacotherapy what we did with counselling? i.e. lower cost quit lines? Can we have bigger impact if we enhance reach at the expense of efficacy?

25 % of Respondents QUIT RATES End of Tx 6-Month NRT only NRT + Counselling PHU CHC Pharmacy Workshop Mass Distribution Tertiary Care Centers but quit rates don t tell the whole story

26 STOP reached across the province including remote areas with little or no service where smoking rates are higher than the provincial rate s p e n

27 Findings and Conclusions The population based models have reached 60,000 smokers in 5 years 6 month quit rates (7 day point prevalence, ITT) are between 11 to 30% Limitations self report by IVR or phone Multiple cohorts Advantage: pragmatic studies possible-

28 RE-AIM Dimensions Evaluation Dimensions Reach Proportion and representativeness of the target population that participate in an intervention Efficacy/ Effectiveness Adoption Implementation Maintenance Magnitude of improvement on outcomes of concern Proportion of settings or organizations that adopt the intervention Consistency and quality of intervention delivery Maintenance of positive outcomes over time (individuallevel) and extent to which the program is sustained (organizational-level)

29 RE-AIM and STOP: Specifics Mass Distribution PHU/CHC Tertiary Care Pharmacies Workshops Reach 33,048 over 12 months 2300 over 40 months 2358 over 2.5 years 7273 over 12 months 6808 over 12 months Efficacy/ Effectiveness 45% quit at EoTX 52% quit at EoTx 47% quit EoTx 41% quit at EoTx 36% quit at EoTx Adoption High: call centre hired Low: 26/127 invited sites High: 3/3 invited sites High: 98 pharmacies High: 36/36 invited sites Implementation Easier: trained staff to protocol Harder: limited capacity Easy in existing TD clinics but Hard to start Easy to Hard increased workload w/o pay Easy: partnered with existing HC agencies Maintenance (individual/ organization) Moderate(21% quit 6M) Easy to Hard:low human res. but funding needed Low to Moderate(16-31% quit at 6M) Hard: human resources High(39% quit at 6M)/Hard(no funding to sustain) Moderate (24% quit at 6M) Harder (need pay for service) Moderate(25% quit at 6M) Easy to Hard (requires continued funding)

30 TRAINING

31 (TEACH) Findings and Conclusions TEACH: Training Enhancement in Applied Cessation Counselling and Health 3 days core + 2 day specialty ( eg addiction/mental health, women, integrated risk factor reduction), cultural adaptations. Communities of practice The training program has trained over 1800 health care professionals across 15 disciplines Over 75% of participants report offering treatment at 6 month follow up (March 2010 cohort) 98.6% report knowledge transfer activities posttraining.

32 Smoking Cessation Guideline development and engagementacross Canada

33 Initial LITERATURE REVIEW for existing Clinical Practice Guidelines COMPREHENSIVE LITERATURE SEARCH 5 Guidelines Included 87 Guidelines Found Version 1.0 February 2009 Currently Posted Appraisal: AGREE 4 independent reviewers (practicing physicians) All formally trained on AGREE instrument Appraisal: AGREE Plus 8 Additional questions developed by CAN-ADAPTT to understand the applicability of the recommendations in the Canadian context The CAN-ADAPTT program engaged the Guidelines Advisory Committee Highest scoring CPG s included 6 Guidelines Included HIGH QUALITY CLINICAL PRACTICE GUIDELINES U.S. Department of Health and Human Services Public Health Service: Treating Tobacco Use and Dependence (2008 Update), New Zealand Smoking Cessation Guidelines (August 2007), Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (March 2007), Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (October 2003), Institute for Clinical Systems Improvement. Tobacco use prevention and cessation for infants, children and adolescents (June 2004), Institute for Clinical Systems Improvement Tobacco use prevention and cessation for adults and mature adolescents (June 2004).

34 HIGH QUALITY CLINICAL PRACTICE GUIDELINES CAN-ADAPTT Summary Statements 7 clinical sections discussed Workshop held: November 1, CAN-ADAPTT members attended and provided feedback The Guideline Development Group (GDG) reviewed the section notes and determined revisions to the summary statements. CAN-ADAPTT Summary Statements Sections: Prevention and Population Health Approaches Workshop TBD: (September 2010) Network input Version 2.0 Release Date June - September 2010 Input from CAN-ADAPTT Network Spring Summer 2010 Version 3.0 Release Date Winter 2010 Network Input

35 A Practice-Informed Approach network includes700 members: 26% Nurses/Nurse Practitioners 23% Dental Hygienists/Assistants 7% Pharmacists 6% RT s/asthma Educators 5% Social Workers 7% Counselors/Therapists.Physicians, psychologists, chiropractors, dentists 20 national professional organizations *As of August, 2010

36 CAN-ADAPTT SEED Grants 23 applications received from across Canada; 12 funded Diverse practitioner groups and disciplines represented For example, grants awarded to projects in optometry: Exploring beliefs, practices and needs of optometrists, related to smoking cessation counselling practices Opportunities for future involvement of optometry community in smoking cessation. Disciplines Optometry Women s health Addictions Mental health/ psychiatry Health sciences Topic Themes Specific populations Role of HCPs Counselling Capacity and theory building Proposed Products Scientific publications Academic posters Grant proposals Collaborative meetings

37 TUSP Tobacco Use in Special Populations CIHR funded training grant over 5 years There have been several fellowship-trained physicians in tobacco dependence through the TUSP project. 1. Dr. Charl Els 2. Dr. Keyghobad Farid Araki 3. Dr. Wajid Ahmed

38 Policies We have implemented and evaluated smoke free policies in psychiatric/addiction facilities and nursing homes.- published in General Hospital Psychiatry

39 The Team STOP Clinical Director, PI, Executive Director Dr. Peter Selby Clinic and Project Manager Rosa Dragonetti TEACH Project Scientist Dr. Laurie Zawertailo Program Secretary Natalie Marconi Project Manager Jess Rogers Project Director Dr. Marilyn Herie Research Coordinators Sarwar Hussein Justine Mascarenhas Sabrina Voci Research Analysts Rackell Levin Bianca Filoteo Dave Teixeira Virginia Ittig Deland Stephen Gallant Kristine Tomcheski Therapists Melonie Ceresne Tania Campbell Stephanie Cohen Linda Fisher Patrick Newland Registered Nurse Alexandra Marconi Pharmacist Eva Janecek Physicians Dr. Kabasele, Dr. Le Foll Dr. Lefevre Project Coordinators Tamar Meyer Katie Hunter Janet Ngo Project Secretary Stephanie Elliott CANADAPTT Clinical Fellow Dr. Pamela Kaduri Project Coordinators Megan Ann Tasker Education Specialist Robin Chapchuk Research Analysts Julia Lecce Education Associates Sheldon Parchment Stephanie Sliekers Megan Barker NICOTINE CLINIC

40 Lessons learned KT is an iterative process Models are still in development KT needs champions Collaboration within and with other partners is key Replication is key: Problem Gambling, Alcohol

41 Corresponding author Peter Selby MBBS, CCFP Associate Professor, Departments of Family and Community Medicine and Psychiatry and the Dalla Lana School of Public Health, University of Toronto Clinical Director, Addictions Program, CAMH PI, Ontario Tobacco Research Unit. Mailing Address: Centre for Addiction and Mental Health 33 Russell Street, Toronto, Ontario M5S 2S1, CANADA