Every Opportunity in Cancer Care Environmental Scan

Transcription

1 Every Opportunity in Cancer Care Environmental Scan Final Report December 2015 Workforce Research and Evaluation Team Michelle Stiphout, Research & Evaluation Consultant Stephanie Hastings, Research & Evaluation Consultant This work was contracted by the Alberta Cancer Prevention Legacy Fund (ACPLF)

2 Acknowledgements Workforce Research and Evaluation would like to thank the tobacco cessation clinic staff and managers who generously contributed time and background documents for this project. The report produced from this project is owned and copyrighted by AHS. It may be reproduced in whole or part for internal AHS use. WRE must be acknowledged in all publications where materials produced under this agreement are copied, published, distributed or reproduced in any way in whole or in part. Citation should appear as follows: Stiphout, M., & Hastings, S. Every Opportunity in Cancer Care Environmental Scan Final Report. Calgary, AB: Workforce Research and Evaluation, Alberta Health Services. For any use external to AHS, this work may be produced, reproduced, and published in its entirety only, and in any form including electronic form solely for educational and non-commercial purposes without requiring consent or permission of AHS and the author. Any reproduction must include citation listed above. Workforce Research and Evaluation, AHS December /29

3 Table of Contents Acknowledgements... 2 Background... 4 Method... 5 Results... 6 Referrals and Intake... 8 Assessment... 9 Treatment Follow-up and Monitoring Overall Staffing Recommendations Quit Rates Cost Effectiveness Barriers and Facilitators Unique Treatment Options Treatment Considerations Resources and Potential Partners References Appendix A: Interview Guide Appendix B: Details of Clinic Activities Workforce Research and Evaluation, AHS December /29

4 Background Smoking is the leading preventable risk factor for cancer and is responsible for an estimated 30% of all cancer related deaths (Alberta Cancer Prevention Legacy Fund [ACPLF], 2014). Furthermore, literature shows that tobacco use can lead to reduced rates of survivorship, hinder adherence to and effectiveness of cancer treatments, and lead to secondary cancers (ACPLF, 2014; McBride & Ostroff, 2003). This evidence provides a foundation for the development of comprehensive prevention-based interventions targeting cancer patients and their families in cancer care settings. The Every Opportunity in Cancer Care project is an opportunity to implement these prevention interventions across cancer care settings in Alberta. The first phase of this project includes establishing prevention and screening care teams and integrating tobacco cessation interventions within CancerControl (ACPLF, 2014). The initial focus of this phase will be on establishing and training two multidisciplinary prevention teams to provide intensive tobacco treatment to cancer patients and their families in clinics near cancer treatment locations in Calgary and Edmonton. Before the clinics can be established, it is important to understand and explore existing tobacco cessation models, particularly those that are integrated in the care of cancer patients. Workforce Research and Evaluation, Alberta Health Services (AHS), was contracted to undertake an environmental scan to examine existing models with a focus on the activities required in cessation clinics and the provider types suitable for employment in these settings. This environmental scan involved two stages; the first, submitted to ACPLF in September, was a brief overview of existing tobacco cessation programs in Alberta and Manitoba. The second stage provides a more in-depth analysis of these programs as well as others identified for inclusion. Workforce Research and Evaluation, AHS December /29

5 Method We conducted semi-structured interviews with managers and staff from eight tobacco cessation clinics: five tobacco cessation clinics in Alberta and Ontario and three cancer-focused tobacco cessation clinics in Manitoba, Texas, and New York. We also interviewed a staff member from one Alberta provincial tobacco reduction education program and two staff members from an endocrine therapy clinic that was identified as having a format that might be suitable for use in the new ACPLF clinics. Interviews began with an affirmation of consent to be interviewed and for the interview to be recorded. The interview guide is in Appendix A. Interviews were recorded and/or detailed notes were taken by the interviewer. We reviewed available documents for each of the programs. This included publicly available resources (e.g., from websites or through journal articles) and program resources such as clinic guidelines and annual reports provided by our contacts in the programs. In addition, we examined the tobacco cessation resources in Alberta (i.e., AHS Tobacco Reduction Program) and the Mayo Clinic tobacco cessation model used by two of the programs. This report covers the cumulative findings based on the preliminary report and all data collection from that point on. Programs reviewed for the initial report include: Foothills Primary Care Network (PCN) My Health Program Quit Smoking Workshop, Calgary AB Mosaic PCN Tobacco Cessation Classes, Calgary AB Red Deer PCN, Red Deer AB Manitoba Cancer Care Tobacco Cessation Program, Winnipeg MB AHS Tobacco Reduction Program The additional programs reviewed for the final report include: Brant Quit Clinic, Brantford ON The University of Ottawa Heart Institute Quit Smoking Program (Ottawa Heart) and the Ottawa Model for Smoking Cessation (the Ottawa Model), Ottawa ON Memorial Sloan Kettering Cancer Center s Tobacco Treatment Program, New York NY MD Anderson Cancer Center s Tobacco Treatment Program, Houston TX Breast Endocrine Group Medical Clinic, Edmonton AB Workforce Research and Evaluation, AHS December /29

6 Results Overview of Models Eight tobacco cessation clinics were reviewed in the environmental scan. Five noncancer focused clinics (hereafter referred to as general tobacco cessation clinics) were included: Foothills PCN s Quit Smoking Workshop, Mosaic PCN s Tobacco Cessation Classes, Red Deer PCN, Brant s Quit Clinic, and the Ottawa Heart /Ottawa Model. Three tobacco cessation clinics specifically for cancer patients (hereafter referred to as cancer-focused tobacco cessation clinics) were also included: Manitoba Cancer Care Tobacco Cessation Program, Memorial Sloan Kettering Center s Tobacco Treatment Program, and MD Anderson Cancer Center s Tobacco Treatment Program. We reviewed the intake and assessment processes of one non-tobacco cessation clinic, the Breast Endocrine Group Medical Clinic in Edmonton, and also interviewed a representative from AHS s Tobacco Reduction Program. Table 1 shows an overview of the eight tobacco cessation models. Table 1. Model Overview Model Type Population Schedule 1 Staffing Format # of Patients 2 Brant Quit Clinic 285 new patients Foothills PCN Manitoba Program MD Anderson Mosaic PCN Ottawa Heart Red Deer PCN Sloan Kettering Not cancer specific Not cancer specific Cancer Cancer Not cancer specific Not cancer specific Not cancer specific Cancer Adult (18+) residents of Brant PCN referred patients Cancer patients, families, staff Cancer patients, families General population Ottawa Heart Hospital inpatients PCN patients Cancer patients, families 4.5 days/ week Clerk, RNs, Evaluation team manager 4-1 hour weekly evening classes Clerk, Clinical Nurse, Pharmacist(s) 3.5 days/ week Clerk, NP, RNs, Pharmacist & pharmacy tech 5 days/ week Support Staff, Counsellors, Medical Staff hour evening or daytime weekly classes 2 ½ days and 1 full day/ week Varies; delivered by nurses offering a variety of programs Clerk, RNs, Pharmacist Clerk, RNs, Automated calling system Clerk, RNs, Pharmacists 5 days/ week Clinic coordinator, NP, Oncology Nurses, Clinical Psychologist 1:1; mostly inperson but phone options available Group classes 1:1 in-person and phone options 1:1 in-person and phone options Group classes 1:1 in-person and phone options; group classes No data 142 total patients 1,242 new patients No data 5000 total patients 1:1 in-person 224 new patients 1:1 in-person and phone options No data 1 Includes the times the clinic is available to patients (either in-person or over the phone). 2 Types of patient data available varied by program Workforce Research and Evaluation, AHS December /29

7 It is important to note that the Ottawa Model is a customizable program that assists clinics in identifying, treating, and providing follow-up care to smokers. The original program was developed in and for the Ottawa Heart Institute. Since then, the Ottawa Model has been expanded and implemented in over 350 sites across Canada. In this report we refer to both the Ottawa Model as a whole and the Ottawa Heart tobacco cessation program specifically. The remainder of this report is divided into four sections: summaries of clinic capacity, clinic activities and staffing, outcomes, and a list of unique or important topics identified in our interviews and document review. Capacity The clinics function at different capacities. The Brant Quit Clinic, MD Anderson, and Sloan Kettering are full-time, stand-alone clinics. The rest of the clinics are open part-time. The Manitoba program runs in parallel with an oncology clinic. Most of its practitioners average 0.2 full-time equivalent (FTE) and the clinic is open to patients three half-days each week. In addition, the nurse works another two full days to do follow-up calls. The PCN programs (Red Deer, Foothills, and Mosaic) are run by multidisciplinary teams offering a number of different healthy living programs. Therefore, the specific tobacco cessation program activities are usually fit in between other program or clinic activities. For example, the Foothills PCN noted that their clerk spends about one-third of her time on tobacco cessation program activities and the multidisciplinary team members rotate facilitating the cessation courses. The patient capacity of these clinics varies depending on each clinic s structure. The Manitoba program had 82 patients in the first half of 2015, the Calgary PCNs register approximately people in their classes which run almost every month (although actual attendance is usually quite a bit lower), and the Red Deer PCN had 216 patients join the program last year. The clinics functioning at a higher capacity were able to reach more patients. Ottawa Heart nurses each see around 1,000 patients per year and MD Anderson provided some kind of support to 5,293 new patients from May 2014-April Most of these patients chose not to join the treatment program and therefore received the minimum level of support (i.e., an educational package and a follow-up phone call); however, MD Anderson still provided either in-person or phone-only support to almost 1,000 new patients that year. Clinic Activities The following section highlights some of the basic activities and the different provider types that should be considered for those activities. For details of the cancerfocused and general tobacco cessation clinic activities, see the tables in Appendix B. Workforce Research and Evaluation, AHS December /29

8 The basic activities in all the smoking cessation programs include: Referrals and Intake Assessment Treatment Follow-up and Monitoring Referrals and Intake Smokers are identified and referred to the cancer-focused tobacco cessation programs through routine screening with their physician or oncologist. Patients can also self-refer to the Manitoba program. The Manitoba program and MD Anderson also provide treatment to cancer patients family members and health centre employees. In the general tobacco cessation clinics, the Red Deer and Foothills PCNs accept only PCN patients whereas the Mosaic PCN accepts both PCN and non-pcn affiliated patients. The Brant Quit Clinic has done extensive work connecting with the health care community and integrating themselves in their processes. As a result, providers in the community are aware of what the clinic offers so they can recommend the Quit Clinic as a resource for smokers. The Brant Quit Clinic also developed a referral form which is a part of hospitals and doctors office computer systems. In all of the clinics, program staff attempt to contact referred patients to sign them up for treatment. This is not a restricted activity. All of the clinics have a clerk or support staff contacting patients. Because this is the patient s first contact with the program, tobacco cessation training, particularly the brief intervention training, was identified as being beneficial for someone in this role. This training provides the clerk with the tools to support the patient and assess motivation. Although the patient may not be ready to quit at that moment, interviewees said that every contact the clinic has with a patient is an opportunity to increase the patient s readiness to quit. Interview participants noted that tobacco cessation programs have high drop-out rates. Therefore, part of the intake person s job is to be persistent in trying to contact patients referred to the program. It is important to have someone in this role that has time to do the bookings, follow-up calls, and reminders. Because motivation for quitting can ebb and flow, some clinics found it helpful to have a real person available to answer the phone if a patient calls rather than having a voice mail message. Finally, many programs noted that there must be high-quality staff in this role. The clerk is often the first contact that the patient has with the program and therefore needs to be able to engage and motivate patients. Workforce Research and Evaluation, AHS December /29

9 Assessment Assessments were done in one of three ways: over the phone, in person, or in a group session. To build rapport and provide consistency, in most cases the assessments are done by the provider who will be the patient s main contact. All of the cancer-focused tobacco cessation programs have individual assessment sessions. Sloan Kettering does a short risk assessment over the phone to determine whether the patients are appropriate for treatment in the telephone program or the in-person program. The Manitoba program and MD Anderson have intensive in-person initial visits as a part of their assessment. Because these clinics provide medication for free, coming in for the initial assessment is a key component of their programs. MD Anderson s two-hour assessment, conducted by a trained counsellor, is particularly intensive. It includes an hour-long online psychological screening for depression, anxiety, and nicotine dependence. The counsellor reviews the results with the patient and together they build an individualized treatment plan. The Brant Quit Clinic also has an intensive initial appointment. Their assessments are conducted by the Registered Nurses (RNs) who are the primary treatment providers. The Calgary PCNs have a clerk do a short assessment over the phone when the patients are registered for the program and any other assessment is done with the group as a part of the classes. We also included the Edmonton endocrine clinic in the report because they offer a unique group introductory session which provides information about endocrine treatment. They use this format because providers noticed that they were repeating the same fairly complex background information over and over in initial appointments. They felt that it would be more efficient to present the information in a group instead. The group session is immediately followed by short (10 minute) one-on-one sessions to discuss appropriate individual treatment options. An added benefit of the group session is that it provides an opportunity for the patients to build connections with peers. While this approach works very well with this specific population (post-menopausal breast cancer patients), staff did note that breast cancer patients tend to be very well informed and that having an in-depth PowerPoint presentation may not be appropriate for all cancer populations. Other than the comprehensive psychological assessments in one clinic, no assessment activities appear to be restricted 3. Based on the clinics reviewed, collecting information about the patient s past smoking habits, quit attempts, and medical background was done by either a clerk or the primary treatment provider. 3 If psychological assessments are to be included, a registered psychologist may be required. For the purposes of this report, we have assumed such assessments will not be used in the new Alberta clinics. Workforce Research and Evaluation, AHS December /29

10 Treatment There are fairly standard treatment activities involved all of the tobacco treatment programs and interventions. The Tobacco Free Futures Guidelines (AHS, 2014) focus on brief tobacco interventions, intensive cessation counselling (including motivational interviewing, practical counselling using cognitive behavioural therapy and social cognitive therapy, and prescriptive relapse prevention), and pharmacotherapy. All of the programs include these elements in their treatment. The models differ not in what treatments are being offered, but how they are offered. Differences include whether the clinics offer group sessions or one-on-one support, if the sessions are delivered in-person or over the phone, and which providers deliver the treatment. Although the treatment options are all based on the same core activities, we did see a variety of providers filling those positions. It was also noted that the level of treatment provided must match each patient s needs (AHS, 2014). Some patients respond to only a brief intervention while others require more intensive support. Best practice guidelines state that a combination of pharmacotherapy and counselling is most effective in tobacco cessation treatment (e.g., AHS, 2014; U.S. Department of Health and Human Services, 2008). Pharmacotherapy includes over-thecounter Nicotine Replacement Therapy (NRT) and prescription medication such as Bupropion SR and Varenicline. Three programs (Manitoba, MD Anderson, and the Brant Quit Clinic), provide smoking cessation medication for free. These programs vary in the types of medication they provide. The Brant Quit Clinic only offers free NRTs while MD Anderson and the Manitoba program offer both NRTs and prescription medication for free. The rest of the programs provide prescriptions, education, and support for different smoking cessation medication options. Several programs identified the lack of free medication as a major barrier for patients trying to quit. Of the provider types we reviewed, only Nurse Practitioners (NPs) and pharmacists with the appropriate certification are allowed to prescribe the prescription medications (i.e., Varenicline and Bupropion SR). Pharmacists can prepare and dispense the medication, as can pharmacy technicians under the supervision of a pharmacist. RNs, Registered Psychiatric Nurses (RPNs), and NPs can dispense medication and all medically trained professionals can provide education on the medication. Clinics that do not have providers on staff with prescribing ability have found ways to provide prescriptions; the Ottawa Heart clinic works under a medical directive to prescribe cessation medication to patients and the PCNs are connected to physicians who write the prescriptions. In addition to the pharmacotherapy, counselling is the other key component in smoking cessation treatment. The two American clinics are very focused on providing psychological support for the cancer patients trying to quit smoking. Sloan Kettering provides two levels of counselling support. A clinical psychologist treats the high-risk Workforce Research and Evaluation, AHS December /29

11 patients in person and tobacco treatment trained oncology NPs provide over-the-phone treatment for the rest of the patients. MD Anderson has a team of counsellors who provide the counselling treatment. In the Manitoba program the primary counselling is done by an RN and the patient is referred to a social worker if they need additional support. All of the general tobacco cessation programs use tobacco cessation trained RNs for their treatment and in some cases a pharmacist is also involved. All three cancer-focused clinics provide treatment to remote patients. This includes patients who live far away from the clinic as well as those who have difficulty keeping consistent in-person appointments. The Manitoba program offers their services to a number of remote patients. Challenges include not being able to provide face-to-face support and the complication of sending the free medication out to those patients. MD Anderson and Sloan Kettering have treatment plans which specifically offer treatment and support over the phone. Sloan Kettering still provides prescriptions for these patients but MD Anderson does not. In Alberta, if intensive tobacco cessation counselling is considered psychosocial therapy (i.e., a restricted activity), only NPs, RNs, RPNs, or trained counsellors are allowed to provide it independently. Licenced Practical Nurses (LPNs) can provide this counselling under the supervision of one of those other providers. While motivational interviewing, education, and cognitive behavioural therapy could be categorized as restricted activities in some cases, the upcoming training offered by AHS s Tobacco Reduction Program trains anyone to do these activities, including people with no medical training. It was noted that these activities are not considered restricted in the case of tobacco cessation. Smoking can impact the body s uptake of medication. Therefore, it is important to have a provider involved in the intervention who can monitor the patient not only for side effects of tobacco cessation medication, but for indications that doses of other medications, including cancer medications, may need to be modified when patients decrease or quit tobacco. Follow-up and Monitoring Follow-up is offered via phone calls or in-person visits. The follow-ups are to check in, provide treatment and support, assess the treatment plan, and gather outcomes information. Rapport was noted as being an important part of follow-up sessions and therefore the follow-ups are usually done by the person who was most involved in the patient s intervention and treatment. The cancer-focused clinics offer both in-person and phone follow-up options. Follow-ups include a status check, as well as counselling and medication treatment. In the Manitoba program the RNs typically do the follow-up appointments; the NP or pharmacist may also join if needed. The Manitoba program dispenses medication on a monthly basis Workforce Research and Evaluation, AHS December /29

12 and the patient has to come to the clinic to receive the medication and review how it is working (remote patients are an exception to this). MD Anderson s counsellors do the inperson or phone counselling and the support staff or counsellors also do periodic follow-up and monitoring calls. Medication is mailed out to patients; medical assessments to assess side effects or determine the need for medication changes are done over the phone with the clinic s medical staff (i.e., medical director, physician assistant, advanced practice nurse, or RN). Similarly, nurses or clerks conduct the follow-ups in the general tobacco cessation clinics. The Red Deer PCN and the Brant Quit Clinic offer both in-person and phone call options and the follow-up sessions can involve additional treatment. This is particularly important for the Brant Quit Clinic as they provide free medication. To reduce wastage, the Brant Quit Clinic only dispenses enough medication to get the patient to their next appointment, which is usually about a week later. The most unique follow-up technique was offered by the Ottawa Heart program. They use an automated calling system to follow-up with patients to see if they need more support and to collect evaluation data in an unobtrusive way. The automated calling system allows the program to make scarce resources go further by using technology to identify the patients who need counselling and support the most and by freeing up staff to focus on other work. Overall Staffing Recommendations Table 2 shows the competencies of the various provider types considered in this review. The providers selected for inclusion in Table 2 were based on the early assumptions of the ACPLF project team as well as the staff mix in the tobacco cessation clinics examined. Two notable positions excluded from the analysis are physicians and clinical nurse specialists. These two positions were excluded to streamline the table and focus on the most viable options. Because it was already decided that NPs would be involved in the new Alberta clinics there was no need to include the role of a physician. Three types of nursing providers are included in the table: RN, RPN, and LPN. The interviews revealed that often the role of clinical nurse was held by an RN and the differences in allowable restricted activities between an RN and clinical nurse specialist do not impact any of the activities outlined in the table. Therefore, including this additional nursing role would not provide any additional information. Two new positions were added for the final report. Based on the interviews with the American clinics and the Ottawa Model, a psychologist and the automated calling system (Interactive Voice Response [IVR]) were added to the table. The optimal staff mix for the ACPLF s Intensive Tobacco Treatment clinics will depend on many factors: the types of treatment offered, the number of patients, the number of staff, Workforce Research and Evaluation, AHS December /29

13 and so on. Based on the findings presented in Table 2, the providers who can do the most clinic activities are the nurses (i.e., NP, RN, RPN, and LPN), psychologist, respiratory therapist, and pharmacist. NPs can prescribe all of the tobacco cessation medication and the pharmacist can prescribe NRTs and, if they are certified, can also prescribe the smoking cessation medications. RNs and RPNs are qualified to do all activities except prescribing; LPNs can do most of those activities, except dispensing medication, but may require supervision for some. There is no apparent added benefit to hiring an RPN over an RN or vice versa. The respiratory therapist was recommended by the AHS Tobacco Reduction Program; however, none of the clinics we interviewed use respiratory therapists. Many of the programs use pharmacists not only to dispense medication but also as a part of the treatment team (e.g., facilitating classes). We found varying support for having counsellors (i.e., psychologists or social workers) involved in the treatment. All of the cancer-focused clinics included the option for some kind of psychological support and the prevalence of mental health co-morbidities in the target population needs to be taken into consideration. The American clinics triage their patients so that those with higher risk factors or diagnosed psychological comorbidities receive treatment from trained counsellors. The Manitoba program noted that although they originally planned to have the social worker available for patients who required additional support, sometimes that interfered with other counselling or support that the patient was receiving (e.g., from a psychologist or social worker associated with the cancer treatment program). That said, the social worker was beneficial when patients required additional support which the clinic did not have the capacity to offer or if they needed more intensive behavioural counselling. Based on the Tobacco Free Futures Guidelines (AHS, 2014), there appears to be limited value to having a social worker involved in the initial intervention. The tobacco-specific counselling skills that they offer can also be done by all the nursing providers and pharmacists with training. However, there are a number of activities that social workers cannot do, including medication administration and assessing symptoms of withdrawal and medication side-effects. The clerk is an essential role for booking, scheduling, and re-scheduling appointments. The extent of the clerk s role will depend on the program s needs but because most of the new AHS Tobacco Reduction Program Learning Series can be taken by anyone, the clerk could also have an engaging role as a member of the tobacco cessation team. Depending on the responsibilities expected of the clerk, a Clerk III (as classified by Alberta Health Services) is likely the most appropriate position. As noted above, using tools such as the automated calling system can assist with the follow-up and monitoring of the patients. This system was found to be very successful in the Ottawa Heart clinic but would need to be investigated for appropriateness with cancer patients. Workforce Research and Evaluation, AHS December /29

14 Intake: Table 2. Competencies of relevant providers in ITT programs Responsibilities NP RN RPN LPN Pharmacist Psychologist Social worker Respiratory Therapist Clerk IVR 4 Accept referral X X X X X X X X X - Triage X X X X X X X X X - Scheduling appointments X X X X X X X X X - Assessment: Complete assessment form X X X X X X X 3 X X 3 - Patient health history X X X X X - - X 2 X - Assessing readiness to quit X X X X X X X X 2 X 2 - Treatment: Treatment plan X X X X X X - X Motivational interviewing X X X X 1 X 2 X X 2 X Cessation education X X X X X X X X - - Cognitive behavioral therapy X X X X 1 X 2 X X 2 X Prescribing pharmaceuticals X X Dispensing pharmaceuticals X X X - X Pharmaceutical education X X X X X X 3 - X - - Follow-up: Assessing withdrawal symptoms X X X X X X 3 - X Assessing side-effects X X X X X X 3 - X Ongoing support X X X X X X X X 2 X 3 X 2 Monitoring: Follow-up phone calls X X X X X X X X X X Collect outcomes data X X X X X X X X X X Program evaluation X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2 X 2-1 Can be completed but requires supervision 2 Depending on the specifics of the activity may be out of scope or require additional certification, further clarification required 3 Can complete but additional expertise for this task is recommended; psychologist can comment on medication and to refer to a physician/psychiatrist 4 Interactive Voice Response Telephony Workforce Research and Evaluation, AHS December /29

15 When asked about the types of people who should be a part of the clinic, the Manitoba program interviewee noted that it is beneficial to hire staff that have a passion for preventative care and if possible, a background in cancer care. Clinic Outcomes Only a few of the clinics could provide us with information on their outcomes. This was either because data was not collected or it is not available to the public. The most common statistics available include patient enrollment, attrition rates, and quit or reduction rates. Although not all of the clinics had outcome measurement strategies in place, the importance of outcome measurement and program evaluation was emphasized by all participants. Some clinics (i.e., the Manitoba program, MD Anderson, Ottawa Heart) had data managers on staff to assist with data collection and analysis. The Ottawa Model recommends that outcome measurement be built into all the clinic processes so that it is ingrained from the beginning rather than an afterthought. Quit Rates It is hard to quit smoking. All of the clinics involved in this review report high attrition rates and no program reported a quit success rate of even 50%. While quitting smoking is challenging for most smokers, the cancer-focused tobacco cessation clinics noted that their patients are a particularly challenging population. Described as very, very sick, these are usually life-long smokers who have been smoking a pack per day for years and who could not or would not quit when faced with a cancer diagnosis. In addition, many patients have mental health co-morbidities which are an additional barrier to quitting. All the clinics noted that an important part of supporting a patient to quit is acknowledging that for many, it takes multiple attempts to quit smoking. All the clinics explicitly state that if a patient relapses, as long as they are willing, they are welcome to try the program again. MD Anderson reported the highest quit rates. At the nine-month follow-up, 46% of the patients they were able to contact reported successfully quitting smoking. Similarly, the Manitoba program reported positive results for 45% of patients: 28% quit and 17% reduced. The Red Deer PCN reported that 27% of their patients quit. The Ottawa Model and in particular the Ottawa Heart clinic have had a number of different evaluations conducted on their quit rates. They found that on average the Ottawa Model increased quit rates by around 15% over usual care (Reid et al., 2010). Cost Effectiveness Cost effectiveness statistics were not available for most clinics but it was noted that higher success rates are more likely with more investment in the program. MD Anderson has the highest quit rates but their costs per patient are also quite high at roughly $2500 Workforce Research and Evaluation, AHS December /29

16 per patient. We calculated that the Manitoba program spends approximately $928 per patient but did they not provide return on investment figures. The Ottawa Model conducted an in-depth cost-effectiveness evaluation comparing the usual smoking cessation treatment (i.e., noting the patient s smoking status and providing an educational booklet) of smokers hospitalized with heart and stroke-related diseases to those smokers who received the Ottawa Model smoking cessation intervention. They found that patients who received the intervention were more likely to quit smoking (usual care: 17% successfully quit vs. intervention: 31% successfully quit; n = per group) and, in total, had 116 fewer repeat hospitalizations, 923 fewer hospital days, 119 fewer deaths, and 2685 more life years. In terms of quality-adjusted life years (QALYs), smokers who received the intervention had a total of 1551 more lifetime QALYs (Mullen et al., 2015). Workforce Research and Evaluation s health economist put these results into context so we can demonstrate the Ottawa Model s financial return on investment. This intervention, taking into consideration the program implementation costs and dollars saved through avoided repeat hospitalizations, cost around $5 per patient. In turn, the oneyear cost per QALY gained was $1386, the cost per quitter was $20, the cost per hospital day avoided was $103, and the cost per death was $803. Using the QALY as a form of measurement allows us to provide a direct comparison of the possible health savings. In Canada, although not a concrete number, the allowable cost per QALY earned is usually between $20000 and $ This program cost only $1386 per QALY. Moreover, this program cost $103 per hospital day saved, compared to a cost of between $1500 and $2000 per day for an actual day stayed in hospital. Therefore, although this program costs more than the usual treatment, the overall program implementation costs are very low ($5 per patient) and the short- and long-terms benefits have the potential for a significant return on investment. Additional Information In this section we briefly highlight some of the important or innovative items identified in the interviews and data collection. The ACPLF clinics should consider these points when designing workflow, training, and delivery of treatment. Barriers and Facilitators Treatment Tobacco cessation programs face high drop-out rates. If there is a wait for the patients first visit there is a greater chance that patient will not attend. For some patients, having the clinic open only in business hours is a barrier. Workforce Research and Evaluation, AHS December /29

17 Providers Many clinics have transportation and parking barriers (e.g., expensive or congested parking, limited public transportation access). Sloan Kettering noted that physicians or other medical professionals may not want to further upset patients who have just received a cancer diagnosis and therefore may be reluctant to bring up quitting smoking. Sloan Kettering identified strong physician support as being very important. Some programs provide education to the cancer treatment units and other community health care providers including information, awareness, and education about the importance of tobacco cessation for cancer patients and information about the quit clinics. System and Organization There must be appropriate commitment and buy-in from the organizational level. The Ottawa Model offers an onsite evaluation for new clinics adopting the model which includes an assessment and discussion with top facility officials to identify the organizational commitment to the clinic. This can include factors such as having an appropriate referral and feedback system with the patient s primary physicians and oncology specialists. It is not just the staff working in the tobacco cessation clinic who need to be on board for the clinic to be a success. Unique Treatment Options Medical Directives The Ottawa Model recommends looking at the appropriateness of a medical directive in tobacco cessation clinics. As there are already NPs associated with the new Alberta clinics this may not be necessary. Automated calling system The Ottawa Heart automated calling system was heralded as being particularly successful because it automatically triaged the patients and focused resources on the patients who needed it the most. This was also noted as a good way of collecting the necessary data for patient tracking and outcome measurement. Treatment Considerations Psychological co-morbidities The possibility and influence of psychological co-morbidities was noted by most clinics. Workforce Research and Evaluation, AHS December /29

18 While all of the models in Canada primarily focused on having health care providers (NPs, nurses, and pharmacists) in the role of the primary treatment provider, both American clinics used more counselling-based providers (e.g., psychologists, social workers, psychiatric nurses). The American clinics try to keep the psychological support specific to how it relates to the patient s smoking habits; if necessary they will refer the patients to a psychologist or psychiatrist for ongoing counselling. Even without a mental health diagnosis, patients may be struggling with the psychological impact of nicotine withdrawal symptoms and cancerrelated distress. A patient may be experiencing double the stress if they are undergoing cancer treatment and trying to quit smoking. Resources and Potential Partners The Red Deer PCN was enthusiastic about supporting Red Deer cancer patients who are a part of the smoking cessation program but cannot travel to Calgary or Edmonton to the ACPLF clinics. The tobacco cessation pharmacist network, which is currently being developed by the Alberta Health Services Tobacco Reduction Program, will include tobacco cessation-trained pharmacists who can provide both counselling and medication to patients. The Ottawa Model offers varying levels of support to clinics and organizations interested in implementing a tobacco cessation strategy. Sloan Kettering has offered to mentor and support the clinic as a part of a knowledge dissemination grant they are currently holding. Workforce Research and Evaluation, AHS December /29

19 References Alberta Cancer Prevention Legacy Fund (2014). Project Charter: Every Opportunity in Cancer Care. Internal document. Alberta Health Services (2014). Tobacco free futures guidelines. Retrieved December 8, 2015 from McBride, C. M., & Ostroff, J. S. (2003). Teachable moments for promoting smoking cessation: the context of cancer care and survivorship. Cancer control, 10(4), Mullen, K. A., Coyle, D., Manuel, D., Nguyen, H. V., Pipe, A. L., & Reid, R. D. (2015). Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in Ontario, Canada. Tobacco Control, 24, Reid, R. D., Mullen, K. A., D'Angelo, M. E. S., Aitken, D. A., Papadakis, S., Haley, P. M.,... & Pipe, A. L. (2010). Smoking cessation for hospitalized smokers: An evaluation of the Ottawa Model. Nicotine & Tobacco Research,12(1), US Department of Health and Human Services (2008). Tobacco Use and Dependence Guideline Panel. Retrieved December 16, 2015 from Workforce Research and Evaluation, AHS December /29

20 Appendix A: Interview Guide 1. Can you tell me about your program? 2. What are the goals of your program? 3. Who is the target population (i.e., demographics, strength of addiction, cancer diagnosis, type, stage? Inpatient, outpatient, both, inclusion/exclusion criteria? a. Can you describe the program for me in detail? b. How does the target population access the program? (referral pathways) c. How do you decide the most appropriate treatment approach? (i.e., do you have an example of a care pathway that you can share?) 4. What services are delivered? (i.e., pharmacotherapy, counseling etc.) a. How are these services delivered? (i.e., individual, group format, inpatient, outpatient) 5. What providers deliver these services? i. What is the provider s professional background or training? ii. Describe their/your role iii. Could another provider deliver these services who? Why/why not? b. How do the providers work together to achieve treatment goals? (i.e. treatment planning) c. Do the providers work as part of the individual s care team outside of the program? (i.e., participate in patient conferences, in communication with primary care physician or inpatient team? d. At what point are clients discharged from the program or do they remain in the program to maintain their quit status? 6. What is the capacity of this program in terms of the number of clients it can serve per day or per week? (i.e., is there a waitlist?) 7. What outcomes do you hope to achieve for those who access this program? (i.e., quit or reduce or both; cancer treatment outcomes?) a. How are these outcomes measured and tracked? (i.e., tools, systems, EMR?) b. How are those identified? c. Are those evaluated regularly? d. Do you track specific clinical outcomes, e.g., relapse rates, successful quits, reduction? e. Can you share the results? 8. Can you describe the successes and challenges of this program so far? a. Successes? b. Challenges? c. Lessons learned, suggestions for improvement? 9. Are there any bottlenecks in the process? If yes, where and why, potential solutions? Workforce Research and Evaluation, AHS December /29

21 10. How is this program connected with other services in the community? (other cancer/tobacco cessation programs/treatment?) 11. How is data/information shared between programs/organizations? 12. Do you have any suggestions for a new clinic trying to emulate your program? 13. How do you create awareness about the program among the general public/patients? a. Do you think there is enough awareness of information about this program? 14. [only for Manitoba interviews] Do you have a standard smoking cessation practice in Manitoba? a. How is your program similar/how does your program differ? b. Do you have any documentation or a recording mechanism to highlight your outcomes in comparison to the standard practice? c. If yes, can you share? d. Do you perceive there to be duplications with other tobacco cessation programs available in the province? If yes, please describe. Workforce Research and Evaluation, AHS December /29

22 Client Population Appendix B: Details of Clinic Activities Cancer-Focused Tobacco Cessation Clinic and Endocrine Clinic Activities CancerCare Manitoba Sloan Kettering MD Anderson Edmonton Endocrine Clinic Cancer patients who are current smokers (smoked in the last 6 weeks) Cancer patients families Cancer clinic staff Intake Patients referred by physician providing cancer care or patients/families can self-refer via 800 number run by clinic nurse Physicians use COMPASS tool to screen for distress and probe further as needed Nurse triages referrals Clerk books the patient Assessment Nurse reviews history and assesses readiness to quit, develops treatment plan and quit date Sloan Kettering cancer patients who are current smokers (smoked in the last 30 days) To a lesser extent cancer patients families Both in- and out-patients Hospital identifies all current smokers There is automatic screening and triage Automated system sends referrals to the cessation clinic (using an order management system) Staff contact the patient The staff member who contacts the patient does an initial assessment over the phone Based on the initial assessment the patient is offered 2 levels of support: Over the phone (80% of patients) treated by oncology nurse practitioners trained as tobacco treatment specialists Face-to-face (higher risk cases) treated by clinical psychologists The initial assessment is based on 5- risk criteria which determine the complexity of the case: 1. Nicotine dependence 2. Motivation to quit 3. Confidence in quitting 4. Co-morbid mental health issues 5. Co-morbid alcohol abuse issues MD Anderson cancer patients who are current smokers (smoked in the last 30 days)or recently quit Anyone who resides with a tobacco treatment program (TTP) patient MD Anderson staff and family Patient self-reports about tobacco use on the medical assessment form through regular screening with the oncology nurse Contact information is sent to the cessation clinic Support staff contact the patient Try to contact four times If they cannot contact the patient an info pack is sent and they call back in three months If the patient wants to be a part of the program the support staff assess their motivation and provide 2 treatment options: 1) Motivational Intervention & Phone Option Phone counselling for patients who either cannot make it to the medical center or who are ambivalent about quitting Patients receive on average 2-3 smoking cessation counseling sessions Long-term follow-ups at 3-month intervals for 15-months Convenient for people who have to travel long distances Do not provide free meds Is like a quit-line 2) Motivational Intervention & In- Person Comprehensive, Individualized Counseling and Pharmacological Breast cancer patients who have been discharged from oncology treatment Must be post-menopausal to participate Unit Clerk does check in RN gets files, walks patients back to meeting room Group introductory session (~12 patients) were doing individual 20 minute sessions but found same information was repeated so moved to group format. Groups run twice/month PowerPoint presentation and questions Facilitated by a pharmacist and NP (take turns running groups). Both attend each group Right after the group session the patients are split up between the pharm and NP for 1:1 s where they also write the prescriptions (approximately 10 min per person). Prescription printed to main desk; RN brings printed copy to room NP and pharmacist decide before session who will see which patient; decision is based on patient case (NP gets medically complicated patients; Workforce Research and Evaluation, AHS December /29

23 CancerCare Manitoba Sloan Kettering MD Anderson Edmonton Endocrine Clinic Treatment First visit scheduled for one hour; mainly spent with RN NP joins first visit (with nurse after assessment) to review cancer meds and determine which pharmacotherapy options are available NP prescribes medication Pharmacist brings medication to the patient and gives med information; medications are offered free of charge through the program Nurse makes follow-up calls every week for 3 weeks On 4 th week, patient has an in-person visit with nurse (possibly also NP) and meets with pharmacist afterwards about medications Medications are prescribed and dispensed on a monthly basis Visits very individualized; may include motivational interviewing Patients can be referred to a social worker for additional support Remote patients can be supported via telehealth Treatment based on the US clinical practice guidelines Phone and face-to-face patients receive the same treatment: behavioural counselling and medication Over the phone: ~4-5 sessions (recommended plan) but if someone needs more they can extend Face-to-face there is no set number of visits; as needed Appointments are scheduled for after cancer treatment visits (try to be flexible) Prescriptions available for both phone and face-to-face patients if appropriate Oncology NPs and clinical psychologists can prescribe Addressing mental health comorbidities: It is a step-care model: patients with more acuity get more intensive treatments, provided by more highly trained clinicians They can provide the treatment/support for the mental health issues and the tobacco as a one stop shop Psychologist may refer patient to receive additional psych treatment, but the patient s care is still managed by the tobacco cessation psychologist Intervention In-person and over the phone treatment The recommended treatment option Treatment described below Motivational Intervention & In-Person Comprehensive, Individualized Counseling and Pharmacological Intervention Includes counseling and medication Patients come in for an intensive faceto-face initial visit (2 hours) Patient completes questionnaires about tobacco use, depression, anxiety, negative emotions and alcohol use, and the Fagerström s test for nicotine dependence Patient meets with counsellor and they review smoking, psychosocial, and mental health history (45 min interview) Medical staff assess medication options and prescribe medication Patient leaves first face-to-face with a counsellor and two weeks of medication to get started Program is usually weeks 6-8 follow-up counselling sessions and a medication check 90% over the phone, but in-person is available Try to be as flexible as possible Counsellors are the main patient contacts Treatment can be extended (e.g., if they change meds) Counsellors provide counselling support but try to keep it in the realm of smoking cessation If patient requires more intensive counselling they refer to a psychologist pharmacist gets those with challenging medication issues) Have computers in the individual meeting rooms so they can view most recent charts and access Netcare if necessary Endocrine medication Prescribed by pharmacist or NP in the clinic; follow-up prescriptions done by GP Workforce Research and Evaluation, AHS December /29