Readiness of Lung Cancer Screening Sites to Implement Smoking Cessation Treatment Services Jamie S. Ostroff, PhD Memorial Sloan Kettering Cancer Center June 20, 2016
Disclosures Research Consultant, New York-Early Lung Cancer Action Program (NY-ELCAP) Research Consultant, International-Early Lung Cancer Action Program (I-ELCAP) 2
Lung Cancer Screening as an Opportunity to Promote Smoking Cessation Access to smokers with longstanding history of heavy tobacco use Opportunity to personalize tobacco-related risks of persistent tobacco use Multiple potential encounters with health care providers provide opportunity for delivery of quitting advice and tobacco cessation treatment Cost-effective evidence 3
Challenges in Promoting Smoking Cessation in Lung Cancer Screening Settings Variable quitting motivation of screening enrollees Most smokers will get good news. Will normal findings reduce quitting motivation and provide license to smoke? Variable organizational priority, readiness, resources and capacity of lung cancer screening sites/staff Inconsistent delivery of smoking cessation treatment in lung screening setting 4
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Integration of Smoking Cessation Treatment in Lung Cancer Screening Part One: The Rights of the People Part Two: The Guiding Principles for Centers of Excellence Offering Lung Cancer Screening in the Continuum of Care Includes a comprehensive smoking cessation program in its screening and continuum of care program based on best practices evidence. 6
ALL existing lung cancer screening guidelines recommend smoking cessation advice and treatment Association for the Treatment of Tobacco Use and Dependence (ATTUD) Society for Research on Nicotine and Tobacco (SRNT) American Society of Clinical Oncology (ASCO) The International Association for the Study of Lung Cancer (IASLC) American College of Chest Physicians Centers for Medicare and Medicaid Services (CMS) National Comprehensive Cancer Network (NCCN) American College of Radiology (ACR) American Cancer Society (ACS) Fucito LM et al 2015, Cancer 7
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Study Aims To describe the current smoking cessation treatment delivery practices of a national sample of lung cancer screening sites (n=93) To examine organizational priority and other site characteristics associated with variation in smoking cessation treatment delivery practices To identify perceived barriers smoking cessation treatment delivery 9
Participants and Recruitment Site coordinators U.S. lung cancer screening sites that pledged adherence to Lung Cancer Alliance s Guiding Principles for Centers of Excellence Initial email invitation plus two reminders within 4 week period Lottery (ipad mini tablet) incentive Response rate: 61% (93/152) 10
Survey Tool Single administration of 67-item online survey of screening site coordinators (Spring, 2014) Background respondent and site information Current smoking cessation treatment delivery Modified 5As (AAMC, 2007) 5-point Likert scale ranging from Never, Rarely, Sometimes, Most of the Time, Always Barriers and beliefs regarding smoking cessation treatment delivery Modified decisional balance (Park et al, 2001) assessed endorsement of barriers Organizational Priority (Klein, Conn & Sorra, 2001) 11
Survey Respondent Characteristics Respondent Characteristics (n=93) n (%) Gender Female 87 (94) Ethnicity Non-Hispanic 91 (99) Race White 84 (90) Black or African American 6 (7) Asian, Native Hawaiian or Other Pacific Islander 1 (1) American Indian or Alaska Native 2 (2) Primary role Patient Care/Clinician 55 (59) Education 3 (3) Research 8 (9) Administration 17 (18) Other 10 (11) Primary area of clinical practice Physician 30 (32) Nursing 42 (45) Not applicable (Not a clinician) 18 (19) Other 3 (3) Mean ± stdev Age (yrs) 45.7± 9.8 12
Lung Cancer Screening Site Characteristics (n=93) n (%) Length of time screening < 1 year 33 (36) 1-3 years 42 (45) 4 years or greater 18 (19) Academic Affiliation No 66 (71) Yes 27 (29) Mean ± stdev, (Median) Patients Screened Per Month 14 ± 13 (10) Payor Mix Medicare 37.4 ± 25.9 Medicaid 7.6 ±12.1 Private commercial 35 ± 26.4 No insurance 7.3 ± 17.5 Other Insurance 12.7 ± 30.5 MTE 31: Smoking Cessation Integrated with Lung Cancer Screening (Window of Opportunity) Jamie S. Ostroff, PhD 13
Comparison of Current Tobacco Treatment Practices at Baseline and Repeat Scans 0 10 20 30 40 50 60 70 80 90 100 Ask patients whether they currently smoke cigarettes? 80.6 98.9 Advise smokers to quit? 91.4 77.4 Assess readiness to quit? 72 64.5 Provide cessation counseling? 57 53.8 Baseline Scan Provide self-help cessation materials? 57 73.1 Repeat Scan Refer smokers to onsite cessation services? 68.8 54.8 Refer smokers to Quitline? 60.2 47.3 Recommend cessation medications? 36.6 32.3 *Percentage of participants responding most of the time and always. 14
Site Characteristics Associated with 5As Smoking Cessation Treatment Delivery Length of time screening Ask Advise Assess Assist Arrange Percentage of respondents selecting 'Most of the time' or 'Always'. < 1 year 100% 93.9% 63.6% 54.5% 39.4% 1-3 years 97.6% 88.1% 76.2% 59.5% 35.7% 4 years or greater 100% 94.4% 77.8% 55.6% 33.3% Site coordinator Physician 96.7% 93.3% 80% 60% 46.7% Nurse 100% 90.5% 71.4% 57.1% 33.3% Not applicable (Not a clinician) 100% 94.4% 61% 50% 27.8% Academic Affiliation 0.8 (0.1-9.4) 2.2 (0.6-8.2) Odds Ratio (Confidence Interval) 3.0 (1.1-8.1)* 1.5 (0.6-3.7) Spearman Rho Correlation Coefficient 2.0 (0.7-5.6) Patients Screened Per Month.162 -.078.001.063 -.032 Spearman Rho Correlation Coefficient Organizational Priority.235*.366**.265*.427**.253* *Significant at the 0.05 level (2-tailed) **Significant at the 0.01 level (2-tailed) 15
Perceived Organizational Priority by Smoking Cessation Treatment Delivery* (initial visit) Spearman s Rho P value Ask patients whether they currently smoke cigarettes?.227.03 Advise patients who smoke to quit?.291.00 Assess smokers readiness to quit?.398.00 Ask patients who smoke if they are interested in smoking cessation materials or other help to quit smoking?.186.07 Document smoking status in medical record chart?.327.01 Document smoking cessation advice and treatment plan given?.350.00 Provide smoking cessation counseling?.464.00 Provide smoking cessation booklets or other patient education materials?.046.66 Refer smokers to a Quitline? -.084.42 Refer smokers to an onsite cessation counseling program (group or individual)? Prescribe or recommend cessation medications (NRT, bupropion, varenicline)?.353.00.295.00 *Dichotomized sites as reporting 'Most of the time/always vs. Never/Rarely/Sometimes 16
Perceived Barriers for Delivery of Smoking Cessation Interventions to Smokers Enrolled in Lung Cancer Screening Programs Patients not motivated to quit 77% Patient resistance to cessation advice and treatment 73% Lack of staff training 44% Lack of time 40% Inadequate reimbursement 38% Lack of a designated tobacco treatment specialist/champion 35% Lack of time during screening visit 33% Lack of confidence in how to help patients quit smoking 32% Lack of knowledge about cessation medications 32% Lack of familiarity with practice guidelines for tobacco treatment 28% Lack of available resources or referrals 24% Lack of institutional support for tobacco treatment 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of participants in agreement 17
Perceived Barriers for Delivery of Smoking Cessation Treatment: Patient Patients not motivated to quit smoking 75% Patient resistance to cessation advice/treatment 71% 0% 20% 40% 60% 80% 100% Percentage of providers who Agree (n = 96) 18
Perceived Barriers for Delivery of Smoking Cessation Treatment: Provider Lack of staff training in providing cessation interventions 43% Lack of time 41% Lack of confidence in how to help patients quit Lack of knowledge about NRT/cessation medications Lack of familiarity with guidelines (5A's) for tobacco dependence treatment 27% 31% 31% 0% 20% 40% 60% Percentage of providers who Agree (n = 96) 19
Perceived Barriers for Delivery of Smoking Cessation Treatment: System Inadequate reimbursement 36% Lack of tobacco treatment specialist/smoking cessation champion Limited direct contact with patients during their visit 31% 34% Lack of readily available resources/referrals for cessation 25% Lack of support for treating tobacco dependence at my site 20% Smoking status is not required in our (electronic) medical record 6% 0% 20% 40% Percentage of providers who Agree (n = 96) 20
Latent class comparative analysis of screening sites with higher and lower readiness for smoking cessation treatment delivery 21
Potential Models of Smoking Cessation Treatment Delivery 22
Gaps in Knowledge How to optimize smoking cessation treatment delivery in the context of lung cancer screening? What implementation strategies are needed to establish and maintain smoking cessation treatment delivery in real world lung cancer screening settings? National Cancer Institute RFA focusing on lung cancer screening and smoking cessation 23
Implementation Research Priorities: Translating Smoking Cessation Research-to-Practice in Lung Cancer Screening Context To design for dissemination evidencebased, scalable smoking cessation interventions To address multi-level barriers (patient, provider, systems) to promote excellent reach and impact. To test various implementation strategies for optimizing cost-effective smoking cessation treatment delivery 24
Take-Away Recommendations Evidence-based smoking cessation interventions should be provided to all smokers throughout the context of lung cancer screening Shared decision making (SDM), baseline and followup scans, results disclosure Regardless of motivation to quit, scan results Scalable, cost-effective clinical workflows Establish standards and metrics for components of quality smoking cessation treatment delivery Require periodic monitoring of quality metrics and performance feedback on smoking cessation treatment delivery 25
Thank You! ostroffj@mskcc.org 26