Tobacco treatment TrAining Network in Crete Constantine Vardavas MD, RN, MPH, PhD, FCCP
Ottawa Model for Smoking Cessation The OMSC is an institutional program that systematically identifies, provides treatment, and offers follow-up to all smokers seen in clinical practice. Phases of the Ottawa Model's implementation plan 1. Program Introduction and Buy-in 2. Pre-Implementation Evaluation 3. Institutional Tobacco Control Protocol Development 4. Physician, Nurse and other Health Professional Training 5. Program Launch 6. Post-Implementation Evaluation and Quality Improvement
Crete One side of the coin
Crete- the other side of the coin The largest Island of Greece Approx. 500,000 inhabitants Mainly rural mountain settings Flourishing academic/research environment
Challenges and Opportunities Challenges One of the highest smoking rates in the world/eu (34%M- 28%F) Lack of implementation of previous national legislations. Pharmacotherapy if not reimbursed, no physician incentive Tobacco Treatment Training not integrated into the medical curriculum Current financial crisis Opportunity Current financial crisis TPD implementation (warning labels, ingredients, additives, reporting etc) Existing Primary Care Based Research Network / partial EMR High percentage of smokers want to quit (64% in the catchment area)
Activity 2.1: Conduct a needs assessment with PHC providers. Activity 2.2: Produce tools, in Greek, designed to support the 3As model. Activity 2.3: Deliver advanced tobacco treatment training. Activity 2.4: Perform program evaluation to inform program refinement. Activity 2.5: Engage PHC practice networks in Greece for continued expansion of the Global Bridges tobacco treatment network.
Evaluation Design pre-post cross controlled study Clinic Recruitment k=25 practices Pre-Intervention Assessment K=25 practices, n=28/practice Global Bridges Intervention Practices Group k=15 practices Control Practices K=10 practices Post-Intervention Assessment k= 15 practices, n=28 patients/practice
TiTAN Crete Baseline Assessment 1059 Patients Screened 38% of all patient reported current tobacco use Type of Visit 43.5% - Medical Examination 43.3% - Prescription 13.2% - Other
% Percentage Provider performance in 5As delivery at index visit and previous 12-months at baseline 60 50 55.4 52.5 Today's Visit 58 40 32.3 33.7 Previous 12-months - 30 17.8 20 16.1 10 7.1 3.5 3.9 5.4 7.68.6 4.1 1.6 1.6 2.5 0 Advise Quit Smoking Advice Health Hazards Assist Assist Quit Date Assist Selfhelp Assist Discuss Medications Assist Prescribe Medication Arrange
Components Description Tobacco Treatment Training Program A one-day core session tailored to cessation intervention in primary care practice setting. The curriculum includes 2/3 theory and 1/3 practical. The program employs teaching techniques including role-play and case-study approaches known to enhance practice change. Local faculty and international faculty delivered the training curriculum. Tool-Kit A toolkit of resources was distributed to providers which includes: Waiting Room Tobacco Use Screener; Provider Smoking Consult Form; Patient Quit Plan Booklet; Quick Reference Sheets; Waiting Room Posters. Booster Sessions Two booster 3-hour sessions were delivered 1- and 3-months after the core training. The booster sessions are designed to reinforce the adoption of new practice behaviors and offer practical skills-based training. Website & Video Series The TiTAN website houses training material and tools as well as 6-part video series was created to support the program. www.titan.uoc.gr
TiTAN CRETE 1-day Kick off Training Sept 22 nd 2015 Health Effects of Tobacco Use in Greece Nicotine Addiction 5As Model Pharmacotherapy Motivational Interviewing Special Population Booster Session #1 Oct 31 & Nov 3rd 2015 Quit Plan Visit Follow-up Visit MI Skills Booster Session #2 Jan 11 th 2016 Cognitive Behavioural Therapy Electronic Cigarettes
TiTAN Crete Clinical Tools
TiTAN Crete Clinical Tools
Other Material
% of Patients Rates of Ask, Advice, Act Pre-and-Post Implementation of TiTAN at Index Visit (Providers=15, n=768) Pre Post 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 17, p<0.001 23.7%, p<0.001 46.2%, p<0.001 75.0% 76.2% 58.0% 62.3% 52.5% 16.1% Ask Advise Assist
Next steps. EXPANDING THE USE OF THE TOOLS
The gap between needing help and receiving help
EPACTT-1 FCTC Article 14 notes each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities Guidelines in English. Adaptation/translation in Armenian, Georgian, Russian, Ukrainian
Networking/Hands on Training (CME) 170 Participants from across the European Region Theory and hands on training - 11 CME Credits In Brussels..two weeks after the Brussels terrorist attack (obstacles may be also of force majeure)
Gap in European Clinicians EPACTT1: Research among trainees in Russia, Ukraine, Georgia Armenia and Romania, indicated that: 70% had not received training on tobacco dependence, 50% had no available process to screen smoking status 66% had no consult forms to guide the intervention. 1/5 clinicians had no process, no self-help material and no consult forms in their clinical practice. The lack of understanding English was an additional noted barrier. Adapted and translated tools and guidelines for clinicians in their national language.
TITAN-2 We plan to partner with the Medical Faculties of five different Universities in Greece and Cyprus, the University of Ottawa Heart Institute, and national and international tobacco control experts to develop a plan to expand the tobacco treatment training network to more than 300 PCPs in Greece and Cyprus. EPACTT-2 Translate/adapt the tobacco treatment guidelines in another 7 languages, enhance the development of the e-learning platform and the clinician tools in 11 different European Countries (Greece, Spain, Poland, Armenia, Georgia, Ukraine, Russia, Belgium, Romania and Bulgaria, Serbia).
C. Vardavas, S. Papadakis, C. Girvalaki, A. Pipe, C. Lionis