1. Tobacco and Population Health in Medical School Getting beyond the 5 A’s Kimber Richter, Edward Ellerbeck University of Kansas Medical Center, KC

2. In Kansas, some address tobacco and some don’t * percent of dr/pt interactions in which tobacco was discussed 38 physician practices

3. Clinical know-how necessary but not always sufficient Many factors outside the examining room impact medical care Many factors outside the examining room impact medical care True for tobacco, true for other issues True for tobacco, true for other issues AAMC, ACGM objectives require medical schools to teach population medicine AAMC, ACGM objectives require medical schools to teach population medicine We teach population medicine concepts and skills through Health of the Public We teach population medicine concepts and skills through Health of the Public Formal lectures and student projects incorporate tobacco in population health Formal lectures and student projects incorporate tobacco in population health

4. AAMC Objectives – Informatics, Population Health Retrieve and analyze information Retrieve and analyze information Employ effective communication Employ effective communication Measure performance in populations Measure performance in populations Able to effect change Able to effect change Apply quality improvement methods Apply quality improvement methods Understand physicians role in systems of medical care Understand physicians role in systems of medical care Medical informatics and population health. Report II of the Medical School Objectives Project. Acad Med 1999; 74:130-141.

5. ACGME and the ‘Outcome Project’ ACGME – Accreditation Council for Graduate Medical Education ACGME – Accreditation Council for Graduate Medical Education ACGME has just announced it will require residencies in all specialties to show that residents meet six competencies: ACGME has just announced it will require residencies in all specialties to show that residents meet six competencies: Provide appropriate & effective patient care Provide appropriate & effective patient care Demonstrate knowledge of medicine Demonstrate knowledge of medicine Interpersonal communication skills Interpersonal communication skills Professionalism & sensitivity to diversity Professionalism & sensitivity to diversity Sound Familiar? Sound Familiar?

6. But that was only four… Practice-based learning and improvement analyze practice experience and perform practice-based improvement activities analyze practice experience and perform practice-based improvement activities locate, appraise, and assimilate evidence from scientific studies locate, appraise, and assimilate evidence from scientific studies obtain and use information about their population of pts. obtain and use information about their population of pts. apply knowledge of study designs and statistical methods to the appraisal of clinical studies apply knowledge of study designs and statistical methods to the appraisal of clinical studies use information technology to manage and access information use information technology to manage and access information

7. And the sixth… Systems-Based Practice Systems-Based Practice understand how their practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice understand how their practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources practice cost-effective health care and resource allocation that does not compromise quality of care practice cost-effective health care and resource allocation that does not compromise quality of care advocate for quality patient care and assist patients in dealing with system complexities advocate for quality patient care and assist patients in dealing with system complexities know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

8. Health of the Public Covers AAMC informatics, pop health Covers AAMC informatics, pop health Prepares students for ACGME practice- based learning, systems-based practice Prepares students for ACGME practice- based learning, systems-based practice 4 th year required 4-week clerkship 4 th year required 4-week clerkship Selected lectures in Population Health CONCEPTS Selected lectures in Population Health CONCEPTS Workshops in Population Health SKILLS Workshops in Population Health SKILLS 50% of time and grade for Capstone Project 50% of time and grade for Capstone Project

9. Course Objectives Define populations Define populations Develop, implement, and evaluate population-based approaches to health care Develop, implement, and evaluate population-based approaches to health care Recognize and address population-wide forces in health care Recognize and address population-wide forces in health care Develop core knowledge and skills in occupational and environmental medicine Develop core knowledge and skills in occupational and environmental medicine

10. Course Themes Population-based medicine* Population-based medicine* Health Care Finance Health Care Finance Quality of and Access to Medical Care* Quality of and Access to Medical Care* Systems of Medical Care* Systems of Medical Care* Injury, Occupational, and Environmental Medicine Injury, Occupational, and Environmental Medicine Capstone* Capstone* * These sections are particularly relevant to tobacco

11. Population-Based Medicine General Concepts Transition from thinking about individual pts to commonalities among groups of patients* Transition from thinking about individual pts to commonalities among groups of patients* Four steps Four steps define populations define populations assess needs assess needs intervene intervene Evaluate Evaluate *Also incorporates concepts from Community-Oriented Primary Care

12. Population-Based Medicine Skills Using PubMed to search medical literature Using PubMed to search medical literature Sophisticated search methods Sophisticated search methods Critical appraisal of literature (journal club) Critical appraisal of literature (journal club) Epi-biostat refresher Epi-biostat refresher Using Excel to analyze clinic data Using Excel to analyze clinic data

13. Quality of and Access to Medical Care Quality measurement Quality measurement Structure Structure Process – HEDIS, CMS Process – HEDIS, CMS Outcome –Hard to get! Outcome –Hard to get! Quality improvement Quality improvement Oversight of quality Oversight of quality

14. Systems of Medical Care Quality improvement Quality improvement Office organization Office organization Disease management Disease management Specific issues Specific issues Diabetes disease management Diabetes disease management Chronic care model Chronic care model

15. CCM ComponentTraditional Primary CareCare in the Disease Management Program* Organization of Care Physician responsible for all smoking cessation activities. Trained counselors will work under the supervision of smoking cessation experts and coordinate pharmacotherapy with physicians. Clinical Information System Notes are handwritten by the physician. Many charts will not indicate if the patient is a smoker. 30 An electronic registry of smokers will be created with quarterly updates on cessation attempts and readiness to quit. The database will store patient-specific data on contraindications to bupropion and NRT. Delivery System Design Physician is responsible for advice, assistance, and follow-up for smoking cessation. Care is dependent upon the patient coming in for an office visit. Trained counselors will provide proactive, telephone-based counseling utilizing principles of motivational interviewing.. Physicians will receive feedback on patient progress. Decision SupportTextbook in the doctor’s office.Health counselors will follow counseling protocols. Computerized algorithms will support decisions on pharmacotherapy. Self-management Support Physician may provide brief advice to quit with 1-2 minutes of ‘counseling’. Patients receive MI-based telephone counseling, written cessation and relapse prevention tips, periodic reminders on the availability of free pharmacotherapy, and follow-up support calls after a quit attempt.* Community Resources Unknown or unavailable in rural communities. Free NRT or bupropion for a smoking cessation attempt.

16. HOP The Capstone Project

17. Capstone puts it all together To provide a small practical experience in population health care To provide a small practical experience in population health care Students choose topic, work in teams Students choose topic, work in teams HOP Mentor/Site Mentor HOP Mentor/Site Mentor 20 hrs/Week on Project 20 hrs/Week on Project Verbal/Poster presentation at end Verbal/Poster presentation at end

18. Capstone Projects: Research or Service Quality of Care Quality of Care Smoking and interest in quitting among parents of pediatric patients at KUMC Smoking and interest in quitting among parents of pediatric patients at KUMC Health Communications Health Communications Reducing passive smoking in a Spanish pediatric population Reducing passive smoking in a Spanish pediatric population Secondary Data Analysis Secondary Data Analysis Gender differences in health issues among Kansas caregivers using 2000 BRFSS Gender differences in health issues among Kansas caregivers using 2000 BRFSS Curriculum Development Curriculum Development Developing a medical school smoking cessation curriculum Developing a medical school smoking cessation curriculum Health Advocacy Health Advocacy Medical student support for a primary seat belt law in Kansas Medical student support for a primary seat belt law in Kansas

19. Population-based health care Identify a population Identify a population Ascertain needs Ascertain needs Intervene to address needs Intervene to address needs Evaluate impact Evaluate impact

21. Health Communication: Passive Smoking at Cabot Clinic Eric Vaughan and Josh Timock University of Kansas School of Medicine Health of the Public, November 2002

22. Health Communication: Passive Smoking at Cabot Clinic Population: Patients attending Cabot Westside Clinic, 82% Hispanic Needs: Knowledge, skills regarding passive smoking and children’s health Intervention: Bilingual brochure Evaluation: none

23. Health Communication: Passive Smoking at Cabot Clinic ▶ A preliminary needs assessment was performed via telephone conversations and personal interviews with clinicians. ▶ A literature review was conducted regarding pediatric morbidity and mortality due to passive smoking and past employed and existing interventional strategies. ▶ Various health communication formats were considered: poster vs. brochure vs. postcard. ▶ A bilingual, color, tri-fold brochure was produced incorporating the health belief model and principles of health communication. ▶ Working models were produced and critiqued by the faculty mentor and clinic staff and revised. ▶ A final version was published and distributed with the financial support of the Block Foundation.

24. Health Communication: Passive Smoking at Cabot Clinic Perceived Susceptibility How vulnerable one feels regarding a condition. Cited prevalence of ETS in the Hispanic pediatric population. Photograph of smoking child. Perceived Severity How seriously one regards a condition. Outlined incidence of ETS associated morbidity. Photograph of ill teenager. Perceived Benefits How one feels regarding efficacy of the intervention. Outlined importance of positive role modeling behavior. Photograph of healthy child. Perceived Barriers The obstacles viewed as impeding the intervention. Addressed “what if” scenarios and provided simple strategies to overcome barriers. Cues to Action Activate readiness to act and stimulate overt behavior. Provided “how to” information regarding home interventions. Self-Efficacy How confident one is in personal ability to take action. Provided Spanish smoking cessation telephone line and other resources.

25. Health Communication: Passive Smoking at Cabot Clinic - Panel 5 What if I’m having trouble quitting? Talk with a doctor about treatments and methods that can help you quit. What if someone does smoke in my home? Make it clear that smoking is not allowed in your home. What if my childrens’ care provider smokes? Ask them not to smoke around your children, or find a new care provider. YOU CAN DO IT! BUT WHAT IF…

26. Population Health Communication: Don’t Choke on Smoke D. Brendan Rice Muhammad Nashatizadeh Health of the Public (PMED960)

29. Population Health Communication: Don’t Choke on Smoke Survey Development Survey Development form-based webpage for elementary school teachers form-based webpage for elementary school teachers Survey Questions Survey Questions 1) Is there anything you do not understand about the handout? 2) What is your FAVORITE part of the handout? 3) What is your LEAST FAVORITE part of the handout? 4) Would you take this handout home to share with family and friends? If NO, please explain why not: 5) Did the handout help you understand more about the dangers of smoking? What did you learn?

30. Population Health Communication: Don’t Choke on Smoke – What did you learn? Selected quotes: –I didn’t know there are 4700 chemicals in each cigarette –The deadly stuff in cigarettes. Yuck! (and a lot more stuff) –That when you take a deep breath and let it out halfway, it is called a emphysema. –I learned smoking kills more people than guns. –That it kills more people than AIDS, guns, pneumonia, accidents combined –What lungs look like when you smoke

31. Needs Assessment, Smoking Cessation Program for Parents of Newborns at KUMC Jason Eppler, Matt Haverkamp, Marc Larsen Health of the Public April 17, 2003

32. Needs Assessment, Postpartum Smoking Cessation Assess the need for a postpartum smoking cessation program for mothers of newborn babies at the University of Kansas Medical Center Assess the need for a postpartum smoking cessation program for mothers of newborn babies at the University of Kansas Medical Center “Need” based on : “Need” based on : Mothers who smoke Mothers who smoke Desire to quit Desire to quit Relapse rate of smoking after delivery Relapse rate of smoking after delivery

33. Needs Assessment, Postpartum Smoking Cessation Population: Former smokers delivering at KUMC. Needs: Smoking cessation, maintenance of cessation Intervention: Survey will evaluate need for intervention Evaluation: None

34. Needs Assessment, Postpartum Smoking Cessation Bilingual survey looked at: Bilingual survey looked at: Demographics of mothers of newborns Demographics of mothers of newborns Mothers current smoking habits Mothers current smoking habits Smoking status of others living in the house Smoking status of others living in the house Mothers/others desire to quit Mothers/others desire to quit Desire to participate in smoking cessation program Desire to participate in smoking cessation program

35. Mothers’ Smoking History

36. Needs Assessment, Postpartum Smoking Cessation Among mothers: Among mothers: 44% of ever smokers stated pregnancy played a role in decision to quit 44% of ever smokers stated pregnancy played a role in decision to quit 47% had smoked at one period in their life 47% had smoked at one period in their life Of these, 22% currently smoke Of these, 22% currently smoke 100% of current smokers indicated they would be interested in a smoking cessation program 100% of current smokers indicated they would be interested in a smoking cessation program

37. Tobacco and Population Health Medical students and GMEs need to know population health to be effective clinicians Medical students and GMEs need to know population health to be effective clinicians Health of the Public teaches population approaches with tobacco in numerous examples Health of the Public teaches population approaches with tobacco in numerous examples Community-oriented primary care also an important perspective that HOP addresses Community-oriented primary care also an important perspective that HOP addresses