1. Ohio’s Fax Referral Initiatives Reach, Enrollment and Participant Characteristics Jeff Willett, PhD Director, NYS Tobacco Control Program March 4 th and 6 th, 2009

2. Fax Referral The Ohio Tobacco Quit Line began providing statewide services in September, 2004. Fax referral was introduced in the first year to increase health provider referral. An average of 68 fax referrals were received per month prior to the study period.

3. Fax Referral Goal: to reduce quit line marketing costs by establishing a sustainable, high volume referral stream from health professionals. Three initiatives were developed or expanded to increase health provider utilization of the fax referral. –Fax Five –Hospital Outreach –Community Promotion

4. Fax Five Direct marketing initiative aimed at health professionals. –Phase I: Promotional folder and 5 fax referral forms placed in the May/June issue of Ohio Medicine. –Phase II: Peer Writing Campaign utilizing the Quit Line’s Advisory Panel. Sent personal letters and 5 fax referral forms to 25,970 health professionals in March, 2007.

5. Hospital Outreach A hospital-focused outreach program funded in March, 2006. 51 hospitals received a small stipend to institute a fax referral process. Rigorous training component –Daylong in-person training –5 one-hour training calls

6. Community Promotion Health professional training program conducted by community tobacco control grantees. Beginning January, 2007 all 50 OTPF community grantees were required to “Promote Ohio Quits” including distribution of and training related to health professional quit kits.

7. Evaluation Evaluation Period June ’06 – Oct. ’07 Fax referral forms including tracking codes for each initiative Fax referrals not tied to study initiatives were treated as “other”

8. Fax Referrals Received June 2006 – October 2007

9. Fax Five

10. Outreach

11. Community

12. Referrals ≠ Enrollments

13. Outcomes of fax referral call attempts by initiative June 2006 – October 2007 (%) Community (n=1,956) Hospital (n=1,916) Fax Five (n=1,065) Other (n=2,014) Total (n=6,951) Enrolled 24.4%21.3%28.4%22.3%23.6% Information only 3.4%3.5%4.5%5.6%4.2% Declined 13.6%14.0%13.2%14.0%13.8% Unreachable 58.6%61.2%53.9%58.1%58.5%

14. Examining the “Unreachable” Rate

15. 3 rd Call Dispositions for the April 2007 “Unreachable” Fax Referrals (N=368) Disconnect / Wrong Number 215.7% No Answer, Busy, Hang up 10127.5% Voice mail message 18349.7% Message left with household 6317.1%

16. Comparing Fax and Traditional Enrollments

17. Quit line enrollee characteristics, by fax referral initiative and fax referral status (%) Fax referral status Fax (n=1,616) Non-fax (n=36,273) Gender Male3342 Female6759 Age Less than 352131 35-647265 65+84 Comorbidity One or more6036 Note: Bold values indicate a cell count that was higher than expected values; italicized values indicate a cell count that was lower than expected values, p<0.001.

18. Quit line enrollee characteristics, by fax referral initiative and fax referral status (%) Fax referral status Fax (n=1,616) Non-fax (n=36,273) Education Less than HS2412 HS/GED4140 More than HS3547 Insurance Status Private5778 Medicaid114 Medicare83 Uninsured2316 Note: Bold values indicate a cell count that was higher than expected values; italicized values indicate a cell count that was lower than expected values, p<0.001.

19. Reach The three initiatives dramatically increased fax referral to the Ohio Tobacco Quit Line. –68 referrals per month during year before initiatives –412 referrals per month during study period –Fax Five: cost-effective, least sustainable Can kick-off fax referral expansion –Community: slow growth, most sustainable

20. Enrollment 23.6% of fax referred individuals enrolled 18% actively declined enrollment (information only or declined all service) Based on one-month disposition data –An estimated 40% of fax referrals passively decline enrollment (do not return voice mail or personal messages left by Quit Line) Raises questions about patients actual readiness to quit.

21. Participant Characteristics Fax referred individuals were more likely to be lower educated, to be uninsured and to have public insurance. Compared to non-fax enrollments driven largely by media efforts, costs per enrollment were much higher for fax referrals.

22. Questions? Willett J, Hood N, Burns E, Swetlick J, Wilson S, Lang D, Levinson A. Clinical Fax Referrals to a Tobacco Quitline: Reach, Enrollment and Participant Characteristics. American Journal of Preventive Medicine;36(4):XXX–XXX; April 2009.