Why do some doctors not treat tobacco dependence?
A National Commission on Prevention Priorities, led by dormer US Surgeon General Dr David Satcher ranked 25 preventive healthcare interventions for their population impact and cost-effectiveness (10). 3 interventions achieved the top ranking on both of these measures (total score=10): Daily aspirin for people over 40, childhood immunizations, and brief counseling and pharmacotherapy for tobacco use. Of all the interventions evaluated, the tobacco intervention was estimated to have by far the biggest impact on Quality-Adjusted Life Years saved if widely implemented (1.3 million annually). Undertreatment of tobacco dependence therefore represents a major failure in the US healthcare system. So what are the causes and potential remedies? Here are my thoughts:
1. Although very thorough evidence-based reviews and clinical practice guidelines are available, most clinicians are unaware of them and few healthcare systems require that they be followed in the same way that guidelines on the treatment of other comparable disorders (e.g. hypertension) are followed. If the healthcare system (whether that be the hospital system or the health plan) does not explicitly value tobacco treatment one should not be surprised that busy clinicians are not going out of their way to find and follow clinical guidelines on this issue.
2. Clinicians have found that it is not simple to get paid for tobacco treatment interventions. Where these are covered by health plans there may be high copays or deductibles, and frequently payments are low and certain effective treatment components are not covered (e.g. OTC NRT or group treatment). So for both clinicians and patients there is uncertainty about what (if any) treatment components are covered and this itself is a barrier to treatment provision.
3. Clinicians are unsure about the effectiveness of tobacco treatment. Their experience is that of 50 patients counseled and offered a medication, 40 will still be smoking when they are seen a year later. This can seem unrewarding compared to some other clinical interventions.
1. We need to make all the effective components of tobacco treatment covered benefits of all health plans. Model benefit designs have already been described and widespread adoption of these would take away that doubt/barrier. http://www.tobaccoprogram.org/cftfkinsurance.htm
This will require patients and employers to ask for it, as well as insurance companies to offer and provide it.
2. We need to ensure that a new tier of healthcare provider can be trained and eligible for reimbursement for tobacco treatment. MDs and other prescribers’ time is valuable and the counseling component is best provided by counselors who have been trained to specialize in that work. In large hospitals or high population densities this tobacco counseling can be provided face-to-face in specialist clinics, but in more rural areas this can best be provided via telephone quitlines and interactive websites. This will require that more tobacco treatment counselors be trained, and approved for reimbursement by health plans. Standards for Practice for Tobacco Treatment Specialists have been developed by the Association for the Treatment of Tobacco Use and Dependence (ATTUD):
3. Steps 1 and 2 above will enable MDs to move to a model where they routinely ask patients about tobacco use, advise them to quit and offer to prescribe a med but then refer on to a local counselor or quitline (ideally via an electronic or “fax-to-quit” service). The MD intervention needn’t require more than one or two 15 minute appointments, and the counselor’s intervention would consist of 4-8 30-minute sessions.
I’d be interested to hear from clinicians regarding what they think could be done to improve tobacco treatment provision. For the patients, I think the advice has to be to ask your clinicians for help. Most clinicians see it as part of their role (even without adequate reimbursement) and are happy to help, but are currently working in a reactive rather than proactive mode.
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