apability, pportunity and otivation
Coding tobacco dependence & interventions
Noel Baxter – GP & Commissioner
Siân Williams – Programme Manager On behalf of London Senate Helping Smokers Quit delivery team
Diagnosis and treatment of tobacco dependence
Opportunities along life course to diagnose and treat tobacco dependence
Right training, right equipment and access to the right medication.
In primary care and in situ – where the smokers are …
Two videos – both using CO monitor. One of ex-smoker and consultation, The other of Bulgarian GP, smoker, showing high reading and reaction. Removed as makes file very big. Available on request.
apability – LTC reviews (templates, tobacco (137)
read codes, also codes for motivation, Fagerstrom
(minutes to first tobacco use), Exhaled CO, drug codes,
non drug codes indicating treatment and type
pportunity – 1:5 current smokers in GP, child
smokers, in-utero smokers at booking /scan /bloods/
imms. Community nurse, day centres, hostels
otivation – Measure impact on consultations saved–
acute asthma, respiratory infection
GP, ANC, At home, At hostel
In hospitals
In hospitals
Q3 Wards DH
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
TOTAL
No of NRT prescriptions
No of patients admitted
% patients screened
No of patients who smoked Prevalence
198 963 66% 154 24.23%
10 629 95% 75 12.55%
8 463 16% 12 16.20%
29 504 76% 64 16.71%
11 478 81% 65 16.79%
25 629 40% 61 24.24%
23 354 42% 15 10.09%
35 437 83% 119 32.81%
20 247 40% 25 25.30%
26 187 40% 17 22.73%
5 317 78% 55 22.24%
105 1033 77% 213 26.78%
48 692 40% 61 22.04%
5 397 44% 30 17.17%
34 631 49% 49 15.85%
582 7961 58% 1015 22.06%
apability – There is no spare capacity – Can
treating tobacco dependence create future
capacity?
pportunity – Vital sign measures on arrival –
A+E, day surgery, stroke unit. Start to populate discharge letter through electronic noting.
otivation – Cutting and down and quitting
reduces admissions – show HCPs how many
beds are occupied by smokers.
In hospitals
At death and in the registrars office
• Stage 1. “The data are wrong.”
• Stage 2. “The data are right, but it’s not a problem.”
• Stage 3. “The data are right; it is a problem; but it is not my problem.”
• Stage 4. “I accept the burden of improvement.”
From Escape Fire, Don Berwick 2003
Let’s face reality: acknowledging these stages but moving on…
Which level of behaviour change are we interested in today?
• Patient
•Clinical • Organisational
The Behaviour Change Wheel. Michie et al 2011
Right Care Pathway for Tobacco Dependent Smokers
Setting the context
• What are trusts’ short and medium term needs to deliver value?
• Where might there be alignment between treating tobacco dependence and these needs?
What is Right Care?
• The primary objective for Right Care is to maximize value:
• The value that the patient derives from their own care and treatment
• The value the whole population derives from the investment in their healthcare
3 types of value:
• Personal – makes a difference to that person (care people need and want, no less and no more)
• Allocative – investing in the right things for the population which means making choices between diseases, between populations and sub-groups
• Technical – doing things right: getting the diagnosis right, tackling overuse/misuse (harmful and wasteful), underuse (inequitable) of treatments
Which of these life course metrics are the best indicators of Right Care? • Deprivation, prevalence (u18, adult, maternal) • Low birthweight • Maternal smoking rate: SATOD • % people with long term condition on primary care register who are current smokers • Respiratory Tract Infection consultation rate for under 18 at primary care • Respiratory Tract Infection consultation rate for adults at primary care • Rate of under 18 attendance at ED with respiratory tract infection • Rate of adult attendance at ED with respiratory tract infection • Rate of admissions of under 18 with respiratory tract infection • Rate of admissions of adults with respiratory tract infection • Percentage of current beds occupied by a current smoker (defined as having quit in last four
weeks or still smoking) by hospital/trust (or smoking attributable admission by CCG and by trust) • % records with smoking status recorded • Primary care prescribing varenicline per ASTRO PU • Hospital prescribing varenicline spend and/or rate • Other tobacco dependence treatment intervention eg referral or could break down by Ask, Advise,
Act? • A measure of frequency and consistency of review of smoking status • Stillbirth rate • Number of asthma deaths in smokers • Mortality rate in people with severe mental illness and years of life lost • Smoking attributable mortality by CCG and by trust/hospital • Training in VBA by staff group and leadership team
Grade as: • Easy consensus [C]:
– most supported by those attending and
– those not workable in anyone’s opinion
• Most useful in highlighting unwarranted variation [V]
• Most useful in motivating engagement [E]
• Most controversial for those attending [!]
• Not appropriate, but there are alternatives [A]
What does the system need to do to support this?
Organisational level – for example: • Motivation
– Incentive schemes – Strategic alignment – Specifications from commissioners – Teaching – Research – Comparative data
• Opportunity – Leadership – Right equipment eg CO monitors, IT systems – Right formulary – Right information for patients
• Capability – Training – Role modelling – Guidance
What does the system need to do to support this?
Policy level: • Guidelines/guidance, pathways • Environmental and social planning • Communication and marketing • Legislation • Service provision • Regulation • Fiscal measures
