San Juan County Rural Health

ProjectSmoking

Cessation in the Elderly

Chiyoung Cha PhC MN RN Kristi Vaughn DNPC ARNP MN RN

UCONJ 501BSchool of Nursing

University of Washington

Introduction◦ Demographics◦ Rural designation

Health issues◦ Elderly population◦ Access

Geographical HCPs

◦ Adult Health Behaviors Tobacco abuse Binge Drinking

◦ Dental◦ Environmental◦ Woman’s Health

HCP communication◦ Access◦ Insurance

Tobacco use in SJ CO Intervention Challenges The Chronic Care Model Evidence-based Interventions

◦ NRT/ HCP counseling◦ Follow up telephone contact◦ Evidence base research◦ Mental Health services

Conclusion References

Table of Contents

San Juan County, WA

Population (2008)◦ 15,294 (8.6% increase from 2000)◦ Predominately live: Orcas, Lopez, Shaw & San Juan Island

Characteristics◦ Well-educated◦ Caucasian (95.7%)◦ Median household income:$52,118 (State,$55,628) ◦ Median age 50 years ◦ Persons poverty level (9.9%)

Occupations◦ Government (23.5%)◦ Construction (16.2%)◦ Wholesale/retail trade (13%)◦ Accommodation/food services (12.9%)

Travel time to work 15.8”

Demographics

RUCA◦ Score10◦ Isolated rural area

HCP (2005)◦ 8-13 primary care

MDs/100,000 (2005) ◦ 13 dentists/100,000

(1998) 6 MUAs: Score 0

Rural Designation

Natural Barriers◦ Water◦ Weather

Travel◦ Ferry 60”◦ Helicopter 7-20”

Hospitals◦ Island Hospital-Anacortes◦ St Joes-Bellingham◦ Harborview MC-Seattle◦ Children's-Seattle

Clinics◦ Lopez- 1◦ Orcas- 2◦ San Juan-2

Inter Island MC; Level 5 TC Future- Peace Health

Health Care Access

Elderly population◦ > 65 years 21.4% (State,11.7%)◦ Increased life expectancy; 80 years◦ Fixed income◦ Chronic illness

Cancer Lung CA 18.2 % increase 85% tobacco related

CV disease Suicide;18 % (firearms) (State, 12%) Falls; 66% unintentional injuries

Access ◦ Health insurance (2006)

Adults30 % uninsured (State, 17%) Children 13%

◦ Unmet medical needs 15% (State,13%)◦ No HCP 26 % (State, 22%)

Adult health behaviors ◦ tobacco abuse 20 % (State, 18%)◦ binge drinking 17% (State, 14%)

Health issues

Dental ◦ 33 % no dental visits (State, 28%)

Environmental◦ Increased waste facilities◦ Sewage 100% failure correction rate

Women’s health ◦ low rate prenatal care 77% (State, 80%)◦ Breast CA screening rate 74% (State, 79%)

Health is-sues

Health Issues identified by SJ CO HCPs(Personal communication) Access

◦ Geographical barrier◦ Limited HCPs

Aging work force Low/slow pay

◦ Rural HC overhead costs◦ No critical access hospital

Insurance◦ Poor reimbursement◦ Uninsured/ under insured◦ HCPs overworked/ no relief from locum tenums

Economic◦ Unemployment◦ Fixed income◦ Increased cost prescription drugs

SJ CO Health Care Providers

514 deaths/100,000 population (State, 724/100,000)

36 cancer related deaths 145/100,000(State, 179 deaths/100,000)◦ 7 deaths lung CA 2007

◦ 18% increase compared to 2003-2005

1,900 adult smokers 200 smokeless tobacco

Tobacco & Cancer Stats

Increasing # users ◦ 15% (State,17%)◦ 1.7% increase past 5 yrs

SJ CO Tobacco use◦ 5.0% (State: 17%)

Adult smokeless tobacco use◦ 1.8% (State: 3.0%)◦ Male 3.3% (State: 5.8%)

Tobacco

Tobacco-con’tSan Juan County WA

County total (%)

Above 200% FPL (%)

At or below200% FPL (%)

At or below 200% FPL (%)

Cigarrette Lifetime use

7,734 (65.3)

5,919 (65.3)

1,185 (54.4)

639,441 (60.4)

Past year use

2,328 (19.7)

1,368 (15.1)

960 (34.6) 324,325 (30.6)

Past 30 days use

2,039 (17.2)

1,159 (12.8)

880 (31.7) 196,158 (28.0)

Any to-bacco

product

Past year use

3,109 (26.3)

2,013 (22.2)

1,096 (39.5)

378,238 (35.7)

*FPL: Federal Poverty Level*Data from 2003 WA Needs Assessment Household Survey

Lack of: Awareness Perceived effective-

ness Participation

Intervention Challenges

Rationale: Effective for elderly

NRT & HCP counseling

Community Resources: Partnerships w/community agenciesFree or Low cost NRT; reduce out of pocket $ forcessation therapies

Health systems:Self-management support: emphasis patient’s central role, 5A’sDecision Support: multi-component interventions, evidence-based guidelines, proven HCP education Delivery system design: all HCPs & community in-volved, intense follow upClinical information system: provider reminder systems w/education, ID individual smokers

Rationale: Limited access to care, geograph-ically isolated area, low cost

Telephone cessation sup-port

CommunityResources: Private physicians, Free cessation counseling, Telepsychiatry service which was proven to be effective (funded through April, 2010)Policies: Encourage smoke free restaurants

Health systemsSelf-management support: Telephone cessation programDecision Support: Health & Community Services Delivery system design: County’s effort to build new cell phone towersClinical information system: Participants

Hung & Shelley, 2009; CCM Adherence 5As (ask, advise, assess, assist, & ar-

range) 500 (PCP’s)/60 community clinics NYC low-income, minority populations 84% of HCPs asked Hx smoking Clinics 3 CCM elements

enhanced delivery system design clinical information systems patient self-management support

6 CCM elements Protocols tobacco use ID & Rx Decision support/clinical guidelines Referral community.

CCM integration (5 and 6 elements) 20.4 to 30.9 x> deliver full spectrum 5A services

Evidence-based research

Tait, Hulse, Waterreus, et al. (2007)   ID success predictors Effectiveness aged >or =75 years 165 intervention subjects vs. 50 smokers

◦ intervention group younger◦ smoked fewer years◦ >nicotine dependence scores◦ >previous quit attempts.

6 months 20 % abstinent NRT use

◦ Male◦ higher anxiety scores◦ quit due to more frequent colds & coughs◦ >=75 years matched cessation criteria.

Conclusion: older smokers brief HCP counseling & NRT can quit smoking.  

NRT & Counsel-ing

Miller, Frieden, Liu, S. et al. (2005) ◦ New York State HD & Roswell Park Cancer Institute ◦ Effectiveness large-scaled distribution program ◦ free nicotine patches

Stop rate 20% NRT recipients 6038 successful quits attributable NRT Cost $464/quit

◦ Conclusion: easy access cessation medication diverse populations may help smok-

ers quit Free or low cost access NRT & counseling by a HCP can

promote smoking cessation in the elderly

Lightwood & Glantz (1997) ◦ new nonsmoker reduces medical costs associated AMI & CVA

$47 1st yr $853 next 7 years

◦ Primary prevention adult smoking pays immediate dividends Health improvement & cost savings

NRT Access & Cost

Elderly population◦ Increased life expectancy◦ Increased # adult smokers◦ Increased prevalence lung CA & other tobacco related illness

Access◦ Geographical barriers◦ decreased # HCPs◦ limited Insurance; Medicare, uninsured◦ fixed income

Chronic Care Model◦ Utilizes all members HC team

Solutions◦ NRT◦ Counseling◦ Telephone contact◦ Community participation

Conclusion

Questions to our colleagues

A. Are there other formats available at a low cost to provide NRT? B. Who else would benefit from this informa-

tion?

Q & A

A Draft Summary of San Juan County Public Health Indicators (2008). Personal commu-nication.

Brandeis University (2002). Treating Tobacco Use and Dependence as a Chronic Dis-ease: A Planning Guide for Practice Sites in Developing an Office-Based System of Care. Retrieved on 8/1/2009 from http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf

Bureau, U. S. C. (2009). State & County Quick Facts: San Juan County, Washington Re-trieved 6/30/09, from http://quickfacts.census.gov/qfd/states/53/53055.html

CDC & Surgeon General (2008). Treating Tobacco Use and Dependence: 2008 update retrieved on 7/30/09 from http://www.surgeongeneral.gov/tobacco/  

CDC. (ND). Smoking and Tobacco: Fast Facts. Retrieved 7/10/2009, from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm#facts

CityData. (2009). San Juan County, Washington (WA). Retrieved 07/08, 2009, from http://www.city-data.com/county/San_Juan_County-WA.html

CommunityGuide. (2009). Tobacco use. Retrieved 7/10/2009 from http://www.thecommunityguide.org/tobacco/index.html

Hung D. Y., & Shelly, D.R. (2009). Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics. HSR: Health Services Research, 44(1), 103-127.

Refer-ences

Manning, J. T., & James, F. (2009). The health of San Juan County. Friday Harbor, WA: Health and Community Serviceso. Document Number)

Miller,N., Frieden, T.R., Liu, S. et al. (2005). Effectiveness of a large-scale distribution pro-gramme of free nicotine patches: a prospective evaluation Lancet, 365, 1849-54.

OFM. (2008). San Juan County Profile. from http://www.ofm.wa.gov/databook/county/sanj.asp#top

SJCWMC. (Date unknown). San Juan County characterization report. Retrieved 07/08/09, from http://www.sanjuanco.com/health/wtrshdpln/part2chap2.html

Tait, R.J., Hulse, G.KL., & Waterreus,A. et al. (2007) Effectiveness of a smoking cessation in-tervention in older adults Addiction, 102,148-55

Wikipedia. (2009). San Juan County, Washington. Retrieved 6/30/09, from http://en.wikipedia.org/wiki/San_Juan_County,_Washington

WSDH. (2007). Tobacco and health in Washington State- County profiles of tobacco use. Retrieved 7/10/2009, from http://www.doh.wa.gov/tobacco/data_evaluation/Data/County_profiles/2007/sanj_profile07.pdf

WSDH. (2009a). Guidelines For Using Rural-Urban Classification Systems for Public Health Assessment. Retrieved 06/26/09, from http://www.doh.wa.gov/data/Guidelines/RuralUrban.htm#classcounty

WSDH. (2009b). San Juan County Tobacco use statistics. Retrieved 7/10/2009,