Economic evaluation of a hospital-initiated intervention for smokers with chronic disease, in Ontario, Canada

Specialist cancer hospital-based smoking cessation service provision in Ireland

BACKGROUND

While much progress has been made in reducing tobacco use in many countries, both active and passive smoking remain challenges. The benefits of smoking cessation are universally recognized, and the hospital setting is an ideal setting where smokers can access smoking cessation services as hospital admission can be a cue to action. Consistent delivery of good quality smoking cessation care across health services is an important focus for reducing the harm of tobacco use, especially among continued smokers.

AIMS

Our objective was to document the smoking cessation medication and support services provided by specialist adult cancer hospitals across Ireland, a country with a stated tobacco endgame goal.

METHODS

A cross-sectional survey based on recent national clinical guidelines was used to determine smoking cessation care delivery across eight specialist adult cancer tertiary referral university hospitals and one specialist radiotherapy center. Survey responses were collected using Qualtrics, a secure online survey software tool. The data was grouped, anonymized, and analyzed in Microsoft Excel.

RESULTS

All responding hospitals demonstrated either some level of smoking cessation information or a service available to patients. However, there is substantial variation in the type and level of smoking cessation information offered, making access to smoking cessation services inconsistent and inequitable.

CONCLUSION

The recently launched National Clinical Guideline for smoking cessation provides the template for all hospitals to ensure health services are in a position to contribute to Ireland's tobacco endgame goal.

Hospital length of stay and readmission after elective surgery: a comparison of current and former smokers with non-smokers

BACKGROUND

The purpose of this study was to investigate differences between non-smokers, ex-smokers and current smokers in hospital length of stay (LOS), readmission (seven and 28 days) and cost of readmission for patients admitted for elective surgery.

METHODS

A retrospective cohort study of administrative inpatient data from 24, 818 patients admitted to seven metropolitan hospitals in Western Australia between 1 July 2016 and 30 June 2019 for multiday elective surgery was conducted. Data included smoking status, LOS, procedure type, age, sex and Indigenous status. LOS for smoking status was compared using multivariable negative binomial regression. Odds of readmission were compared for non-smokers and both ex-smokers and current smokers using separate multivariable logistic regression models.

RESULTS

Mean LOS for non-smokers (4.7 days, SD=5.7) was significantly lower than both ex-smokers (6.2 days SD 7.9) and current smokers (6.1 days, SD=8.2). Compared to non-smokers, current smokers and ex-smokers had significantly higher odds of readmission within seven (OR=1.29; 95% CI: 1.13, 1.47, and OR=1.37; 95% CI: 1.19, 1.59, respectively) and 28 days (OR=1.35; 95% CI: 1.23, 1.49, and OR=1.53; 95% CI: 1.39, 1.69, respectively) of discharge. The cost of readmission for seven and 28-day readmission was significantly higher for current smokers compared to non-smokers (RR=1.52; 95% CI: 1.1.6, 2.0; RR=1.39; 95% CI: 1.18, 1.65, respectively).

CONCLUSION

Among patients admitted for elective surgery, hospital LOS, readmission risk and readmission costs were all higher for smokers compared with non-smokers. The findings indicate that provision of smoking cessation treatment for adults undergoing elective surgery is likely to produce multiple benefits.

Budget impact analysis of adopting primary care-based case detection of chronic obstructive pulmonary disease in the Canadian general population

BACKGROUND

An estimated 70% of Canadians with chronic obstructive pulmonary disease (COPD) have not received a diagnosis, creating a barrier to early intervention, and there is growing interest in the value of primary care-based opportunistic case detection for COPD. We sought to build on a previous cost-effectiveness analysis by evaluating the budget impact of adopting COPD case detection in the Canadian general population.

METHODS

We used a validated discrete-event microsimulation model of COPD in the Canadian general population aged 40 years and older to assess the costs of implementing 8 primary care-based case detection strategies over 5 years (2022-2026) from the health care payer perspective. Strategies varied in eligibility criteria (based on age, symptoms or smoking history) and testing technology (COPD Diagnostic Questionnaire [CDQ] or screening spirometry). Costs were determined from Canadian studies and converted to 2021 Canadian dollars. Key parameters were varied in one-way sensitivity analysis.

RESULTS

All strategies resulted in higher total costs compared with routine diagnosis. The most cost-effective scenario (the CDQ for all patients) had an associated total budget expansion of $423 million, with administering case detection and subsequent diagnostic spirometry accounting for 86% of costs. This strategy increased the proportion of individuals diagnosed with COPD from 30.4% to 37.8%, and resulted in 4.6 million referrals to diagnostic spirometry. Results were most sensitive to uptake in primary care.

INTERPRETATION

Adopting a national COPD case detection program would be an effective method for increasing diagnosis of COPD, dependent on successful uptake. However, it will require prioritisation by budget holders and substantial additional investment to improve access to diagnostic spirometry.

Estimating the Cost of Delivering Tobacco Cessation Intervention Package at Noncommunicable Disease Clinics in Two Districts of North India

INTRODUCTION

Integrated care is likely to improve outcomes in strained healthcare systems while limiting costs. NCD clinics were introduced under the "National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke" (NPCDCS) in India; however, there is limited literature on the costs of delivering tobacco cessation interventions within NPCDCS. One of the study's objectives was to estimate the cost of delivering a culturally specific patient-centric behavioral intervention package in two district-level NCD clinics in Punjab, India.

METHODS

Costing was undertaken using the health systems perspective. A top-down or financial costing approach and a bottom-up or activity-based approach were employed at each step of development and implementation. The opportunity cost was used to include the cost of human resources, infrastructure, and capital resources used. All infrastructure and capital costs were annualized using a 3% annual discount rate. Four additional scenarios were built up concerning three major components to reduce costs further when rolled out on a large scale.

RESULTS

The cost of intervention package development, human resource training, and unit cost of implementation were estimated to be INR 6,47,827 (USD 8,874); INR 134,002 (USD 1810); and INR 272 (USD 3.67), respectively. Based on our sensitivity analysis results, the service delivery cost varied from INR 184 (USD 2.48) to INR 326 (USD 4.40) per patient.

CONCLUSION

The development costs of the intervention package accounted for the majority proportion of the total cost. Of the total unit cost of implementation, the telephonic follow-up, human resources, and capital resources were the major contributory components.

IMPLICATIONS

The current study aims to fill gaps by estimating the unit-level health systems cost of a culturally sensitive, disease-specific, and patient-centric tobacco cessation intervention package delivered at the outpatient settings of NCD clinics at the secondary level hospital, which represents a major link in the health care system of India. Findings from this study could be used to provide supportive evidence to policymakers and program managers for rolling out such interventions in established NCD clinics through the NPCDCS program of the Indian Government.

Motivational support intervention to reduce smoking and increase physical activity in smokers not ready to quit: the TARS RCT

Background

Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear.

Objectives

The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective.

Design

This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation.

Setting and participants

Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458).

Intervention

The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity.

Main outcome measures

The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed.

Results

The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval -£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236).

Conclusions

There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective.

Limitations

Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence.

Future work

Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence.

Trial registration

This trial is registered as ISRCTN47776579.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.

Health and economic impact of a smoking cessation program in Korean workplaces

Smoking is a leading cause of diseases and death, with significant socioeconomic consequences. The purpose of this study was to evaluate the health and economic effectiveness of a workplace smoking cessation program. A total of 89 smokers from seven workplaces in Korea were the participants of the program. For 4 months, individual counseling based on the transtheoretical model (TTM) was conducted and interpersonal and organizational components were applied to encourage entire workplaces to encourage employee smoking cessation. The primary outcome was whether participants quit smoking or not. We also evaluated the changes in attitude and perceptions related to smoking cessation before and after the program and estimated the program's economic effects. Economic effects were defined as reductions in productivity losses and medical expenses. We calculated the return on investment (ROI) values representing the averted cost through the program compared to program cost. At the end of the program, 40.4% of participants quit smoking. Improvements were observed in TTM-based attitudes and perceptions. The mean reduction in productivity losses was estimated to be $187,609.94 for 2 yr and the mean reduction in medical expenses was $3,136.49 at 20 yr among seven workplaces. When accounting for these reductions, the ROI was 15.39 (ranging from -1.00 to 44.53). These effects were robust under various scenarios. The smoking cessation program should be expanded to a wider variety of workplaces. In the future, more sophisticated economic assessment methods should be developed and applied to facilitate workplace recruitment and attract management support.

Smoking cessation: health system challenges and opportunities

The systematic integration of evidence-based tobacco treatment has yet to be broadly viewed as a standard-of-care. The Framework Convention on Tobacco Control recommends the provision of support for tobacco cessation. We argue that the provision of smoking cessation services in clinical settings is a fundamental clinical responsibility and permits the opportunity to more effectively assist with cessation. The role of clinicians in prioritising smoking cessation is essential in all settings. Clinical benefits of implementing cessation services in hospital settings have been recognised for three decades-but have not been consistently provided. The Ottawa Model for Smoking Cessation has used an 'organisational change' approach to its introduction and has served as the basis for the introduction of cessation programmes in hospital and primary care settings in Canada and elsewhere. The significance of smoking cessation dwarfs that of many preventive interventions in primary care. Compelling evidence attests to the importance of providing cessation services as part of cancer treatment, but implementation of such programmes has been slow. We recognise that the provision of such services must reflect the realities and resources of a particular health system. In low-income and middle-income countries, access to treatment facilities pose unique challenges. The integration of cessation programmes with tuberculosis control services may offer opportunities; and standardisation of peri-operative care to include smoking cessation may not require additional resources. Mobile phones afford unique opportunities for interactive cessation programming. Health system change is fundamental to improving the provision of cessation services; clinicians can be powerful advocates for such change.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

Cost Effectiveness of Case Detection Strategies for the Early Detection of COPD

OBJECTIVES

The value of early detection and treatment of chronic obstructive pulmonary disease (COPD) is currently unknown. We assessed the cost effectiveness of primary care-based case detection strategies for COPD.

METHODS

A previously validated discrete event simulation model of the general population of COPD patients in Canada was used to assess the cost effectiveness of 16 case detection strategies. In these strategies, eligible patients (based on age, smoking history, or symptoms) received the COPD Diagnostic Questionnaire (CDQ) or screening spirometry, at 3- or 5-year intervals, during routine visits to a primary care physician. Newly diagnosed patients received treatment for smoking cessation and guideline-based inhaler pharmacotherapy. Analyses were conducted over a 20-year time horizon from the healthcare payer perspective. Costs are in 2019 Canadian dollars ($). Key treatment parameters were varied in one-way sensitivity analysis.

RESULTS

Compared to no case detection, all 16 case detection scenarios had an incremental cost-effectiveness ratio (ICER) below $50,000/QALY gained. In the most efficient scenario, all patients aged ≥ 40 years received the CDQ at 3-year intervals. This scenario was associated with an incremental cost of $287 and incremental effectiveness of 0.015 QALYs per eligible patient over the 20-year time horizon, resulting in an ICER of $19,632/QALY compared to no case detection. Results were most sensitive to the impact of treatment on the symptoms of newly diagnosed patients.

CONCLUSIONS

Primary care-based case detection programs for COPD are likely to be cost effective if there is adherence to best-practice recommendations for treatment, which can alleviate symptoms in newly diagnosed patients.

Cost-effectiveness of a nurse-delivered, inpatient smoking cessation intervention

Randomized controlled trials have shown that inpatient tobacco cessation interventions are highly efficacious and cost-effective. However, the degree to which smoking interventions implemented in nonrandomized, real-world practice settings are effective, and consequently, cost-effective, remains unclear. This study evaluated the cost-effectiveness of a nurse-delivered, inpatient smoking cessation intervention, Tobacco Tactics, compared with usual care within the context of an observational, real-world study design. In this quasi-experimental study, five Michigan hospitals (N = 1,370 patients) were assigned to implement either Tobacco Tactics or usual care during October 2011-May 2013. Statistical analysis was conducted during January 2017-February 2018. Controlling for confounding using stabilized inverse probability of treatment weights, incremental cost-effectiveness ratios were calculated and cost-effectiveness acceptability curves were generated. The per person cost of tobacco cessation services in the intervention group exceeded that of usual care ($175.52 vs. $67.80; p < .001). The intervention group had a higher propensity-adjusted self-reported quit rate compared to the control group (15.7% vs. 7.0%; p < .0001). The propensity-adjusted incremental cost-effectiveness ratio was $1,325 per quit (95% confidence interval: $751-$2,462), with 99.9% probability of being cost-effective at a willingness to pay of $5,000 per quit. The Tobacco Tactics intervention was found to be cost-effective and well within the range of incremental cost-per-quit findings from other studies of tobacco cessation interventions, which range from $918 to $23,200, adjusted for inflation.

Variability in patient sociodemographics, clinical characteristics, and healthcare service utilization among 107,302 treatment seeking smokers in Ontario: A cross-sectional comparison

Background

Since 2005, the Smoking Treatment for Ontario Patients (STOP) program has provided smoking cessation treatment of varying form and intensity to smokers through 11 distinct treatment models, either in-person at partnering healthcare organizations or remotely via web or telephone. We aimed to characterize the patient populations reached by different treatment models.

Methods

We linked self-report data to health administrative databases to describe sociodemographics, physical and mental health comorbidity, healthcare utilization and costs. Our sample consisted of 107,302 patients who enrolled between 18Oct2005 and 31Mar2016, across 11 models operational during different time periods.

Results

Patient populations varied on sociodemographics, comorbidity burden, and healthcare usage. Enrollees in the Web-based model were youngest (median age: 39; IQR: 29–49), and enrollees in primary care-based Family Health Teams were oldest (median: 51; IQR: 40–60). Chronic Obstructive Pulmonary Disease and hypertension were the most common physical health comorbidities, twice as prevalent in Family Health Teams (32.3% and 30.8%) than in the direct-to-smoker (Web and Telephone) and Pharmacy models (13.5%-16.7% and 14.7%-17.7%). Depression, the most prevalent mental health diagnosis, was twice as prevalent in the Addiction Agency (52.1%) versus the Telephone model (25.3%). Median healthcare costs in the two years up to enrollment ranged from $1,787 in the Telephone model to $9,393 in the Addiction Agency model.

Discussion

While practitioner-mediated models in specialized and primary care settings reached smokers with more complex healthcare needs, alternative settings appear better suited to reach younger smokers before such comorbidities develop. Although Web and Telephone models were expected to have fewer barriers to access, they reached a lower proportion of patients in rural areas and of lower socioeconomic status. Findings suggest that in addition to population-based strategies, embedding smoking cessation treatment into existing healthcare settings that reach patient populations with varying disparities may enhance equitable access to treatment.

Clinical impact and cost-effectiveness of integrating smoking cessation into lung cancer screening: a microsimulation model

BACKGROUND

Low-dose computed tomography (CT) screening can reduce lung cancer mortality in people at high risk; adding a smoking cessation intervention to screening could further improve screening program outcomes. This study aimed to assess the impact of adding a smoking cessation intervention to lung cancer screening on clinical outcomes, costs and cost-effectiveness.

METHODS

Using the OncoSim-Lung mathematical microsimulation model, we compared the projected lifetime impact of a smoking cessation intervention (nicotine replacement therapy, varenicline and 12 wk of counselling) in the context of annual low-dose CT screening for lung cancer in people at high risk to lung cancer screening without a cessation intervention in Canada. The simulated population consisted of Canadians born in 1940-1974; lung cancer screening was offered to eligible people in 2020. In the base-case scenario, we assumed that the intervention would be offered to smokers up to 10 times; each intervention would achieve a 2.5% permanent quit rate. Sensitivity analyses varied key model inputs. We calculated incremental cost-effectiveness ratios with a lifetime horizon from the health system's perspective, discounted at 1.5% per year. Costs are in 2019 Canadian dollars.

RESULTS

Offering a smoking cessation intervention in the context of lung cancer screening could lead to an additional 13% of smokers quitting smoking. It could potentially prevent 12 more lung cancers and save 200 more life-years for every 1000 smokers screened, at a cost of $22 000 per quality-adjusted life-year (QALY) gained. The results were most sensitive to quit rate. The intervention would cost over $50 000 per QALY gained with a permanent quit rate of less than 1.25% per attempt.

INTERPRETATION

Adding a smoking cessation intervention to lung cancer screening is likely cost-effective. To optimize the benefits of lung cancer screening, health care providers should encourage participants who still smoke to quit smoking.

Cost-effectiveness of smoking cessation programs for hospitalized patients: a systematic review

OBJECTIVE

This systematic review examined the characteristics of published cost-effectiveness analyses of inpatient smoking cessation programs and assessed the methodological quality of the selected studies, to provide policymakers with economic evidence for this type of program.

METHODS

A literature search was undertaken using a relevant database by three investigators. Only full economic evaluations with results in the form of the incremental cost-effectiveness ratio (ICER) were included. Costs were adjusted to 2016 US dollars using the Gross Domestic Product deflator and purchasing power parities. The British Medical Journal checklist was utilized to appraise the methodological quality of the included studies.

RESULTS

Nine articles were ultimately selected. The inpatient smoking cessation programs appeared to be a highly cost-effective intervention according to the recommended cost-effectiveness thresholds by the World Health Organization or individual studies. The highest ICERs among the selected studies were $5593 per additional quit, $10,550 per life year gained, and $5680 per quality-adjusted life year gained.

CONCLUSIONS

This study provides robust evidence supporting the cost-effectiveness of smoking cessation programs for hospitalized patients. In addition, the results indicated that the degree of cost-effectiveness of the inpatient smoking cessation program might not be related to either the components of the program or methodological variations in the cost-effectiveness analysis. Policymakers should provide hospitals with resources and strong incentives to promote wider implementation of the smoking cessation program.

Patient perceptions of tobacco control after smoke-free hospital grounds legislation: Multi-center cross-sectional study

OBJECTIVE

To examine patient perceptions of the role of health care providers in tobacco control and tobacco-related services they should provide after the introduction of national smoke-free hospital grounds legislation in Spain.

DESIGN

Multi-center cross-sectional study.

SETTING

Thirteen hospitals in Barcelona province in 2014-2015.

PARTICIPANTS

A total of 1,047 adult hospital patients, with a stay ≥ 24 h were randomly selected.

METHOD

We explored participants' perceptions of the role of health professionals and hospitals in tobacco control by asking about their agreement with several statements after the introduction of national legislation on smoke-free hospital grounds: (i) health professionals "should set an example and not smoke" and "should provide smoking cessation support"; (ii) hospitals "should provide smoking cessation treatments" and are "role model organizations in compliance with the smoke-free legislation", and (iii) "hospitalization is a perfect moment to quit smoking". Responses were described overall and according to participant and hospital characteristics: patient sex and age, type of hospital unit, number of beds, and smoking prevalence among hospital staff.

RESULTS

The majority of participants considered that health professionals should be role models in tobacco cessation (75.3%), should provide smoking cessation support to patients (83.0%), and that hospitalization is a good opportunity for initiating an attempt to quit (71.5%). Inpatients admitted to general hospitals where smoking cessation was not given as part of their portfolio, with a low level of implementation in tobacco control, and who stayed in surgical units had higher expectations of receiving smoking cessation interventions.

CONCLUSIONS

Inpatients strongly support the role of hospitals and health professionals in tobacco control and expect to receive smoking cessation interventions during their hospital stay. Systematically providing smoking cessation services in hospitals may have a relevant impact on health outcomes among smokers and on health care system expenditures.

Development of interventions for an intelligent and individualized mobile health care system to promote healthy diet and physical activity: using an intervention mapping framework

Background

The mortality of coronary heart disease can be largely reduced by modifying unhealthy lifestyles. However, the long-term effectiveness of interventions for modifying unhealthy diet and physical inactivity of patients with coronary heart disease remain unsatisfactory worldwide. This study aims to systematically design a set of theory-based and evidence-based, individualized, and intelligent interventions for promoting the adoption and maintenance of a healthy diet and physical activity level in patients with coronary heart disease.

Methods

The interventions will be delivered by a mobile health care system called Individualized, Intelligent and Integrated Cardiovascular Application for Risk Elimination. Three steps of the intervention mapping framework were used to systematically develop the interventions. Step 1: needs assessment, which was carried out by a literature review, in-depth interviews and focus group discussions. Step 2: development of objective matrix for diet and physical activity changes, based on the intersection of objectives and determinants from the Contemplation-Action-Maintenance behavior change model. Step 3: formulation of evidence-based methods and strategies, and practical applications, through a systematic review of existing literature, research team discussions, and consultation with multidisciplinary expert panels.

Results

Three needs relevant to content of the intervention, one need relevant to presentation modes of the intervention, and four needs relevant to functional features of the application were identified. The objective matrix includes three performance objectives, and 24 proximal performance objectives. The evidence-based and theory-based interventions include 31 strategies, 61 evidence-based methods, and 393 practical applications.

Conclusions

This article describes the development of theory-based and evidence-based interventions of the mobile health care system for promoting the adoption and maintenance of a healthy diet and physical activity level in a structured format. The results will provide a theoretical and methodological basis to explore the application of intervention mapping in developing effective behavioral mobile health interventions for patients with coronary heart disease.

Trial registration

Chinese Clinical Trial Registry: ChiCTR-INR-16010242. Registered 24 December 2016. http://www.chictr.org.cn/index.aspx

Using a Health Economic Framework to Prioritize Quality Indicators: An Example With Smoking Cessation in Chronic Obstructive Pulmonary Disease

Background. Health care performance monitoring is a major focus of the modern quality movement, resulting in widespread development of quality indicators and making prioritizations an increasing focus. Currently, few prioritization methods of performance measurements give serious consideration to the association of performance with expected health benefits and costs. We demonstrate a proof-of-concept application of using a health economic framework to prioritize quality indicators by expected variations in population health and costs, using smoking cessation in chronic obstructive pulmonary disease (COPD) as an example. Methods. We developed a health state transition, microsimulation model to represent smoking cessation practices for adults with COPD from the health care payer perspective in Ontario, Canada. Variations in life years, quality-adjusted life years (QALYs), and lifetime costs were associated with changes in performance. Incremental net health benefit (INHB) was used to represent the joint variation in mortality, morbidity, and costs associated with the performance of each quality indicator. Results. Using a value threshold of $50,000/QALY, the indicators monitoring assessment of smoking status and smoking cessation interventions were associated with the largest INHBs. Combined performance variations among groups of indicators showed that 81% of the maximum potential INHB could be represented by three out of the six process indicators. Conclusions. A health economic framework can be used to bring dimensions of population health and costs into explicit consideration when prioritizing quality indicators. However, this should not preclude policymakers from considering other dimensions of quality that are not part of this framework.

Implementing smoking cessation within cancer treatment centres and potential economic impacts

Background

Although the health benefits of smoking cessation in newly diagnosed cancer patients are well established, systematic efforts to help cancer patients stop smoking have rarely been implemented in cancer centres.

Methods

Starting in 2012, the 14 regional cancer centres overseen by Cancer Care Ontario in the province of Ontario, Canada began to screen ambulatory cancer patients for their smoking status, to provide smokers with advice on the health benefits of quitting and to offer referral to smoking cessation services. Multiple initiatives were undertaken to educate healthcare providers and patients on the health benefits of cessation. Critical to the success of the initiative was strong leadership from Cancer Care Ontario executives and regional vice presidents, advice from an advisory committee of smoking cessation experts, engagement of regional champions and support from a provincial secretariat. The quarterly review of performance metrics was an important driver of change.

Results

Most cancer centres now screen in excess of 75% of ambulatory patients but rates for the acceptance of a referral to smoking cessation services remain low (less than 25%). Introduction of an opt-out referral process appears to increase referral acceptance. Economic analyses suggest that smoking cessation is cost-effective in a cancer centre environment.

Conclusions

Although there are barriers to the implementation of smoking cessation in cancer centres, it is possible to change the culture to one in which smoking cessation is considered part of high-quality treatment.

Effect of an Evidence-based Inpatient Tobacco Dependence Treatment Service on 1-Year Postdischarge Health Care Costs

Background:

In 2014, the Medical University of South Carolina (MUSC) implemented a Tobacco Dependence Treatment Service (TDTS) consistent with the Joint Commission (JC) standards recommending that hospitals screen patients for smoking, provide cessation support, and follow-up contact for relapse prevention within 1 month of discharge. We previously demonstrated that patients exposed to the MUSC TDTS were approximately half as likely to be smoking one month after discharge and 23% less likely to have a 30-day hospital readmission. This paper examines whether exposure to the TDTS influenced downstream health care charges 12 months after patients were discharged from the hospital.

Methods:

Data from MUSC’s electronic health records, the TDTS, and statewide health care utilization datasets (eg, hospitalization, emergency department, and ambulatory surgery visits) were linked to assess how exposure to the MUSC TDTS impacted health care charges. Total health care charges were compared for patients with and without TDTS exposure. To reduce potential TDTS exposure selection bias, propensity score weighting was used to balance baseline characteristics between groups. The cost of delivering the MUSC TDTS intervention was calculated, along with cost per smoker.

Results:

The overall adjusted mean health care charges for smokers exposed to the TDTS were $7299 lower than for those who did not receive TDTS services (P=0.047). The TDTS cost per smoker was modest by comparison at $34.21 per smoker eligible for the service.

Discussion:

Results suggest that implementation of a TDTS consistent with JC standards for smoking cessation can be affordably implemented and yield substantial health care savings that would benefit patients, hospitals, and insurers.

Smoking among hospitalized patients: A multi-hospital cross-sectional study of a widely neglected problem

INTRODUCTION

A comprehensive smoking ban was recently enacted for acute-care hospital campuses in Spain. The aim of this study was to assess the prevalence and patterns of smoking among inpatients before and during hospitalization.

METHODS

Multi-center cross-sectional study was conducted in 13 hospitals in the province of Barcelona, Spain from May 2014 to May 2015. Participants were adults who provided informed consent. The sample size was calculated to be representative of each hospital (prevalence 29.4%, precision ± 5%, error 5%). We approached 1228 subjects, 888 accepted to participate and 170 were replaced (were not available or declined to participate). Final sample comprised 1047 subjects. We used a computer-assisted personal interview system to collect data, including sociodemographic variables and use of tobacco before and during hospitalization. Smoking status was validated with exhaled carbon monoxide. We calculated overall tobacco prevalence and investigated associations with participant and center characteristics. We performed multiple polytomous and multilevel logistic regression analyses to estimate odds ratios (ORs) and 95% confidence intervals (CIs), with adjustments for potential confounders.

RESULTS

In all, 20.5% (95% CI: 18.1–23.0) of hospitalized patients were smokers. Smoking was most common among men (aOR=7.47; 95% CI: 4.88–11.43), young age groups (18–64 years), and individuals with primary or less than primary education (aOR=2.76; 95% CI: 1.44–5.28). Of the smokers, 97.2% were daily consumers of whom 44.9% had medium nicotine dependence. Of all smokers, three-quarters expressed a wish to quit, and one-quarter admitted to consuming tobacco during hospitalization.

CONCLUSIONS

Our findings indicate the need to offer smoking cessation interventions among hospitalized patients in all units and service areas, to avoid infringements and increase patient safety, hospital efficiency, and improve clinical outcomes. Hospitalization represents a promising window for initiating smoking interventions addressed to all patients admitted to smoke-free hospitals, specially after applying a smoke-free campus ban.

Development and application of an economic model (EQUIPTMOD) to assess the impact of smoking cessation

BACKGROUND AND AIMS

Although clear benefits are associated with reducing smoking, there is increasing pressure on public health providers to justify investment in tobacco control measures. Decision-makers need tools to assess the Return on Investment (ROI)/cost-effectiveness of programmes. The EQUIPT project adapted an ROI tool for England to four European countries (Germany, the Netherlands, Spain and Hungary). EQUIPTMOD, the economic model at the core of the ROI tool, is designed to assess the efficiency of packages of smoking cessation interventions. The objective of this paper is to describe the methods for EQUIPTMOD and identify key outcomes associated with continued and cessation of smoking.

METHODS

EQUIPTMOD uses a Markov model to estimate life-time costs, quality-adjusted life years (QALYs) and life years associated with a current and former smoker. It uses population data on smoking prevalence, disease prevalence, mortality and the impact of smoking combined with associated costs and utility effects of disease. To illustrate the tool's potential, costs, QALYs and life expectancy were estimated for the average current smoker for five countries based on the assumptions that they continue and that they cease smoking over the next 12 months. Costs and effects were discounted at country-specific rates.

RESULTS

For illustration, over a life-time horizon, not quitting smoking within the next 12 months in England will reduce life expectancy by 0.66, reduce QALYs by 1.09 and result in £4961 higher disease-related health care costs than if the smoker ceased smoking in the next 12 months. For all age-sex categories, costs were lower and QALYs higher for those who quit smoking in the 12 months than those who continued.

CONCLUSIONS

EQUIPTMOD facilitates assessment of the cost effectiveness of smoking cessation strategies. The demonstrated results indicate large potential benefits from smoking cessation at both an individual and population level.

The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Background

Cold homes and fuel poverty contribute to health inequalities in ways that could be addressed through energy efficiency interventions.

Objectives

To determine the health and psychosocial impacts of energy performance investments in low-income areas, particularly hospital admissions for cardiorespiratory conditions, prevalence of respiratory symptoms and mental health status, hydrothermal conditions and household energy use, psychosocial outcomes, cost consequences to the health system and the cost utility of these investments.

Design

A mixed-methods study comprising data linkage (25,908 individuals living in 4968 intervention homes), a field study with a controlled pre-/post-test design (intervention,n = 418; control,n = 418), a controlled multilevel interrupted time series analysis of internal hydrothermal conditions (intervention,n = 48; control,n = 40) and a health economic assessment.

Setting

Low-income areas across Wales.

Participants

Residents who received energy efficiency measures through the intervention programme and matched control groups.

Main outcome measures

Primary outcomes – emergency hospital admissions for cardiorespiratory conditions, self-reported respiratory symptoms, mental health status, indoor air temperature and indoor relative humidity. Secondary outcomes – emergency hospital admissions for chronic obstructive pulmonary disease-related cardiorespiratory conditions, excess winter admissions, health-related quality of life, subjective well-being, self-reported fuel poverty, financial stress and difficulties, food security, social interaction, thermal satisfaction and self-reported housing conditions.

Methods

Anonymously linked individual health records for emergency hospital admissions were analysed using mixed multilevel linear models. A quasi-experimental controlled field study used a multilevel repeated measures approach. Controlled multilevel interrupted time series analyses were conducted to estimate changes in internal hydrothermal conditions following the intervention. The economic evaluation comprised cost–consequence and cost–utility analyses.

Data sources

The Patient Episode Database for Wales 2005–14, intervention records from 28 local authorities and housing associations, and scheme managers who delivered the programme.

Results

The study found no evidence of changes in physical health. However, there were improvements in subjective well-being and a number of psychosocial outcomes. The household monitoring study found that the intervention raised indoor temperature and helped reduce energy use. No evidence was found of substantial increases in indoor humidity levels. The health economic assessment found no explicit cost reductions to the health service as a result of non-significant changes in emergency admissions for cardiorespiratory conditions.

Limitations

This was a non-randomised intervention study with household monitoring and field studies that relied on self-response. Data linkage focused on emergency admissions only.

Conclusion

Although there was no evidence that energy performance investments provide physical health benefits or reduce health service usage, there was evidence that they improve social and economic conditions that are conducive to better health and improved subjective well-being. The intervention has been successful in reducing energy use and improving the living conditions of households in low-income areas. The lack of association of emergency hospital admissions with energy performance investments means that we were unable to evidence cost saving to health-service providers.

Future work

Our research suggests the importance of incorporating evaluations with follow-up into intervention research from the start.

Funding

The National Institute for Health Research Public Health Research programme.

Using Bioinformatics to Treat Hospitalized Smokers: Successes and Challenges of a Tobacco Treatment Service

BACKGROUND

Hospitals face increasing regulations to provide and document inpatient tobacco treatment, yet few blueprint data exist to implement a tobacco treatment service (TTS).

METHODS

A hospitalwide, opt-out TTS with three full-time certified counselors was developed in a large tertiary care hospital to proactively treat smokers according to Chronic Care Model principles and national treatment guidelines. A bioinformatics platform facilitated integration into the electronic health record to meet evolving Centers for Medicare & Medicaid Services meaningful use and Joint Commission standards. TTS counselors visited smokers at the bedside and offered counseling, recommended smoking cessation medication to be ordered by the primary clinical service, and arranged for postdischarge resources.

RESULTS

During a 3.5-year span, 21,229 smokers (31,778 admissions) were identified; TTS specialists reached 37.4% (7,943), and 33.3% (5,888) of daily smokers received a smoking cessation medication order. Adjusted odds ratios (AORs) of receiving a chart order for smoking cessation medication during the hospital stay and at discharge were higher among patients the TTS counseled > 3 minutes and recommended medication: inpatient AOR = 7.15 (95% confidence interval [CI] = 6.59-7.75); discharge AOR = 5.3 (95% CI = 4.71-5.97). As implementation progressed, TTS counseling reach and medication orders increased. To assess smoking status ≤ 1 month postdischarge, three methods were piloted, all of which were limited by low follow-up rates (4.5%-28.6%).

CONCLUSION

The TTS counseled approximately 3,000 patients annually, with increases over time for reach and implementation. Remaining challenges include the development of strategies to engage inpatient care teams to follow TTS recommendations, and patients postdischarge in order to optimize postdischarge smoking cessation.

The Effect of an Inpatient Smoking Cessation Treatment Program on Hospital Readmissions and Length of Stay

OBJECTIVE

The objective of this study is to estimate the impact of an inpatient tobacco cessation treatment program on 30-day readmission rates and length of stay (LOS).

METHODS

Participants were 28,994 patients admitted to the hospital between July 2012 and July 2014. Smokers were identified through the electronic medical records system and were offered cessation treatment. Program effects were estimated by using a difference-in-differences approach, comparing all smokers to all nonsmokers before versus after introduction of the program. Readmission rates were modeled by using probit regression; LOS was modeled by using truncated negative binomial regression. Models controlled for age, sex, race, payer, hospital department, severity of illness, and intensive care unit days.

RESULTS

The hospital-initiated smoking cessation intervention had no significant effect on 30-day readmission rates or LOS. Other control variables had the expected signs and were statistically significant.

CONCLUSIONS

The evaluation of an inpatient tobacco dependence treatment did not find significant short-term changes in healthcare utilization in the first 30 days after initial hospitalization.

Validation of an algorithm to identify children with biopsy-proven celiac disease from within health administrative data: An assessment of health services utilization patterns in Ontario, Canada

Importance

Celiac disease (CD) is a common pediatric illness, and awareness of gluten-related disorders including CD is growing. Health administrative data represents a unique opportunity to conduct population-based surveillance of this chronic condition and assess the impact of caring for children with CD on the health system.

Objective

The objective of the study was to validate an algorithm based on health administrative data diagnostic codes to accurately identify children with biopsy-proven CD. We also evaluated trends over time in the use of health services related to CD by children in Ontario, Canada.

Study design and setting

We conducted a retrospective cohort study and validation study of population-based health administrative data in Ontario, Canada. All cases of biopsy-proven CD diagnosed 2005–2011 in Ottawa were identified through chart review from a large pediatric health care center, and linked to the Ontario health administrative data to serve as positive reference standard. All other children living within Ottawa served as the negative reference standard. Case-identifying algorithms based on outpatient physician visits with associated ICD-9 code for CD plus endoscopy billing code were constructed and tested. Sensitivity, specificity, PPV and NPV were tested for each algorithm (with 95% CI). Poisson regression, adjusting for sex and age at diagnosis, was used to explore the trend in outpatient visits associated with a CD diagnostic code from 1995–2011.

Results

The best algorithm to identify CD consisted of an endoscopy billing claim follow by 1 or more adult or pediatric gastroenterologist encounters after the endoscopic procedure. The sensitivity, specificity, PPV, and NPV for the algorithm were: 70.4% (95% CI 61.1–78.4%), >99.9% (95% CI >99.9->99.9%), 53.3% (95% CI 45.1–61.4%) and >99.9% (95% CI >99.9->99.9%) respectively. It identified 1289 suspected CD cases from Ontario-wide administrative data. There was a 9% annual increase in the use of this combination of CD-associated diagnostic codes in physician billing data (RR 1.09, 95% CI 1.07–1.10, P<0.001).

Conclusions

With its current structure and variables Ontario health administrative data is not suitable in identifying incident pediatric CD cases. The tested algorithms suffer from poor sensitivity and/or poor PPV, which increase the risk of case misclassification that could lead to biased estimation of CD incidence rate. This study reinforced the importance of validating the codes used to identify cohorts or outcomes when conducting research using health administrative data.

Guidelines for the Treatment of Smoking in Hospitalized Patients

Between 15 and 27% of patients admitted to Spanish hospitals are smokers. Hospitalization is an ideal time for a smoker to decide to quit. We performed a MEDLINE search of controlled, randomized or observational studies associated with helping hospitalized patients quit smoking, published between January 1, 2002 and September 30, 2015. On the basis of the results of those studies, we have issued some recommendations for the treatment of smoking in hospitalized patients. The recommendations were drawn up according to the GRADE system. Offering the smoker psychological counselling and prolonging follow-up for at least 4 weeks after discharge is the most effective recommendation for helping hospitalized patients to quit.

Effectiveness of a hospital-initiated smoking cessation programme: 2-year health and healthcare outcomes

Background

Tobacco-related illnesses are leading causes of death and healthcare use. Our objective was to determine whether implementation of a hospital-initiated smoking cessation intervention would reduce mortality and downstream healthcare usage.

Methods

A 2-group effectiveness study was completed comparing patients who received the ‘Ottawa Model’ for Smoking Cessation intervention (n=726) to usual care controls (n=641). Participants were current smokers, >17 years old, and recruited during admission to 1 of 14 participating hospitals in Ontario, Canada. Baseline data were linked to healthcare administrative data. Competing-risks regression analysis was used to compare outcomes between groups.

Results

The intervention group experienced significantly lower rates of all-cause readmissions, smoking-related readmissions, and all-cause emergency department (ED) visits at all time points. The largest absolute risk reductions (ARR) were observed for all-cause readmissions at 30 days (13.3% vs 7.1%; ARR, 6.1% (2.9% to 9.3%); p<0.001), 1 year (38.4% vs 26.7%; ARR, 11.7% (6.7% to 16.6%); p<0.001), and 2 years (45.2% vs 33.6%; ARR, 11.6% (6.5% to 16.8%); p<0.001). The greatest reduction in risk of all-cause ED visits was at 30 days (20.9% vs 16.4%; ARR, 4.5% (0.4% to 8.7%); p=0.03). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 (11.4% vs 5.4%; ARR 6.0% (3.1% to 9.0%); p<0.001) and year 2 (15.1% vs 7.9%; ARR, 7.3% (3.9% to 10.7%); p<0.001).

Conclusions

Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage.