Budget impact analysis for implementation decision making, planning, and financing

Shelley et al. (in Accelerating integration of tobacco use treatment in the context of lung cancer screening: relevance and application of implementation science to achieving policy and practice. Transl Behav Med 2022;12:1076-1083) laid out how implementation science frameworks and methods can advance the delivery of tobacco use treatment services during lung cancer screening services, which until recently was mandated by the Centers for Medicare and Medicaid Services. Their discussion provides an important overview of the full process of implementation and highlights the vast number of decisions that must be made when planning for implementation of an evidence-based practice such as tobacco use treatment: what specific tobacco use treatment services to deliver, when to deliver those services within the lung cancer screening process, and what implementation strategies to use. The costs of implementation play a major role in decision making and are a key implementation determinant discussed in major implementation frameworks. When making decisions about what and how to implement, budget impact analyses (BIAs) can play an important role in informing decision making by helping practitioners understand the overall affordability of a given implementation effort. BIAs can also inform the development of financing strategies to support the ongoing sustainment of tobacco use treatment service provision. More attention is needed by the research community to produce high-quality, user-friendly, and flexible BIAs to inform implementation decision making in health system and community settings. The application of BIA can help ensure that the considerable time and effort spent to develop and evaluate evidence-based programs has the best chance to inform implementation practice.

Advancing Proficiencies for Health Professionals in the Treatment of Tobacco Use Among Marginalized Communities: Development of a Competency-Based Curriculum and Virtual Workshop

BACKGROUND

Tobacco-related disparities are a leading contributor to health inequities among marginalized communities. Lack of support from health professionals is one of the most cited barriers to tobacco cessation reported by these communities. Improving the proficiencies with which health professionals incorporate social and cultural influences into therapeutic interactions has the potential to address this critical barrier. In general, training to improve these proficiencies has shown promise, but the specific proficiencies required for treating tobacco use among marginalized communities are unknown. This project aimed to develop a competency-based curriculum to improve these proficiencies among health professionals with experience and training in the evidence-based treatment of tobacco use, and then pilot test the content delivered via an expert review of a virtual, self-paced workshop.

METHODS

We used the Delphi Technique to systematically identify the specific competencies and corresponding knowledge and skill sets required to achieve these proficiencies. Educational content was developed to teach these competencies in a virtual workshop. The workshop was evaluated by 11 experts in the field by examining pre- and post-training changes in perceived knowledge, skill, and confidence levels and other quantitative and qualitative feedback. Repeated measures analysis of variance and paired sample t-tests were used to examine pre-post training differences.

RESULTS

Six competencies and corresponding skill sets were identified. After exposure to the virtual workshop, the experts reported significant increases in the overall proficiency for each competency as well as increases in nearly all levels of knowledge, skill, and confidence within the competency skill sets. Qualitative and quantitative findings indicate that content was relevant to practice.

CONCLUSIONS

These findings provide preliminary support for 6 competencies and skills sets needed to improve therapeutic interpersonal interactions that recognize the importance of social and cultural influences in the treatment of tobacco use.

Educating Substance Use Treatment Center Providers on Tobacco Use Treatments Is Associated with Increased Provision of Counseling and Medication to Patients Who Use Tobacco

Tobacco use is the leading preventable cause of death in America and is elevated among patients with non-tobacco substance use disorders. Substance use treatment centers (SUTCs) do not commonly address their patients' tobacco use. Lack of knowledge on treating tobacco use with counseling and medication may be a barrier that underlies this inaction. A multi-component tobacco-free workplace program implemented in Texas SUTCs educated providers on treating tobacco use with evidence-based medication (or referral) and counseling. This study examined how center-level changes in knowledge from pre- to post-implementation (i.e., over time) affected center-level behavioral changes in providers' provision of tobacco use treatment over time. Providers from 15 SUTCs completed pre- and post-implementation surveys (pre N = 259; post N = 194) assessing (1) perceived barriers to treating tobacco use, specifically, a lack of knowledge on treating tobacco use with counseling or medication; (2) receipt of past-year education on treating tobacco use with counseling or medication; and (3) their intervention practices, specifically, the self-reported regular use of (a) counseling or (b) medication intervention or referral with patients who use tobacco. Generalized linear mixed models explored associations between provider-reported knowledge barriers, education receipt, and intervention practices over time. Overall, recent counseling education receipt was endorsed by 32.00% versus 70.21% of providers from pre- to post-implementation; the regular use of counseling to treat tobacco use was endorsed by 19.31% versus 28.87% from pre- to post-implementation. Recent medication education receipt was endorsed by 20.46% versus 71.88% of providers from pre- to post-implementation; the regular use of medication to treat tobacco use was endorsed by 31.66% versus 55.15% from pre- to post-implementation. All changes were statistically significant (ps < 0.05). High versus low reductions in the provider-reported barrier of "lack of knowledge on pharmacotherapy treatment" over time were a significant moderator of effects, such that SUTCs with high reductions in this barrier were more likely to report greater increases in both medication education receipt and medication treatment/referral for patients who use tobacco over time. In conclusion, a tobacco-free workplace program implementation strategy that included SUTC provider education improved knowledge and resulted in increased delivery of evidence-based treatment of tobacco use at SUTCs; however, treatment provision rates-in particular, offering tobacco cessation counseling-remained less than desirable, suggesting that barriers beyond lack of knowledge may be important to address to improve tobacco use care in SUTCs. Moderation results suggest (1) differences in the mechanisms underlying uptake of counseling education versus medication education and (2) that the relative difficulty of providing counseling versus providing medication persists regardless of knowledge gains.

Impact of a tobacco cessation intervention on adherence to tobacco use treatment guidelines among village health workers in Vietnam

Community health workers (in Vietnam referred to as village health workers) have the potential to play a key role in expanding access to evidence-based tobacco use treatment. We conducted a cluster randomized controlled trial in community health centers in Vietnam that compared the effect of provider advice and cessation assistance (i.e. brief counseling and patient education materials) (BC) vs. BC + three sessions of in-person counseling delivered by a village health worker (BC+R) on providers' and village health workers' adherence to tobacco use treatment guidelines. All village health workers and health care providers received training. This paper presents data on the effect of the intervention on village health workers' adherence to tobacco use treatment guidelines, including asking about tobacco use, advising smokers to quit, offering assistance and their attitude, norms, and self-efficacy related to tobacco use treatment. We examined changes in adherence to tobacco use treatment guidelines before and 12 months after the intervention among 89 village health workers working in the 13 community health centers enrolled in the BC+R study condition. Village health workers' adherence to tobacco use treatment guidelines increased significantly. Village health workers were more likely to ask about tobacco use (3.4% at baseline, 32.6% at 12 months), offer advice to quit (4.5% to 48.3%) and offer assistance (1.1% to 38.2%). Perceived barriers to treating tobacco use decreased significantly. Self-efficacy and attitudes towards treating tobacco use improved significantly. Increased adherence to tobacco use treatment guidelines was associated with positive attitudes towards their role in delivering tobacco use treatment and increasing awareness of the community health center smoke-free policy. The findings suggest that, with training and support systems, village health workers can extend their role to include smoking cessation services. This workforce could represent a sustainable resource for supporting smokers who wish to quit.