Purpose:

Managed Care Organizations (MCOs) such as Aetna Inc. provide an opportunity to expand tobacco cessation interventions to a large dental practitioner audience, and to the patients within their practices. The Aetna MCO has access to a population of dental patients and dental providers that enables the Columbia University/Deschutes Research Institute (DRI) research team to integrate tobacco cessation into the routine of dental practice. The proposed project will evaluate the effectiveness of a CD-ROM as the primary source of continuing education for the dental provider; it will utilize clinical practice guidelines, and performance feedback, via links to the Columbia/DRI research team. The CD-ROM, and electronic detailing via electronic mail and enhanced reimbursement, will be used to stimulate tobacco cessation behaviors by subject-dentists. The project will incorporate systems-based strategies including tobacco user identification systems, education, financial incentives, and feedback. The project will also evaluate the cost-effectiveness of the intervention.

Continuing education modules provided via CD-ROMs will provide the vehicle for implementing the Public Health Service guidelines in the dental office. The Columbia/Aetna Inc. approach will integrate cessation into routine dental prevention visits. The goal of the Columbia/Aetna approach is to facilitate and create systems change within the dental managed care system and in the dental office. The aim of the effort is to develop and disseminate a comprehensive interactive CD-ROM and related materials on tobacco cessation in the Aetna DMO® and evaluate its effectiveness in altering dental provider tobacco cessation behaviors. This program would have the potential of expanding the “communication” of cessation to thousands of practicing dentists in the United States.

Objectives:

The primary goal of the Columbia/Aetna approach is to determine whether an MCO sponsored tobacco related system can be created, facilitated and maintained within the dental office. The second goal is to determine whether a CD-ROM based educational intervention can increase the prevalence of cessation activities within the MCO dental practices. A third goal is to measure the cost-effectiveness of the proposed systems changes.

The CD-ROM based education integrated with electronic updates will educate Aetna Dental Maintenance Organization (DMO®) providers in tobacco cessation strategies using a multi-component intervention. These components include: 1) use of continuing education via CD-ROMs to provide education on tobacco control; 2) flagging of records of patients who smoke; 3) the setting of quit dates; 4) provision of tobacco cessation materials for dissemination to flagged patients; and 5) development of health plan performance measures for cessation related efforts.

The CD-ROM which will be sent by Columbia University/Aetna to dentists in the intervention arm will include the following elements: 1) the five A’s as promulgated by the United States Public Health Service (Fiore, 2000); 2) the effect of tobacco on systemic and oral health; 3) the identification and flagging of patients who use tobacco; 4) the psychological aspects of tobacco addiction; 5) the importance of the dental office interventions in motivating patients to quit tobacco use; 6) a detailed description and prescribing information for all Nicotine Replacement Therapy (NRT) and pharmacotherapy adjuncts; 7) the benefits of patient tobacco cessation for participating offices, 8) links to Columbia/Aetna; 9) a link to Aetna for submission of relative value units (RVUs); 10) a CME credit form and link for free registration; 11) links to tobacco-cessation web sites; and 12) information about how to obtain patient education materials in addition to the materials distributed in the office from Columbia University/Aetna.

The Columbia/Aetna relationship will create continuing education CD-ROM modules on tobacco cessation that will be integrated into routine office practice. The continuing education modules will educate dentists on the importance of tobacco cessation to their practice and how to integrate tobacco cessation into patient care. Dental providers will be informed about the Aetna enhanced payment system for tobacco cessation performed in the dental office and will be given instructions on obtaining continuing education credits from Columbia University. Continuing education (CME) has been shown to be effective in disseminating new information to dental providers. The requirement for CME credits for licensure and the MCO’s commitment to financial remuneration will help to encourage the dental providers to participate in the program.

Primary outcome measures for the Columbia ATMC project include: 1) setting a quit date (patient report that the dental provider talked to them about setting a quit date, and dentist report regarding proportion encouraged to set a quit date); and 2) flagging of smokers’ charts as reported by chart review. Secondary outcome measures include: 1) request of relative value unit enhanced payment; 2) time spent on the CD-ROM; and 3) quit rates and other tobacco cessation behaviors (patient report of change in readiness to quit, quit attempts since enrollment).