Pharmacists' role in a smoking-cessation program at a managed health care organization

A smoking-cessation program at a managed health care organization and the involvement of pharmacists are described. Kaiser Permanente Northwest Region is a prepaid group-practice managed health care organization serving more than 380,000 members in Oregon and southwest Washington. A multidepartmental team at Northwest Region designed and implemented a stepped-care approach to smoking cessation in March 1992. The program progresses from advising and helping patients to quit on their own to enrolling patients in a behavioral-modification course to referring them to nicotine-replacement therapy to be given concurrently with the behavioral modification. The program was established with the help of pharmacists, and pharmacists are deeply involved in its operation. They work closely with each patient, the health educator instructing the patient, and the prescribing physician. Pharmacists attend 5 of the 10 behavioral modification/nicotine-replacement course sessions and take responsibility for enrollees throughout the program. Pharmacists prescribe and monitor nicotine-replacement therapy by protocol. They also monitor each patient for the dose-response effect, adverse drug reactions, drug interactions, concurrent medical conditions, and progress and outcome. The physician is informed about any important changes in the patient's status. In 1992, more than 80 courses were held with nearly 1000 participants, and rates of long-term abstinence achieved compare favorably with literature rates for community-based group smoking-cessation programs. Satisfaction of patients, pharmacists, and physicians with the program has been high. Pharmacists at a managed health care organization participate in a smoking-cessation program by helping with behavioral modification, educating patients about nicotine-replacement therapy, and prescribing and monitoring therapy by protocol.     

Vestibular hypersensitivity to clicks is characteristic of the Tullio phenomenon

OBJECTIVES: This study evaluated the cost-effectiveness of a smoking cessation and relapse-prevention program for hospitalized adult smokers from the perspective of an implementing hospital. It is an economic analysis of a two-group, controlled clinical trial in two acute care hospitals owned by a large group-model health maintenance organization. The intervention included a 20-minute bedside counseling session with an experienced health counselor, a 12-minute video, self-help materials, and one or two follow-up calls. METHODS: Outcome measures were incremental cost (above usual care) per quit attributable to the intervention and incremental cost per discounted life-year saved attributable to the intervention. RESULTS: Cost of the research intervention was $159 per smoker, and incremental cost per incremental quit was $3,697. Incremental cost per incremental discounted life-year saved ranged between $1,691 and $7,444, much less than most other routine medical procedures. Replication scenarios suggest that, with realistic implementation assumptions, total intervention costs would decline significantly and incremental cost per incremental discounted life-year saved would be reduced by more than 90%, to approximately $380. CONCLUSIONS: Providing brief smoking cessation advice to hospitalized smokers is relatively inexpensive, cost-effective, and should become a part of the standard of inpatient care.     

Managed behavioral health services for children under carve-out contracts

OBJECTIVE: Service costs and utilization patterns of children in carved-out behavioral health care plans were examined and compared with those of adults. METHODS: Twelve-month data on utilization and costs of behavioral health care from one managed behavioral health care carve-out organization, United Behavioral Health, were examined for three age groups of children--birth to five years, six to 12 years, and 13 to 17 years-and for adults. More than 600,000 enrollees in 108 different plans were included in the data. Rates of use and intensity of use were examined separately by type of service-inpatient, outpatient, and partial hospitalization. RESULTS: Only a small number of all enrollees used any behavioral health care services--4.2 percent used outpatient services, .3 percent used inpatient services, and .2 percent used partial hospitalization services. Adolescents were more than twice as likely as adults and about seven times as likely as children aged 6 to 12 to use inpatient services. Adolescents also had a slightly higher probability of using outpatient care than adults, while younger children had lower rates of outpatient use than adolescents or adults. Adolescents were also more likely than adults and other children to have very high costs of inpatient care (mean costs=$8,975 for adolescents and $4,750 for adults). Adults were more likely than other groups to have higher outpatient costs ($640 for adults and $513 for all children). CONCLUSIONS: The finding that children, and adolescents in particular, are more likely to have very high inpatient costs compared with adults implies that they may benefit most from the elimination of caps on mental health care costs covered by insurance. This profile of children's behavioral health care utilization patterns can be useful to policy makers in considering expansions in children's health insurance coverage.     

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.     

Cost of comprehensive pharmaceutical services in a 45-bed rural hospital

The financial impact of a comprehensive pharmacy program on patient charges and hospital operating costs in a 45-bed community hospital was studied. Data were collected retrospectively for the fiscal year prior to initiating pharmacy services (FY73), the fiscal year during program development (FY74) and the fiscal year following full operations (FY75). The total cost of pharmacy services increased 75% from FY73 to FY75, with the largest dollar increase being in pharmacy salaries. Large increases among other cost items also were noted. The average total cost for pharmacy services increased from $3.28 per patient day in FY73 to $6.04 in FY75 (84%). Total hospital cost per patient day increased by approximately $35 from FY73 to FY75 (5%). The pharmaceutical services fee per dose of medication administered did not change from FY73 to FY75. Patient charges per day for medications and pharmaceutical services increased $0.55 (9.8%) from FY73 to FY75. There was a 55% reduction in the number of items carried in pharmacy inventory from FY73 to FY74 following the initiation of a formulary and a unit dose drug distribution system.     

Factors predicting participant attrition in a community-based, culturally specific smoking-cessation program for Hispanic smokers.

Factors predicting participant attrition in a community-based, culturally specific smoking-cessation program enrolling 93 Hispanic smokers were examined. Analysis of univariate predictors showed noncompleters (n?=?18) to have lower incomes, to have expressed greater initial confidence in their ability to stop smoking, and to have perceived themselves to be in poorer general health and poorer health in relation to peers, than completers. Noncompleters were also more likely to have reported cardiovascular problems. Multivariate logistic regression analysis showed that confidence in stopping smoking, health compared with that of peers, and reported cardiovascular problems contributed significantly to prediction while controlling for other significant univariate predictors. The results are discussed in terms of factors that might mitigate premature termination in community-based smoking-cessation interventions targeting Hispanic smokers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Adenocarcinoma arising in "J" pouch after total proctocolectomy for familial polyposis coli

Cigarette smoking has a major impact both on oral health and general systemic health. Because up to 70 percent of smokers see their dentists each year, the dentist is in a very powerful position to intervene with the smokers to help them stop smoking. I have suggested a four-step program for assisting patients to quit, based on the National Cancer Institute's suggested protocol for the dental office, which uses techniques shown in clinical trials to be effective for helping smokers quit. The core of the NCI program involves identifying smokers, advising them to quit, providing assistance to patients trying to quit, and following-up on patients as a means of enhancing success rates. Dentists who implement an effective smoking cessation program in their practices can expect to achieve quit rates up to 10 to 15 percent each year among their patients who smoke. Such a rate of success, if established nationwide and continued over a period of years, would markedly reduce the prevalence of smoking in the United States.     

An estimate of the cost of in vitro fertilization services in the United States in 1995

OBJECTIVE: To estimate the cost of adding IVF treatment to a standard health care benefits package. In vitro fertilization cost is defined as the average charge for a single cycle of treatment in an existing IVF program. DESIGN: Cost analysis. SETTING: Two hundred sixty IVF centers active in the United States in 1993. MAIN OUTCOME MEASURES: In vitro fertilization utilization and outcomes for 1993 were estimated from data in an existing registry. In vitro fertilization charges were determined from a 1993 survey of IVF clinics. The resulting expenditures for benefits and premiums were projected to 1995 together with the additional cost if utilization were to increase by 300% or 500%. RESULTS: In the United States in 1993 there were 31,718 IVF cycles for which the average charge was $6,233, leading to a total expenditure of approximately $197.70 million for IVF services in 1993. The projected cost of adding IVF services to a typical employer health plan in 1995 would be $2.79 per annum and the premium would be $3.14. Benefits and premium costs for a 300% utilization increase were $8.37 and $9.41, respectively, and for a 500% increase, $13.95 and $15.69, respectively. CONCLUSIONS: The cost of IVF services would be a minute fraction of the annual cost of a typical family benefits program ($3,393). Savings from reduced utilization of alternative treatments would offset a portion of this increase. Increases in utilization rates should be controlled by clinical criteria.     

Program adherence and coping strategies as predictors of success in a smoking treatment program.

94 smokers (mean age 39 yrs) in a 6-wk behavioral smoking-cessation program were administered weekly questionnaires on their use of major program recommendations and other quitting strategies throughout treatment. An "affect-regulation" coping inventory was administered at the beginning and end of treatment. Adequate adherence was reported for most recommendations. Although a composite measure of adherence did not predict quitting success, adherence and coping assessments were associated with maintenance of treatment gains. Short-term maintenance was associated with an extensive affect-regulation repertoire and use of stimulus control strategies; long-term maintenance was associated with consistent self-monitoring of smoking during treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of smoking on bone mass and the rates of bone loss among elderly Japanese-American men

Bone density and bone loss rates were examined among Japanese-American men categorized as current cigarette smokers, past smokers, and nonsmokers. The design included a retrospective study of smoking and bone density and a prospective study of current smoking and bone loss rates. The mean length of follow-up was 5 years; the setting was the island of Oahu. The subjects included 1303 men in the Hawaii Osteoporosis Study, 51-82 years old at their initial examination. Twenty percent were current smokers, 45% past smokers, and 35% had never smoked. Their bone density was measured at the distal and proximal radius and calcaneus using single photon absorptiometry. Compared with never smokers, current and past smokers had significantly lower bone density, especially in the predominantly cancellous calcaneus (4.8 and 4.3% lower, respectively) and partially trabecular distal radius (1.8 and 3.3% lower, respectively). The magnitude of the smoking effect was linked strongly to the duration of smoking and also to the number of cigarettes smoked. Bone loss rates subsequent to the initial measurement were greater in the current smokers than the never smokers (20.5, 27.2, and 9.7% greater at the calcaneus, distal, and proximal radius, respectively) but the differences did not achieve significance. Smokers of more than one pack per day had 32.0, 77.6, and 30.7% greater loss rates than never smokers in these same sites; the difference achieved significance at the distal radius. The results from the distal radius suggest that these smokers may increase their fracture risk 10-30% per decade of smoking. The adverse effects of smoking appeared to be greater in cancellous than cortical bone.     

Prader-Willi and Angelman syndromes. Disorders of genomic imprinting

OBJECTIVE: To develop estimates of state Medicaid expenditures attributable to smoking for fiscal year 1993. METHODS: The smoking-attributable fractions (SAFs) of state Medicaid expenditures were estimated using a national model that describes the relationship between smoking and medical expenditures, controlling for a variety of sociodemographic, economic, and behavioral factors. RESULTS: In fiscal year 1993, the SAF for all states (all types of expenditures) was 14.4%, with a range from 8.6% in Washington DC to 19.2% in Nevada. On average, SAFs ranged from a low of 7.9% for home health services expenditures to 21.7% for hospital expenditures. An estimated total of $12.9 billion of fiscal year 1993 Medicaid expenditures was attributable to smoking. The relative error of this estimate was 40.3%. CONCLUSIONS: Cigarette smoking accounts for a substantial portion of annual state Medicaid expenditures, with considerable variation among states. The range in expenditures among the states is due to differences in smoking prevalence, health status, other socioeconomic variables used in the model, and the level and scope of the Medicaid program.     

Effects of biochemical validation of self-reported cigarette smoking on treatment success and on misreporting abstinence.

Investigated the measurement of alveolar carbon monoxide (CO) levels to validate self-reported smoking rates at the end of treatment. 127 volunteer smokers, mostly middle-aged, who were in behavioral smoking-cessation clinics were randomly assigned to 1 of 3 conditions that varied in timing of exposure to information regarding CO measurement: (a) at the beginning of treatment (demonstration of CO measurement, discussion of smoking effects on CO levels, and notification that individual CO levels would be measured at the conclusion of the clinic); (b) at the end of treatment (demonstration, discussion, and notification of CO measurement prior to self-reports of smoking levels); or (c) at the end of treatment (demonstration and discussion of CO measurement subsequent to self-reports of smoking levels). Only 16% of self-reports of abstinence were not verified by CO measurement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Desire and efforts to quit smoking among cigarette smokers in Wisconsin

This research studied the desire and attempts of cigarette smokers in Wisconsin to quit smoking. Data were based on the 1993 Wisconsin Division of Health's Behavioral Risk Factor Surveillance System (BRFSS). Among the 23% of respondents who were current smokers, 79% said they wanted to quit smoking and 60% said they had quit smoking for a day or more in the preceding year. High rates of wanting to quit and having tried to quit were found in all demographic subgroups of smokers studied. Compared to lighter smokers, heavy cigarette smokers (20 or more cigarettes per day) were less likely to have tried quitting in the past year, but were almost as likely to want to quit. These results demonstrate the great demand for smoking cessation services among smokers in Wisconsin and support for efforts to increase the use and effectiveness of these interventions.     

Increased left ventricular muscle mass after long-term altitude training in athletes

STUDY OBJECTIVES: To compare the costs and effectiveness of directly observed therapy (DOT) vs self-administered therapy (SAT) for the treatment of active tuberculosis. DESIGN: Decision analysis. SETTING: We used published rates for failure of therapy, relapse, and acquired multidrug resistance during the initial treatment of drug-susceptible tuberculosis cases using DOT or SAT. We estimated costs of tuberculosis treatment at an urban tuberculosis control program, a municipal hospital, and a hospital specializing in treating drug-resistant tuberculosis. OUTCOME MEASURES: The average cost per patient to cure drug-susceptible tuberculosis, including the cost of treating failures of initial treatment. RESULTS: The direct costs of initial therapy with DOT and SAT were similar ($1,206 vs $1,221 per patient, respectively), although DOT was more expensive when patient time costs were included. When the costs of relapse and failure were included in the model, DOT was less expensive than SAT, whether considering outpatient costs only ($1,405 vs $2,314 per patient treated), outpatient plus inpatient costs ($2,785 vs $10,529 per patient treated), or outpatient, inpatient, and patients' time costs ($3,999 vs $12,167 per patient treated). Threshold analysis demonstrated that DOT was less expensive than SAT through a wide range of cost estimates and clinical event rates. CONCLUSION: Despite its greater initial cost, DOT is a more cost-effective strategy than SAT because it achieves a higher cure rate after initial therapy, and thereby decreases treatment costs associated with failure of therapy and acquired drug resistance. This cost-effectiveness analysis supports the widespread implementation of DOT.     

Exercise, smoking cessation, and short-term changes in serum lipids in women: a preliminary investigation

PURPOSE: This study investigated the combined effects of exercise and smoking cessation on serum lipids. METHODS: Eighteen female smokers quit smoking using standard behavioral methods combined with exercise (N = 9) or with a nonexercise contact time control (N = 9). The smoking cessation program for both groups consisted of 12 weekly 1-h behavioral modification sessions held over 12 wk. Exercise training consisted of three supervised 45-min sessions per week for 12 wk. Contact control consisted of three health education lectures/discussions per week for 12 wk. Fitness (estimated VO2 peak), dietary variables, and fasting serum lipids and lipoproteins were assessed before and at the end of treatment. VO2 peak increased in the exercise subjects compared with the controls. RESULTS: Total caloric intake as well as total fat and carbohydrate increased significantly after smoking cessation in the controls, but there were no dietary changes in the exercise group. high density lipoprotein (HDL)-C2 increased (7.6 mg x dL(-1), P < 0.01) in the exercise group, whereas the increases in HDL and its subfractions did not attain statistical significance in the contact control group. Total cholesterol, low density lipoprotein (LDL)-C, and triglycerides did not change in either group. CONCLUSIONS: We conclude that exercise training magnifies the increase in HDL-C that usually occurs with smoking cessation.     

Factors associated with smoking and the reasons for stopping in Maori and Europeans: a comparative study

AIM: To compare the prevalence of smoking, factors associated with smoking, ex-smokers and reasons for stopping in Maori and Europeans aged 10 years and older. METHODS: Demographic and smoking data were obtained by personal interview using a standard questionnaire and assisted by Maori health carers. Report-back meetings were held. RESULTS: The smoking status in 713 subjects (Maori 52.5%, Europeans 47.5%) was: current smokers (Maori 48.1%, Europeans 19.8%); never smoked (Maori 28.1%, Europeans 47.5%); ex-smokers (Maori 23.8%, Europeans 32.7%). Of Maori smokers, 66.1% were women whereas of European smokers 47.8% were women. Significantly more Maori aged 10 to 29 years smoked than Europeans (p = 0.0002). Nineteen percent of smokers smoked < 5 cigarette equivalents per day, 68.8% smoked 5 to 20, and 12.2% smoked > 20 cigarettes per day. There was no gender difference in cigarette consumption. Maoridom (p = 0.00001), a less skilled occupation (p = 0.0008), lower income (< or = $15,000 p = 0.002) and alcohol consumption (p = 0.00001) were significantly associated with current smoking. Reasons for giving up smoking were health (majority), awareness of risks (Europeans), financial (Maori men), pregnancy (Maori women), social unacceptability (European women), on advice of medical practitioner (minority). CONCLUSIONS: Smoking remains a major problem in New Zealand, particularly in Maori. Stricter anti-tobacco measures than already exist, greater input from medical practitioners and particularly ongoing participation by Maori health carers should lead to a further decline in smoking.     

Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke

BACKGROUND: Most analyses of the economic benefits of smoking cessation consider long-term effects, which are often not of interest to public and private policy makers. These analyses fail to account for the time course of the short-run cost savings from the rapid decline in risk of acute myocardial infarction (AMI) and stroke. METHODS AND RESULTS: We estimate the time course of the fall in risk of AMI and stroke after smoking cessation and simulate the impact of a 1% absolute reduction in smoking prevalence on the number of and short-term direct medical costs associated with the prevented AMIs and strokes. In the first year, there would be 924+/-679 (mean+/-SD) fewer hospitalizations for AMI and 538+/-508 for stroke, resulting in an immediate savings of $44+/-26 million. A 7-year program that reduced smoking prevalence by 1% per year would result in a total of 63,840+/-15,521 fewer hospitalizations for AMI and 34,261+/-9133 fewer for stroke, resulting in a total savings of $3.20+/-0.59 billion in costs, and would prevent approximately 13,100 deaths resulting from AMI that occur before people reach the hospital. Creating a new nonsmoker reduces anticipated medical costs associated with AMI and stroke by $47 in the first year and by $853 during the next 7 years (discounting 2.5% per year). CONCLUSIONS: Although primary prevention of smoking among teenagers is important, reducing adult smoking pays more immediate dividends, both in terms of health improvements and cost savings.     

Ethylmorphine O-deethylation in isolated rat hepatocytes. Involvement of codeine O-demethylation enzyme systems

Smoking cessation programs may be an important component in the implementation of worksite smoking policies. This study examines the impact of a smoke-free policy and the effectiveness of an accompanying hypnotherapy smoking cessation program. Participants in the 90-minute smoking cessation seminar were surveyed 12 months after the program was implemented (n = 2642; response rate = 76%). Seventy-one percent of the smokers participated in the hypnotherapy program. Fifteen percent of survey respondents quit and remained continuously abstinent. A survey to assess attitudes toward the policy was conducted 1 year after policy implementation (n = 1256; response rate = 64%). Satisfaction was especially high among those reporting high compliance with the policy. These results suggest that hypnotherapy may be an attractive alternative smoking cessation method, particularly when used in conjunction with a smoke-free worksite policy that offers added incentive for smokers to think about quitting.