Drive Time and Receipt of Guideline-Recommended Screening, Diagnosis, and Treatment.

Importance: Many patients do not receive recommended services. Drive time to health care services may affect receipt of guideline-recommended care, but this has not been comprehensively studied. Objective: To assess associations between drive time to care and receipt of guideline-recommended screening, diagnosis, and treatment interventions. Design, Setting, and Participants: This cohort study used administrative data from the National Veterans Health Administration (VA) data merged with Medicare data. Eligible participants were patients using VA services between January 2016 and December 2019. Women ages 65 years or older without underlying bone disease were assessed for osteoporosis screening. Patients with new diagnosis of chronic obstructive pulmonary disease (COPD) indicated by at least 2 encounter codes for COPD or at least 1 COPD-related hospitalization were assessed for receipt of diagnostic spirometry. Patients hospitalized for ischemic heart disease were assessed for cardiac rehabilitation treatment. Exposures: Drive time from each patient's residential address to the closest VA facility where the service was available, measured using geocoded addresses. Main Outcomes and Measures: Binary outcome at the patient level for receipt of osteoporosis screening, spirometry, and cardiac rehabilitation. Multivariable logistic regression models were used to assess associations between drive time and receipt of services. Results: Of 110 780 eligible women analyzed, 36 431 (32.9%) had osteoporosis screening (mean [SD] age, 66.7 [5.4] years; 19 422 [17.5%] Black, 63 403 [57.2%] White). Of 281 130 patients with new COPD diagnosis, 145 249 (51.7%) had spirometry (mean [SD] age, 68.2 [11.5] years; 268 999 [95.7%] men; 37 834 [13.5%] Black, 217 608 [77.4%] White). Of 73 146 patients hospitalized for ischemic heart disease, 11 171 (15.3%) had cardiac rehabilitation (mean [SD] age, 70.0 [10.8] years; 71 217 [97.4%] men; 15 213 [20.8%] Black, 52 144 [71.3%] White). The odds of receiving recommended services declined as drive times increased. Compared with patients with a drive time of 30 minutes or less, patients with a drive time of 61 to 90 minutes had lower odds of receiving osteoporosis screening (adjusted odds ratio [aOR], 0.90; 95% CI, 0.86-0.95) and spirometry (aOR, 0.90; 95% CI, 0.88-0.92) while patients with a drive time of 91 to 120 minutes had lower odds of receiving cardiac rehabilitation (aOR, 0.80; 95% CI, 0.74-0.87). Results were similar in analyses restricted to urban patients or patients whose primary care clinic was in a tertiary care center. Conclusions and Relevance: In this retrospective cohort study, longer drive time was associated with less frequent receipt of guideline-recommended services across multiple components of care. To improve quality of care and health outcomes, health systems and clinicians should adopt strategies to mitigate travel burden, even for urban patients.

Cost-effectiveness of population-level proactive tobacco cessation outreach among socio-economically disadvantaged smokers: evaluation of a randomized control trial.

AIMS: To estimate the cost-effectiveness at population-level of the OPT-IN proactive tobacco cessation outreach program for adult smokers enrolled in publicly funded health insurance plans for low-income persons (e.g. Medicaid). DESIGN: Cost-effectiveness analysis using a state transition model based on data from the Offering Proactive Treatment Intervention (OPT-IN) randomized control trial. SETTING: The trial was conducted in Minnesota, USA, and the economic analysis was conducted from the Medicaid program perspective. PARTICIPANTS: Data were used from 2406 smokers who were randomized into the intervention or comparator groups. INTERVENTION AND COMPARATOR: The intervention was comprised of proactive outreach (mailed invitation and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive telephone counseling). The comparator was usual care, which comprised access to a primary care physician, insurance coverage of Food and Drug Administration (FDA)-approved smoking cessation medications and the state's telephone quitline. MEASUREMENTS: Smoking status, quality of life and health-care use at varying times, including at baseline and 1 year. FINDINGS: The OPT-IN program cost an average of $84 per participant greater than the comparator. One year after randomization, the population-level, 6-month prolonged smoking abstinence rate was 16.5% in the proactive outreach intervention group and 12.1% in the usual care group (P < 0.05). The model projected that the proactive outreach intervention added $78 in life-time cost and generated 0.005 additional quality-adjusted life-years (QALYs), with an expected incremental cost-effectiveness ratio of $4231 per QALY. Probabilistic sensitivity analysis found that the proactive outreach intervention would be cost-effective against a willingness-to-pay threshold of $50 000/QALY approximately 68% of the time. CONCLUSIONS: Population-level proactive tobacco treatment with personal telephone outreach was effective in achieving higher population-level quit rates and was cost-effective at various willingness-to-pay thresholds, compared with usual care (i.e. reactive treatment). Taken together with prior research, population-level proactive tobacco cessation outreach programs are judged to be highly cost-effective over the long term.

The Equity Impact of Proactive Outreach to Smokers: Analysis of a Randomized Trial.

INTRODUCTION: Population-based smoking-cessation services tend to preferentially benefit high-SES smokers, potentially exacerbating disparities. Interventions that include proactive outreach, telephone counseling, and free or low-cost cessation medications may be more likely to help low-SES smokers quit. This analysis evaluated the role of SES in smokers' response to a population-based proactive smoking-cessation intervention. METHODS: This study, conducted in 2016 and 2017, was a secondary analysis of the Veterans Victory Over Tobacco Study, a multicenter pragmatic RCT of a proactive smoking-cessation intervention conducted from 2009 to 2011. Logistic regression modeling was used to test the effect of income or education level on 6-month prolonged abstinence at 1-year follow-up. RESULTS: Of the 5,123 eligible, randomized participants, 2,565 (50%) reported their education level and 2,430 (47%) reported their income level. The interactions between education (p=0.07) or income (p=0.74) X treatment arm were not statistically significant at the 0.05 level. The largest effect sizes for the intervention were found among smokers in the lowest education category (≤11th grade), with a quit rate of 17.3% as compared with 5.7% in usual care (OR=3.5, 95% CI=1.4, 8.6) and in the lowest income range (<$10,000), with a quit rate of 18.7% as compared with 9.4% in usual care (OR=2.2, 95% CI=1.2, 4.0). CONCLUSIONS: In a large, multicenter smoking-cessation trial, proactive outreach was associated with higher rates of prolonged abstinence among smokers at all SES levels. Proactive outreach interventions that integrate telephone-based care and facilitated cessation medication access have the potential to reduce socioeconomic disparities in quitting. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT00608426.

A Proactive Smoking Cessation Intervention for Socioeconomically Disadvantaged Smokers: The Role of Smoking-Related Stigma.

Introduction: Smoking denormalization has been paralleled by reduced smoking prevalence, but smoking rates among socioeconomically disadvantaged populations remain high. The social unacceptability of smoking has also led to increased perceptions of smoking-related stigma. By examining how smoking stigma influences cessation intervention effectiveness, we can better tailor interventions to socioeconomically disadvantaged smokers. Aims and Methods: Data are from a randomized controlled trial evaluating the effectiveness of a proactive cessation intervention on abstinence. Current smokers enrolled in Minnesota Health Care Programs were randomized to proactive outreach (n = 1200) or usual care (n = 1206). The intervention included mailings, telephone outreach, counseling, and access to free cessation treatments. Using baseline measurements, groups with lower (n = 1227) and higher (n = 1093) perceived stigma were formed. Intervention, stigma, and their interaction term were added to a logistic regression modeling abstinence at 12 months. Results: Lower perceived smoking-related stigma was associated with less support for quitting, lower rates of physician quitting advice, and less motivation for quitting. A logistic regression modeling abstinence found a significant intervention × stigma interaction. The proactive intervention was more effective among smokers with lower perceived smoking-related stigma (odds ratio 1.94, 95% confidence interval, 1.29 to 2.92) than those with higher perceived smoking-related stigma (odds ratio 1.04, 95% confidence interval, 0.70 to 1.55). Discussion: Smokers with lower perceived smoking-related stigma had social environments that were conducive to smoking, received less physician advice to quit, and were less motivated to quit than higher stigma smokers. Despite these barriers, the intervention was more effective for lower stigma smokers, suggesting that proactive outreach is an efficient treatment for these hard-to-reach smokers. Implications: Smoking denormalization has led to increased perceptions of smoking-related stigma among many smokers; however, little is known about how this stigma influences the cessation process. In the present study, smokers with lower levels of perceived smoking-related stigma lived in social environments that were more conducive to smoking and were less motivated to quit than higher stigma smokers. Despite these barriers, our proactive outreach cessation intervention was more effective for lower stigma smokers, suggesting that interventions which utilize proactive outreach to stimulate interest in quitting and offer facilitated access to free cessation treatments are an effective treatment approach for these hard-to-reach smokers. These strategies may be particularly effective for motivating smokers enrolled in government-subsidized health insurance programs to take advantage of cessation resources.

Treatment barriers among younger and older socioeconomically disadvantaged smokers.

OBJECTIVES: Underutilization of smoking cessation treatments contributes to high rates of smoking in socioeconomically disadvantaged populations. Guided by a conceptual framework, the present study explored how healthcare provider factors, social environment characteristics, and cessation beliefs influence treatment utilization among low-income smokers and whether these associations vary by age. STUDY DESIGN: Analyses were conducted on baseline data from 2406 participants enrolled in a randomized controlled trial that evaluated the effectiveness of a proactive outreach cessation intervention among a sample of younger (18-34 years) and older (35-64 years) smokers enrolled in public healthcare assistance programs. METHODS: Multivariable logistic regression models predicted past year cessation treatment utilization (CTU) among younger and older smokers. Independent variables included measures of healthcare provider barriers, social environment characteristics, and cessation beliefs. RESULTS: Younger smokers were less likely to have CTU than older smokers (27.2% vs 36.2%; P <.001). In both groups, number of cigarettes per day, more problems accessing healthcare, receiving medication-related cessation advice, and readiness to quit were positively associated with CTU (P <.05). Among younger smokers, living with another smoker was associated with lower odds of CTU while receipt of cessation advice was associated (P = .033) with higher odds of CTU. CONCLUSIONS: In this sample of low-income smokers, interest in quitting was high but treatment utilization was low. Increasing utilization of cessation treatments via interventions that target issues specific to low-income smokers, including healthcare provider access and advice, the home environment, and motivation to quit, is an important step toward reducing smoking rates in this population.

The association of military discharge variables with smoking status among homeless Veterans.

OBJECTIVE: There is a dearth of research examining the health correlates of tobacco use within the homeless population, particularly with respect to homeless Veterans. An aim of the present study was to compare homeless Veteran and homeless non-Veteran smokers across a series of socio-demographic and health variables, and to determine whether any of these variables were independently associated with Veteran status. A subsequent aim was to compare the socio-demographic and health profiles of Veteran smokers and Veteran nonsmokers, and to determine whether any of these variables were independently associated with current smoking. METHODS: Data were obtained from the 2009 Homelessness in Minnesota survey conducted by the Wilder Research Foundation. The final sample included 4750 homeless individuals living throughout Minnesota. RESULTS: The prevalence of smoking was greater among homeless Veterans (74%) than homeless non-Veterans (70%). The prevalence of physical and mental health problems was higher among homeless Veteran smokers than homeless non-Veteran smokers, although these variables were not independently associated with Veteran status after controlling for socio-demographics. Analyses of the homeless Veteran sample indicated that receipt of Veterans' benefits, type of discharge, and alcohol and/or chemical dependence were independently associated with current smoking. CONCLUSION: Homeless Veteran smokers exhibit heightened rates of physical and mental health problems compared to homeless non-Veteran smokers. Military service and discharge characteristics may contribute to this high smoking prevalence. Future efforts should focus on increasing Veterans' access to and knowledge of Veterans' health resources, and on developing innovative strategies to boost cessation in this population.

Associations between smoking behaviors and financial stress among low-income smokers.

OBJECTIVE: Many American households struggle to bring in sufficient income to meet basic needs related to nutrition, housing, and healthcare. Nicotine addiction and consequent expenditures on cigarettes may impose extra financial strain on low-income households. We examine how cigarette use behaviors relate to self-reported financial stress/strain among low-income smokers. METHODS: At baseline in 2011/12, OPT-IN recruited adult smokers age 18-64 from the administrative databases of the state-subsidized Minnesota Health Care Programs (N = 2406). We tested whether nicotine dependency, type of cigarettes used, and smoking intensity were associated with self-reported difficulty affording food, healthcare, housing, and living within one's income. All regression models were adjusted for race, education, income, age, and gender. RESULTS: Difficulty living on one's income (77.4%), paying for healthcare (33.6%), paying for housing (38.4%), and paying for food (40.8%) were common conditions in this population. Time to first cigarette and cigarettes smoked per day predicted financial stress related to affording food, housing, and living within one's income (all p < 0.05). For instance, those whose time to first cigarette was greater than 60 minutes had about half the odds of reporting difficulty paying for housing compared to those who had their first cigarette within five minutes of waking (adjusted odds ratio = 0.55 [95% CI: 0.41, 0.73]). Type of cigarette used was not associated with any type of financial stress/strain. CONCLUSIONS: Smoking and particularly heavy smoking may contribute in an important way to the struggles that low-income households with smokers face in paying for necessities.