Will healthcare take tobacco addiction seriously? Using policy to drive practice.

Despite being the leading preventable cause of disability, death, and economic burden on society, tobacco-use detection and treatment is yet to be taken as seriously as the prevention and treatment of chronic diseases or other addictive behaviors (eg, hypertension, diabetes, alcohol/substance abuse, and mammography screening). This paper outlines the process of intervening at the policy level to incorporate tobacco-use screening and treatment in health practice. The National Committee for Quality Assurance (NCQA) call for new measures presented a window of opportunity. The NCQA report card (the Health Plan Employer Data Information Set [HEDIS]) is the most widely used and influential performance measure in managed care. Consequently, a 6-month process consisting of an expert panel review of research evidence and consensus building was initiated. Two measures were submitted to NCQA: (1) a primary measure based on chart review of tobacco-use screening and treatment implementation and (2) an adjunctive measure of population prevalence of tobacco use and physician advice to quit, based on a self-report survey of members. HEDIS eventually accepted the second measure. The mixed results, potential impact on societal disease burden and cost savings, and the lessons learned from the process are discussed.

Developing performance indicators that reflect an expanded view of health: findings from the use of an innovative methodology.

BACKGROUND: The increasing presence of managed health care in the United States has been accompanied by the widespread use of performance indicators to assess health plans along various dimensions of quality. Current performance indicator sets virtually ignore psychosocial and behavioral factors in the prevention and management of illness, especially chronic illness, in spite of documented evidence in the medical literature of the importance of these factors. Instead, current indicator sets focus primarily on biomedical interventions to prevent, treat, and manage illness. METHODOLOGY: In a novel method for developing performance indicators--the use of a storytelling methodology--eight interdisciplinary panels, composed of health care experts at the community, state, and national levels, each completed two stories about patients with chronic illnesses. The first story described experiences a patient might have in the health care system as it is today; the second story retold the events that might transpire if attention to psychosocial and behavioral factors were integrated into the health care system. FINDINGS: Differences between the two sets of stories developed by the panels revealed common themes and specific areas where indicator development might prove fruitful. Performance indicators were identified from these themes, and work is underway to operationalize them; to identify barriers and opportunities for their inclusion in indicator sets; and to further document their potential health and cost-effectiveness. DISCUSSION: Although not scientifically rigorous, the storytelling method was found to provide consistent results and may be applied to many aspects of the health care planning process, health education, and quality improvement efforts.

Rating our progress in population health promotion: report card on six behaviors.

Using McKinlay's population model of prevention, this series assesses the current state of the art for six lifestyle behaviors: tobacco use, alcohol abuse, drug abuse, unhealthy diet, sedentary lifestyle, and risky sexual practices related to human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). More progress has been made in "downstream" individually oriented treatments than in broader, more environmentally focused interventions. Promising trends include: a shift toward lower cost minimal-contact and self-help "downstream" programs; the development of tailored messages and stage-based "midstream" initiatives that can reach everyone in a defined population or setting; and the emergence of "upstream" policy advocacy strategies. Improving the power and reach of health behavior change will require advances in biobehavioral research to develop more powerful behavior change strategies along with efforts to more widely disseminate the effective interventions that already exist. Growing evidence supports McKinlay's premise that full-spectrum (downstream to upstream) interventions are needed for greatest population impact. Progress also will depend on finding new ways to address the needs of special populations--including underserved low-income groups, racial and ethnic minorities, individuals with multiple risk behaviors, and youth and their families.

Organizing health care for people with seizures and epilepsy.

The day-to-day responsibilities of managing seizures and epilepsy fall most heavily on patients and their families. Unfortunately, health care services in the United States are not organized to identify, diagnose, and treat people with seizures effectively nor are they delivered in such a way that patients and their families can engage in a positive, collaborative relationship with health care providers. This article describes a model of chronic illness care as applied to seizures and epilepsy, that is, how care should be structured to help people with seizures live as well as possible.

Collaborative management of chronic illness.

In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of self-management training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.

Essential elements of self-help/minimal intervention strategies for smoking cessation.

Two decades of research suggest that self-help/minimal intervention strategies for smoking cessation may be the preferred means by which smokers stop and can produce success rates approximating those of more formal programs, at lower cost and with greater access to relevant populations. In order to make the best possible use of these self-help/minimal intervention approaches, the National Cancer Institute (NCI) supported a series of randomized, controlled intervention trials and, in June of 1988, convened an Expert Advisory Panel to address the question "What are the essential elements of self-help/minimal intervention strategies for smoking cessation?". The panel's recommendations were that: (1) Intervention efforts should focus on increasing smokers' motivations to make serious quit attempts; (2) Delivery of programs be broadened to include all smokers; (3) Programs be targeted to stages of cessation and specific populations; (4) All programs include (a) elements focused on health and social consequences of smoking, and (b) strategies and exercises aimed at quitting, maintenance of nonsmoking, relapse prevention, and recycling; (5) Materials and programs be made widely available rather than "fine tuning" existing programs or developing new ones; and (6) Programs make use of specific adjunctive strategies. In this way, a reacceleration of the decline in smoking prevalence may be realized in the 1990s and significantly contribute to the NCI's Year 2000 goals and the Surgeon General's aim of a smoke-free society.

Participation in workplace health promotion programs: the contribution of health and organizational factors.

Interest in workplace health promotion programs has raised important questions regarding these programs' ability to attract participants. Typically, participation has been examined as a function of personal characteristics of employees. But participation in a workplace health promotion program may be influenced as much by organizational characteristics as by health-related characteristics of employees. This preliminary study, conducted at AT&T Communications, used path analysis, a statistical technique for controlling for the effects of causally prior variables, to develop a model of participation. The influence of three sets of factors was detected: (1) Sex of employee was significant, with women more likely than men to participate in the program, (2) Increased perceived risk of illness led to decreased health satisfaction which in turn led to increased intention to change health habits culminating in increased participation, and (3) The organizational climate factor of perceived supportiveness of the supervisor contributed to participation. While several potential limitations require that these findings be replicated and extended, the study suggests that developers of workplace health promotion programs should attend to organizational work climate as well as personal health characteristics of employees in an effort to increase program impact.