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The American Journal of Accountable Care June 2019
Reducing Low-Value Care in Virginia
Daniel Carey, MD, Secretary of Health and Human Resources, Commonwealth of Virginia
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The Role of Health Systems in Reducing Tobacco Dependence
Megan N. Whittet, MPH; Traci R. Capesius, MPH; Heather G. Zook, MA; and Paula A. Keller, MPH
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Bernadette Mazurek Melnyk, PhD, APRN-CNP
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Curtailing Utilization of Low-Value Medical Care
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Dennis P. Scanlon, PhD

The Role of Health Systems in Reducing Tobacco Dependence

Megan N. Whittet, MPH; Traci R. Capesius, MPH; Heather G. Zook, MA; and Paula A. Keller, MPH
Addressing tobacco use is an important health system role. This process evaluation discusses facilitators and barriers to implementing systems changes to improve tobacco treatment delivery.

Objectives: Health systems play an important role in addressing tobacco use. Research indicates that implementing systems changes in clinical settings may lead to greater rates of tobacco treatment delivery and reductions in tobacco use prevalence compared with clinics and health systems that do not implement such changes. Few studies have described facilitators and barriers to implementing these changes.

Study Design: A process evaluation was conducted of 5 Minnesota health systems that implemented multiple systems changes to make tobacco treatment delivery a standard of care. Three large integrated health systems (1 in the Twin Cities metropolitan area, 1 in northern Minnesota, and 1 in central Minnesota), a federally recognized Minnesota Chippewa Tribe, and a safety net dental practice were evaluated.

Methods: An external evaluator conducted 3 waves of key informant interviews with each system. Purposive sampling was used to select key informants from each health system. A total of 49 interviews among 30 staff were conducted. Project documents were also reviewed. Evaluators used both deductive and inductive approaches to identify cross-cutting themes.

Results: Several facilitators were identified, including using a team-based approach to engage staff, implementing new protocols and training staff, and utilizing tools such as electronic health records and data to conduct quality improvement initiatives. Barriers included delays in electronic health record changes and keeping tobacco treatment prioritized in the organization.

Conclusions: Health systems change can provide a renewed sense of enthusiasm and ownership of tobacco treatment among providers and staff and can be an effective way to help prioritize addressing tobacco use.

The American Journal of Accountable Care. 2019;7(2):4-11
Tobacco use screening and brief intervention is 1 of the top 3 preventive services in terms of cost savings and potential population health improvement.1,2 Health systems play an important role in addressing tobacco use. Seventy-five percent of current smokers report visiting a healthcare provider in the past year.3 The majority of smokers want their healthcare provider to address their smoking,4,5 and satisfaction with care is highest among smokers who receive cessation assistance or follow-up.4,6

The US Public Health Service (PHS) Clinical Practice Guideline, Treating Tobacco Use and Dependence, recommends implementing the 5 As (Ask, Advise, Assess, Assist, and Arrange) to systematically address tobacco use.7,8 Implementing the 5 As, including brief interventions by providers, is associated with greater tobacco cessation efforts among patients compared with no intervention9; research also demonstrates that brief advice from a physician increases successful quitting.10 Nationally, healthcare providers consistently assess for tobacco use (90%) and frequently advise patients to quit (71%), but far fewer assist patients to quit (49%).4 A similar gap is seen in Minnesota.11

The PHS Clinical Practice Guideline and the CDC also recommend that clinics and health systems implement health systems changes to improve tobacco treatment delivery (eg, establishing a process to identify tobacco users, educating staff on tobacco treatment, providing resources and feedback to promote interventions).7,12 Evidence suggests that health systems change can improve care delivery processes compared with clinical settings where such changes were not implemented.7,13 Although the evidence is mixed regarding whether systems change improves cessation outcomes,13 some studies have shown that systems change in clinic settings can reduce the prevalence of tobacco use.8,9 However, few studies have examined factors that influence systems change implementation.14

ClearWay Minnesota, an independent nonprofit organization, released a competitive request for proposals to fund Minnesota healthcare systems for the implementation of health systems changes to more successfully address tobacco use. Applicants applied for up to $200,000 to fund a 2-year project; they were instructed to propose evidence-based strategies that aligned with their organization’s goals to better assess and address tobacco use. ClearWay Minnesota identified 3 areas of interest for applicants to consider: incorporating best practices for systems change, such as those outlined in the Clinical Practice Guideline7; optimizing their electronic health record (EHR); and using quality improvement processes. An expert review panel evaluated proposals and made funding recommendations. Funding decisions were made by ClearWay Minnesota’s Board of Directors. Three integrated health systems (1 in the Twin Cities metropolitan area, 1 in northern Minnesota, and 1 in central Minnesota), a federally recognized Minnesota Chippewa Tribe, and a safety net dental practice were funded (see Table 1 for health system characteristics).

We conducted a process evaluation to better understand facilitators and barriers to systems change implementation experienced by these diverse health systems. The insights reported in this paper can inform other systems change efforts.


Study Design

Professional Data Analysts, an independent external evaluation firm, conducted the process evaluation. A qualitative approach, informed by Yin’s case study methodology15 and Patton’s qualitative design principles,16 was used to capture the complexity of the systems change process, as well as to gain insight on the facilitators, barriers, lessons learned, and potential sustainability of these changes. Intervention approaches differed across sites; examples included training staff and providers on delivering the 5 As, optimizing EHRs for clinical decision support and documentation, and creating standard workflows and procedures for identifying and treating tobacco users. All 5 health systems conducted their systems change activities over a 2-year period; 3 sites conducted activities from 2014 to 2016 and 2 sites from 2015 to 2017. A contracted technical assistance provider supported grantees on an as-needed basis.

Document review. ClearWay Minnesota provided the evaluators with key documents for each health system (eg, grant application, progress reports, meeting notes). Throughout the grant period and before each round of interviews, 2 evaluators independently reviewed all documents to inform interview protocol development.

Key informant interviews. The evaluators conducted 3 waves of semistructured interviews with key informants at each health system at the beginning, midpoint, and end of each 2-year grant period. Interview protocols were based on document review, previous systems change studies,4,8,9,14 tobacco control best-practice guidelines,12 and input from ClearWay Minnesota staff. Although each health system’s interview protocol was tailored to its project, all interviews were used to gather information about facilitators, barriers, lessons learned, and potential sustainability. Table 2 lists example interview questions.


Interviewees were selected through purposive sampling.16 ClearWay Minnesota staff and health system staff identified key informants within each system who were knowledgeable about the project, and evaluators invited them to participate by email. No participants declined an interview. Table 3 describes key informant characteristics.

Evaluators interviewed a minimum of 2 key informants from each health system during each interview wave. Interviews lasted 30 to 90 minutes; almost all were conducted face to face by 2 evaluators (1 primary, 1 secondary), but 2 interviews were conducted by phone. The primary evaluator was involved in all interviews; 1 of 2 other evaluators served as a secondary interviewer. A total of 49 interviews were conducted with 30 individuals across waves and across the 5 health systems (Table 3). All interviewees consented to have their interviews recorded. The evaluators created a detailed summary of each interview and sent it to the interviewees to review for completeness and accuracy. Subsequent corrections or additions from interviewees were incorporated into final summaries.

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