Background: Smokers receiving pharmacotherapy and individualizedsmoking cessation counseling through telephone quitlineshave been found to have higher quit rates than smokers receivingpharmacotherapy alone. Health plans are often positioned toencourage their members to use quitline services in addition topharmacotherapy.
Objective: To determine if healthcare members who werereceiving pharmacotherapy increased their participation in smokingquitline services after receiving proactive telephone calls orpostcards.
Study Design: Randomized controlled trial.
Methods: Health plan members filing pharmacotherapy claimswere identified weekly from health plan pharmacy claims data andrandomized to 1 of the following 3 conditions: control, recruitmentpostcard, or recruitment telephone call by a nurse quitline counselor.Enrollment of study members into the quitline program wastracked for 1 month after randomization.
Results: During 5 months, 625 individuals were identified forparticipation in the study, with the following enrollment into theprogram: 0% to the control group, 1.3% to the postcard group, and20.6% to the telephone call group (< .001 for significance bygroup). Although costs for the telephone intervention were themost expensive, it was also the most cost effective, given its successin enrolling members into the program.
Conclusions: Proactive telephone calling by smoking cessationnurse counselors to smokers receiving pharmacotherapy may be aneffective method of enrolling smokers into a cessation quitline.Health plans should consider proactive telephone recruitment toimprove use of quitline services.
(Am J Manag Care. 2005;11:501-507)
Smoking continues to be the number one cause ofpreventable death in the United States and is asignificant public health problem.1 Effectivemethods are available to assist smokers with cessation,including pharmacotherapy (nicotine replacement therapyor bupropion hydrochloride) and group or individualbehavioral counseling. Investigations of the effect ofbrief physician advice have yielded quit rates of approximately10% at 1 year.2 Pharmacotherapy, in addition tobrief physician advice, can boost these results to 15% to25%.3-5 However, the addition of behavioral counselingalong with pharmacotherapy demonstrates the highestquit rates of 25% to 36% at 1 year.6,7
Although many smokers attempting cessation usesome type of adjunctive pharmacotherapy, many do notaccess telephone quitline services that are available tothem. Previous research identifies that only 2.4% ofsmokers with partial health insurance coverage and 10%of smokers with full coverage will use smoking cessationservices, including a behavioral program and nicotinereplacement therapy, within 1 year.8 Methods forencouraging participation in quitline programs areneeded. Recruitment methods can make a difference inthe overall participation in a program. Most recruitmentstrategies are passive, in which subjects are informedabout the availability of a program through advertising,such as newsletters, television, and newspapers, and theparticipant makes the initial contact to the program forenrollment. In contrast, proactive recruitment occurswhen the program identifies eligible subjects and contactsthe subjects directly (through mail, electroniccommunication, or, most commonly, telephone calls) tooffer services.9 Passive approaches typically result inlower participation levels,10 and passively recruitedstudy samples tend to be different from proactivelyrecruited samples. Passively recruited participants aremore likely to be ready to change, more highly educated,and predominantly female.11
Research regarding proactive strategies reveals thatthey are an effective method of recruiting targetedgroups to services.12,13 Prochaska et al9 found that 80%of smokers who were proactively "cold-called" by telephoneparticipated in a smoking cessation intervention,and Lando et al14 found that smokers were receptive toproactive telephone calls offering assistance with quitting.Britt and colleagues15 found high acceptance ofproactive telephone calls for smoking cessation, evenamong smokers not yet contemplating quitting, with86% of all contacted smokers accepting at least 1 telephonecounseling call. "Telephone outreach proceduresmay be a useful channel for increasing the proportion ofsmokers recruited into treatment," conclude Lando andcolleagues.14,p45
Because proactive strategies are typically much moreeffective in recruiting participants than passive strategies,they also tend to be more cost effective. Previousstudies16,17 of the proactive activities of quitlines havefound the additional costs to be inexpensive. Yet, forproactive identification of smokers to occur, there mustbe a mechanism in place to identify a target group.Identification of smokers using nicotine replacementtherapy or bupropion through pharmacy claims may bea strategy to identify smokers ready to quit in a healthplan population, and quitline participation can increasetheir success with cessation.
A major health plan based in the midwestern UnitedStates was interested in increasing the use of quitlineservices among members who smoke. The objective ofthis study was to determine if proactive recruitment ofhealth plan members filing a claim for smoking cessationpharmacotherapy was effective in increasing participationin quitline services. The costs associated withsuch recruitment are also calculated. This study mayserve as a model for other health plans in applyingproactive outreach measures.
Study subjects were health plan members of a largeopen-access health insurance company serving nearly5 million covered lives. These subjects had filled a prescriptionfor smoking cessation pharmacotherapy.Subjects were enrolled in a preferred provider organizationor a traditional fee-for-service insurance planand had pharmacy benefit coverage through theseplans (a subset of the total insured population).Pharmacy benefits for smoking cessation includedbupropion and nicotine replacement products, such asthe nicotine patch, gum, inhaler, and spray. Memberswho did not have health plan coverage for pharmacotherapyor otherwise made out-of-pocket purchasesfor over-the-counter nicotine replacement productswere not considered as subjects for this study. Personswere considered ineligible for participation in the studyif they (1) were a member of the health plan's healthmaintenance organization (excluded because of recentreceipt of postcard mailings encouraging quitline participation),(2) lacked an address or telephone numberon file, (3) were previously enrolled in the quitline program,or (4) were a patient of a provider enrolled in alarger ongoing study of smoking cessation interventions.Because members included in the study hadalready filled a prescription for smoking cessationpharmacotherapy, this group appeared to have inherentmotivation to quit smoking.
Study Design and Procedures
The study was approved by the UniversityCommittee for Research Involving Human Subjects atMichigan State University. The study design was a randomizedcontrolled trial. A priori sample size calculationsassuming a 3% baseline enrollment rate indicatedthat 134 subjects were needed in each group to detect a10% absolute difference between the control and eachintervention group with 80% power and a significancelevel of < .05. Identification of subjects was done by aweekly query to the insurance plan's pharmacy claimsdatabase. Members with a claim for smoking cessationpharmacotherapy were listed. This list was then crosscheckedwith the relevant databases, and memberswere eliminated if they were found to have 1 or more ofthe ineligibility criteria. The remaining members wereconsidered eligible for study participation and were randomizedto 1 of the following 3 conditions: control(usual procedure, ie, passive recruitment in whichsmokers learn about the quitline from providers ornewsletters and self-contact the quitline), recruitmentpostcard, or recruitment telephone call by a nurse quitlinecounselor. The randomization to conditions was a2:1:1 ratio, with the recruitment telephone call conditionhaving twice the assigned sample size to accommodatethe expected modest contact rate. Subjectidentification began in March 2003 and continued untilat least 134 subjects were identified for each group,which occurred in July 2003.
The control group received no direct contact otherthan the typical communications, such as the quitlinetelephone number listed in the health plan newsletter.There were 2 intervention groups, the postcard groupand the telephone call group. The postcard group wassent 1 of 2 postcards normally used by the health planto encourage participation in the quitline containing 1of the following 2 motivational messages: "Want anextra $2000 next year?" or "Quit smoking! No charge.No hassle. No joke." Each included the quitline telephone number to call and messages about the programsbeing free of charge and offering 24/7 telephone-basedenrollment, nurse counselor support, and educationaltools.
The telephone call group received a personal callfrom a smoking cessation quitline nurse. No letters weresent, so the telephone call was effectively a "cold call"from the quitline nurse. The content of the call includeda brief motivational message, description of the quitlineprogram, and an invitation for the member toenroll. The quitline program is based on a model ofcounselor support and relapse prevention. Participantsare offered 1 of 2 levels of participation and were offeredthe option of selecting participation in level 1, in level 2,or not at all. Level 1 requires the participant to set a quitdate within the next 14 days and includes an intake sessionand 6 sessions at intervals of 1, 3, 7, 14, 30, and 60days after the quit date, with follow-up at 90, 180, and360 days after the quit date. This follows the typicalrelapse curve after attempts at smoking cessation.6Level 2 is for participants not ready to set a quit datewithin the next 14 days, and participants are insteadsent educational materials and receive a series of telephonecallbacks (at which time participants enter level1 or drop out). For both levels, all follow-ups and contactsare conducted by telephone.
Subjects in the telephone call group were asked additionalquestions by the nurse. This included the member'sreason for not signing up for the program (if he orshe did not enroll); whether the member had alreadyquit smoking (7-day quit) and, if yes, his or her successwith this attempt to quit; the type of smoking cessationproduct used; and the member's rating of his or hervalue placed on and confidence in quitting smoking(score range, 1, not important or not confident, to 10,very important or very confident). Nurses made up to 4contact attempts, calling at different times of day andleaving messages before considering the member a noncontactedsubject. Consent to use the data was obtainedverbally by the nurse during telephone call contacts.Enrollment into the quitline program was tracked for 35days after the data pull.
Enrollment rate differences between the control andintervention groups were compared using the Fisherexact test. Any further differences between the groupswere compared using the Fisher exact test for categoricalvariables and the 2-tailed unpaired test or the 2-sample Wilcoxon signed rank test for continuousvariables, as appropriate. All analyses were conductedusing SAS statistical software, version 8.02 (SASInstitute Inc, Cary, NC).
To calculate costs, the resource costs were used forthe proactive interventions. The mean annual salary andbenefit costs were applied to 39.5 hours of the nurse'stime ($54 600) and to 33.5 hours of administrative stafftime ($72 602 for an analyst and $26 000 for a clerk),while actual costs were used for supplies ($0.31 permailed postcard and $1.25 per mailed educational materialspackage, which included a coping tips booklet, personaldiary, and "Clearing the Air" brochure). Costswere categorized as fixed or variable, an important differencein that the latter costs are incurred and changewith the intervention levels. Because the quitline programwas already purchased, available, and staffed, itscost represented a fixed cost. Increased use of the programassociated with the interventions did not result inan incremental, marginal cost increase relative to thecontrol group, although in the long run, more volumewould be expected to generate higher mean costs.
For all members in the study, the mean ± SD age was49.1 ± 12.6 years, and the sex distribution was 50.4%female and 49.6% male. There was no significant differenceby group in age or sex. Additional demographicdata were not available. Most claims were for bupropion(366 claims [58.6%]), followed by nicotine inhaler (138claims [22.1%]), nicotine patch (101 claims [16.2%]),and nicotine nasal spray (20 claims [3.2%]).
For those in the telephone call group, among 146 contacted,the sex distribution was 50.6% female, with a meanage of 48.8 years. Bupropion was again the most commonpharmacotherapy (77 claims [52.7%]), followed by nicotineinhaler (38 claims [26.0%]), nicotine patch (24 claims[16.4%]), nicotine nasal spray (7 claims [4.8%]), and acombination of 2 products (7 claims [4.8%]).
The Figure outlines the flow of participants throughthe study, including exclusions, randomization togroups, contact rates, and enrollment into the quitlineprogram. Regarding the contact rate, 155 of 156 postcardsthat were mailed successfully reached their recipients.The contact rate among the telephone call groupwas 46.8% (146/312). Of the 166 persons unable to becontacted by telephone, 75.3% (125/166) were due tononresponse, despite multiple contact attempts.
Increased enrollment into the quitline program wassignificant by randomization group (< .001). Thissignificance remained when the telephone call groupsample size was considered to be 312 (intention totreat) or 146 (contacted). Of those contacted, theenrollment rate was 43.8% (64/146) for any level ofthe program and 15.1% (22/146) for level 1 only. Ofthose enrolling, most (n = 42) enrolled in level 2 ofthe program, which provides educational informationand periodic telephone callbacks. Level 1 initiates thecounseling program, setting a quit date within thenext 14 days and a series of telephone counselingcalls. The mean ± SD time to contact from the prescriptionfill date to the nurse telephone call was 15.6± 1.6 days.
Other data were gathered for those contacted in thetelephone call group. Of 146 contacted, 7 declinedanswering the additional questions, leaving 139 in theexpanded data set. As noted in Table 1, about half ofthe group self-reported that they had already quitsmoking and were self-identified as "smoke free" bythe time of the telephone call. The value placed onquitting was rated as high (mean ± SD score, 9.4 ±1.6), as was the confidence in quitting (mean ± SDscore, 8.1 ± 2.6). The enrolled group was significantlyolder (51.9 vs 48.1 years; = .03, paired test) thanthose not enrolling, although there was no significantdifference in the sex distribution. Two other factorswere significantly predictive of quitline enrollment:(1) having quit and relapsed vs remaining smoke freeat contact (52.9% vs 19.2% enrollment; < .001, Fisherexact test) and (2) reporting a lower vs higher confidencein quitting (mean score, 7.7 vs 8.5; = .04, 2-sample Wilcoxon signed rank test). Those who hadalready quit reported higher scores for the valueplaced on quitting (mean score, 9.8 vs 8.9; = .001)and their confidence in quitting (mean score, 9.0 vs7.2; < .001). We only measured quit rates in the telephonecall group; at 60 days after enrollment, 4 subjectsremained in the quitline program and had quitsmoking. The quit rate in this group (18.2% [4/22entering level 1]) was similar to the usual member-reportedquit rates for the program.
The literature indicates that smokers using pharmacotherapyand quitline counseling have quit ratesof 25% or higher.6,7 Among those receiving brief physicianadvice and pharmacotherapy, the quit rates are15% to 25%.3-5 Extrapolating to the subjects in thisstudy, we estimate that 25% of the 22 level-1 enrolleesand 15% of the 42 level-2 enrollees quit smoking,resulting in 12 smokers who quit in the telephone callgroup. We estimate that there would have been 0.5smokers who quit in the postcard group (25% of 2enrollees).
The costs associated with the postcard and telephonecall interventions per outcome are shown in Table 2.The total costs were $3389 for the postcard interventionand $4766 for the telephone call intervention.The summary of incremental costs (ie, the variablecosts, a portion of the total costs) were $146.50 for thepostcard intervention and $1523.20 for the telephonecall intervention, or $73.25 and $23.80 pertotal program contact, respectively. Although the totalinvestment of personally contacting individuals bytelephone call is high relative to the postcard group,the resulting enrollment makes it the less costly way ofencouraging participation when evaluated on a cost-per-enrollee basis. To calculate the costs per smokerwho quit, 2 methods were used. First, actual quit ratesamong level-1 enrollees at 60 days after enrollmentrevealed total costs per smoker who quit of $1191 andincremental costs per smoker who quit (with the additionof the proactive telephone calls) of $380.73. Allsmokers who quit were in the telephone call group.Second, using estimated quit rates based on the literature,3-7 extrapolated to this study, we would expecthigher numbers of quitters, as already noted, of 0.5 inthe postcard group and 12 in the telephone call group,reducing the total and incremental costs per smokerwho quit in the telephone call group.
The key findings of this study were that proactivetelephone calling of members filing claims for smokingcessation pharmacotherapy can be an effective methodof recruiting these smokers into quitline participation.Smokers who have quit and relapsed are more likely toenroll than those who have quit and maintained cessation.Because 95% to 98% of untreated smokers and 70%to 80% of treated smokers will relapse, this finding mayprove valuable in understanding how to sustain quitrates.18,19 The postcard mailing was ineffective in influencingparticipation in the program.
These results were similar to those found by others.Zhu et al20 found that proactive telephone counselingwas a promising adjuvant treatment for nicotinereplacement therapy users. Nicotine replacement therapyusers who received follow-up telephone sessionswere more likely to succeed in smoking cessation in thelong term than those receiving only a single counselingsession (25.6% vs 16.1% at 1 year). There was a dose-responserelationship between counseling intensity andtreatment effect. McDonald13 found that telephone andother interpersonal recruitment strategies produceresults superior to those of media or mail, whether usedindependently or in combination with one another.
Two thirds of the enrollees were to level 2 of the quitlineprogram, providing educational materials and periodiccallbacks, rather than to level 1 of the program,which requires setting a quit date within 14 days.Possible reasons for the greater level-2 enrollmentinclude participants' being interested in some level ofassistance but not the complete program, not beingready to quit within 14 days (ie, they preferred to set aquit date at a later time), or simply not wanting to sayno to the nurse counselor.
The length of time it takes to contact the participantis an issue for other health plans to consider in implementingsimilar interventions. A lag in contact waslargely a result of how current the data were in the pharmacydatabase. In most health plans, getting pharmacydata less than a week old is problematic. This may havebeen a factor in the low enrollment; however, many participantswere simply averse to the idea of participatingin a program (30.1% did not believe that they needed aprogram or did not like the idea of a program). Yet, inmost cases, members agreed to accept the telephonecall and answer questions. Another consideration is thelimited reliability of telephone numbers in health plandatabases, which adds to the burden of staff who arecontacting participants. In this study, half of the participantswere not reachable by telephone in up to 4 contactattempts, and this was among members who had atelephone number on file.
Although the total costs per participant were higherin the telephone call group, the enrollment rate was alsohigher than in the postcard group or the control group,which brought the cost per enrolled participant downand made the telephone call group the most cost effectiveof the intervention and control groups. Resourcecosts of the interventions wereminimal, compared with thecost of running the quitlineprogram. In this case,increased use of the quitlinecan be considered an additionalbenefit of the study to theextent that it helps fill unusedprogram capacity. If the interventionhad led to increaseduse of the quitline beyond theexisting program capacity, thenthe additional resource costswould need to be considered inthis analysis. Staff costs may befurther reduced by the use oftrained nonclinical personnel,a strategy that has been shownto be effective in quitlines.21
Limitations of this studyinclude the selection bias of thestudy sample, which did notinclude the health maintenanceorganization members of the health plan, subjects nothaving smoking cessation pharmacotherapy coverage,subjects not needing or seeking pharmacotherapy, andsubjects having providers enrolled in a larger ongoingstudy. The size of the subject pool was small, and self-reportdata from the telephone call group did not includea specific time frame regarding cessation experience.Quit rates were not validated by carbon monoxide orcotinine tests, although research on cessation data byself-report is reliable.22,23 Beyond age and sex, additionaldemographic data were not available, and quit rates andfurther information on subjects in the control group andthe postcard group were not available.
In summary, proactive telephone recruitment of healthplan members receiving pharmacotherapy for smokingcessation was effective in enrolling members to participatein quitline counseling. Health plans should considerproactive telephone recruitment to improve the useof quitline services with excess program capacity.
We thank Rene Jarinski, RN, Carol Lingl, RN, and Ruth De Vine, RN, forassistance with the proactive telephone calls.
From the Department of Family Practice, College of Human Medicine, Michigan StateUniversity, East Lansing (JSH, WCW, DW); and Center for Health Care Quality andEvaluative Studies, Blue Cross Blue Shield of Michigan, Detroit (SV, HF).
This study was funded by grant 43968 from the Addressing Tobacco in Managed CareInitiative, The Robert Wood Johnson Foundation, Princeton, NJ.
Address correspondence to: Jodi Summers Holtrop, PhD, Department of Family Practice,College of Human Medicine, Michigan State University, B107 Clinical Center, EastLansing, MI 48824. E-mail: firstname.lastname@example.org.
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