Tobacco Cessation Counseling Among Underserved Patients: A Report from CaReNet

,

Original Research

Tobacco Cessation Counseling Among Underserved Patients: A Report from CaReNet

J Fam Pract. 2002 January;51(1):65-69

By

Bennett Parnes, MD

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References

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ABSTRACT

OBJECTIVES: The purpose of our study was to determine the frequency of smoking cessation counseling in relation to insurance status in a practice-based research network.

STUDY DESIGN: We administered a modified National Ambulatory Medical Care Survey (NAMCS), with an additional payment category to identify uninsured patients, quarterly to 100 random patients at each practice site for 1 year.

POPULATION: The study population included the patients at the 7 practices within the Colorado Research Network (CaReNet), associated with the Department of Family Medicine, University of Colorado Health Science Center.

OUTCOMES MEASURED: We measured the prevalence of smoking and the frequency of cessation counseling.

RESULTS: Of 2773 visits analyzed, 1443 were made by adults who were either was uninsured (39%), had Medicaid (22%), or had private or a health maintenance organization insurance (private/HMO; 40%). Smoking prevalence was significantly greater in uninsured patients (30%) and Medicaid patients (31%), compared with private/HMO patients (22%) (P =.008). However, those smokers with private/HMO insurance were more likely to receive tobacco counseling (50%) than Medicaid (41%) and uninsured (25%) patients (P <.001). After controlling for potential confounders, this difference remained significant.

CONCLUSIONS: Although smoking is more common among Medicaid and uninsured patients, these smokers are less likely to receive counseling. Possible explanations for this disparity include lack of access to cessation interventions or lower quality of care for underserved patients. This finding may have implications for achieving national public health goals on smoking cessation.

KEY POINTS FOR CLINICIANS

Prevalence of smoking is greater in patients who are uninsured or who have Medicaid insurance.
Advice on smoking cessation is given less frequently to these same patients.
Not providing cessation counseling is a missed opportunity in underserved patients.

Among underserved populations, the burden of tobacco is substantial. There is a clear association between poverty and high rates of tobacco use,^1-3 and smoking is more prevalent among the uninsured (39%) than those with insurance (23%).⁴ Smoking cessation interventions can be successful among low-income and minority patients, especially when tailored to these populations.^5-8 Tobacco counseling, including simple advice to quit, has been shown effective in primary care.^9-11 Since disadvantaged patients, including 63% of the uninsured,¹² are commonly seen in primary care settings, primary care providers are in a unique position to impact tobacco use in underserved patients.

Previous research on cessation counseling rates in low-income patients has yielded conflicting results. Taira and colleagues¹¹ demonstrated that cessation advice by primary care providers was given more frequently to low-income groups. However, this study’s results were based on a written patient questionnaire, and recall may have been a significant limitation. Another study examined physician-reported rates of tobacco cessation counseling, and found that cessation was addressed more frequently with health maintenance organization (HMO)–insured patients (30%) than Medicaid patients (24%).¹³ However, this analysis did not differentiate between primary care providers and specialists, and neither of these studies identified low-income uninsured patients.

It thus remains unclear whether this effective intervention is routinely provided to underserved patients, including the uninsured, in primary care settings. Using a provider survey instrument that clearly identified medically indigent patients, this study examined the frequency with which primary care providers address tobacco use with their Medicaid-insured and uninsured patients compared with those with private or HMO insurance.

Methods

This study was conducted in the 7 primary care practices in the Colorado Research Network (CaReNet) in 1998 and 1999. CaReNet is a state-wide primary care, practice-based research network founded in 1997 with a particular focus on disadvantaged populations, including rural people, minorities, and the urban poor. The practices in CaReNet are affiliated with the University of Colorado Department of Family Medicine. Of the 7 practices, 4 are family medicine residency sites, 2 are federally-funded community health centers, and 1 is a clinic for the medically indigent. The provider mix in CaReNet includes 56% residents (residents average approximately 3 half-day clinics weekly), 21% full-time clinical faculty, 7% private physicians, and 15% other providers (nurse practitioners, physician assistants, and so forth). At the time of our study, none of the practices had a comprehensive tobacco cessation program on site. Colorado Medicaid recipients were eligible for a limited amount of smoking cessation products (this benefit required prior authorization), but Medicaid did not cover comprehensive programs.

A modified version of the 1994 National Ambulatory Medical Care Survey (NAMCS) was administered in each CaReNet practice. The NAMCS instrument is a physician survey that collects information about an ambulatory visit; it has been used by the National Center for Health Statistics since 1973 to analyze trends of ambulatory care. In the context of our study, the key modification was the addition of “uninsured” in the Expected Source of Payment category. This category included patients who were in 1 of several programs that discount charges on the basis of income, thus covering some of the costs of care. All providers received detailed instructions on completing this modified NAMCS form.