Sidorov J, Christianson M, Girolami S, Wydra C
Geisinger Health Plan, Danville, PA 17822, USA.
Am J Manag Care. 1997 Feb;3(2):207-14.
We conducted a descriptive study of a tobacco cessation program sponsored by a health maintenance organization (HMO) and led by primary care nurses. The tobacco cessation program was conducted at 20 primary care clinics in northeastern and central Pennsylvania. We gauged the successfulness of the program by the patients' self-reported quit rates at 1 year. We also examined the association between quit rates and compliance with scheduled counseling visits, the impact of the availability of an HMO pharmacy benefit that supported the costs of nicotine replacement therapy, and the quit rates among patients with HMO insurance versus those with insurance other than managed care. Of 1,695 patients enrolled in the program from July 1993 to March 1996, 1,140 completed 1 year of follow-up. Of these, 348 (30.5%) reported they had quit using tobacco. Among the 810 HMO enrollees who participated in the program, the quit rate was 280 (34.6%); among the 330 non-HMO participants, the quit rate was 69 (20.9%), a statistically significant difference (P < 0.001). For all patients, keeping more than four visits with the program nurse was associated with a significantly higher likelihood of quitting (317/751 [42.2%] versus 32/389 [8.2%]; P < 0.001). Non-HMO patients were less likely than HMO enrollees to keep four or more visits (165 [50%] versus 586 [72.3%]; P < 0.001). We were unable to detect a difference in quit rates among those with and those without a pharmacy benefit (196/577 [34%] versus 84/233 [36.1%]). These data are limited by their descriptive nature and the lack of information about other factors important in determining the quit rate among program participants. Nevertheless, they suggest that HMOs can successfully sponsor nurse-led tobacco cessation programs in multiple primary care settings and achieve 1-year quit rates significantly higher than the 15% quit rate reported in the medical literature. In addition, successfully quitting tobacco use appeared to be associated with use of counseling visits but not with use of a pharmacy benefit to pay for nicotine replacement therapy. Even though tobacco cessation programs have the best chance of benefitting HMO enrollees, patients not enrolled in managed care plans also appear to benefit significantly. This finding has important implications for developing future strategies--including the role of managed care organizations, the need to defray the costs of nicotine replacement therapy, and the best approach to provide counseling to patients--to meet the Healthy People 2000 goal of reducing tobacco smoking.
我们对一项由健康维护组织（HMO）赞助、由初级护理护士主导的戒烟项目进行了描述性研究。该戒烟项目在宾夕法尼亚州东北部和中部的20家初级护理诊所开展。我们通过患者自我报告的1年戒烟率来衡量该项目的成功率。我们还研究了戒烟率与按时参加咨询就诊的依从性之间的关联、HMO药房福利对尼古丁替代疗法费用的支持所产生的影响，以及拥有HMO保险的患者与拥有非管理式护理保险的患者的戒烟率情况。在1993年7月至1996年3月期间登记参加该项目的1695名患者中，1140名完成了1年的随访。其中，348名（30.5%）报告称已戒烟。在810名参加该项目的HMO参保者中，戒烟率为280名（34.6%）；在330名非HMO参与者中，戒烟率为69名（20.9%），差异具有统计学意义（P < 0.001）。对于所有患者而言，与项目护士进行超过4次就诊与显著更高的戒烟可能性相关（751名中有317名[42.2%]，而389名中有32名[8.2%]；P < 0.001）。非HMO患者比HMO参保者进行4次或更多次就诊的可能性更小（165名[50%]对586名[72.3%]；P < 0.001）。我们未能检测出有无药房福利的患者在戒烟率上的差异（577名中有196名[34%]对233名中有84名[36.1%]）。这些数据受限于其描述性性质以及缺乏关于其他对确定项目参与者戒烟率很重要的因素的信息。尽管如此，它们表明HMO能够在多个初级护理环境中成功赞助由护士主导的戒烟项目，并实现显著高于医学文献中报道的15%戒烟率的1年戒烟率。此外，成功戒烟似乎与咨询就诊的使用相关，而与使用药房福利支付尼古丁替代疗法无关。尽管戒烟项目使HMO参保者受益的机会最大，但未参加管理式护理计划的患者似乎也能显著受益。这一发现对于制定未来策略具有重要意义——包括管理式护理组织的作用、支付尼古丁替代疗法费用之必要性以及为患者提供咨询的最佳方法——以实现“健康人2000”减少吸烟的目标。
