10x Success Rate. 2x Enrollment. Inside Duke’s Smoking Cessation Program.

Smoking cessation programs are challenging. Not just because getting people to quit is hard, but also because it is difficult to get people to enroll in programs in the first place. The Duke Smoking Cessation Program has overcome both challenges. Through a combination of technology and best practice they have increased quit smoking rates 10-fold and doubled enrollment in their program.

Smoking

According to the CDC, in 2019, 14% of all adults in the United States (34.1 million people) smoked cigarettes and each day 1,600 youth try their first one. Smoking is the leading cause of preventable death in the US – almost 1 in 5 deaths can be attributed to the health impact of smoking.

The good news is that smoking continues to decline from a peak of 42.6% in the mid 1960’s. Since 2002, more people are quitting the habit than are picking it up.

Quitting is hard

Quitting smoking is hard. A paper published in 1999 found that only 3-5% of unassisted self-quitters remain abstinent 6 months after a quit attempt.

The success rate increases when a physician gets involved. A study in 2015 found that a 3-10 minute discussion with a physician raises the likelihood of success by 1.6x and a >10min discussion can increase it by 2.3x. Yet according to the CDC, only 11% sought counseling when trying to quit.

Duke’s 10x Success Rate

A few years ago, the team at Duke Health decided to take a new approach to smoking cessation.

“We have moved away from an older model where patients would meet only briefly with their primary care physician,” explained Jill Dirkes, LCSW, Program Manager, Duke Smoking Cessation Program which is housed within Duke Cancer Institute. “As part of their annual physical, they might get a bit of advice on smoking less and maybe get a nicotine patch. Is that really enough to change an addiction someone has been smoking for 30 years? Probably not.”

Designed with patients at the center, the new Duke program offers both medical and behavioral support. The kind of support provided is tailored to the unique needs of each patient and is adjusted as the patient progresses through the program. Clinicians with specialized training in tobacco treatment meet with patients and prescribe medication regimens that are refined to meet patient needs. Next, behavioral health providers, also with specialized training in tobacco treatments work with patients on behavior change and the mental health side of smoking cessation.

According to Dirkes, the success rate of Duke’s program is 30-35%. That is almost 10x the unassisted success rate – a phenomenal number. Dirkes attributes their success to the highly individualized approach to each patient: “There is no one-size fits all.”

Increasing Enrollment

One of the challenges that is often overlooked when designing smoking cessation programs, is getting people to enroll. Duke recognized this and worked hard to make it as easy as possible for physicians to refer patients to the smoking cessation program.

Duke physicians are trained to discuss tobacco use at every visit. In fact, there is a “gold bar that lights up” in their EPIC system when a physician is seeing a patient that uses tobacco. This alert helps prompt the physician to have a conversation about tobacco.  If a patient expresses the desire to quit smoking during their visit, the physician can make a note in EPIC and someone from the smoking cessation program will contact the patient to discuss the program and make an appointment.

“Using just this best practice of having a prompt in EPIC, we have received 200-250 referrals each month,” said Dirkes. “But when we added proactive outreach, we almost doubled our enrollment. We now have 400-450 people reaching out and being referred each month.”

Every time that patient self-schedules an appointment or has one scheduled for them, Duke has an automated system that checks the tobacco use flag in EPIC and if that flag is checked, an email message is sent to the patient to make them aware of Duke’s smoking cessation program.

That email message lets the patient know there are new resources in Duke’s Digital Care system that have been recommended by their physician. Digital Care is the name Duke has given to the Xealth platform that powers it. To access Digital Care, the patient simply logs into Duke’s MyChart portal and clicks on the Digital Care menu option.

When the patient arrives there, they find an excellent video from Dr. James Davis, the Medical Director of Duke’s smoking cessation program waiting for them. The Digital Care platform tracks when and if the video has been watched.

Below the video is a simple question for the patient: “Would you like to learn more about Quit at Duke?”. If the patient clicks YES, then someone from the smoking cessation program will call the patient.

“This took things to the next level,” said David Claxton, Delivery Lead for the Digital Strategy Office (DSO) at Duke University Health System. “Rather than just sending the video and hoping people would reach out the program to find out more, we reversed it. Now we reach out to the patient.”

Digital + Clinical Collaboration

The DSO at Duke is a group that matches technologies to challenges being experienced by internal clinical and operational teams. The group works closely with end users to understand their challenges and then looks for solutions that may be deployed in other areas of the health system that could be adopted to solve those challenges.

Duke implemented the Xealth platform in April 2019. Shortly after, the use case for the smoking cessation program was identified by the DSO. They noticed that the program was having tremendous success at helping people to quit, but were struggling to get more people enrolled. The DSO believed that proactive outreach that leveraged the Xealth platform could help.

“We just thought it would be a much better interaction experience for patients,” explained Claxton. “With the platform, patients could go easily back and review content that had been recommended to them whenever they wanted. We were fortunate that Dr. Davis and Jillian were forward thinking innovators and willing to collaborate with us to try it.”

What’s next

Duke is continuing to expand the use of Xealth at their organization.

“In a few months everything will be available in Digital Care – Duke custom content like Dr. Davis’s video, along with materials from Healthwise our patient education partner,” said Ally Alexander, Digital Strategy Analyst at Duke. “Having everything in one place will be a huge benefit vs having to go to multiple libraries right now.”

For the smoking cessation program, Dirkes and the team are now working on ways to maintain the momentum they have built up over the past year. Enrollment during the COVID-19 pandemic has increased, partly due to the proactive outreach and partly because of the increased public awareness of smoking as a COVID risk factor.

As well, the smoking cessation team is working to make the incorporation of telehealth a permanent fixture of the program. “Telehealth made things much easier for patients,” said Dirkes. “It’s more convenient and allows them to be in a comfortable environment – their own home. With telehealth patients easily meet with our providers between sessions.”

Closing Thought

There are so many impressive and noteworthy facets to this story.

First, there is the Duke smoking cessation team who were not satisfied with the status quo and was willing to buck tradition to explore a novel approach to treatment. There is also their willingness to adopt technology to make their program even better when by all accounts the program was already successful.

Second, there is the Duke DSO team, who saw an opportunity to use a technology platform that had been purchased for a different clinical area to address an unmet need for the smoking cessation team. On top of that, the DSO didn’t try to force fit the platform, but rather worked with their clinical partners and customized it to fit their unique needs.

Lastly, and perhaps most importantly, Duke has kept the patient at the center of their program and system design. They adapted their technology and their processes to meet patients where they are rather than the other way around. Instead of asking patients to call in or go to a website to make an appointment with the smoking cessation team, they just had to click a button and the team would reach out them instead. That is truly patient-centric thinking.

“Technology is just one aspect of patient care,” stated Claxton. “The work we are doing with Xealth and the way we are reaching out to patients is great. But without the work of Dr James Davis and Jillian Dirkes on the medical side, coupled with the work of the Digital Strategy Office, we wouldn’t be nearly as successful with the technology. They go hand in hand together. Having that successful program that they have built is key to this success and they deserve the bulk of the credit for the amazing work they have done.”

To find out more about Duke’s smoking cession program, visit http://www.dukehealth.org/quit or call 919-613-QUIT.

Watch the full interviews with Dirkes, Claxton and Alexander to hear:

  • Why Patients are reluctant to speak with a physician face-to-face about tobacco use
  • How the blend of clinical and behavioral support is the key to smoking cessation
  • How Duke is making patient education more accessible
  • The approach that the DSO uses to work with Health IT vendors
  • Why revisiting technologies periodically is important

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About the author

Colin Hung

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

   

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