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San Juan County Health Project
- 1. San Juan County Rural HealthProjectSmoking Cessation in the Elderly Chiyoung Cha PhC MN RN Kristi Vaughn DNPC ARNP MN RN UCONJ 501B School of Nursing University of Washington
- 2. Table of Contents Introduction Demographics Rural designation Health issues Elderly population Access Geographical HCPs Adult Health Behaviors Tobacco abuse Binge Drinking Dental Environmental Woman’s Health HCP communication Access Insurance Tobacco use in SJ CO Intervention Challenges The Chronic Care Model Evidence-based Interventions NRT/ HCP counseling Follow up telephone contact Evidence base research Mental Health services Conclusion References
- 3. San Juan County, WA
- 5. Demographics Population (2008) 15,294 (8.6% increase from 2000) Predominately live: Orcas, Lopez, Shaw & San Juan Island Characteristics Well-educated Caucasian (95.7%) Median household income:$52,118 (State,$55,628) Median age 50 years Persons poverty level (9.9%) Occupations Government (23.5%) Construction (16.2%) Wholesale/retail trade (13%) Accommodation/food services (12.9%) Travel time to work 15.8”
- 6. RUCA Score10 Isolated rural area HCP (2005) 8-13 primary care MDs/100,000 (2005) 13 dentists/100,000 (1998) 6 MUAs: Score 0 Rural Designation
- 7. Health Care Access Natural Barriers Water Weather Travel Ferry 60” Helicopter 7-20” Hospitals Island Hospital-Anacortes St Joes-Bellingham Harborview MC-Seattle Children's-Seattle Clinics Lopez- 1 Orcas- 2 San Juan-2 Inter Island MC; Level 5 TC Future- Peace Health
- 8. Health issues Elderly population > 65 years 21.4% (State,11.7%) Increased life expectancy; 80 years Fixed income Chronic illness Cancer Lung CA 18.2 % increase 85% tobacco related CV disease Suicide;18 % (firearms) (State, 12%) Falls; 66% unintentional injuries Access Health insurance (2006) Adults30 % uninsured (State, 17%) Children 13% Unmet medical needs 15% (State,13%) No HCP 26 % (State, 22%) Adult health behaviors tobacco abuse 20 % (State, 18%) binge drinking 17% (State, 14%)
- 9. Health issues Dental 33 % no dental visits (State, 28%) Environmental Increased waste facilities Sewage 100% failure correction rate Women’s health low rate prenatal care 77% (State, 80%) Breast CA screening rate 74% (State, 79%)
- 10. Health Issues identified by SJ CO HCPs (Personal communication) Access Geographical barrier Limited HCPs Aging work force Low/slow pay Rural HC overhead costs No critical access hospital Insurance Poor reimbursement Uninsured/ under insured HCPs overworked/ no relief from locum tenums Economic Unemployment Fixed income Increased cost prescription drugs SJ CO Health Care Providers
- 11. Tobacco & Cancer Stats 514 deaths/100,000 population (State, 724/100,000) 36 cancer related deaths 145/100,000 (State, 179 deaths/100,000) 7 deaths lung CA 2007 18% increase compared to 2003-2005 1,900 adult smokers 200 smokeless tobacco
- 12. Tobacco Increasing # users 15% (State,17%) 1.7% increase past 5 yrs SJ CO Tobacco use 5.0% (State: 17%) Adult smokeless tobacco use 1.8% (State: 3.0%) Male 3.3% (State: 5.8%)
- 13. Tobacco-con’t *FPL: Federal Poverty Level *Data from 2003 WA Needs Assessment Household Survey
- 14. Lack of: Awareness Perceived effectiveness Participation Intervention Challenges
- 16. NRT & HCP counseling Rationale: Effective for elderly Community Resources: Partnerships w/community agencies Free or Low cost NRT; reduce out of pocket $ for cessation therapies Health systems: Self-management support: emphasis patient’s central role, 5A’s Decision Support:multi-component interventions, evidence-based guidelines, proven HCP education Delivery system design: all HCPs & community involved, intense follow up Clinical information system: provider reminder systems w/education, ID individual smokers
- 17. Rationale: Limited access to care, geographically isolated area, low cost Telephone cessation support Community Resources: Private physicians, Free cessation counseling, Telepsychiatry service which was proven to be effective (funded through April, 2010) Policies: Encourage smoke free restaurants Health systems Self-management support: Telephone cessation program Decision Support: Health & Community Services Delivery system design: County’s effort to build new cell phone towers Clinical information system: Participants
- 18. Evidence-based research Hung & Shelley, 2009; CCM Adherence 5As (ask, advise, assess, assist, & arrange) 500 (PCP’s)/60 community clinics NYC low-income, minority populations 84% of HCPs asked Hx smoking Clinics 3 CCM elements enhanced delivery system design clinical information systems patient self-management support 6 CCM elements Protocols tobacco use ID & Rx Decision support/clinical guidelines Referral community. CCM integration (5 and 6 elements) 20.4 to 30.9 x> deliver full spectrum 5A services
- 20. NRT & Counseling Tait, Hulse, Waterreus, et al. (2007) ID success predictors Effectiveness aged >or =75 years 165 intervention subjects vs. 50 smokers intervention group younger smoked fewer years >nicotine dependence scores >previous quit attempts. 6 months 20 % abstinent NRT use Male higher anxiety scores quit due to more frequent colds & coughs >=75 years matched cessation criteria. Conclusion: older smokers brief HCP counseling & NRT can quit smoking.
- 21. NRT Access & Cost Miller, Frieden, Liu, S. et al. (2005) New York State HD & Roswell Park Cancer Institute Effectiveness large-scaled distribution program free nicotine patches Stop rate 20% NRT recipients 6038 successful quits attributable NRT Cost $464/quit Conclusion: easy access cessation medication diverse populations may help smokers quit Free or low cost access NRT & counseling by a HCP can promote smoking cessation in the elderly Lightwood & Glantz (1997) new nonsmoker reduces medical costs associated AMI & CVA $47 1st yr $853 next 7 years Primary prevention adult smoking pays immediate dividends Health improvement & cost savings
- 22. Conclusion Elderly population Increased life expectancy Increased # adult smokers Increased prevalence lung CA & other tobacco related illness Access Geographical barriers decreased # HCPs limited Insurance; Medicare, uninsured fixed income Chronic Care Model Utilizes all members HC team Solutions NRT Counseling Telephone contact Community participation
- 23. Questions to our colleagues A. Are there other formats available at a low cost to provide NRT? B. Who else would benefit from this information? Q & A
- 25. References A Draft Summary of San Juan County Public Health Indicators (2008). Personal communication. Brandeis University (2002). Treating Tobacco Use and Dependence as a Chronic Disease: A Planning Guide for Practice Sites in Developing an Office-Based System of Care. Retrieved on 8/1/2009 from http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf Bureau, U. S. C. (2009). State & County Quick Facts: San Juan County, Washington Retrieved 6/30/09, from http://quickfacts.census.gov/qfd/states/53/53055.html CDC & Surgeon General (2008). Treating Tobacco Use and Dependence: 2008 update retrieved on 7/30/09 from http://www.surgeongeneral.gov/tobacco/ CDC. (ND). Smoking and Tobacco: Fast Facts. Retrieved 7/10/2009, from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm#facts CityData. (2009). San Juan County, Washington (WA). Retrieved 07/08, 2009, from http://www.city-data.com/county/San_Juan_County-WA.html CommunityGuide. (2009). Tobacco use. Retrieved 7/10/2009 from http://www.thecommunityguide.org/tobacco/index.html Hung D. Y., & Shelly, D.R. (2009). Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics. HSR: Health Services Research, 44(1), 103-127.
- 26. Manning, J. T., & James, F. (2009). The health of San Juan County. Friday Harbor, WA: Health and Community Serviceso. Document Number) Miller,N., Frieden, T.R., Liu, S. et al.(2005).Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation Lancet,365, 1849-54. OFM. (2008). San Juan County Profile. from http://www.ofm.wa.gov/databook/county/sanj.asp#top SJCWMC. (Date unknown). San Juan County characterization report. Retrieved 07/08/09, from http://www.sanjuanco.com/health/wtrshdpln/part2chap2.html Tait, R.J., Hulse, G.KL., & Waterreus,A. et al. (2007)Effectiveness of a smoking cessation intervention in older adults Addiction, 102,148-55 Wikipedia. (2009). San Juan County, Washington. Retrieved 6/30/09, from http://en.wikipedia.org/wiki/San_Juan_County,_Washington WSDH. (2007). Tobacco and health in Washington State- County profiles of tobacco use. Retrieved 7/10/2009, from http://www.doh.wa.gov/tobacco/data_evaluation/Data/County_profiles/2007/sanj_profile07.pdf WSDH. (2009a). Guidelines For Using Rural-Urban Classification Systems for Public Health Assessment. Retrieved 06/26/09, from http://www.doh.wa.gov/data/Guidelines/RuralUrban.htm#classcounty WSDH. (2009b). San Juan County Tobacco use statistics. Retrieved 7/10/2009,
Hinweis der Redaktion
- The demographics of health issues are similar to other rural areas, where there are higher numbers of elderly. In 2007, persons over 65 composed 21.4% of the island population while it was 11.7% in Washington State (Bureau, 2009). In 2007, the average life expectancy at birth was higher in San Juan County than the state average, especially for men. In the state, the average life expectancy in 2007 for both sexes was 80 years, for San Juan County residents total life expectancy at birth was 84 years. In the County, women were expected to live 85 years, while men were expected to live 83 years. In Washington State, women were expected to live 82 years and men were expected to live 77 years. In the United States in 2006, (2007 data is not yet available,) life expectancy at birth for females was 80 years and life expectancy at birth for males was 75 years. Total life expectancy reached a record high of 78 years in 2006. San Juan County’s 2007 age-adjusted death rate was 514 deaths per 100,000 population. This was a significantly lower overall mortality rate than Washington State 724/100,000 and the United States 776/100,000. According to the Center for Disease Control’s National Center for Health Statistics , age-adjusted death rates continue to decline significantly in Western countries over the last ten years, which matches the trend in San JuanCounty, as well. At the same time the death rate is decreasing, life expectancies are hitting record highs. In addition, death rates for 8 of the 10 leading causes of death in the United States all dropped significantly in 2006, including a very sharp drop in mortality from influenza and pneumoniaOver the last ten years Major Cardiovascular Disease and Cancer have been the leading causes of death in San Juan County, with a shift only in recent years to cancer as the more common cause of death. The third leading cause of death varies from year to year as our number of events are so small, one event changes the rank order when there are only 2 or 3 occurrences.ALL CANCER DEATHS-Malignant Neoplasms (MNP) : San Juan County has had a variable cancer death rate, without a significant trend, but that rate has been consistently lower than the state rate. In 2007 there were 36 cancer -caused deaths in San Juan County for a rate of 145 deaths per 100,000 age-adjusted population. At the state level there were 11,525 cancer deaths for a rate of 179 deaths per 100,000. The United States estimated total number of all cancer deaths for 2007 is 559,650 and there were 559,888 deaths in 2006 for a rate of 187 deaths per 100,000 age-adjusted population. These incidences resulted in cancer becoming the #2 cause of death in the United States in 2006. Because cigarette smoking is responsible for approximately 85% of lung cancer deaths, tobacco use and exposure remain the most common risk factors associated with death from lung cancer. Smoking prevention and cessation are the most important interventions for reducing lung cancer.Although mortality rates are declining, lung cancer remains the leading cause of cancer death among men and women in Washington State. Lung cancer death estimates for the United States are 160,390 deaths (2007). Washington State 3,172 deaths (2007) and 7 deaths in San Juan County (2007). The State 2006 age adjusted mortality rate was 49 deaths per 100,00 people, down 7.8% from 2000. The 2006 rate for males was 60 deaths per 100,000 men. The rate for females was 42 deaths per 100,000, which is an increased rate from years prior to 2000 . While rates for men in Washington have dropped 3.2% per year since 1993, rates for women have continued to increase 1.3% per year since 1990.The 2006 San Juan County age-adjusted incidence rate for cancer cases was 30 per 100,000 people, up 18% from the 2003-2005 period. The rate for females in 2006 was 16 cases per 100,000. The rate for males in 2006 was 46 cases per 100,000 . Rates in San Juan County can fluctuate widely due to our small population size. The 2006 San Juan County age-adjusted mortality rate was 37 deaths per 100,000 people, up 18.23% from the 2003-2005 period. The mortality rate for females was 33 per 100,000 in 2006, up 19% form the 2003-1005 period. The rate for males in 2006 was 38 per 100,000, up 18% from the 2003-2005 period. For the most part, variations in lung cancer incidence and death were consistent with smoking patterns among the different racial, ethnic and socioeconomic groups. While interest in early detection of lung cancer through screening has been growing, studies indicate that even when screening identifies lung cancer in an early stage, there is no reduction in mortality.In 2006,Washington State had a rate of 12 per 100,000 for intentional self-harm, while San Juan County had a rate of 11. Intentional self-harm included cut/pierce, firearm, poisoning, suffocation and obstructing actions. This statistic over time shows from 2002-2006 that San Juan County had 12 deaths from suicides and 27 hospitalizations from suicide attempts. These numbers of suicidal actions are significant in our small populationbase as there were 26 deaths from all types of unintentional injuries over the same time period. The most prevalent cause of death by suicide in San Juan County was by firearm among 45-54 year olds.Unintentional injury is the leading cause of hospitalizations in San Juan County and the third most prevalent cause of death in the county (2006). In Washington State it is the 5th leading cause of death and in the United States the 4th leading cause of death (2006). The issue of unintentional injuries is important as unintentional injuries are events we can impact by our personal choices, community behaviors and infrastructure. Included in this category are motor vehicle crashes, drowning, falls, burns, suffocation and poisoning. Unintentional poisoning is a broad category that includes ingesting too much of any substance, like alcohol or pain medication.Access: Like other rural communities, access to health care clinics is a major issue for the island population. Unlike other communities, San Juan County posses a unique access problem due to geography with limited transportation across waterways. Health insurance coverage is critically important for obtaining access to health care. Almost all people aged 65 years and older have health insurance coverage through the Medicare program. The majority of persons under age 65 have private employer-sponsored group health insurance or some other type of coverage. The Centersfor Disease Control and Prevention estimated in 2007 that there were 43 million uninsured Americans, resulting in 16% of the total population. The percent of persons with private insurance was estimated at 67% and 13% were insured thorough Medicaid or other types of public coverage, and 16% were uninsured. The CDC also estimated 8.9% of children under age 18 were uninsured. In 2007, 60% of children under age 18 had private insurance with 33% having a public health plan type of coverage. The percent of uninsured persons has increased in both the county and state since 2000.Persons without health insurance coverage were for30% for adults and children under18 without health insurance coverage were in 2006. Four of every five adults ages 18 and older had a health care provider in 2006. In 2006, about 96% of Washington children had insurance, which included Medicaid. For the population ages 65 and older, insurance covered more than 99% of Washingtonians, due mainly to Medicare. The most critical insurance gap was for adults ages 18-64, among whom only 87% reported having insurance when interviewed in 2006. All together, nearly 600,000 Washington residents were uninsured at that time. San Juan County residents report higher numbers of people than both Washington State and the United States who need to see a doctor within the past year but could not due to cost. Adult health behaviorsThe 2006 San Juan County percentage of the population who reported binge drinking was 17%, higher than both the national and state figures. About 90% of the alcohol consumed by youth under the age of 21 years in the United States is in the form of binge drinking. Alcohol is implicated in nearly a third of youth fatalities and recent research shows that alcohol can affect the developing adolescent brain. Binge drinkers are 14 times more likely to report alcohol-impaired driving than non binge drinkers. Binge drinking is associated with many health problems, including but not limited to; unintentional injuries (e.g. car crashes, falls, burns, drowning) and intentional injuries such as firearm injuries, sexual assault, and domestic violence. Alcohol poisoning , unintended pregnancies, and sexually transmitted disease prevalence increase from the effects of binge drinking as well.A Draft Summary of San Juan County Public Health Indicators (2008). Personal communication.
- Dental: Total tooth loss is more prevalent among the elderly. Loosing six or more teeth leads to inadequacy of oral functioning, such as chewing and speaking. In Washington in 2004 and 2006 combined, 5% of adults ages 35-44 years and 38% of seniors 65 years and older had lost six or more teeth. Despite improvements in partial and complete tooth loss, disparities remain among older adults, non-whites, people of Hispanic origin, smokers, and low-income groups. San Juan County residents had a lower percentage of its population (67%) visit a dentist within the past year(2006) than both Washington State (72%) and the United States(70%).Environmental:The on-site sewage program protects public health by regulating the treatment and disposal of human sewage in a manner that minimizes the potential for public exposure and detrimental impacts to ground water, surface water, shellfish and ground surfaces. Diseases that spread through contact with untreated or inadequately treated sewage are many and are well documented. They include, but are not limited to, shigellosis, poliomyelitis, infestations with various round and flat worms, cholera, typhoid, bacillary dysentery and amoebic dysentery, cholera, typhoid fever, giardiasis, and Hepatitis A. Public health and environmental protection officials acknowledge that onsite systems are not just temporary installations that will be replaced eventually by centralized sewage treatment services, but permanent approaches to treating wastewater for release and reuse in the environment. The Environmental Health Department regulations provide for the proper location, design, installation operation, maintenance, and monitoring of on-site septic systems. Most exposures to sewage occur after a septic system fails. One way to measure our success in preventing exposures is the percent of identified failures with corrective action initiated within 2 weeks. In 2008, San Juan County had a 100% failure correction rate.Woman’s health:From the period 2003-2005 San Juan County averaged 77% of its women receiving first trimester prenatal care.A Draft Summary of San Juan County Public Health Indicators (2008). Personal communication.
- This rural health project in San Juan County, Washington will focus on smoking cessation in the elderly using Nicotine replacement therapy (NRT), health care provider (HCP) counseling and follow up telephone contact. Tobacco use is responsible for more than 430,000 deaths/ year and is the largest cause of preventable morbidity and mortality in the United States (CDC,ND). Long term smoking leads to multiple chronic health problems such as chronic obstructive pulmonary disease (COPD), recurrent respiratory infections, pneumonia, heart disease, peripheral vascular disease, stroke, oxygen dependence and frequent hospitalizations. Management of chronic illness generates substantial health care cost to the HC system. The Chronic Care Model (CCM) provides a framework by which smoking cessation interventions can be utilized by HCPs managing elderly with limited health care access.
- The Community Guide, what works to promote health recommends several proven interventions for smoking cessation such as provider reminder systems, provider reminder systems with education, reducing out of pocket cost for cessation therapies and multi-component interventions that include telephone support (CommunityGuide, 2009). The CDC and Surgeon General (2008) developed recent evidence based guidelines for smoking cessation in the elderly. Researchers from Brandeis University (2002) identified several barriers to implementing a CCM model to promote smoking cessation. Reductions in state spending on tobacco-related projects could discourage implementation of innovative treatment models. They felt that in the absence of state-supported programs, integration of tobacco treatment into primary care practice is extremely important. Without outreach to practice sites, promulgation of the CCM and ongoing technical support that self-generated practice site changes is unlikely.Using the CCM and the 5A’s in San Juan County for smoking cessation in the elderly, can be an effective and sustainable treatment approach. The model does not solely rely on PCPs to provide smoking cessation counseling and telephone contact rather all members of the HC team and the community can provide ongoing support and resources to the individual attempting to quit. One advantage to living in a small community is that everyone knows the individuals who smoke, so support by all members of the community can provide encouragement for sustainable smoking abstinence. The community pharmacists are compassionate about their work and can provide NRT at a low cost to their patrons.
- Smoking cessation project for elderly in San Juan County fits with the Chronic Care Model (CCM), for the following reasons: (a) the characteristics of this community are different from others which require special assessment and (b) smoking cessation should be approached with multi-component interventions. Based on the CCM, community resources are free cessation counseling provided by Washington State Quit Line (1-877-270-STOP), and San Juan County have private physicians. Recommended private physicians for smoking cessation are: SAN JUAN HEALTH CARE ASSOCIATES 378-1338INTER ISLAND MEDICAL CENTER 378-2141ORCAS ISLAND MEDICAL CENTER 376-2561LOPEZ ISLAND MEDICAL CLINIC 468-2245Community policies can be described as encouragement of smoke free restaurants. They are listed in the Health & Community Services website.http://www.sanjuanco.com/health/tobacco1.aspx?page=svces2 Providing telephone counseling for the elderly smokers will fall into self-management Support. The County has been trying to build more cell phone towers. It can aid the delivery system by providing more areas with cell phone access. Health and Community Services have ‘Tobacco Prevention and Cessation’ program, and provide various information. This can be a decision support. The link to the website is http://www.sanjuanco.com/health/tobacco1.aspx?page=links2Clinical information systems will be the database of participants who called for the telephone counseling.
- One study looked at characteristics of older smokers, evaluated the effectiveness of nicotine replacement therapy (NRT), identified predictors of those who successfully quit, and evaluated the effectiveness of intervention in those aged >or =75 years (Tait, Hulse, & Waterreus,A. et al. 2007) . There were 165 intervention subjects compared to 50 continuing smokers. Those in the intervention group were younger, had smoked less number of years, greater nicotine dependence scores and had more previous quit attempts. At six months 20 % remained abstinent. Those who used NRT were male, had higher anxiety scores, and quit due to more frequent colds and coughs. Those >=75 years matched cessation criteria. They concluded that older smokers engaged in a brief HCP counseling and provision of NRT can quit smoking.
- In another study, the New York State HD and Roswell Park Cancer Institute evaluated the effectiveness of a large-scaled distribution program of free nicotine patches (Miller, Frieden, Liu, S. et al. (2005) . They found the stop rate was 20% among NRT recipients and 6038 successful quits were attributable to NRT at a cost of $ 464/quit. They concluded that easy access to cessation medication for diverse populations may help smokers quit. Free or low cost access to NRT and counseling by a HCP can promote smoking cessation in the elderly. Lightwood and Glantz (1997) they found that creating a new nonsmoker reduces anticipated medical costs associated with acute myocardial infarction (AMI) and stroke by $47 in the first year and by $853 during the next 7 years (discounting 2.5% per year). They concluded that primary prevention of smoking among teenagers is important, but reducing adult smoking pays more immediate dividends, both in terms of health improvements and cost savings.
- In San Juan county there are higher numbers of elderly > 65 years 21.4% (State,11.7%), whose averagelife expectancy is 80 years. These individual depend on a fixed income and are dependent on Medicare for HC insurance. 30 % of adults in SJ county lack HC insurance. There a insufficient numbers of HCPs to meet the needs of this county. As the elderly age there will be an increased incidence of chronic illness. There is a 18.2 % increase in lung CA. Tobacco abuse to contributes to 85% of cancer deaths. 26 % of SJ county residents have no HCP. Tobacco use is preventable. Using the chronic care model, this project proposes to use a multi-pronged approach to tobacco cessation in the elderly; providing NRT at a low cost, encouraging all members of the HC team to counsel their patients, phone contact, the patient and community involvement.
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