Tobacco and
Population Health
in
Medical School
Getting beyond the 5 A’s
Kimber Richter, Edward Ellerbeck
University of Kansas Medical Center, KC
In Kansas, some address tobacco
and some don’t
90
80
70
60
50
40
30
20
10
0
38 physician practices
* percent of dr/pt interactions in which tobacco was discussed
Clinical know-how necessary but
not always sufficient
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Many factors outside the examining room
impact medical care
True for tobacco, true for other issues
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AAMC, ACGM objectives require medical
schools to teach population medicine
We teach population medicine concepts and
skills through Health of the Public
Formal lectures and student projects
incorporate tobacco in population health
AAMC Objectives – Informatics,
Population Health
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Retrieve and analyze information
Employ effective communication
Measure performance in populations
Able to effect change
Apply quality improvement methods
Understand physicians role in systems of
medical care
Medical informatics and population health. Report II of the
Medical School Objectives Project. Acad Med 1999; 74:130-141.
ACGME and the ‘Outcome
Project’
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ACGME – Accreditation Council for
Graduate Medical Education
ACGME has just announced it will require
residencies in all specialties to show that
residents meet six competencies:
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Provide appropriate & effective patient care
Demonstrate knowledge of medicine
Interpersonal communication skills
Professionalism & sensitivity to diversity
Sound Familiar?
But that was only four…
Practice-based learning and improvement
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analyze practice experience and perform practice-based
improvement activities
locate, appraise, and assimilate evidence from scientific
studies
obtain and use information about their population of pts.
apply knowledge of study designs and statistical
methods to the appraisal of clinical studies
use information technology to manage and access
information
And the sixth…
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Systems-Based Practice
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understand how their practices affect other health care
professionals, the health care organization, and the larger
society and how these elements of the system affect their
own practice
know how types of medical practice and delivery systems
differ from one another, including methods of controlling
health care costs and allocating resources
practice cost-effective health care and resource allocation
that does not compromise quality of care
advocate for quality patient care and assist patients in
dealing with system complexities
know how to partner with health care managers and health
care providers to assess, coordinate, and improve health
care and know how these activities can affect system
performance
Health of the Public
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Covers AAMC informatics, pop health
Prepares students for ACGME practicebased learning, systems-based practice
4th year required 4-week clerkship
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Selected lectures in Population Health CONCEPTS
Workshops in Population Health SKILLS
50% of time and grade for Capstone Project
Course Objectives
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Define populations
Develop, implement, and evaluate
population-based approaches to health
care
Recognize and address population-wide
forces in health care
Develop core knowledge and skills in
occupational and environmental medicine
Course Themes
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Population-based medicine*
Health Care Finance
Quality of and Access to Medical Care*
Systems of Medical Care*
Injury, Occupational, and Environmental
Medicine
Capstone*
*These sections are particularly relevant to tobacco
Population-Based Medicine
General Concepts
Transition from thinking about individual
pts to commonalities among groups of
patients*
 Four steps
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define populations
assess needs
intervene
Evaluate
*Also incorporates concepts from Community-Oriented Primary Care
Population-Based Medicine
Skills
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Using PubMed to search medical literature
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Sophisticated search methods
Critical appraisal of literature (journal club)
Epi-biostat refresher
Using Excel to analyze clinic data
Quality of and Access to
Medical Care
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Quality measurement
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Structure
Process – HEDIS, CMS
Outcome –Hard to get!
Quality improvement
Oversight of quality
Systems of Medical Care
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Quality improvement
Office organization
Disease management
Specific issues
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Diabetes disease management
Chronic care model
CCM Component
Traditional Primary Care
Care in the Disease Management
Program*
Organization of
Care
Physician responsible for all
smoking cessation activities.
Trained counselors will work under the
supervision of smoking cessation experts
and coordinate pharmacotherapy with
physicians.
An electronic registry of smokers will be
created with quarterly updates on
cessation attempts and readiness to quit.
The database will store patient-specific
data on contraindications to bupropion and
NRT.
Trained counselors will provide proactive,
Clinical Information
System
Notes are handwritten by the
physician. Many charts will not
indicate if the patient is a smoker.30
Delivery System
Design
Physician is responsible for advice,
assistance, and follow-up for smoking
cessation. Care is dependent upon the
patient coming in for an office visit.
Decision Support
Textbook in the doctor’s office.
Health counselors will follow counseling
protocols. Computerized algorithms will
support decisions on pharmacotherapy.
Self-management
Support
Physician may provide brief advice
to quit with 1-2 minutes of
‘counseling’.
Patients receive MI-based telephone
counseling, written cessation and relapse
prevention tips, periodic reminders on the
availability of free pharmacotherapy, and
follow-up support calls after a quit attempt.*
Community
Resources
Unknown or unavailable in rural
communities.
Free NRT or bupropion for a smoking
cessation attempt.
telephone-based counseling utilizing principles of
motivational interviewing. . Physicians will
receive feedback on patient progress.
HOP
The Capstone Project
Capstone puts it all together
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To provide a small practical experience in
population health care
Students choose topic, work in teams
HOP Mentor/Site Mentor
20 hrs/Week on Project
Verbal/Poster presentation at end
Capstone Projects:
Research or Service
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Quality of Care
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Health Communications
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Gender differences in health issues among Kansas caregivers
using 2000 BRFSS
Curriculum Development
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Reducing passive smoking in a Spanish pediatric population
Secondary Data Analysis
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Smoking and interest in quitting among parents of pediatric
patients at KUMC
Developing a medical school smoking cessation curriculum
Health Advocacy
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Medical student support for a primary seat belt law in Kansas
Population-based health care
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Identify a population
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Ascertain needs
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Intervene to address needs
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Evaluate impact
Health Communication: Passive
Smoking at Cabot Clinic
Eric Vaughan and Josh Timock
University of Kansas School of Medicine
Health of the Public, November 2002
Health Communication: Passive
Smoking at Cabot Clinic
Population: Patients attending Cabot
Westside Clinic, 82% Hispanic
Needs: Knowledge, skills regarding
passive smoking and children’s health
Intervention: Bilingual brochure
Evaluation: none
Health Communication: Passive
Smoking at Cabot Clinic
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A preliminary needs assessment was performed via
telephone conversations and personal interviews with clinicians.
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A literature review was conducted regarding pediatric morbidity
and mortality due to passive smoking and past employed and
existing interventional strategies.
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Various health communication formats were considered:
poster vs. brochure vs. postcard.
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A bilingual, color, tri-fold brochure was produced
incorporating the health belief model and principles of health
communication.
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Working models were produced and critiqued by the faculty
mentor and clinic staff and revised.
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A final version was published and distributed with the financial
support of the Block Foundation.
Health Communication: Passive
Smoking at Cabot Clinic
Perceived
Susceptibility
How vulnerable one feels
regarding a condition.
Cited prevalence of ETS in the
Hispanic pediatric population.
Photograph of smoking child.
Perceived Severity
How seriously one regards
a condition.
Outlined incidence of ETS
associated morbidity.
Photograph of ill teenager.
Perceived Benefits
How one feels regarding
efficacy of the intervention.
Outlined importance of positive
role modeling behavior.
Photograph of healthy child.
Perceived Barriers
The obstacles viewed as
impeding the intervention.
Addressed “what if” scenarios
and provided simple strategies to
overcome barriers.
Cues to Action
Activate readiness to act
and stimulate overt
behavior.
Provided “how to” information
regarding home interventions.
Self-Efficacy
How confident one is in
personal ability to take
action.
Provided Spanish smoking
cessation telephone line and
other resources.
Health Communication: Passive Smoking
at Cabot Clinic - Panel 5
What if I’m having trouble
quitting?
Talk with a doctor about treatments
and methods that can help you quit.
What if someone does smoke
in my home?
Make it clear that smoking is not
allowed in your home.
What if my childrens’ care
provider smokes?
Ask them not to smoke around
your children, or find a new care
provider.
YOU CAN DO IT!
BUT WHAT IF…
Population Health
Communication:
Don’t Choke on Smoke
D. Brendan Rice
Muhammad Nashatizadeh
Health of the Public (PMED960)
Population Health Communication:
Don’t Choke on Smoke
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Survey Development
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form-based webpage for elementary school teachers
Survey Questions
1)
2)
3)
4)
Is there anything you do not understand about the handout?
What is your FAVORITE part of the handout?
What is your LEAST FAVORITE part of the handout?
Would you take this handout home to share with family and
friends? If NO, please explain why not:
5) Did the handout help you understand more about the dangers of
smoking? What did you learn?
Population Health Communication:
Don’t Choke on Smoke – What did
you learn?
• Selected quotes:
–I didn’t know there are 4700 chemicals
in each cigarette
–The deadly stuff in cigarettes. Yuck!
(and a lot more stuff)
–That when you take a deep breath and
let it out halfway, it is called a
emphysema.
–I learned smoking kills more people
than guns.
–That it kills more people than AIDS,
guns, pneumonia, accidents combined
–What lungs look like when you smoke
Chemicals
General Facts
Smoking Diseases
Rank the Killers
Nothing
Lung Pathology
Needs Assessment, Smoking
Cessation Program for
Parents of Newborns at
KUMC
Jason Eppler, Matt Haverkamp,
Marc Larsen
Health of the Public
April 17, 2003
Needs Assessment,
Postpartum Smoking Cessation
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Assess the need for a postpartum
smoking cessation program for mothers
of newborn babies at the University of
Kansas Medical Center
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“Need” based on :
Mothers who smoke
 Desire to quit
 Relapse rate of smoking after delivery
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Needs Assessment,
Postpartum Smoking Cessation
Population: Former smokers delivering at
KUMC.
Needs: Smoking cessation, maintenance
of cessation
Intervention: Survey will evaluate need
for intervention
Evaluation: None
Needs Assessment,
Postpartum Smoking Cessation
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Bilingual survey looked at:
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Demographics of mothers of newborns
Mothers current smoking habits
Smoking status of others living in the
house
Mothers/others desire to quit
Desire to participate in smoking cessation
program
Mothers’ Smoking History
60%
53%
50%
37%
40%
30%
20%
10%
10%
0%
Non-Smoker
Ex-Smokers
Current Smoker
Needs Assessment,
Postpartum Smoking Cessation
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Among mothers:
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44% of ever smokers stated pregnancy
played a role in decision to quit
47% had smoked at one period in their life
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Of these, 22% currently smoke
100% of current smokers indicated they
would be interested in a smoking cessation
program
Tobacco and Population Health

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Medical students and GMEs need to know
population health to be effective clinicians
Health of the Public teaches population
approaches with tobacco in numerous
examples
Community-oriented primary care also an
important perspective that HOP addresses