Family medicine is an important setting for managing cardiovascular risk factors and preventing the onset of heart disease, as well as managing risk factors following a cardiac event. If a patient is a smoker, explained Dr. Andrew Pipe, Chief of Prevention and Rehabilitation at the University of Ottawa Heart Institute, helping that patient quit smoking should be a priority.
“Helping a patient quit smoking is in fact the most important thing we can do to prevent heart disease and reduce risk of a future cardiac event in those with heart disease,” said Sophia Papadakis, PhD, MHA, Program Director of the Primary Care Smoking Cessation Program at the Heart Institute. Quitting smoking is more powerful in reducing risk than lowering blood pressure or managing cholesterol, but it is not always addressed in the same way in family medicine settings as are other risk factors, she added.
To support positive changes in the way smoking cessation is managed in the community, the Heart Institute has adapted its Ottawa Model for Smoking Cessation, a comprehensive smoking cessation program originally developed for patients who have been hospitalized, for use by primary care physicians.
“While several other smoking cessation education programs are available today for physicians, they are not as specifically tailored to the realities of a family doctor in Canada.” – Sophia Papadakis, Program Director Primary Care, Smoking Cessation Program, UOHI
Since 2002, the Ottawa Model for Smoking Cessation has specifically targeted smokers admitted as inpatients (for any medical condition, not only heart disease). The program’s success in getting participants to quit has led to its adoption in more than 120 hospitals across Canada. The model ensures all patients who smoke are identified and offered evidence-based counseling and smoking cessation medications. Those who attempt to quit also receive automated follow-up support for two to six months or a referral to a community-based support program.
The results have proven impressive: In an evaluation of the Ottawa Model in hospitals within the Champlain Local Health Integration Network, quit rates rose from less than 19 per cent to almost 30 per cent. Since 2006, the Heart Institute has been involved in supporting the wider rollout of the model across Canada. To date, the Ottawa Model for Smoking Cessation Network has reached more than 50,000 smokers. Word of the Ottawa Model’s effectiveness soon spread to practitioners outside the hospital setting. “Around 2008, we began receiving calls from primary care and family doctors asking why we weren’t working in the primary care setting,” recounted Papadakis.
In response to this unmet need, the Heart Institute’s Division of Prevention and Rehabilitation rolled out a pilot program called the Ottawa Model for Smoking Cessation in Primary Care. Following the success of that pilot, the primary care program, led by Papadakis, is now being tested in 39 group practices in Ontario.
But targeting group practices cannot reach all primary care doctors. Some 200,000 family physicians in Canada work as solo practitioners, without the resources available to larger practices, said Papadakis. To bring the Ottawa Model’s proven techniques to these doctors, the Heart Institute has developed the Effective Smoking Cessation in Primary Care (ESCAPE) program. Funded by an educational grant from Pfizer Canada Inc., ESCAPE is a continuing medical education program. The DVD-based training will be available to solo practitioners across Canada beginning in June 2012.
While the challenges and opportunities of treating smokers vary across solo practice, group primary practice and hospitals, the principles of the Ottawa Model remain the same. “What we want to introduce,” explained Dr. Pipe, “is a very integrated, systematic approach to the identification and documentation of smokers and provide the appropriate interventions in terms of advising about cessation and acting to help smokers with cessation.”
Papadakis refers to ESCAPE as “Ottawa Model in a box.” Unlike the implementation of the Model in hospitals and clinics that involves on-site coaching and training from Heart Institute staff over three to six months, ESCAPE is designed to be an “implement-on-your-own” version. “Resources don’t allow us to work directly with solo practitioners all over Canada. We had to figure out what the most important parts of what we did were and streamline them so the program could be delivered in this alternative format, as opposed to our being there and providing that training ourselves,” she explained.
The ESCAPE program includes a 40-minute overview of how to deliver a state-of-the-art smoking cessation intervention in a solo primary care setting. Six additional modules provide more detailed skills training and protocols to family physicians, such as how to work with a patient who is not ready to quit and an overview of the latest information on smoking cessation medications. The program also includes patient scenarios performed by doctors and actors playing patients. “These scenarios model what best practice really looks like, what best practice sounds like,” said Papadakis.
Much of the material aims to correct outdated beliefs about tobacco use and smoking cessation still found in the medical community. “Many clinicians bring outdated concepts and outdated attitudes to addressing smoking,” said Dr. Pipe.
One of the most common, and counterproductive, of these is an underuse of available drug therapies to aid quitting. “The idea that you ‘just need to use a patch or chew gum for this many weeks and then it should all be over’ has been shown to be completely outdated,” he explained. The same principles used to manage other risk factors for heart disease, such as high blood pressure and high cholesterol, should be used for smoking cessation, including continuing medication for as long as needed, he elaborated.
Doctors participating in ESCAPE will also learn to address patients’ common reluctance to use medication to help them quit. “There’s been a lot of work documenting that patients would prefer to quit on their own—‘cold turkey’—rather than with medication,” said Papadakis. “But one of the standards of care for smoking cessation is that every patient ready to quit would be prescribed pharmacotherapy. It’s considered an essential ingredient for success.”
While several other smoking cessation education programs are available today for physicians, they are not as specifically tailored to the realities of a family doctor in Canada, explained Papadakis. “We’ve worked very closely with family physicians over the last few years, to really understand what’s most relevant to them, what’s most applicable, and we’ve put that all into the ESCAPE program.”
“This program is a good example of a way in which the Heart Institute is working in an integrated fashion with our primary care colleagues,” said Dr. Pipe. “Our approach in putting this program together emphasizes cooperation and coordination—learning from each other.”