Health care financing systems for increasing utilisation of tobacco dependence treatment
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
The primary objective of this systematic review is to evaluate the effects of financial interventions on the utilisation of tobacco dependence treatment by smokers. In this review the following hypotheses will be tested:
1. Reimbursement of tobacco dependence treatment for smokers will increase the utilisation of these methods and increase the number of quit attempts and the number of long term quitters.
2. Reimbursement for healthcare professionals for the time and effort invested in the treatment of smokers will increase the prescription of tobacco dependence treatment and increases the utilisation of these means by their smoking patients. As a result, reimbursement for healthcare providers will also increase the number of quit attempts and the number of long term quitters.
Results will also be evaluated taking the costs of the intervention into account.
Background
Although much smoking cessation research and clinical practice has focused on identifying the one intervention that would turn all smokers into permanent non‐smokers (Fiore 1995), the efficacy of available smoking cessation strategies seems to be rather low. The available smoking cessation literature shows that approximately 70 to 80% of the (non‐chronically ill) motivated‐to‐quit smokers relapse within the first year (Silagy 2002; Hughes 2002). It is clear that we have not (yet) found the one intervention that can turn all smokers into permanent non‐smokers. In order to increase the number of successful quitters and reduce the number of smokers, optimising the accessibility and affordability of existing smoking cessation treatments might be a promising approach. By these means, the utilisation of smoking cessation treatment increases, which can in turn increase the number and the quality of quit attempts. In this study, the effects of financial interventions will be studied.
Objectives
The primary objective of this systematic review is to evaluate the effects of financial interventions on the utilisation of tobacco dependence treatment by smokers. In this review the following hypotheses will be tested:
1. Reimbursement of tobacco dependence treatment for smokers will increase the utilisation of these methods and increase the number of quit attempts and the number of long term quitters.
2. Reimbursement for healthcare professionals for the time and effort invested in the treatment of smokers will increase the prescription of tobacco dependence treatment and increases the utilisation of these means by their smoking patients. As a result, reimbursement for healthcare providers will also increase the number of quit attempts and the number of long term quitters.
Results will also be evaluated taking the costs of the intervention into account.
Methods
Criteria for considering studies for this review
Types of studies
Controlled trials with or without randomisation (RCTs and CCTs) and interrupted time series (ITS) will be included.
Types of participants
We include those studies in which the study population consists of smokers. Due to the objective of this review (ie to evaluate the effects of financial interventions directed at smokers and/or healthcare professionals), we also include studies in which healthcare professionals comprise the study population (eg general practioners, lung physicians, nurses). The reported effects must concern patients who are smokers.
Types of interventions
Trials in which the effects of financial interventions (eg delivered by government or insurance plans) are being studied will be included. These interventions could be smoker‐directed like co‐payment, out‐of‐pocket payment (Dovey 2002), user fees and incentives. Interventions directed at healthcare professionals include salary (Gosden 2002), capitation, fee‐for‐service, target payment (Giuffrida 2002), fund holding (Miller 1994) and organisation level payment systems. (Hillman 1992) (Table 1)
| Smoker‐directed | Provider directed | Definition |
| co‐payment, out‐of‐pocket payment | patient payment in addition to health insurance (Dovey, 2002) | |
| user fees, incentives | patient payment which encourages the use of medical services by paying all or part of the cost | |
| salary | provider payment for a set number of working hours or sessions per week (Gosden 2002) | |
| capitation | provider was paid a set amount per patient for providing specific care | |
| fee‐for‐service, target payment | payment for every item of service or unit of care provided (Giuffrida 2002) | |
| fund holding, organisation level payment systems | payment systems, which influence the personal income of the health care provider indirectly (Miller 1994 and Hillman 1992) |
There are no restrictions on the type of tobacco dependence treatment for which reimbursement is offered. This may include advice, behavioural interventions, pharmacotherapy, etc. A distinction will be made between partial and complete reimbursement. When possible a subdivision will also be made for the location of care and/or the setting of the intervention.
Types of outcome measures
Studies will only be included when at least one of the outcome measures mentioned below can be obtained. Outcome measure 1 is the primary outcome measure of the review and the preferred source of evidence. Outcome measures 2, 3 and 4 are secondary outcome measures. Studies with only these latter outcome measures provide less strong evidence.
1. Abstinence from smoking at least six months after the start of the intervention.
Studies reporting either self reported or biochemically validated smoking status will be included. The most conservative measure of abstinence from smoking will be used at the longest follow‐up. A sustained quit rate (continuous abstinence or prolonged abstinence) is used in preference to point prevalence, and abstinence at 12 months follow‐up or longer is used in preference to abstinence at six months follow‐up (SRNT 2002; Hughes 2003).
2. Number of quit attempts
Studies with self reported quit attempts will be included.
3. Self reported and registered utilisation of tobacco dependence treatment by smokers.
Like the first two outcome measures, registered utilisation will be preferred to self reports.
4. Prescription by healthcare providers of tobacco dependence treatment
The costs of the intervention are also an important outcome measure and will be reported whenever possible. When the costs of the intervention are not reported, the study will not be excluded.
Search methods for identification of studies
All relevant trials meeting our inclusion criteria and published up to February 2003 will be identified by:
1. A computer‐aided search of MEDLINE (from 1966), EMBASE (from 1989) and Psyclit (from 1971) databases;
2. Screening references of relevant reviews and identified RCTs or quasi‐experimental studies ;
3. Screening of the Cochrane controlled trials register (CENTRAL), Issue 3 2002 (or otherwise the most recent issue) ;
4. In order to reveal unpublished studies experts in the field will be contacted.
Unpublished studies or abstracts will be included if sufficient detail is available. In the literature search, search terms from the EPOC and Tobacco Addiction Group will be used. The terms will be connected and the results will be limited to studies reporting only on human subjects. There is no limitation on language.
The following terms, MeSH subheadings and free text words will be used in the literature search: randomized controlled trial, controlled clinical trial, random*, research design, experiment, intervention studies, comparative studies, evaluation studies, time adj series, tobacco*, nicotine*, smok*, smoking, smoking‐cessation, quit*, stop*, abstin*, abstain*, cessat*, ceas*, control*, coverage*, reimburse*, target*, payment*, remunerat*, incentive*, financ*, salar*, fee*, deductibles*, coinsurance*, co‐payment*, capita*, cost next shar, prospective payment*, fund hold, prepay, prepaid, health care costs, health insurance, health care organization, health maintenance organization or health care system (* indicates wild card symbol).
Data collection and analysis
STUDY SELECTION
Two reviewers will independently select the studies to be included in the review by applying the selection criteria to papers retrieved by the literature search. Any discrepancies will be resolved by consensus meetings. A third reviewer will be consulted if disagreement persists.
METHODOLOGICAL QUALITY ASSESSMENT
The methodological quality of the studies will be assessed using the Delphi List (Verhagen 1998), which also contains the Jadad scale (Jadad 1996). Methodological quality of the included studies will be assessed by JK and EJW. Any disagreement between the two reviewers will be resolved by a third reviewer. If a study does not contain enough information on methodological criteria or if the information is unclear, the authors will be contacted for additional information.
DATA EXTRACTION
Data from studies meeting the inclusion criteria will be extracted by the first reviewer and checked by the second. Any discrepancies will be resolved by consensus meetings. A third reviewer will be consulted if disagreement persists. The following data will be extracted:
1. Details of participants (method of recruitment to the study, smoking behaviour and characteristics of participants: age, gender, ethnicity, smoking status, average baseline cigarette consumption and motivation to quit);
2. Healthcare provider;
3. Study design;
4. Description of the financial intervention;
5. Location of care, setting of intervention, country;
6. Definition of smoking cessation and quit attempt;
7. Outcome measures (prescription and use of tobacco dependence treatment, number of quit attempts, prolonged abstinence or point prevalence abstinence and costs of the intervention).
DATA ANALYSES
When possible a meta‐analysis of the research findings will be performed. When the selected studies are heterogeneous or do not provide data to undertake a meta‐analysis, a qualitative analysis will be carried out.
| Smoker‐directed | Provider directed | Definition |
| co‐payment, out‐of‐pocket payment | patient payment in addition to health insurance (Dovey, 2002) | |
| user fees, incentives | patient payment which encourages the use of medical services by paying all or part of the cost | |
| salary | provider payment for a set number of working hours or sessions per week (Gosden 2002) | |
| capitation | provider was paid a set amount per patient for providing specific care | |
| fee‐for‐service, target payment | payment for every item of service or unit of care provided (Giuffrida 2002) | |
| fund holding, organisation level payment systems | payment systems, which influence the personal income of the health care provider indirectly (Miller 1994 and Hillman 1992) |
