Motivate patients to stop smoking
Motivate patients to stop smoking
Reimbursement for cessation counseling
A just-released study showing that smokers have significantly more complications post-surgery than non-smokers, including a higher death rate, coupled with new Medicare reimbursement for physicians who provide counseling to prevent tobacco use for outpatients and hospitalized patients have outpatient surgery managers taking a new look at smoking cessation programs.
The results from the study conducted by The Cleveland Clinic, released at the recent 2010 meeting of the American Society of Anesthesiologists, show increased incidents of adverse outcomes among smokers, including surgical-site infections, respiratory complications, pneumonia risk, unplanned intubation, artificial mechanical ventilation, cardiac arrest, heart attack, stroke, and death. The more patients smoke, the more complications they were likely to experience, the study found.
"Hopefully, surgeons can utilize the upcoming operation as a 'teachable moment' to educate their patients about their risks of postoperative wound infection, failure of the intended procedure i.e. recurrence of an incisional hernia hospital readmission, prolonged intubation, and postoperative pneumonia, which are clearly documented in the medical literature," says John Maa, MD, FACS, assistant professor in the department of surgery and assistant chair, surgery quality improvement program, at the University of California San Francisco.
And now physicians have another incentive. Since Aug. 25, 2010, the Centers for Medicare & Medicaid Services (CMS) has covered counseling services to prevent tobacco use for outpatients and hospitalized patients. CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries:
- who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;
- who are competent and alert at the time that counseling is provided; and
- whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner. Some private payers have followed Medicare and also are reimbursing physicians for tobacco cessation counseling. There is no reimbursement from Medicare that covers the facility fee.
Some studies have indicated that people are more likely to quit smoking when they have a surgical procedure scheduled. During informed consent, surgeons can discuss active smoking and its risks "and many patients, once they are made aware of the potential adverse outcomes resulting from their active smoking, will choose to delay surgery and try to stop smoking in their own interest of safety," Maa says.
Smoking cessation is not without its challenges, he acknowledges. "Smoking cessation is indeed a lengthy and challenging process, which often requires multiple efforts to achieve success," Maa says. "It is indeed difficult for surgeons to counsel patients in this time-intensive process, and recruiting the assistance of additional staff and resources is essential, as attempting to achieve this task alone is unlikely to be fruitful."
Consider involving the patient's referring provider, as well as family and children, anesthesiologists, administrators, and respiratory therapy staff, Maa advises.
Anesthetists play a role
The American Society of Anesthesiologists (ASA) encourages anesthesiologists to use a three-step method of "ask, advice, and refer," says David O. Warner, MD, professor of anesthesiologist, Mayo Clinic, Rochester, MN, and leader of the smoking cessation initiative of the ASA. According to Warner, anesthesiologists should:
- Ask all patients about their tobacco use.
- Advise those who do use to stop.
- Refer patients to other resources that can get them the assistance they need to quit successfully. The primary resources are free telephone quitlines, which provide extended counseling services, Warner says. Those services can be accessed through the toll-free number (800) QUIT NOW, which directs callers to quitline services in their area. The quitline counselors tailor a quit plan and advice for each individual caller, Maa says.
Maa says, "Having adequate brochures and cards to refer patients to quitlines and outpatient counseling services ... can help save time."
Physicians can prescribe low dose nicotine replacement, Maa says, "and it may be worthwhile to familiarize oneself with the types of medications and services that Medicare, Medicaid, and standard insurance companies will reimburse for patient out-of pocket expenses."
Also, it might be appropriate to cancel the operation, even on the morning of surgery, if there is evidence that a patient has not been compliant with required preop smoking cessation, or if the anesthetic and cardiopulmonary risks to the patient are significant, he says. "For some patients at risk of noncompliance, it is useful to encourage compliance by alerting the patient that a serum cotinine concentration or a urinary test strip for nicotine content can be performed the morning of surgery to monitor their tobacco use," Maa adds.
Physicians have a "special and unique opportunity" when it comes to smoking cessation, he says. Discussing smoking cessation not only will provide benefits for the surgical procedures, "but also for their patient's overall health looking beyond the procedure," Maa says. He advises physicians to "not allow this excellent opportunity to improve the overall health of Americans to be lost."
A just-released study showing that smokers have significantly more complications post-surgery than non-smokers, including a higher death rate, coupled with new Medicare reimbursement for physicians who provide counseling to prevent tobacco use for outpatients and hospitalized patients have outpatient surgery managers taking a new look at smoking cessation programs.Subscribe Now for Access
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