Video Counseling For Treating Tobacco Dependence

Kimber Richter, Ph.D., M.P.H.Genevieve Casey, M.A.Paula Cupertino, Ph.D.

University of Kansas Medical CenterDepartment of Preventive Medicine and Public Health

KU-MPH

For more info in this talk, contact Kim or Genevieve at krichter@kumc.edu or gcasey@kumc.edu

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Objectives

Understand rationale for/feasibility of video counseling

How we have used it at KUMC• Group-based video counseling• Individual video counseling

Grief vs Benefit

(Briefly) How we’re experimentally evaluating it • From Connect2Quit, a RCT of Telemedicine for Smoking Cessation in Rural

Primary Care (R01, NHLBI, Richter P.I.)

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What is video counseling? And what should we call it?

Telemedicine/Telecounseling/Video Counseling/Webcam Counseling

Delivery of interactive coaching/counseling in real time, using video/audio interface

Made possible by low cost computers, international telecom standards such as ISDN, and affordable high-speed internet services• But many lower income/rural smokers still don’t have

“Telemedicine” is reimbursable by Medicare and in Kansas by Medicaid

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Does it work? No data available for treating tobacco dependence

• Why we’re running a trial

Other health behaviors/outcomes: Cochrane review of telemedicine vs face-to-face patient care

• Telemedicine was as effective as face-to-face treatment and achieved high levels of satisfaction among patients and providers (Currell et al., 2000)

AHRQ review of 455 Telemedicine programs concluded the same

• Important to examine costs, cost-effectiveness (Hersh, 2004)

• May 1) provide equivalent care at less cost, 2) deliver better care at less or equivalent cost, 3) increase access to health care for patients who would otherwise not receive any care at all

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What are the potential benefits?

Counseling quality• Increase therapeutic alliance – bond between counselor and client

Increase adherence, impact

• Enhance counseling accuracy and quality by allowing counselor to see non-verbal cues

• Easier for counselor to remember details about smoker

Draw more smokers into treatment• Quitlines are underutilized

• Novelty factor

Wave of the future

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What are the barriers? Smokers tend to have lower incomes

Smokers tend to be less well educated

Although many have a computer in home, isn’t always working

Although many areas have >access< to high-speed internet, many residents don’t purchase it

• Only 53% of Kansans have home internet, the majority of which is dial-up connection with variable download time

Even with high-speed internet, the bandwidth required for high-quality telemedicine connection is large

• Requires firewall exceptions and periodic updates that internet providers typically do not provide

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How does it work?From Connect2Quit

Individually-based counseling

Delivered in physician offices – patients’ medical homes• Computer/webcam typically installed in an examining room

4 sessions (Week 0, 2, 4, 8)• Session 1/ Week 0-2 = D2-21 (D14 = target)• Session 2/ Week 2-3 = D14-28 (D21 = target)• Session 3/ Week 4-6 = D28-48 (D35 = target)• Session 4 / Week 8-11 = D56-83 (D63 = target)

Combined Motivational Interviewing/Cognitive Behavioral approach

Strong focus on pharmacotherapy assistance

Counseling/materials/assessments in Spanish and English

Also have done in group format – can discuss later

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Our equipmentProject would not be possible without fantastic support from

KUCTT – KU Center for Telemedicine and Telehealth• Technicians travel state installing/troubleshooting equipment issues

Equipment• We provide computers/webcams/software to physician offices

• Counselors have widescreen monitors to view Polycom and other needed documents (e.g. web browser for pharmacotherapy assistance)

Software: Polycom PVX• Delivers higher-quality video with less freeze-ups than freeware• Costs:

– PVX software is $112.00 per user – Cameras prices fluctuate, however $95.00 is average• Permits us to “show desktop” to the patient

Computer equipment requirementsResource Requirements

• Audio recording sessions for fidelity/ QI– Camtasia – the only program that would audio record Polycom– Required a gaming soundcard (multiple channels)

• Issue with Polycom shutting down or Access freezing intermittently – Multiple programs running at once – uses a large amount of RAM– Polycom PVX places a high demand on CPU– Polycom PVX is graphic intensive (as are Access and Camtasia)– Solution: (1) shut down all programs but Polycom, Camtasia and Access (2) Have a paper backup

in the case of Access freezing/ shutting down

Connection • Requires high-speed internet connection at both ends (dial up does not cut it)• Firewall issues• Internet bandwidth requirements

– Minimum bandwith requirements to connect– Consider clinic use variations throughout the day

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A typical session (on an ideal day…)

Counselor makes reminder call to pt and physician office day prior to session (Some clinics prefer weekly emails)

Patient checks in, goes straight to telemedicine room

Counselor dials C2Q computer at appointed office time

Counselor conducts session• 45 mins session 1, 20 mins follow-up sessions

Counselor faxes follow up materials (prescription request, quit plan) to front desk for pt to pick up at checkout• Provide 2 copies of each – 1 for pt, 1 for physician/medical record

Counselor/pt set follow up appt with receptionist at checkout

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Great things about a great sessionCounseling takes place in a clinic room with few distractions

Show educational materials on desktop to patient in session

Face to face connection – much like an in person session• Counselor can pick up on important non-verbal cues• It is a more personal connection than phone

Patient receives materials that day

Access to PCP at the clinic • Prescription request goes to physician that day• Pharmacy assistance needing physician signature can be completed right away• Physician and staff are aware of patient goals and generally supportive of the

program• Patient has higher accountability to call in or show up to a real in person

appointment

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What happens when things go wrong… Difficulty scheduling

• Some clinics have limited hours/ room availability – may not fit patient schedules• Clinics need staff identified to log on to computer/ make appointments

Despite reminder calls, some patients don’t show• Patient work schedules, more of a time commitment for patient (vs. phone)• Patient may not have transportation to the clinic• Less motivated patients may be less likely to show (vs. answer a phone call)

Clinic technology problems• We can not connect, or the clinic staff have to call us

– We can never connect because of the clinic’s slow internet connection – Occasional connection problems result from high traffic times– Firewall means the clinic always had to call out we can not call in

• Sound quality: echoes or delays at some clinics (movable speakers may work)• Sometimes the image quality is poor (pixilated) over time or freezes completely

– Ask the patient to move the mouse to avoid security lock out/ computer sleeping.

• Sometimes the connection is dropped – usually we can call back but not always. This can happen more than once during a call

– Interferes with the flow of the session, though patients have been tolerant.

Pros/Cons of C2Q Video versus Telephone Counseling

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Design, Connect2QuitNot a pure test of technology

• More a comparative effectiveness study of 2 models of care at a distance

Telephone “Quitline” condition versus Telemedicine integrated into Doctor’s office • All participants get same number of reminder calls, rescheduling calls, missed

appointments, counseling “windows”

All get 4 sessions, same materials and counseling content• Weekly supervision, plus sessions are digitally recorded /coded to ensure equal

content

Outcomes• Biochemically verified cessation at 12 months• Cost per quit in each condition (costs include patient and provider costs)

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Mechanism, Connect2Quit

Hypothesis is that integrated telemedicine, compared to telephone alone, will:• Lead to higher perceived support from physician/counselor which will • Lead to higher autonomous motivation and competence for change which will• Lead to higher cessation rates (directly) as well as higher medication use, which will also lead to

higher cessation rates• Also, higher cessation rates will result in equal or lower cost per quit

We’ll see!!

Integrated Telemedicine

vs.Telephone Counseling

Medicine Use

Cessation

Support from

Counselor

Autonomous Motivation

Support from

Physician

Competence for Change

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Questions ?