No abstract

Background: Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral.Methods: This is a clinic randomized trial that compared usual care (n=25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n=24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic).Results: Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals,441) for usual care clinics (P=.001).Rates of referral were similar in intervention vs usual care clinics (n=9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P=.85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n=18 clinics; 10.1% vs 1.1%; P=.02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300. Conclusion:A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.

No therapies are known to substantially alter the course of dementia and associated treatment costs. However, enhanced support services for caregivers of people with dementia have been shown to improve caregivers' capabilities and well-being and delay patients' institutionalization. Using a model that simulated disease progression, place of residence, and direct costs of care, we estimated the potential savings to Minnesota from offering the New York University Caregiver Intervention, a program of enhanced support services for spouse and adult child caregivers of community-dwelling people with dementia, to all eligible people in the state from 2010 to 2025. Results indicate that approximately 5 percent more people with dementia would remain in the community from year 3 (2013) on and that 19.3 percent fewer people with dementia would die in institutions over fifteen years. During those years Minnesota could save $996 million in direct care costs (with a range of nearly $100 million to $2.64 billion under worst- and best-case scenarios, respectively). These findings suggest that broader access to enhanced caregiver supports could produce a positive return on investment or be cost-effective--assuming widespread implementation, reasonable program costs, and substantial caregiver participation.

There are disparities in both the receipt of cessation medication orders and the likelihood of filling them for some special populations. The causes are likely to be complex, but this information provides a starting point for learning to improve this problem.

The results present a strong rationale for regulating smoking in public places and were used to support the passage of Minnesota's Freedom to Breathe Act of 2007.