Mixed-methods Economic Evaluation of the Implementation of Tobacco Treatment Programs in National Cancer Institute-designated Cancer Centers

Abstract

Background: The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications.Methods: We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one six-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs.Results: Total monthly operating costs across funded centers ranged from $6,453 to $20,751. The largest operating cost category was personnel ($4,122-$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly cost ranges for other categories were: medications ($17-$573), materials ($6-$435), training ($96-$516), technology ($171-$2,759), and equipment ($10-$620). Cost-per-participant ranged from $70 to $3,500 (median, $537) and cost-per-quit ranged from $330 to $9,799 (median, $2,699) with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications.Conclusions: Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Implementation strategies for integrating tobacco cessation treatment in cancer care: A qualitative study

“…On the other hand, oncologists noted that co-located treatment would present logistical challenges and require additional resources. It remains unclear which tobacco cessation treatment model, or combination of models, is most effective (Salloum et al, 2021). More research is needed to determine the optimal design of tobacco cessation treatment programs and implementation strategies in cancer care in relation to effectiveness and sustainability while recognizing that this will likely be dependent on healthcare system context.…”

Integrating Tobacco Treatment Into Oncology Care: Reach and Effectiveness of Evidence-Based Tobacco Treatment Across National Cancer Institute–Designated Cancer Centers

“…Demonstrating success and return on investment are critical to sustaining implementation of evidence-based practices. 32,33 Future hybrid effectiveness-implementation trials should investigate stepped care strategies for scaling up tobacco treatment services ranging from low-burden, low-cost strategies to more intensive multicomponent tobacco treatment counseling and pharmacotherapy to support patients' quit attempts and to maintain smoking abstinence. Longitudinal research examining change in reach and effectiveness over time, and the association of these changes with implementation strategies could identify temporal effects of implementation strategies on reach and effectiveness.…”

Sustainability of Tobacco Treatment Programs in the Cancer Center Cessation Initiative

“…Sustainability capacity refers to the existence of structures and processes that enable a program to effectively implement and maintain evidence-based practices. 7 Although tobacco cessation and sustained abstinence have been demonstrated to benefit patients with cancer and reduce cancer treatment costs, 8 and even though documented costs-per-quit in C3I have been modest, 9 sustainability remains a critical challenge. Consistent with recommended definitions and conceptualizations that consider complex health interventions, 5,6,10 the sustainability of tobacco treatment programs can be conceptualized in 3 critical domains: maintenance of (1) core program components (ie, evidence-based interventions to improve cessation; eg, counseling, pharmacotherapy), (2) ongoing implementation strategies (ie, methods to enhance the adoption, implementation, and sustainment of an intervention; eg, automated referral, opt-out referral, point-of-care treatment), and (3) program outcomes evaluation (ie, consequences of implementing the intervention; eg, reach, effectiveness).…”