Ohio’s Fax Referral Initiatives
Reach, Enrollment and Participant Characteristics
Jeff Willett, PhDDirector, NYS Tobacco Control Program
March 4th and 6th, 2009
Fax Referral
• The Ohio Tobacco Quit Line began providing statewide services in September, 2004.
• Fax referral was introduced in the first year to increase health provider referral.
• An average of 68 fax referrals were received per month prior to the study period.
Fax Referral
• Goal: to reduce quit line marketing costs by establishing a sustainable, high volume referral stream from health professionals.
• Three initiatives were developed or expanded to increase health provider utilization of the fax referral. – Fax Five– Hospital Outreach– Community Promotion
Fax Five
• Direct marketing initiative aimed at health professionals.– Phase I: Promotional folder and 5 fax referral
forms placed in the May/June issue of Ohio Medicine.
– Phase II: Peer Writing Campaign utilizing the Quit Line’s Advisory Panel. Sent personal letters and 5 fax referral forms to 25,970 health professionals in March, 2007.
Hospital Outreach
• A hospital-focused outreach program funded in March, 2006.
• 51 hospitals received a small stipend to institute a fax referral process.
• Rigorous training component– Daylong in-person training– 5 one-hour training calls
Community Promotion
• Health professional training program conducted by community tobacco control grantees.
• Beginning January, 2007 all 50 OTPF community grantees were required to “Promote Ohio Quits” including distribution of and training related to health professional quit kits.
Evaluation
• Evaluation Period June ’06 – Oct. ’07
• Fax referral forms including tracking codes for each initiative
• Fax referrals not tied to study initiatives were treated as “other”
Fax Referrals ReceivedJune 2006 – October 2007
0
100
200
300
400
500
600
700
800
Nu
mb
er o
f re
ferr
als
Fax Five
0
100
200
300
400
500
600
700
800
Nu
mb
er o
f re
ferr
als
Outreach
0
100
200
300
400
500
600
700
800
Nu
mb
er o
f re
ferr
als
Community
0
100
200
300
400
500
600
700
800
Nu
mb
er o
f re
ferr
als
Referrals ≠
Enrollments
Outcomes of fax referral call attempts by initiativeJune 2006 – October 2007 (%)
Community(n=1,956)
Hospital (n=1,916)
Fax Five(n=1,065)
Other(n=2,014)
Total(n=6,951)
Enrolled 24.4% 21.3% 28.4% 22.3% 23.6%
Information only 3.4% 3.5% 4.5% 5.6% 4.2%
Declined 13.6% 14.0% 13.2% 14.0% 13.8%
Unreachable 58.6% 61.2% 53.9% 58.1% 58.5%
Examining the “Unreachable”
Rate
3rd Call Dispositions for the April 2007 “Unreachable” Fax Referrals (N=368)
Disconnect / Wrong Number
21 5.7%
No Answer, Busy, Hang up
101 27.5%
Voice mail message
183 49.7%
Message left with household
63 17.1%
Comparing Fax and Traditional
Enrollments
Quit line enrollee characteristics, by fax referral initiative and fax referral status (%)
Fax referral status
Fax (n=1,616)
Non-fax (n=36,273)
Gender
Male 33 42
Female 67 59
Age
Less than 35 21 31
35-64 72 65
65+ 8 4
Comorbidity
One or more 60 36
Note: Bold values indicate a cell count that was higher than expected values; italicized values indicate a cell count that was lower than expected values, p<0.001.
Quit line enrollee characteristics, by fax referral initiative and fax referral status (%)
Fax referral status
Fax (n=1,616)
Non-fax (n=36,273)
Education
Less than HS 24 12
HS/GED 41 40
More than HS 35 47
Insurance Status
Private 57 78
Medicaid 11 4
Medicare 8 3
Uninsured 23 16
Note: Bold values indicate a cell count that was higher than expected values; italicized values indicate a cell count that was lower than expected values, p<0.001.
Reach
• The three initiatives dramatically increased fax referral to the Ohio Tobacco Quit Line.– 68 referrals per month during year before
initiatives– 412 referrals per month during study period– Fax Five: cost-effective, least sustainable
• Can kick-off fax referral expansion
– Community: slow growth, most sustainable
Enrollment
• 23.6% of fax referred individuals enrolled
• 18% actively declined enrollment (information only or declined all service)
• Based on one-month disposition data– An estimated 40% of fax referrals passively
decline enrollment (do not return voice mail or personal messages left by Quit Line)
• Raises questions about patients actual readiness to quit.
Participant Characteristics
• Fax referred individuals were more likely to be lower educated, to be uninsured and to have public insurance.
• Compared to non-fax enrollments driven largely by media efforts, costs per enrollment were much higher for fax referrals.
Questions?
Willett J, Hood N, Burns E, Swetlick J, Wilson S, Lang D, Levinson A. Clinical Fax Referrals to a Tobacco Quitline: Reach, Enrollment and Participant Characteristics. American Journal of Preventive Medicine;36(4):XXX–XXX; April 2009.
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