A coast-to-coast CME initiative is tackling one of the biggest public heath problems facing the U.S. today. Resulting in more than 440,000 deaths every year, tobacco addiction is the single most preventable cause of death. Now nine organizations have partnered to create Cease Smoking Today (CS2day), a three-year project, which began rolling out this spring. Aiming to reach nearly 46,000 physicians through 176 activities, CS2day will use four different performance-improvement (PI) models to measure every level of outcomes all the way up to Level 6, changes in population health.

“We are in an era now, I believe, when no one or two organizations can solve these major issues in public health,” says George Mejicano, MD, associate dean for continuing professional development at the University of Wisconsin School of Medicine and Public Health in Madison, one of the architects of the initiative. “Working collaboratively we can tackle problems that we otherwise would not be able to tackle — partly because of resources and partly because of the reach and talent and skill sets of all the different [partners].”

And Then There Were Nine

In early 2007, the Center for Tobacco Research and Intervention at the University of Wisconsin was awarded the contract by the U.S. Agency for Healthcare Research and Quality to update the national tobacco cessation guidelines. Renowned for its tobacco research, CTRI wrote the guidelines the last time they were updated in 2000.

Enter Mejicano. Working at UW, he was aware that CTRI was again writing the guidelines, and planned to develop a program to educate physicians about the new treatment recommendations. Before he even created a proposal, Mejicano received inquiries from other providers who had heard about the guideline update and figured Mejicano might be interested in collaborating on a CME project.

The first to contact Mejicano were Shelly Rodrigues, deputy executive vice president at the California Academy of Family Physicians, San Francisco; and Mary Ales, executive director, Interstate Postgraduate Medical Association, a Madison, Wis.-based CME provider. Mejicano serves on the board of directors at IPMA.

Through Ales, Mejicano learned that another IPMA board member who represented the Iowa Foundation for Medical Care was also interested in the project. IFMC is the quality-improvement organization for the states of Illinois and Iowa, contracted by the U.S. Center for Medicaid and Medicare Services to improve the performance of doctors in the region. Through its network of physicians and access to government health data, IFMC brought the capability to measure Level 6 outcomes.

The chance to do Level 6 outcomes got Mejicano thinking about the huge potential of the initiative. Deciding it needed a few more pieces, he contacted Chris Larrison, co-founder of Healthcare Performance Consulting, Carmel, Ind., which specializes in needs assessment and outcomes assessment; and CME Enterprise, an Indianapolis-based education company, which could handle meeting logistics, communications, and project management. To broaden the project's reach to states with the highest addiction rates, Mejicano invited Robert Addleton, EdD, executive vice president, Physicians Institute for Excellence in Medicine at the Medical Association of Georgia, to join. Addleton was developing a block grant initiative for a group of state medical associations.

As Mejicano was about to convene the group for the first time, he heard from Jann Balmer, PhD, director of CME, University of Virginia School of Medicine, Charlottesville, who was interested in offering an online CME series about tobacco cessation, as well as television and streaming video courses through UVA's partnership with the Discovery Health television network. By adding UVA's online expertise, the project would have additional opportunities to offer “serial education” — activities that would reach physicians multiple times to reinforce lessons.

When the participants held an initial meeting last summer, they agreed that it would be beneficial to reach pharmacists in addition to the learners they had already identified — primary care physicians, cardiologists, pulmonologists, and psychiatrists. They invited Purdue University, which has the largest continuing pharmacy education school in the country, to join. The nine-partner coalition was now complete.

Pfizer Says Yes

After calling Pfizer, which had a new tobacco cessation drug, on the market, and learning that the company would be issuing a request for proposals for smoking cessation CME in September, the collaborative drafted a 100-plus-page proposal seeking $12.3 million in funding.

Pfizer's CME team was impressed by the fact that nine organizations came together to share best practices and co-create a project instead of competing for funding, says Jacqueline Mayhew, director, Medical Education Group, U.S. External Medical Affairs, Pfizer Inc., New York. Mayhew also appreciated that CS2day's educational tools would be posted online, available to other CME providers; that the project would help small providers through the block grant system; and that the coalition planned to publish the results of its PI initiatives, another benefit to the wider CME community. “The efficiency and the spirit of collaboration came through,” says Mayhew. “CS2day has the potential to really make a difference.” Pfizer approved the grant in December 2007.

Curriculum Changes

Although the first sessions were scheduled for March, at the American College of Cardiology's annual meeting, and April, at the California Academy of Family Physicians' annual meeting, the new guidelines would not be released until May. The group developed the curriculum for those first sessions using the 2000 guidelines and sent it to the Center for Tobacco Research and Intervention to make sure it was not at odds with the update.

The rest of the sessions will be taught using the new guidelines, which came out on May 7. There are some important differences, explains Mejicano. “One is that we now know that counseling, together with drug therapy, is better than drug therapy alone,” he says. (Among the recommended drugs in the CTRI guidelines is Pfizer's Chantix; see sidebar for more). CS2day's curriculum sticks strictly to the evidence-based government guidelines, says Mejicano. “This is where we have to be as pure as the driven snow. The evidence is the evidence.”

At press time, the team was working on developing the new curriculum based on the updated guidelines, which will be reviewed by an external advisory board.

176 Activities

The vast majority of the activities are live sessions, scheduled to take place over the next year, ending in summer 2009. The courses, whose teaching faculty and format will differ depending on the sponsor and the audience, will be disseminated through American Academy of Family Physicians chapters in around 20 states, through five state medical associations via Addleton's block grant system, as well as at annual meetings held by national associations, including the American Academy of Family Physicians, the American College of Cardiology, and American Psychology Association. They will also be presented at five of the regional Pri-Med conferences.

In addition to the live activities, CS2day includes seven enduring activities, released through outlets including the Discovery Health television network and several online platforms such as Medscape.com. The coalition's Web site, www.ceasesmoking2day.com, will feature an online tool kit, which will also be available in DVD and other formats.

Four PI Models

One of the most exciting aspects of the initiative, say the partners, is that it employs four different models to measure Level 6 outcomes. In total, the treatment of about 34,000 patients will be evaluated.

The California Academy of Family Physicians is partnering with four other AAFP chapters to create teams of physicians in five states. They expect to measure outcomes of at least 6,000 patients using the Institute for Healthcare Improvement's Model for Improvement, where teams work together to implement change.

The Interstate Postgraduate Medical Association is hosting a live workshop in November, where physicians will perform self-assessments and improve their knowledge and counseling skills by responding to case vignettes. Using a data registry, they then will measure their performance and identify changes over the course of a year. IPMA hopes to evaluate 10,000 patients.

The third project is being done through the Iowa Foundation for Medical Care, the QIO, which will deliver smoking cessation education to physicians in Iowa and Illinois at their respective offices. The QIO will install a patient registry in doctors' offices so they can measure and improve their treatment approaches. The outcomes of 6,000 patients will be measured.

Conducted by the University of Wisconsin, the fourth PI project will give about 60 physicians throughout Wisconsin access to an online, self-directed process to measure and improve their treatment of 12,000 patients.

The PI projects will take a year to 15 months to complete, with results expected through the middle of 2010. “Through those four techniques, we will do direct measurement of patient outcomes, asking: How many patients quit smoking? How many patients did you ask to quit smoking? What sort of counseling did you do?” says Ales. The coalition will publish research reports on smoking cessation, including an analysis of the benefits, costs, and results of implementing these PI approaches, which will help inform the CME community about which method is most effective in motivating physicians to change their behavior.

Playing Together

The biggest challenge in mounting such a massive collaborative effort, says Mejicano, is learning how to “play in the same sandbox.” To maximize efficiency and cooperation, the group is divided into various committees. For example, the four-member executive committee — composed of Ales, Rodrigues, Mejicano, and Larrison — meets weekly by phone to set the strategic direction and handle the day-to-day problems. The partners also have individual responsibilities. Mejicano, for example, acts as the liaison with the ACCME; Rodrigues is the main point of contact with Pfizer, and she and the California Academy of Family Physicians manage the funding. Through a system that the collaborative created, funding is released when each activity meets specific milestones. While the committees and partners are empowered to make some decisions, when a major decision must be made, all nine coalition members vote.

For CS2day to succeed, all the partners had to come together for the common good. “We had to adopt a philosophy that together we can do things that we couldn't achieve by ourselves,” says Mejicano. “There might not be as much individual benefit as there would be for smaller projects, but there's going to be greater benefit for more people and more organizations.”

Future of CME

The coalition may expand the project internationally, and CS2day may spawn offshoot projects among the partners. Mejicano also hopes the initiative encourages other CME collaborations. “I think this is absolutely historic,” says Mejicano. “No one has ever tried anything close to this in terms of magnitude, number of partners, and frankly, public health importance. I hope that initiatives like this will be the future of CME.”

Chantix Concerns

Issued in May, the 2008 U.S. Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, recommended Pfizer's smoking cessation drug Chantix as one of the most effective drug therapies in certain cases. But in recent months, there's been growing concern about its safety. While it tested well in clinical trials, in February the Food and Drug Administration issued a warning about potential side effects.

How might the evolving information about Chantix affect CS2day and the government guidelines? Both the Center for Tobacco Research and Intervention, which wrote the guidelines, and the CS2day coalition take their guidance from the FDA, says George Mejicano, MD, associate dean for continuing professional development at the University of Wisconsin School of Medicine and Public Health in Madison, one of the architects of the CS2day initiative. “We're going to use CTRI's expertise to keep the curriculum up-to-date as the studies roll out,” he says. “If the FDA came out with a black box warning, then the curriculum would change; if the drug went off-market, then the curriculum would change; if the FDA said it's safe for this population but not for that population — it would change.”

Hypothetically speaking, if the drug is pulled off the market, what would become of CS2day since Pfizer is the sole funder? “I believe that Pfizer would have the obligation to continue funding the unrestricted educational grant because it is independent of content,” says Mejicano. “This would, in fact, be the poster child for the independence of CME.”

CS2day*: A 9-member Coalition

  • University of Wisconsin School of Medicine and Public Health, Madison. CME provider; oversees Web-based, performance-improvement models, featuring Level 6 outcomes; liaison with ACCME. www.med.wisc.edu

  • California Academy of Family Physicians, San Francisco. CME provider; brings activities to AAFP chapters; conducts Level 6 outcomes measures; liaison with Pfizer. www.familydocs.org

  • Physicians Institute for Excellence in Medicine at the Medical Association of Georgia, Atlanta. CME provider; distributes education to state medical associations through a block grant system. www.physiciansinstitute.org

  • Iowa Foundation for Medical Care, West Des Moines. Quality-improvement organization; brings CS2day to doctors in Iowa and Illinois; facilitates Level 6 outcomes measures. www.ifmc.org

  • Interstate Postgraduate Medical Association, Madison, Wis. CME provider; facilitates Level 6 outcomes through performance improvement project. www.ipmameded.org

  • Healthcare Performance Consulting, Carmel, Ind. Outcomes measurement provider; will assess and measure the four performance-improvement projects. www.changingperformance.com

  • CME Enterprise, Indianapolis. CME provider; a medical education and communication company; handles meeting logistics and project management. www.cmeenterprise.com

  • University of Virginia School of Medicine, Charlottesville. CME provider; distributes education online and via television through a partnership with Discovery Health TV network. www.healthsystem.virginia.edu/

  • Purdue University School of Pharmacy, West Lafayette, Ind. Provider for continuing pharmacy education; brings CS2day to pharmacists. www.pharmacy.purdue.edu