Healthcare financing systems for increasing the use of tobacco dependence treatment

Floor A van den Brand; Gera E Nagelhout; Ayalu A Reda; Bjorn Winkens; Silvia M A A Evers; Daniel Kotz; Onno CP van Schayck

doi:10.1002/14651858.CD004305.pub5

Sistemas de financiamiento de la atención sanitaria para el aumento del uso del tratamiento del tabaquismo

Appendices

Appendix 1. Specialised Register Search Strategy

Search strategy used for Specialised Register (using Cochrane Register of Studies (CRS) software)

#1 MeSH DESCRIPTOR Insurance Explode All

#2 MeSH DESCRIPTOR Insurance Coverage Explode All

#3 MeSH DESCRIPTOR Insurance, Health Explode All

#4 MeSH DESCRIPTOR Reimbursement Mechanisms Explode All

#5 MeSH DESCRIPTOR Insurance, Health, Reimbursement Explode All

#6 MeSH DESCRIPTOR social control policies Explode All

#7 MeSH DESCRIPTOR health care costs Explode All

#8 MeSH DESCRIPTOR Quality of Health Care Explode All

#9 MeSH DESCRIPTOR Fee‐for‐Service Plans Explode All

#10 MeSH DESCRIPTOR Physician Incentive Plans Explode All

#11 MeSH DESCRIPTOR Costs and Cost Analysis Explode All

#12 MeSH DESCRIPTOR Cost‐Benefit Analysis Explode All

#13 health care costs

#14 health insurance

#15 coverage*:AB,TI

#16 reimburse*

#17 payment*

#18 remunerat*

#19 incentive*

#20 salary or salaries

#21 fee or fees

#22 deductible*

#23 co?insurance

#24 co?payment

#25 capita*

#26 fund?hold*

#27 prepay or prepaid

#28 financ* NEAR incentive*:AB,TI

#29 cost? NEAR (shar* or free or no):TI,AB

#30 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 or #28

Appendix 2. MEDLINE search strategy

The following topic related terms were combined with MeSH and free text terms concerning smoking and tobacco use, and with terms to identify trials and other evaluations of healthcare effects used by Cochrane Tobacco Addiction for regular searches of MEDLINE. (See Specialized Register section of Tobacco Addiction Group Module). The free text term 'time series' was included in the trials identification set.

exp Insurance, Health, Reimbursement/ or exp Insurance/ or exp Insurance Coverage/ or exp Insurance, Health/ or exp Reimbursement Mechanisms/ or exp Insurance, Health, Reimbursement/ or exp social control policies/ or exp health care costs/ or "Quality of Health Care"/ec or exp Fee‐for‐Service Plans/ or exp Managed Care Programs/ or exp Physician Incentive Plans/ or exp Employee Incentive Plans/ or (coverage or reimburs$ or target$ or payment$ or remunerat$ or incentive$ or financ$ or salar$ or fee or fees or deductible$ or coinsurance or copayment or capita$ or cost$ or payment$ or fundhold$ or prepay$ or prepaid).mp. [mp=title, original title, abstract, name of substance word, subject heading word]

Appendix 3. Glossary of terms

Term	Definition
Abstinence	A period of being quit, i.e. stopping the use of cigarettes or other tobacco products, may be defined in various ways; see also: point prevalence abstinence; prolonged abstinence; continuous/sustained abstinence
Biochemical verification	Also called 'biochemical validation' or 'biochemical confirmation'. A procedure for checking a tobacco user's report that he or she has not smoked or used tobacco. It can be measured by testing levels of nicotine or cotinine or other chemicals in blood, urine, or saliva, or by measuring levels of carbon monoxide in exhaled breath or in blood.
Bupropion	A pharmaceutical drug originally developed as an antidepressant, but now also licensed for smoking cessation; trade names Zyban, Wellbutrin (when prescribed as an antidepressant)
Carbon monoxide (CO)	A colourless, odourless highly poisonous gas found in tobacco smoke and in the lungs of people who have recently smoked, or (in smaller amounts) in people who have been exposed to tobacco smoke. May be used for biochemical verification of abstinence.
Cessation	Also called 'quitting' The goal of treatment to help people achieve abstinence from smoking or other tobacco use, also used to describe the process of changing the behaviour
Continuous abstinence	Also called 'sustained abstinence' A measure of cessation often used in clinical trials involving avoidance of all tobacco use since the quit day until the time the assessment is made. The definition occasionally allows for lapses. This is the most rigorous measure of abstinence
'Cold turkey'	Quitting abruptly, and/or quitting without behavioural or pharmaceutical support
Craving	A very intense urge or desire [to smoke]. See: Shiffman et al 'Recommendations for the assessment of tobacco craving and withdrawal in smoking cessation trials' Nicotine & Tobacco Research 2004: 6(4): 599‐614
Dopamine	A neurotransmitter in the brain that regulates mood, attention, pleasure, reward, motivation and movement
Efficacy	Also called 'treatment effect' or 'effect size' The difference in outcome between the experimental and control groups
Harm reduction	Strategies to reduce harm caused by continued tobacco/nicotine use, such as reducing the number of cigarettes smoked, or switching to different brands or products, e.g. potentially reduced exposure products (PREPs), smokeless tobacco
Lapse/slip	Terms sometimes used for a return to tobacco use after a period of abstinence. A lapse or slip might be defined as a puff or two on a cigarette. This may proceed to relapse, or abstinence may be regained. Some definitions of continuous, sustained or prolonged abstinence require complete abstinence, but some allow for a limited number or duration of slips. People who lapse are very likely to relapse, but some treatments may have their effect by helping people recover from a lapse.
nAChR	Neural nicotinic acetylcholine receptors Areas in the brain that are thought to respond to nicotine, forming the basis of nicotine addiction by stimulating the overflow of dopamine
Nicotine	An alkaloid derived from tobacco, responsible for the psychoactive and addictive effects of smoking.
Nicotine replacement therapy (NRT)	A smoking cessation treatment in which nicotine from tobacco is replaced for a limited period by pharmaceutical nicotine. This reduces the craving and withdrawal experienced during the initial period of abstinence while users are learning to be tobacco‐free. The nicotine dose can be taken through the skin, using patches, by inhaling a spray, or by mouth using gum or lozenges.
Outcome	Often used to describe the result being measured in trials that is of relevance to the review. For example smoking cessation is the outcome used in reviews of ways to help smokers quit. The exact outcome in terms of the definition of abstinence and the length of time that has elapsed since the quit attempt was made may vary from trial to trial.
Pharmacotherapy	A treatment using pharmaceutical drugs, e.g. NRT, bupropion
Point prevalence abstinence (PPA)	A measure of cessation based on behaviour at a particular point in time, or during a relatively brief specified period, e.g. 24 hours, 7 days. It may include a mixture of recent and long‐term quitters. See prolonged abstinence, continuous abstinence
Prolonged abstinence	A measure of cessation which typically allows a 'grace period' following the quit date (usually of about two weeks), to allow for slips/lapses during the first few days when the effect of treatment may still be emerging. See: Hughes 2003
Relapse	A return to regular smoking after a period of abstinence
Secondhand smoke	Also called passive smoking or environmental tobacco smoke (ETS) A mixture of smoke exhaled by smokers and smoke released from smouldering cigarettes, cigars, pipes, bidis, etc. The smoke mixture contains gases and particulates, including nicotine, carcinogens and toxins.
Self‐efficacy	The belief that one will be able to change one's behaviour, e.g. to quit smoking
SPC (Summary of Product Characteristics)	Advice from the manufacturers of a drug, agreed with the relevant licensing authority, to enable health professionals to prescribe and use the treatment safely and effectively.
Tapering	A gradual decrease in dose at the end of treatment, as an alternative to abruptly stopping treatment
Tar	The toxic chemicals found in cigarettes. In solid form, it is the brown, tacky residue visible in a cigarette filter and deposited in the lungs of smokers.
Titration	A technique of dosing at low levels at the beginning of treatment, and gradually increasing to full dose over a few days, to allow the body to get used to the drug. It is designed to limit side effects.
Varenicline	A pharmaceutical drug prescribed to treat nicotine addiction; trade names Chantix and Champix
Withdrawal	A variety of behavioural, affective, cognitive and physiological symptoms, usually transient, which occur after use of an addictive drug is reduced or stopped. See: Shiffman 2004

Appendix 4. Quality assessment of economic evaluations

Item	An 2008	Curry 1998	Halpin 2006	Hughes 1991	Joyce 2008	Kaper 2006a	Salize 2009 (Twardella 2007)	Schauffler 2001
1. Is the study population clearly described?	no	no	yes	yes	yes	yes	yes	no
2. Are competing alternatives clearly described?	yes	yes	yes	yes	yes	yes	yes	yes
3. Is a well‐defined research question posed in answerable form?	yes	yes	yes	yes	yes	yes	yes	yes
4. Is the economic study design appropriate to the stated objective?	yes	yes	yes	yes	yes	yes	yes	yes
5. Is the chosen time horizon appropriate in order to include relevant costs and consequences?	no	yes	yes	yes	no	yes	yes	yes
6. Is the actual perspective chosen appropriate?	no	yes	yes	yes	no	yes	yes	no
7. Are all important and relevant costs for each alternative identified?	no	no	no	no	no	yes	yes	no
8. Are all costs measured appropriately in physical units?	no	no	no	no	no	yes	no	no
9. Are costs valued appropriately?	no	no	no	no	no	yes	no	no
10. Are all important and relevant outcomes for each alternative identified?	no	no	no	no	no	no	no	no
11. Are all outcomes measured appropriately?	no	no	yes	yes	no	yes	yes	no
12. Are outcomes valued appropriately?	yes	yes	yes	yes	no	yes	yes	yes
13. Is an incremental analysis of costs and outcomes of alternatives performed?	no	no	no	no	yes	yes	yes	no
14. Are all future costs and outcomes discounted appropriately?	yes	yes	yes	yes	no	yes	yes	yes
15. Are all important variables appropriately subjected to sensitivity analysis?	no	no	no	no	no	no	yes	no
16. Do the conclusions follow from the data reported?	yes	yes	yes	no	no	yes	yes	yes
17. Does the study discuss the generalisability of the results to others settings/ patients?	Yes	no	yes	yes	no	no	yes	yes
18. Does the article indicate that there is no potential conflict of interest of researchers and funders?	yes	no	yes	no	yes	yes	yes	no
19. Are ethical and distributional issues discussed appropriately?	no	no	no	no	no	no	no	no
Total score	8	8	12	10	6	15	15	8

Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Figure 2

Prisma study flow diagram of studies included in most recent update of this review

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Analysis 1.1

Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 1 Full versus no financial coverage.

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Analysis 1.2

Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 2 Full versus partial financial coverage.

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Analysis 1.3

Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 3 Partial versus no financial coverage.

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Analysis 1.4

Comparison 1 Interventions directed at individuals: abstinence from smoking, Outcome 4 Partial versus another partial coverage (at least 6 months CA).

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Analysis 2.1

Comparison 2 Interventions directed at individuals: number of participants making a quit attempt for at least 24 h, Outcome 1 Full versus no financial coverage.

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Analysis 2.2

Comparison 2 Interventions directed at individuals: number of participants making a quit attempt for at least 24 h, Outcome 2 Full versus partial financial coverage.

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Analysis 2.3

Comparison 2 Interventions directed at individuals: number of participants making a quit attempt for at least 24 h, Outcome 3 Partial versus no financial coverage.

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Analysis 3.1

Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 1 Full versus no financial coverage.

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Analysis 3.2

Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 2 Full versus partial financial coverage.

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Analysis 3.3

Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 3 Partial versus no financial coverage.

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Analysis 3.4

Comparison 3 Interventions directed at individuals: use of smoking cessation treatment, Outcome 4 Partial versus partial financial coverage.

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Analysis 4.1

Comparison 4 Interventions directed at healthcare providers, Outcome 1 Abstinence from smoking.

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Analysis 4.2

Comparison 4 Interventions directed at healthcare providers, Outcome 2 Use of nicotine replacement therapy and/or bupropion.

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Analysis 4.3

Comparison 4 Interventions directed at healthcare providers, Outcome 3 Use of behavioural interventions.

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Summary of findings for the main comparison. Interventions directed at individuals: full financial coverage compared to no financial coverage for increasing abstinence from smoking

Interventions directed at individuals: full financial coverage compared to no financial coverage for increasing abstinence from smoking
Patient or population: smokers Setting: medical practises, companies, members of a health insurance company, outpatient respirology clinic Intervention: full financial coverage for abstinence from smoking Comparison: no coverage
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with no coverage	Risk with full financial coverage
Abstinence from smoking	Study population		RR 1.77 (1.37 to 2.28)	9333 (6 RCTs)	⊕⊕⊕⊝ Moderate^1,2
	84 per 1000	149 per 1000 (115 to 192)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level because of risk of bias: all studies except for Hughes 1991 had a serious risk of bias. ²We rated Hughes 1991 and Twardella 2007 serious for imprecision, and Pakhale 2015 very serious for imprecision, however, we did not downgrade the evidence because these studies were small and had a minor effect on the outcome.

Summary of findings for the main comparison. Interventions directed at individuals: full financial coverage compared to no financial coverage for increasing abstinence from smoking

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Summary of findings 2. Interventions directed at healthcare providers compared to placebo for increasing the use of smoking cessation treatment

Interventions directed at healthcare providers compared to no interventions for increasing the use of smoking cessation treatment
Patient or population: physicians and clinics from a multispecialty group practice Setting: health clinics in the USA and group practices in Germany Intervention: financial interventions directed at healthcare providers (pay for performance and direct payment) Comparison: no financial intervention
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with no interventions	Risk with interventions directed at healthcare providers
Abstinence from smoking	Study population		RR 1.16 (0.98 to 1.37)	2311 (2 RCTs)	⊕⊕⊕⊝ Moderate¹
	181 per 1000	209 per 1000 (177 to 247)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level because both studies were judged to be at serious risk of bias.

Summary of findings 2. Interventions directed at healthcare providers compared to placebo for increasing the use of smoking cessation treatment

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Comparison 1. Interventions directed at individuals: abstinence from smoking

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Full versus no financial coverage Show forest plot	6	9333	Risk Ratio (M‐H, Random, 95% CI)	1.77 [1.37, 2.28]

1.1 Continuous abstinence (at least 6 months)	2	1486	Risk Ratio (M‐H, Random, 95% CI)	4.38 [1.94, 9.87]
1.2 Point prevalence abstinence	4	7847	Risk Ratio (M‐H, Random, 95% CI)	1.64 [1.45, 1.86]
2 Full versus partial financial coverage Show forest plot	5	5914	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.71, 1.48]

2.1 Continuous abstinence (at least 6 months)	1	28	Risk Ratio (M‐H, Random, 95% CI)	2.17 [0.50, 9.35]
2.2 Point prevalence abstinence	4	5886	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.67, 1.44]
3 Partial versus no financial coverage Show forest plot	5	7108	Risk Ratio (M‐H, Random, 95% CI)	1.27 [1.02, 1.59]

3.1 Continuous abstinence (at least 6 months)	2	3707	Risk Ratio (M‐H, Random, 95% CI)	1.08 [0.81, 1.45]
3.2 Point prevalence	3	3401	Risk Ratio (M‐H, Random, 95% CI)	1.49 [0.98, 2.24]
4 Partial versus another partial coverage (at least 6 months CA) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 1. Interventions directed at individuals: abstinence from smoking

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Comparison 2. Interventions directed at individuals: number of participants making a quit attempt for at least 24 h

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Full versus no financial coverage Show forest plot	4	9065	Risk Ratio (M‐H, Random, 95% CI)	1.11 [1.04, 1.17]

2 Full versus partial financial coverage Show forest plot	4	5486	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.84, 1.17]

3 Partial versus no financial coverage Show forest plot	5	6944	Risk Ratio (M‐H, Random, 95% CI)	1.13 [0.98, 1.31]

Comparison 2. Interventions directed at individuals: number of participants making a quit attempt for at least 24 h

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Comparison 3. Interventions directed at individuals: use of smoking cessation treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Full versus no financial coverage Show forest plot	7		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Nicotine replacement therapy	7	9455	Risk Ratio (M‐H, Random, 95% CI)	1.79 [1.54, 2.09]
1.2 Bupropion	3	6321	Risk Ratio (M‐H, Random, 95% CI)	3.22 [1.41, 7.34]
1.3 Behavioural interventions	4	9215	Risk Ratio (M‐H, Random, 95% CI)	1.77 [1.19, 2.65]
1.4 Pharmacotherapy, not specified	1	48	Risk Ratio (M‐H, Random, 95% CI)	1.11 [0.73, 1.68]
2 Full versus partial financial coverage Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 Nicotine replacement therapy	4	22380	Risk Ratio (M‐H, Random, 95% CI)	1.76 [1.27, 2.43]
2.2 Bupropion	2	3700	Risk Ratio (M‐H, Random, 95% CI)	1.42 [0.84, 2.41]
2.3 Behavioural interventions	1	16922	Risk Ratio (M‐H, Random, 95% CI)	3.95 [3.15, 4.95]
2.4 Pharmacotherapy, not specified	1	28	Risk Ratio (M‐H, Random, 95% CI)	1.19 [0.70, 2.02]
3 Partial versus no financial coverage Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

3.1 Nicotine replacement therapy	5	6944	Risk Ratio (M‐H, Random, 95% CI)	1.37 [0.99, 1.91]
3.2 Bupropion	3	6765	Risk Ratio (M‐H, Random, 95% CI)	1.15 [1.03, 1.29]
3.3 Varenicline	1	1380	Risk Ratio (M‐H, Random, 95% CI)	1.85 [1.68, 2.03]
3.4 Behavioural interventions	1	104	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.22, 2.71]
4 Partial versus partial financial coverage Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4.1 Nicotine replacement therapy	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 Behavioural interventions	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Interventions directed at individuals: use of smoking cessation treatment

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Comparison 4. Interventions directed at healthcare providers

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Abstinence from smoking Show forest plot	2	2311	Risk Ratio (M‐H, Random, 95% CI)	1.16 [0.98, 1.37]

1.1 Continuous abstinence (at least 6 months)	1	222	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.10, 11.30]
1.2 Point prevalence	1	2089	Risk Ratio (M‐H, Random, 95% CI)	1.16 [0.98, 1.37]
2 Use of nicotine replacement therapy and/or bupropion Show forest plot	2	2311	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.76, 1.18]

3 Use of behavioural interventions Show forest plot	3	25820	Risk Ratio (M‐H, Random, 95% CI)	1.69 [1.01, 2.86]

Comparison 4. Interventions directed at healthcare providers

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Sistemas de financiamiento de la atención sanitaria para el aumento del uso del tratamiento del tabaquismo

Appendices