Optimizing Smoking Treatment on Both Effectiveness and Cost As Part of the Multiphase Optimization Strategy (MOST)

While smoking abstinence is a critical treatment outcome, translation into real-world clinical practice in primary care settings requires that smoking cessation interventions be affordable for patients and cost-effective for healthcare systems. The final step of the optimization phase of the Multiphase Optimization Strategy (MOST) is the selection of promising combinations of intervention components based on an a priori optimization criterion. Using results from a 2⁵ factorial screening experiment (N=637) conducted in primary care clinics, we selected promising component combinations based on a criterion of cost-effectiveness. We used estimated abstinence rates for each experimental condition and the costs derived from the Medicaid portal for providing the treatment per protocol to estimate the cost/quit for the 10 (of a possible 32) intervention combinations with the highest estimated 26-week self-reported abstinence rates (40-54%). The two treatment combinations with the lowest cost/quit for the healthcare payer (<$770) were: 1) 3 weeks of prequit and 8 weeks of postquit nicotine patch+gum and 6 counseling sessions, and 2) 3 weeks of prequit patch, 8 weeks of postquit patch+gum, and 3 prequit and 3 postquit phone counseling sessions. The next phase of MOST is to evaluate the optimized treatment against a standard of care. We do not have direct evaluation data of the two most promising treatment combinations based on the optimization criterion of cost-effectiveness, but we do have data from a randomized controlled trial (RCT) that evaluated the effectiveness and cost-effectiveness of a treatment package identified using maximized abstinence rates as the optimization criterion. Specifically, the RCT (N=623) compared the A-OT (3 in-person and 8 phone counseling sessions, automated medication adherence calls, and 26 weeks of patch+gum) to a Recommended Usual Care treatment (R-UC; 1 in-person counseling session, referral to a quitline, and 8 weeks of nicotine patch). We compared the costs/quit from the two cost-effectiveness optimized treatments to the cost-effectiveness of the Abstinence-Optimized Treatment (A-OT). While the A-OT had better effectiveness in terms of abstinence than the Recommended Usual Care, when put into terms of cost-effectiveness, the A-OT had higher cost/quit ($2270) than the two cost-effectiveness optimized treatments, while the R-UC had a lower cost/quit ($660) but a low abstinence rate (18%). We also estimated cost-effectiveness using costs based on treatment utilization. This research illustrates treatment optimization based on cost-effectiveness, contrasts it with effectiveness-based optimization, and suggest that the former optimization criterion holds promise for identifying treatments that are attractive to healthcare systems and appropriate for primary care.

Funded by National Cancer Institute grants P01CA180945, 9P50CA143188 and 1K05CA139871.