ASSIST: Assessment of Medicaid policy on Smoking Cessation Assistance and Surgical Outcomes

PROJECT SUMMARY Smoking is associated with a variety of adverse health effects, including increased postoperative wound healing time, wound infections, and cardiovascular complications among surgery patients. The associations between pre-operative smoking cessation and improved surgical outcomes have led surgeons and hospitals to implement policies that require patients to quit smoking prior to elective surgeries. Given the high rate of smoking among low-income populations and the even higher rate among Medicaid-insured surgery patients, these policies will disproportionately impact patients of lower socioeconomic status (SES). In 2017, Oregon implemented the first statewide policy in the United States that requires Medicaid-insured patients to quit smoking prior to a broad range of elective surgeries as a condition of payment for surgery by the state Medicaid program. This policy creates an opportune time to assist patients in quitting smoking pre-surgery (i.e., a “teachable moment”) and to support continued abstinence during post-operative visits; thus, this policy could result in higher rates of cessation assistance and cessation among patients of lower SES, potentially mitigating long-standing differences in smoking-related health outcomes, providing support for implementation of similar policies among payers and health care systems. That said, some suggest that if patients do not receive cessation assistance and are denied surgery because they were unable to quit, these policies will exacerbate already existing health differences related to smoking and surgery among those who are of low SES. The impact of these policies on smoking- and surgery-related outcomes among patients of lower SES are unknown. To address this knowledge gap, we will conduct a quasi-experimental study using a sequential mixed methods design. We will link electronic health record (EHR) data to Medicaid claims from 148 Oregon community health centers (CHCs) to examine changes in smoking- (cessation assistance and quit rates) and surgery- (rates of surgery and surgery complications) related outcomes among patients seeking elective orthopedic surgeries between 1/1/2014-12/31/2016 (pre-policy) and 1/1/2017-12/31/2019 (post-policy implementation). Informed by our quantitative analyses, we will conduct semi-structured interviews with health care leaders, primary care clinicians, orthopedic surgeons, and patients, and survey Care Coordination Organization leaders to explore organizational workflows and protocols related to this policy (e.g., increased cessation assistance), and perceptions and experiences of the policy on intended and unintended consequences. This innovative study will provide rigorous, actionable evidence to inform states and policy makers of the extent to which this policy results in the desired changes.