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Nicky Williams
Team Leader
Clinical Coding
Waikato DHB
Coding the
Smokefree Health Target
in New Zealand

Overview
Lindauer, Gottfried, 1839-1926. Lindauer, Gottfried, 1839-1926
:Horiana Tiakitai. Carnell, Samuel 1832-1920 :Maori portrait
negatives. Ref: 1/1-019379-G. Alexander Turnbull Library,
Wellington, NZ. http://beta.natlib.govt.nz/records/22340191
• Around 700,000 (20% adults)
New Zealanders smoke
• 40% Maori
• Smoking kills an estimated
5000 people in NZ every year
• Estimated half of all smokers
die of a smoking related
illness
• Smoking-related diseases
significant cost to health
sector

NZ forefront tobacco control
• MoH discussed raising packet to $100 over next 8 years
• No tobacco advertising since 1976
• 2004 NZ 3rd country to make all indoor workplaces smokefree
• July 2012; tobacco products can no longer be displayed in
public view in retail outlets
• Like Australia, NZ is looking at plain packaging

Background health target
• In 2009 the Minister of Health
introduced 6 health targets for DHBs in
NZ to achieve
• One is Better help for smokers to quit
• Providers routinely ask about smoking
status as a clinical ‘vital sign’
• Provide brief advice & offer quit support
to current smokers
• Estimated that 69% of smokers tried to
quit in last 5 years

Cumulative chances chances of quitting of quitting over time over when time making when one making quit one
attempt quit attempt per year per with year and without and cessation without treatment cessation treatment
Aveyard and West. Managing Smoking
Cessation. BMJ 2007;335:37-41

Health target objectives
80% of hospitalised smokers will be provided with
advice and help to quit by July 2010
90% by July 2011
95% by July 2012 (and ongoing)
By 2025 NZ will be SMOKEFREE

Hospitalised smokers
• All people who are:
• admitted as an inpatient to a facility, and
• aged 15 and over, and
• identified as a tobacco smoker at the time of admission
(ie: has smoked tobacco within the last month)

Measuring the target
• The following ICD-10-AM codes are used to
measure the target:
– F17.1 Mental and behavioural disorders due to
tobacco, harmful use
– F17.2 Mental and behavioural disorders due to
tobacco, tobacco dependence syndrome
– Z72.0 Tobacco use, current
– Z71.6 Counselling for tobacco use disorder
• F17.1 has text edited to say ‘current’ or ‘ex-smoker’
and the ex-smokers are excluded from target

Smoking prevalence
Number of events coded with F17.1 or F17.2 or Z72.0
Number of admissions

% smokers offered ABC
Number of events coded with Z71.6
Number of events coded with F17.1 or F17.2 or Z72.0

Coding ABC
• A - ask whether a person
smokes
• B - give brief advice to quit to
all people who smoke and
• C - make an offer of, and
provide or refer for cessation
treatment
• Coders assign Z71.6 if there is
documentation:
– of B or C (even if declined)
– charting or prescribing
pharmacotherapy, eg: NRT

Implementation in 2009
• NZ Coding Convention created
• Included in MoH regional coder study days
• All DHBs have a Smokefree Co-ordinator
• Monthly meetings with smokefree team
• Smoke-free form/sticker created with ABC tick boxes
• Education given to clinical staff by SFC on ABC and
documentation

Issues for clinical staff
• Coders can be blamed for missing ABC but clinical staff don’t
realise it can be the following:
– Has to be documented, not just asked
– Sticker/ form must be dated
– Can’t code from pre-admission documentation
– Ex-smoker should still be offered ABC if smoked within last
month (ACS 0503 - current)
– Conflicting documentation, eg: some smokers tell the nurse
(who provides ABC) they don’t smoke but tell the doctor or
anaesthetist they do smoke
– Which ward is measured when pt transferred – discharging
ward

Issues for clinical staff
• Whose responsibility to document;
doctors or nurses? KPI for nurses at
Waikato DHB
• EDS helped some DHBs but still
option ‘not known’ as sometimes is
the case
• Smokers who are dying/ in coma; not
possible to offer ABC
• ED struggles as such a busy dept

Waikato Hospital Revue 2011 – Clinical Coding Team

Issues for coders
• Increased work for coders
– Don’t want to miss ABC
– Multiple forms to review and places to search for ABC
– Which documentation to use when conflicting
• Increased work for team leaders; meetings, reviewing notes

Improved process
• Waikato DHB started with 1 form
• Each area incorporated smoking/ABC into their own form -
over 30 places to look
• Now agreed on sticker being placed on inside front cover of
chart for easy spotting

Results Waikato DHB – ABC offered & prevalence
100.0%
Percent of smokers within Waikato DHB hospitals being offered an intervention during October 2009 - August 2012
90.0%
80.0%
70.0%
60.0%
Percent
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Oct-
09
Nov-
09
Dec- Jan- Feb- Mar-
09 10 10 10
Apr-
10
May- Jun- Jul-
10 10 10
Aug-
10
Sep- Oct-
10 10
Nov-
10
Dec- Jan- Feb-
10 11 11
Mar- Apr-
11 11
Month - Year
May- Jun- Jul-
11 11 11
Aug-
11
Sep- Oct-
11 11
Nov-
11
Dec- Jan- Feb- Mar-
11 12 12 12
Apr-
12
May- Jun- Jul- Aug-
12 12 12 12
Percent Offered Intervention Target Prevalance
• Steady increase % of smokers offered help - target reached
• Prevalence increased - due to asking/ documenting more
Elaine Collinson, GIS analyst,
Population Health, Waikato DHB

Results Waikato DHB – NRT issued by wards
180
160
140
d
e
120
scrib
re 100
p
r
e 80
b
m
u
60
N
40
20
0
Number of prescribed inhaler and inhaler refills
NICOTINE 10MG INHALER
STARTER PACK
NICOTINE 10MG INHALER
REFILLS (PACK/42)
• NRT inhalers issued by
wards increased
• Refill packs increased
Month/Year
1600
1400
1200
d
e
1000
scrib
re
p 800
r
e
b
m 600
u
N
400
200
0
Jan 09 ‐ Jun
09
Jul 09 ‐ Dec
09
Jan 10 ‐ Jun
10
Total NRT usage
Jul 10 ‐ Dec
10
Month/Year
Jan 11 ‐ Jun
11
Jul 11 ‐ Dec
11
Jan 12 ‐ Jun
12
Total NRT
usage
Linear (Total
NRT usage)
• NRT (all - incl patches,
gum) issued increased
• Peak mid 2010 when
Mental Health unit went
smokefree
Elaine Collinson, GIS analyst,
Population Health, Waikato DHB

Outcome
What the health target has
done is to put smoking
interventions into a clinical role
so that smoking is considered
part of their health assessment

"Tobacco tax? Paid it already..." 4 January 2010. Body, Guy Keverne, 1967-:Cartoons published in New Zealand Herald from 2004 onwards.
Ref: DCDL-0003464. Alexander Turnbull Library, Wellington, New Zealand. http://beta.natlib.govt.nz/records/22315241

Acknowledgements:
Kate Dallas, Smokefree Co-ordinator, Waikato DHB
Andrew Wooding, Clinical Coding Training and Quality Manager, Auckland DHB
Patsy MacAulay, Manager Clinical Coding, Waikato DHB
Ministry of Health, New Zealand
www.kiwiwise.co.nz