About the Authors:
Shannon Riley is currently a Respirology PGY5 Resident at the University of Toronto. Nicole Sitzer recently completed
an Interstitial Lung Disease Fellowship at the University of Toronto and is a community respirologist. Sophie
Corriveau is with the Department of Respirology, McMaster University, Hamilton, Ontario. Gregory Pond is with the
Department of Oncology, McMaster University, Hamilton, Ontario. Yayoi Goto is with Clinical Informatics at St. Josephs
Healthcare, Hamilton, Ontario. Jill Rudkowski is with the Department of Medicine, McMaster University, Hamilton, Ontario.
Corresponding Author: rudkowj@mcmaster.ca
Submitted: January 31, 2018. Accepted: June 10, 2018. Published: November 9, 2018. DOI: 10.22374/cjgim.v13i4.271
Teaching Residents How to Effectively
Prescribe Nicotine Replacement Therapy
on the Clinical Teaching Unit
Shannon Riley, Nicole Sitzer, Sophie Corriveau,
Gregory Pond, Yayoi Goto, Jill Rudkowski
ABSTRACT
Cigarette smoking is the leading cause of preventable death. On the Clinical Teaching Unit,
medical students and residents are well positioned to provide smoking cessation resources to
patients with the aim of improving quit rates. However, there is a paucity of data evaluating
their role in counselling patients on smoking cessation. A survey at our centre identified that
medical trainees had a lack of knowledge regarding Nicotine Replacement Therapy (NRT) as
a barrier to smoking cessation counselling. We hypothesized that a teaching session on NRT
during an inpatient Internal Medicine rotation would increase learner comfort in prescribing
these products.
Medical trainees on the Internal Medicine Clinical Teaching Unit (CTU) attended a teaching
session during week 4 of an 8-week rotation. Pharmacy records from the 8-week period were
retrospectively analyzed to determine NRT prescribing behaviour. Pre-intervention, 5.8%
(13/225) of new admissions received an NRT prescription. Post-intervention, 17% (31/182)
of new admissions received an NRT prescription. Using a Fisher’s exact test, the percentage of
new admissions that received a prescription was significantly different (p<0.001) between the
pre- and post-intervention time frames.
This data suggests that integrating education on NRT into CTU teaching can significantly
alter prescribing behaviour and improve access to NRT for patients who need it.
RESUME
Le tabagisme est la principale cause de décès évitable. Dans lunité denseignement clinique,
les étudiants en médecine et les résidents sont bien placés pour fournir aux patients des
ressources sur le renoncement au tabac dans le but daméliorer les taux de renoncement au tabac.
Cependant, il existe peu de données évaluant leur rôle dans le conseil aux patients en matière
de renoncement au tabac. Une enquête menée dans notre centre a révélé que les stagiaires en
médecine manquaient de connaissances sur la thérapie de remplacement de la nicotine (TRN) en
tant quobstacle aux conseils en matière de renoncement au tabac. Nous avons émis l’hypothèse
Canadian Journal of General Internal Medicine
Volume 13, Issue 4, 2018 17
Teaching and Learning
quune session denseignement sur la TRN au cours dune rotation en médecine interne pour
patients hospitalisés augmenterait le confort du stagiaire lors de la prescription de ces produits.
Les stagiaires en médecine de lunité denseignement clinique en médecine interne (UTC)
ont assisté à une session denseignement au cours de la semaine 4 dune rotation de 8 semaines.
Les dossiers de pharmacie de la période de 8 semaines ont été analysés rétrospectivement pour
déterminer le comportement de prescription des TRN. Avant l’intervention, 5,8% (13/225) des
nouvelles admissions ont reçu une ordonnance de TRN. Après lintervention, 17% (31/182) des
nouvelles admissions ont reçu une ordonnance de TRN. En utilisant un test exact de Fisher,
le pourcentage de nouvelles admissions ayant reçu une ordonnance était significativement
différent (p <0,001) entre les périodes de temps pré et post-intervention.
Ces données suggèrent que lintégration de léducation sur les TRN dans lenseignement de
la CTU peut modifier considérablement le comportement de prescription et améliorer laccès
aux TRN pour les patients qui en ont besoin.
A causal relationship has been established between smoking and
several disease states, including lung cancer, cardiovascular disease,
type 2 diabetes, and rheumatoid arthritis.
1
Tobacco smoking is the
most important risk factor for developing Chronic Obstructive
Pulmonary Disease (COPD) by causing an accelerated decline
in forced expiratory volume in one second (FEV1).
2
Currently,
over 17% of Canadian adults smoke either daily or occasionally.
3
The risk of developing COPD falls by approximately half with
smoking cessation. Furthermore, with sustained abstinence
from smoking, the rate of decline of pulmonary function among
former smokers returns to that of never smokers.
4,5
There is
additional evidence that smoking cessation reduces cancer
risk and decreases the risk of mortality from vascular diseases
including coronary artery disease.
6,7
There is also a substantial
economic benefit associated with successful smoking cessation.
Despite these advantages, it often takes several attempts for
patients to quit smoking.
On the Clinical Teaching Unit (CTU), trainees have an
opportune time to provide smoking cessation material to patients.
At our centre, a survey was distributed to medical learners,
primarily to help elucidate potential barriers to smoking cessation
interventions. This survey identified a lack of knowledge regarding
Nicotine Replacement Therapy (NRT) as a barrier to smoking
cessation counselling by the medical learners.
Study Rationale
Smoking cessation is associated with a mortality and economic
benefit; however, many medical schools do not have a formal
curriculum at the undergraduate or postgraduate level on smoking
cessation counselling. While residents and medical students play
a pivotal role in the care of Internal Medicine inpatients, there
is a paucity of data evaluating their role in counselling patients
on smoking cessation.
7
Despite evidence that smoking cessation is best achieved
through the combination of counselling and pharmacotherapy,
residents perceive many barriers to providing this standard of care.
In our recently distributed survey at McMaster University, 53%
(19/36) of learners rotating through General Internal Medicine
identified a lack of knowledge regarding NRT as a common
barrier to smoking cessation counselling. We hypothesized that
a teaching intervention promoting the role of NRT in smoking
cessation would bridge an identified gap in medical education
and promote health advocacy among learners on the CTU. Our
teaching intervention aimed to provide the knowledge and
resources necessary to increase learner awareness and comfort in
prescribing NRT and hopefully facilitate this behaviour change.
Methods
A 25-minute teaching session was developed to present to learners
on the CTU at a McMaster teaching hospital. This centre did
not have a nurse-driven NRT prescription protocol or electronic
prescription reminders during the study period. The session
emphasized the importance of promoting smoking cessation to
patients on the CTU as well as the impact of pharmacotherapy
as an adjunct to smoking cessation counselling. Prescribing
guidelines for NRT and current evidence-based recommendations
for smoking cessation pharmacotherapy were included.
Trained senior residents presented this information during a
mandatory scheduled teaching session for all learners (residents
and medical students) on the CTU during week 4 of an 8-week
rotation.
Electronic pharmacy records were retrospectively extracted
from the hospital database to determine NRT prescribing
behaviour for patients admitted to Internal Medicine teaching
teams. The search strategy was to identify prescriptions for all
patients under a given Most Responsible Physician during the
Canadian Journal of General Internal Medicine
18 Volume 13, Issue 4, 2018
Teaching Residents How to Effectively Prescribe Nicotine Replacement Therapy
specified time frame. This allowed for identification of patients
admitted to Internal Medicine teaching teams only. The vast
majority of admissions to Internal Medicine teaching teams at
our centre involve the clinical clerk and/or resident writing the
admission orders. We therefore made the assumption that most,
if not all, admission prescriptions for these patients are either
written directly by a resident, or by a clinical clerk, in which
case, the resident would be co-signing the order. The amount
and type of NRT prescribed during the 4-weeks pre-intervention
was used to establish a control rate for current teaching team
patients. After the teaching intervention, another 4 weeks of
pharmacy electronic records were obtained to reassess if this
intervention had an impact on the amount and type of NRT
prescribed to a similar cohort of patients.
Data was also collected on the number of new admissions
and current admissions under Internal Medicine teaching teams
during this 8-week period. The amount of NRT prescribed was
then adjusted for patient volumes.
A chart audit was performed on 100 patients was undertaken
to understand the rate of active smoking of the Internal Medicine
teaching team patients during this time frame.
Results
Of the 225 new patient admissions during the pre-intervention
time frame, 13(5.8%) received a nicotine replacement prescription.
Conversely, there were 182 new patient admissions during
the post-intervention time frame, and 31(17.0%) received a
nicotine replacement prescription during the post-intervention
period. Using a Fishers exact test, the percentage of new
patients who received a prescription was significantly different
(p value<0.001) between the pre- and post-intervention time
frames (Table 1).
The chart audit of 100 patients revealed that 23 were
documented as active smokers, 70 as previous or non-smokers,
and smoking status was unknown for 7 patients.
Table 1 demonstrates a comparison between the type and
amount of NRT prescribed on the CTU at St. Josephs Hospital
during a 4-week period before and after a teaching session
intervention. The absolute amount of NRT prescribed is also
adjusted for CTU patient flow during this time period.
Prior to the teaching session, 15 nicotine replacement
prescriptions were prescribed to 13 patients. The median duration
of prescriptions was 3 (range 1 to 21) days, and 12 (80%) of the
prescriptions were for the 21 mg patch. Following the teaching
session, 36 prescriptions were provided to 31 patients. The median
duration of prescriptions was 3.5 (range 1 to 38) days, and 17
(47.2%) of the scripts were for the 21 mg patch (see Table 1).
The type of NRT prescription was also statistically different
using an exact χ
2
test (p value = 0.016). Further, since only one
patient received a cartridge, and only one received a 7 mg patch,
a secondary analysis was performed comparing the prescription
of a 21 mg patch versus a 14 mg patch. A Fisher’s exact test was
performed and the results were statistically significant (p = 0.024),
demonstrating increased variability in these prescriptions for
NRT post-intervention.
A Wilcoxon rank sum test was performed to test if the
duration of each prescription was different between the pre- and
post-intervention phases; no statistically significant difference
was observed (p = 0.62).
Discussion
Providing an innovative strategy to teach smoking cessation
to learners on an inpatient rotation at a teaching hospital has
demonstrated improved rates of NRT prescribing for active
Table 1. Descriptive Statistics
Characteristic
Pre-teaching
Intervention
Post-teaching
Intervention p Value
Number of Scripts N 15 36
Number of Patients N 13 31
Percentage of New Admissions 5.8% 17.0% <0.001
Percentage of All Admissions 4.0% 11.2% <0.001
Number of MRPs 7 10
Duration of Prescription Median (range) 3 (1-21) 3.5 (1-38) 0.62
Type of Prescription Cartridge 10 mg
Patch 7 mg
Patch 14 mg
Patch 21 mg
1 (6.7)
0 (0.0)
2 (13.3)
12 (80.0)
0 (0.0)
1 (2.8)
18 (50.0)
17 (47.2)
0.016
MRP = most responsible physician.
Canadian Journal of General Internal Medicine
Volume 13, Issue 4, 2018 19
Riley et al.
smokers. Statistically significant differences were observed
between the pre- and post-intervention time periods in terms
of both the percentage of patients who received a prescription
as well as the type of NRT prescription. Educating learners on
the delivery of effective smoking cessation counselling may help
target previously identified barriers.
The purpose of NRT is to replace the nicotine from cigarettes
to both reduce withdrawal symptoms and the motivation to
smoke. The ultimate goal is to assist the patients transition
from smoking to abstinence.
7
Current Canadian best practice
guidelines recommend that all hospitals have a system in place
to identify current smokers and manage nicotine withdrawal
during hospitalization.
8
Despite this, the study centre did not
have such a system and these recommendations have been
difficult to sustain when implemented. A multi-faceted approach
is required that includes enabling front-line practitioners, such
as medical residents, to ensure patients have access to NRT
during hospitalization.
9
This study adjusted for the number of patients admitted
to the CTU during the pre and post-intervention time period;
however, the relative number of smokers was not captured in the
database. The prevalence of smokers in the general population
of the study area was estimated at 22.4%
10
which is far above
the number of patients NRT was prescribed for during the
study period. Although possible, it is unlikely that the change
in NRT prescription pre- and post-intervention was due solely
to a change in the prevalence of smokers admitted. A chart audit
undertaken during the study period confirmed that >23% of
patients admitted were active smokers which is expected based
on population data. Future studies should look to find reliable
ways to ascertain the prevalence of active smokers among
admitted patients. Although limited by a small sample size,
this data suggests that integrating formal education on NRT
into the residency curriculum can alter resident prescribing
behaviour in the short-term and is one way to improve the
numbers of hospitalized patients receiving NRT. Sustainability of
our educational session on NRT prescribing was not evaluated,
however this would be helpful to assess in future studies to
determine long-term impact.
Commercial Interests
None.
Financial Support
Parveen Wasi Resident Research Grant in Medical Education,
McMaster Internal Medicine Program ($3500).
Ethics Approval
Hamilton Integrated Research Ethics Board (HiREB).
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Teaching Residents How to Effectively Prescribe Nicotine Replacement Therapy