Effectiveness of a clinical practice change intervention in increasing the provision of nicotine dependence treatment in inpatient psychiatric facilities: an implementation trial

Smoking remains a leading global cause of death and disability [1]. While smoking rates and the corresponding burden of premature death and disability have declined in the general population, this has not been observed among persons with a mental disorder [2, 3]. As a consequence, smoking rates are two to three times higher [4], nicotine dependence is more severe [4], quit attempts are less likely to be successful [5, 6], and rates of smoking related morbidity and mortality are substantially higher among persons with such a disorder [7, 8]. Smoking prevalence and its’ associated burden appear to increase with greater severity of mental illness [9], with higher prevalence among psychiatric inpatients [10]. Reduction of the prevalence of smoking in this population is both a recognised public health priority and a clinical priority for mental health services [11, 12].

Despite clinical practice guidelines [13, 14] recommending the provision of nicotine dependence treatment to patients in mental health treatment settings in developed nations such as the United States, United Kingdom and Australia [13‐15], the provision of such treatment in psychiatric facilities has been suboptimal, with assessment of nicotine dependence and provision of nicotine replacement therapy (NRT) in inpatient psychiatric facilities occurring rarely (0%–0.5%) [16, 17]. Reported barriers to the provision of such treatment include lack of time and clinician skill and experience, and lack of organisational support, even when comprehensive nicotine dependence treatment guidelines are in place [18].

Systematic review evidence supports the effectiveness of a number of clinical practice change strategies for improving health-related practices across a range of clinical settings, including: engaging local opinion leaders [19], audit and feedback [20], reminders [21], clinical decision support systems [22], training and education [23], the development and dissemination of clinical practice guidelines [24], and dissemination of educational materials [22]. Such strategies found to be effective in increasing the implementation of nicotine dependence treatment specifically, include staff training and education [25], and use of electronic health records [26]. A systematic review and meta-analysis of controlled studies demonstrated that such clinical practice change strategies can increase staff provision of assistance to quit to patients in hospital settings (pooled risk difference: 16.6; 95% confidence interval: 4.9 to 28.3) but no effect was found for staff assessment of smoking status, advice to quit, or the provision or discussion of NRT [27]. The review identified no studies that reported the effectiveness of clinical practice change interventions in increasing the implementation of nicotine dependence treatment in inpatient psychiatric facilities.

To address this evidence gap, a study was undertaken to assess the effectiveness of a multi-modal clinical practice-change intervention in increasing clinician recorded provision of five recommended elements of nicotine dependence treatment: 1) assessment of smoking status; 2) assessment of nicotine dependence; 3) provision of brief advice to quit; 4) provision of NRT; and 5) provision of nicotine dependence treatment at discharge to patients admitted to inpatient psychiatric facilities.

This is the first study to examine the effectiveness of a clinical practice change intervention in increasing the recorded provision of nicotine dependence treatment in inpatient psychiatric facilities. The findings suggest that the intervention was effective in increasing clinician-recorded provision of nicotine dependence treatment, with increases identified for all five nicotine dependence treatment measures during the intervention period, and continuing for up to five months post-intervention.

The magnitude of the observed improvement in recording of nicotine dependence treatment in our study are similar to [18], and in some cases greater than [37] those reported in previous studies conducted in general hospital facilities. For example, a four-year interrupted time series study utilising a similar multi-component clinical practice change intervention in 37 general public hospitals in Australia [38] found significant increases in recorded provision of nicotine dependence treatment from pre to post-intervention, including: advice to quit (8.6% increase vs. 8% in our study); and provision of inpatient NRT (16% vs. 18%) [38]. Similarly a controlled study conducted across four hospitals in the same state as the current study identified increases in nicotine dependence treatment that ranged from 9 to 22% [39]. It is particularly encouraging that in the present study, the increases in nicotine dependence treatment occurred in inpatient psychiatric settings—settings known to have higher rates of patient smoking [10], and negative staff attitudes to delivering smoking treatment [40].

The observed rates of recorded provision of the five nicotine dependence treatment variables were stable across the pre-intervention period, and increased in accordance with the timing of the delivery of the clinical practice change intervention. Critically, these increases continued into the post-intervention period, suggesting not only the efficacy of the clinical practice change intervention, but some degree of sustainability of effect. This finding adds to the growing body of evidence that multimodal nicotine dependence treatment interventions show efficacy in increasing nicotine dependence treatment provision in hospital settings both during, and after implementation of the intervention [38]. Further, the observed increases across multiple elements of nicotine dependence treatment are noteworthy, as previous studies have indicated improvements in some but not all forms of treatment assessed [27, 38]. This finding is particularly important, as there is evidence that patient receipt of multiple elements of such treatment increases the likelihood of stopping smoking [13, 41, 42]. It is possible that the lower baseline proportions of patients receiving nicotine dependence treatment in our study (e.g. 0.85% for quit advice) compared to general medical settings (e.g. 5.4% for quit advice in Slattery et al.’s [38] study), paired with the higher rates of smoking and nicotine dependence in these samples relative to the general population [3, 10] meant that there was greater scope for improvement to be made and detected across all nicotine dependence outcomes in the current study. Further, there are inherent differences across studies in intervention length, intensity, follow-up length and outcome measurement that may have differentially influenced the results across these studies, the degree to which is unknown.

Notwithstanding the consistent increases in all outcomes, at post-intervention, an assessment of smoking status occurred for only 52% of patients, with even lower rates for other elements of nicotine dependence treatment. This suggests that additional strategies may be required to ensure that all patients receive nicotine dependence treatment. Previous research has indicated that interventions that are integrated with, and address existing hospital systems and procedures may maximise nicotine dependence treatment delivery [13, 32, 39, 43]. For example, enhancing hospital accountability by including nicotine dependence treatment indicators in hospital accreditation and performance processes has been suggested to increase the provision of such care [44, 45]. Similarly, incorporating nicotine dependence treatment within existing hospital computer systems (such as an electronic medical record system) has been shown to increase smoking care, and may also reduce clinician time burden [32]. The improved, but still suboptimal rates of smoking status assessment and nicotine dependence treatment at post-intervention in this study may have been due to the absence of such strategies in the intervention, and/or the length of the intervention period. Little research has investigated the intervention strategy intensity or duration required for successful guideline implementation and clinical practice change [19, 20]. Similarly, due to the complex, multi-modal and interrelated nature of the intervention components used in the current study, we are unable to comment on which single component—or combinations of components—had the greatest effect, which may be important for implementation in clinical settings where resources may be limited. Future researchers in this area may consider examining the effect of individual intervention components and collecting data regarding intervention implementation costs, in order to advise cost-effectiveness analyses.

This study has multiple strengths, including its’ large sample size, inclusion of a number of patient diagnostic groups, and use of systematically independently collected medical record audit data. However, a number of study characteristics may have impacted on its findings. Firstly, we relied on medical record audit as a measure of clinical staff provision of nicotine dependence treatment. It is possible that clinical staff may have recorded care delivery in the absence of it occurring, and hence overestimated actual delivery of nicotine dependence treatment. However, systematic review evidence suggests that medical record audit is more likely to underestimate clinical staff behaviour [46]. Although the audit staff were non-clinical health service staff who were independent of the research team and were not privy to the intervention activities, they may have become aware of the intervention process via being part of the broader health system. Thus we cannot exclude the possibility that the audit staff may have recorded data more rigorously in the post-intervention period than before. Further, although the hospital nicotine dependence treatment guidelines recommend a clear ‘pathway’ of care (see Additional file 1) where smoking status is assessed, brief advice is provided, NRT is prescribed and patients are monitored until discharge, it is unclear from the audit data to what extent clinical staff followed this pathway in a linear matter. For example, NRT may have been provided before (or in the absence of) provision of brief advice to quit, particularly so for patients who may be well known to clinical staff due to repeat admissions. While it is out of scope here to comment on each individual patient’s nicotine dependence treatment pathway, future studies in this area may aim to examine both global increases care delivery (as demonstrated here), but also improvements in adherence to the care pathway as detailed in clinical practice guidelines.

Secondly, given that the recording of smoking status did not occur systematically for all patients at any time point during the study, the true sample of smokers for whom nicotine dependence treatment should be delivered was unknown. Previous research conducted among patients in the same facility within the same timeframe indicated that smoking rates were approximately 53% [47, 48]. Hence, the rates of nicotine dependence treatment presented here are likely to underestimate the true proportion of smokers receiving nicotine dependence treatment. Nevertheless, assuming that the prevalence of smoking status remained stable across the study period [32, 33], the observed increases in nicotine dependence treatment provision over time are considered to likely reflect an increase in nicotine dependence treatment delivery to patients who are smokers.

Third, given our focus on increasing clinician-recorded nicotine dependence treatment according to the standard hospital care guidelines, we did not collect data on other factors that may have had an impact on the likelihood of clinical staff providing and recording such treatment to patients. This may have included the voluntary or involuntary status of patients, which has shown to be important in the implementation of smoke-free policies in locked psychiatric facilities, given the relative abilities of these patients to leave the grounds to smoke. While we did not collect such data in our study, in Australia in 2014–15 it was estimated that 31.1% of all hospitalisations to specialised psychiatric care services were for patients who had an involuntary admission [49]. These two groups may represent distinct clinical cohorts for whom there may have been a differential effect of the intervention [50]. We also did not collect data regarding patient use of other pharmacological treatments for smoking cessation outside of those provided as part of standard hospital care guidelines, including varenicline and bupropion (which were not available through the hospital pharmacy) or oral or nasal nicotine spray (which was not approved for use in Australia at the time of the study). The use of such other pharmacotherapies outside of those provided as standard hospital care may have influenced the likelihood of clinicians providing routine hospital nicotine dependence treatment to patients.

Further, utilising a controlled trial design was not feasible, and the use of a non-controlled design constrains our ability to directly attribute the observed increases in recording of nicotine dependence treatment to the intervention component. Given the limited resources available, the study facilities were required to be within close geographical proximity to the administering University, and were too dissimilar in size and annual patient admissions in order for one site to act as a comparator to the other. As such, the interrupted time series design was adopted, as it has been demonstrated to be appropriate in evaluating the efficacy of clinical practice change interventions in hospital settings where whole-of-system practice change is the focus of the intervention [38]. Further, this pragmatic study design provides one means of accelerating the research translation process by simultaneously disseminating the intervention strategy whilst conducting the evaluation [51]. Where feasible, future researchers aiming to examine the efficacy of a clinical practice change intervention should consider the inclusion of a comparison condition, such as through the use of a randomised controlled trial design (e.g. [52]) or through hybrid evaluation designs, such multiple baseline (e.g. [53]) or stepped wedge cluster randomised designs [51].

Finally, although the study data were collected from 2009–2010, more recent evaluations of the study facilities by the authorship team indicate that prevalence of smoking among patients, and clinician provision of nicotine dependence treatment (including both patient report and medical record audit) are unlikely to have changed in this time [34, 47, 54]. Given that this study is the first to examine the efficacy of a clinical practice change intervention in increasing nicotine dependence treatment to smokers within inpatient psychiatric facilities, it provides a strong basis for future studies further develop the intervention design and outcome measures, and to explore potential differential effects of the intervention among specific subgroups of the patient population, including those with voluntary/involuntary admission status, and those who may be using other pharmacotherapies, such as varenicline and bupropion.

This study is the first to examine the effectiveness of a multi-modal clinical practice change intervention in increasing recorded nicotine dependence treatment in inpatient psychiatric facilities. The use of inpatient psychiatric facilities as a setting for supporting and encouraging smokers to change behaviour may make an important contribution to addressing the recognised need to reduce smoking rates for this population group. Our results provide evidence that improvement in the routine recording of nicotine dependence treatment is achievable on a whole-of hospital basis and are sustainable in the short to medium term. However additional strategies are required to ensure all smokers are systematically identified and offered nicotine dependence treatment.