WHO-CC Copenhagen would like to thank The Minister of Health Rajko Ostojić, Dr. Antoinette Kaic-Rak, Head of WHO Country Office, Prof. Mirna Šitum, Head

WHO-CC Copenhagen would like to thank

The Minister of Health Rajko Ostojić,

Dr. Antoinette Kaic-Rak, Head of WHO Country Office,

Prof. Mirna Šitum, Head City of Zagreb Health Authority,

Prof. Davor Miličić, Dean Medical School University of Zagreb,

Prof. Mirna Šitum, Head City of Zagreb Health,

Prof. Davor Miličić, Dean Medical School University of Zagreb,

Prof. Jadranka Božikov, Director Andrija Štampar School of Public Health, Medical School University of Zagreb,

Selma Šogorić, The SEEHN Network,

All teachers and presenters,

All the participants

Day 1• Welcome addresses • Break• Evidence-Based Clinical HP (H Tønnesen)• The International HPH Network (T B Jensen)• WHO Country Office Croatia (A Kaić-Rak)• Example: HPH National Network of Ireland (N Eldin)• Lunch• Importance of HPH Development in Croatia (S Šogorić)• Workshop: HP in your department? (H Tønnesen)• Break• Workshop: HP in your department? (cont.) (H Tønnesen)• Final reflections and wrap-up of day 1 (All participants)

Day 2• Welcome • The WHO HPH Standards (H Tønnesen)• Workshop: Using WHO HPH Standards (All participants)• Break • The HPH DATA Model (H Tønnesen)• Lunch• The HPH Doc Act Model (H Tønnesen)• Workshop: Using the HPH Models (All participants)• Break• Other HPH Resources and Training (T B Jensen)• Example: HPH Task Forces (H Tønnesen)• Final reflections and wrap-up of day 2 (All participants)

Day 3• Welcome • WHO HPH Recognition Process: Fast track implementation (H Tønnesen)• Ex: WHO HPH Recognition Project Slovenia (J Farkas-Lainscak) • Break • Possibility of development of WHO HPH Recognition Project in

Croatia (H Tønnesen)• Panel discussion: Networking and collaboration to sustain and

expand HPH developments in Croatia (Key persons)• Lunch• Final Reflections (H Tønnesen)• Evaluation, Certificates and Photos (All participants)• Farewell

We hope that you will• Take active part in the Seminar• Become familiar with HPH topics at hand • Ask questions and discuss • Make your own network within the

Seminar • Give us inspiration for subjects, content

and form for the upcoming HPH Seminars and Schools

• Use your new knowledge at home

Evidence-Based Clinical Health Promotion

Prof. Hanne Tønnesen MD PhD

CEO at the International HPH secretariat, WHO-CC Copenhagen

WHO-CC support countries to:

• Implement WHO principles for HP• Use HP strategies and standards• Create further evidence• Teach and train staff in EB HP• Implement best EB practice for HP

WHO: Terms of references

Distribution of members by April 2014

>950 member Hospitals and Health Services world wide

Best HP PracticeIncludes all three parts

Patient preference

Staff expertise

BestEvidence

(Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

What is CHP?

Health Promotion = “enabling people to increase control over, and to improve their health”*Clinical = involving patients (klinikos)EB: Evidence at highest possible levels

*WHO 1998

What is CHP? HPH

CHP bridges clinical treatment and public health - thus helping patients, families, community and society

• High prevalence of patients with unhealthy lifestyle and NCDs

• Adding HP to treatment improves the outcome on short and long term

• Hazardous working conditions in hospitals– Reduce risks & improve working conditions

• Hospitals as knowledge-organizations– Intersectoral development of HP activities for

community orientation• Production of waste & hazardous substances

– Ecological approach towards waste, energy management

Why is HP important in health care?

Facts about Clin HP

Poor lifestyle

+ Treatment

-----------------------------------------

= Poor outcomes

Facts about Clin HP

Poor lifestyle

+ Clinical Health Promotion

+Treatment-----------------------------------------

= Better treatment results

Description

Smoking abuse Smoking-related physical and psychosocial damage

Aggravation of other diseases & conditions, outcome & prognoses

Intervention

No abuse

Reduced smoking-related damage

Improved outcome & prognoses of others

Factors of importance for the outcome in patient path-ways

Disease / diagnosisInterventionOrganisationIndividual patient-related factors

– Health• Diet and nutrition • Smoking • Alcohol • Physical activity

– Co-morbidity (chronic diseases)

Prevalence

Surgical patients

30% daily smokers

7-49% hazardous alcohol consumption

(Tønnesen et al 2008, Neumann et al 2008)

• Hazardous intake: >14 units/week for women and >21 for men

• 1 unit =12 g ethanol

Cont.Smokers and drinkers are over-represented in hospitals compared to the general population

The surgical agenda

Focus on a clear risk reductionChanging to a better risk group

Fixed day for surgeryShort preoperative periodLong postoperative stay for complicated patients

Patient expectationComplication-free surgerySupport of motivation to doing their “home-work”

Window of opportunity

Postoperative morbidity> 40 studies have shown that hazardous alcohol intake is related to increased postoperative morbidity> 300 studies have shown that smoking is associated to increased postoperative morbidity

Br J Anaesth 2009

How much is too much?Daily smokingAlcohol shows a dose respons relationship

0

2

4

6

8

0 1 - 7 8 - 14 15 - 21 22 - 35 >35

OR

Units per week

How much is too much?

Dose response curve for anastomosis leakage after colorectal resection

Sørensen LT: Ann Surg 2002

Alcohol intake(compared to 0-2 units per day)

3-4 units per day in average– 50% increased complications

5 units per day or more:– 400% increased complications

Daily smoking200% increase in posoperative morbidity

The most frequent compl.

Alcohol

Wound rupture & infectionsCardiac complPulmonary complBleeding episodes

Smoking

Wound rupture & infections

Pulmonary compl

Increased risk for postoperative compl.

All types of surgical interventionsAll types of surgical settings

Br J Anaesth 2009

Smoking

Effect of intervention on postop morbidity

What is the documentation?

+ Quality

Evidence degree: Pyramid

In Vitro studies

Animal Studies

Editorial papers and Consensus (’GOBSAT’)

Cases (Obs)

Cohorts, Case-Control studies (Obs)

CCT (intervention)

RCT (intervention)

Meta-analysesSyst reviews

(Eccles M BMJ 1998)

Quit smoking before surgery (OBS)

0

20

40

60

80

100Cont

< 8 weeks

> 8 weeks

Never

*

%

(DO Warner Anaest 1984)

Conclusion

It is very dangerous to stop smoking less than 8 weeks before surgery !

(i.e. it is better to recommend cont smoking instead of risking more complications)


In Vitro studies

Animal Studies


Cases (Obs)


CCT (intervention)

RCT (intervention)


DO Warner

Smoking cessation intervention at surgery

• 13 RCT on preoperative smoking cessation intervention

• 6 RCT have evaluated the effect on postoperative complications

• 3 RCT showed significant reduction in complication rate

(T Thomsen, Cochrane 2014)

Periop. SCI 6 included complications

(T Thomsen, Cochrane 2014)

Postop complications

All complicationsBrief intervention incl. Q

– RR = 0.96 (0.74 – 1.25)

Intensive programmer = Gold Standard

Programs (GSP)– RR = 0.42 (0.27 – 0.65)

Wound complBrief intervention incl. Q

– RR = 0.99 (0.70 – 1.40)

Intensive programs = Gold Standard Programs (GSP)

– RR = 0.31 (0.16 – 0.62)

Postop complications

0

20

40

60

80

100

All compl Infections

Smoking

Reduced smoking

Stopped smoking

*

%

*

AM Møller et al: Lancet 2002

Effect on postop complication 6-8 week intensive prior to knee and hip replacement

surgery

0

20

40

60

80

100

Completers Q 6 w FU Q 6m Satisfied

%

Is smoking cessation >50% possible ?RSB Standard: > 80 000 ptt


In Vitro studies

Animal Studies


Cases (Obs)


CCT (intervention)

RCT (intervention)


Møller SørensenLindströmThomsen

DO Warner

Thomsen

Alcohol

Postoperative complications

(BMJ 1999)

0

20

40

60

80

100 WithoutIntervention

Intervention

*

%

0

20

40

60

80

100%

(Pilot project)

0

20

40

60

80


Intervention

*

%

(Alc Alc 1999)

(K Oppedal, Cochrane 2012)


In Vitro studies

Animal Studies


Cases (Obs)


CCT (intervention)

RCT (intervention)


Tønnesen

Shourie

Oppedal

42 alc patients7 (5-40)

n = 20 7 (5-40)

n = 226 (5-40)

R

n = 1 withdrawn:polyneurop

n = 200 (0-0)

n = 216 (5-40)

0-4w

OP

n = 4withdrawn:2 no OP1 laparosc1 delayed

n = 2withdrawn:1 no OP1 laparosc

Alcohol intake in units/day RCT: 4 weeks abstinence program before colorectal resection

n = 160 (0-7)

n = 191 (0-11)

4-8w

4 weeks preop program - aimed at abstinence from alcohol

Prophylaxis: B-vitamins + thiamine Clordiazepoxide 10x10 mg tabletsControlled Disulfiram 2 x 200 mg/ wk Psychosocial: Weekly visits at surgical dept Open hotline Measurements of organ functions

(BMJ 1999)

Intervention• Effective alcohol intervention program

– 5% effect on alcohol abuse: NNT = 40,

– 90% effect: NNT = 2-3

– The long-term effect is a positive ‘side-effect’

• Brief intervention has no significant effect in hospital settings

Cochrane Review 2008

Even physical exercise …

0

20

40

60

80


Intervention

*

%

Postop complications(BMJ 1999)

Alcohol cessation int.Colorectal Resection

0

2

4

6

8


Intervention

*

days

Postop recovery(BMC Health Serv Res 2008)

Physical exercise int.Spine Surgery

0

20

40

60

80


Intervention

*

%

Postop complications(Lancet 2002)

Smoking cessation int.Hip/Knee Replacement

Staff expertise

Patient preference

Staff expertise

BestEvidence


Clinical expertise The influence of especially trained nurses

100 + 100 Emergency patients (smokers and alcohol abusers)47 of 100 accepted when offered brief intervention by the staff nurses97 of 100 accepted when offered BI by an trained nurse from HP Clinic

Nelbom et al 2004, Backer et al 2007

Trained nurses

Smokers and alcohol abusers from the emergency wards accepted BI

– 97 / 100 from dept internal medicine– 121 / 200 from orthopaedic department– 68 / 100 from dept neurology

Quit rates– 30 to 50% stopped smoking and alcohol abuse for a

short period– 5 to 10% stopped for at least a year

Nelbom et al 2004, Backer et al 2007, Tonnesen et al 2009 submitted

Patient preference

Staff expertise

Best Evidence


Patient experiences

Patient experiences

• Being offered a 6-8 weeks preop program before knee or hip replacement therapy– All would like to have the program offered

• Quitters • Smokers

Møller & Villebroe Ugeskr Laeger 2004

Patient experiences

• Being offered a few days preop program before breast cancer surgery– All found it relevant

• The kick I needed• Insufficient in the present situation

Thomsen et al 2009 Eur J Oncol Nurs

Patient experiences

• Being randomised to the control group instead the 4+4 weeks intervention program in relation to general and hip/knee surgery– Half of the patients were disappointed

• No influence on the drop-out rate • More stopped smoking by them-selves

Lindström et al: In press

Long term effect: Smoking

Anesthesia 2009 (Azodi et al)Quit rate after 1 year

– Intervenstion 33%– Controll %

• p<0.01

Lancet 2002 (Villebro et. al 2008)Quit rate after 1 year

– Intervenstion 22%– Controll 3%

• p<0.01

Thank you very muchfor your attention

Documents

WHO-CC Copenhagen would like to thank The Minister of Health Rajko Ostojić, Dr. Antoinette Kaic-Rak, Head of WHO Country Office, Prof. Mirna Šitum, Head