1. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Health Promotion: value and importance for clinical practice – international context Hanne Tønnesen, MD, DMSc Head of Research and Centre (specialist in surgery)

2. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Presentation Best evidence-based practice –Short history Evidence –Example –Score for degree and quality Patient preferences –Example HP in hospitals and health services –The future patient

3. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Best Evidence-Based HP Includes all three parts Patient preference Staff expertise Best Evidence (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

4. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Evidence-Based Platform Decision-making in health should be based on evidence Zsuzsanna Jakab, WHO Regional Director for Europe Clin HP, 2011

5. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital + 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-analyses Syst reviews

6. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Smoking and surgery > 300 OBS studies have shown that smoking is associated to increased postoperative morbidity

7. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Smoking before surgery (OBS) 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)

8. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Smoking cessation intervention 9 (11) RCT on preoperative smoking cessation intervention 5 RCT evaluated the effect on postoperative complications –2 intensive programmes –3 less intensive (Thomsen T et al Br J Surg 2009)

9. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital 120 patients Hip and knee replacement therapy 6-8 weeks preoperative intervention program Complications –Controll group 52% –Intervention group 18% P=0.0003 No effect of smoking reduction Møller A et al Lancet 2002 Møller A et al. Lancet 2002

10. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Lindström et al. Ann Surg 2008 102 patients Generel and orthopaedic surgery 4 weeks preoperative + 4 weeks postoperative intervention program Complications –Controll group 41% –Intervention group 21% P=0.03 Lindstrøm et al. Ann Surg 2008

11. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Outcome: Complications

12. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Postop complications Any complication Brief intervention incl. Q –RR = 0.96 (0.74 – 1.25) Intensive programs = Gold Standard Programs (GSP) –RR = 0.42 (0.27 – 0.65)

13. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Postop complications Wound complication Brief intervention incl. Q –RR = 0.99 (0.70 – 1.40) Intensive programs = Gold Standard Programs (GSP) –RR = 0.31 (0.16 – 0.62)

14. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital AM Møller et al: Lancet 2002 Effect upon postop compl. 6-8 weeks intervention before knee / hip replacement

15. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Outcome: Quit Rate 6-8 uger, knæ-hoftealloplastik Møller et al: Lancet 2002 4+4 uger, galde, brok, knæ, hofte Lindström et al. Ann Surg 2008 60 + 60 ptt55 + 62 ptt

16. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Quit rates on short term Brief intervention incl. Q –RR = 1.41 (1.22 – 1.63)p<0.00001 Intensive programs = Gold Standard Programs (GSP) –RR = 10.76 (4.55 – 25.46) p<0.00001

17. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital 12 months quit-rate Moller 2002 Lindstrom 2008 Intensive Program 2.96 [1.57-5.55] I 2 = 38% Ratner 2004 Thomsen 2010 Brief Intervention 1.09 [0.68-1.75] I 2 = 0 Total 1.61 [1.12-2.33] I 2 = 38% Thomsen et al. Cochrane 2010

18. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Smoking intervention Intensive smoking cessation intervention continuing for at least 4 weeks intervention (but not BI) is effective in hospitals settings Cochrane Review 2008 Brief intervention has no significant effect in on surgical outcomes Thomsen et al Br J Surg 2009

19. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital 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-analyses Syst reviews Møller Sørensen Lindström DO Warner

20. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Previously –Egg, milk and biscuits + major surgery –Antacida + selective surgery –H-2 Blockers and Inhibiters of the proton- pump + super-selective surgery To day –Eradiation of Helicobacter + emergency surgery, exclusively To morrow ? Another example The history of peptic ulcer intervention

21. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Best Evidence-Based HP Clinical expertise Use of clinical expertise and experiences in relation to –intervention –meet the patients’ needs and wishes

22. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Patient approach After information of high risk at surgery: 80 % patients scheduled for surgery wanted the hospital to support smoking cessation, stop drinking and weight loss 67-95% participate in RCT of preop lifestyle intervention –The compliance to life-style change in the intervention groups is high too (70-90%) –The control groups seldom change life-style in a risk reduction way (0-10%) Møller et al 2002 + 2004, Tonnesen et al 1999, Nielsen et al 2007 Boel et al 2004

23. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital 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

24. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Patient experiences Being offered a few days preop program before breast cancer surgery –All found it relevant Most: Insufficient in the present situation A few: The kick I needed Thomsen et al 2009 Eur J Oncol Nurs

25. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital 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 Lindström et al: Contemp Clin Trials 2009

26. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital New Research Acute surgery Ankle fractures in smokers (RCT) –Posttraumatic smoking cessation program: 4 weeks (Nåsell H et al JBJS 2010) Ankle fractures in hazardous drinkers (RCT) –Posttraumatic alcohol cessation program: 4 weeks (Scand-Ankle)

27. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Long term effect 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

28. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital www.asmokefreeoperation.se Number of hospitals with smoke-free operations in Sweden: Today 37 hospitals Tomorrow ?

29. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital If all Danish smokers undergoing surgery were offered intensive smoking cessation intervention programs ……..

30. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital … the annual smoking reduction would double up in DK population 2010

31. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Ex: High compliance in surgical settings Postop complications (BMJ 1999) Alcohol cessation int. Colorectal Resection Postop recovery (Accepted 2009) Physical exercise int. Spine Surgery Postop complications (Lancet 2002) Smoking cessation int. Hip/Knee Replacement

32. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital The future HP patient Professionalism - Leader of own health and disease intervention - Education (internet, self-help groups etc) - Participant in new partnerships: networks, patient organizations - Focusing on health gain, not survival - Demanding, not grateful - Requiring evidence-based HP as part of clinical pathway (otherwise complaining)

33. WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals Bispebjerg University Hospital Presentation Best evidence-based practice Short history Evidence Example Score for degree and quality Patient preferences Example HP in hospitals and health services The future patient