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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.

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Presentation on theme: "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."— Presentation transcript:

1 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

2 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)

3 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)

4 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

5 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

6 Evidence-Based Clinical Health Promotion Prof. Hanne Tønnesen MD PhD CEO at the International HPH secretariat, WHO-CC Copenhagen

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8 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

9 Distribution of members by April 2014 >950 member Hospitals and Health Services world wide

10 Best HP Practice Includes all three parts Patient preference Staff expertise Best Evidence (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

11 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

12 What is CHP? HPH CHP bridges clinical treatment and public health - thus helping patients, families, community and society

13 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?

14 Facts about Clin HP Poor lifestyle + Treatment = Poor outcomes

15 Facts about Clin HP Poor lifestyle + Clinical Health Promotion +Treatment = Better treatment results

16 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

17 Factors of importance for the outcome in patient path-ways Disease / diagnosis Intervention Organisation Individual patient-related factors –Health Diet and nutrition Smoking Alcohol Physical activity –Co-morbidity (chronic diseases)

18 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

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

20 The surgical agenda Focus on a clear risk reduction Changing to a better risk group Fixed day for surgery Short preoperative period Long postoperative stay for complicated patients Patient expectation Complication-free surgery Support of motivation to doing their “home-work” Window of opportunity

21 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

22 How much is too much? Daily smoking Alcohol shows a dose respons relationship

23 >35 OR Units per week How much is too much? Dose response curve for anastomosis leakage after colorectal resection Sørensen LT: Ann Surg 2002

24 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

25 Daily smoking 200% increase in posoperative morbidity

26 The most frequent compl. Alcohol Wound rupture & infections Cardiac compl Pulmonary compl Bleeding episodes Smoking Wound rupture & infections Pulmonary compl

27 Increased risk for postoperative compl. All types of surgical interventions All types of surgical settings Br J Anaesth 2009

28 Smoking

29 Effect of intervention on postop morbidity What is the documentation?

30 + 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 (Eccles M BMJ 1998)

31 Quit 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)

32 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 DO Warner

33 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)

34 Periop. SCI 6 included complications (T Thomsen, Cochrane 2014)

35 Postop complications All complications Brief intervention incl. Q –RR = 0.96 (0.74 – 1.25) Intensive programmer = Gold Standard Programs (GSP) –RR = 0.42 (0.27 – 0.65)

36 Wound compl Brief 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

37 AM Møller et al: Lancet 2002 Effect on postop complication 6-8 week intensive prior to knee and hip replacement surgery

38 % Is smoking cessation >50% possible ? RSB Standard: > ptt

39 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 Thomsen DO Warner Thomsen

40 Alcohol

41 Postoperative complications (BMJ 1999) (Pilot project)(Alc Alc 1999) (K Oppedal, Cochrane 2012)

42 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 Tønnesen Shourie Oppedal

43 42 alc patients 7 (5-40) n = 20 7 (5-40) n = 22 6 (5-40) R n = 1 withdrawn: polyneurop n = 20 0 (0-0) n = 21 6 (5-40) 0-4w OP n = 4 withdrawn: 2 no OP 1 laparosc 1 delayed n = 2 withdrawn: 1 no OP 1 laparosc Alcohol intake in units/day RCT: 4 weeks abstinence program before colorectal resection n = 16 0 (0-7) n = 19 1 (0-11) 4-8w

44 4 weeks preop program - aimed at abstinence from alcohol Prophylaxis: B-vitamins + thiamine Clordiazepoxide 10x10 mg tablets Controlled Disulfiram 2 x 200 mg/ wk Psychosocial: Weekly visits at surgical dept Open hotline Measurements of organ functions (BMJ 1999)

45 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

46 Even physical exercise … Postop complications (BMJ 1999) Alcohol cessation int. Colorectal Resection Postop recovery (BMC Health Serv Res 2008) Physical exercise int. Spine Surgery Postop complications (Lancet 2002) Smoking cessation int. Hip/Knee Replacement

47 Staff expertise Patient preference Staff expertise Best Evidence (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

48 Clinical expertise The influence of especially trained nurses Emergency patients (smokers and alcohol abusers) 47 of 100 accepted when offered brief intervention by the staff nurses 97 of 100 accepted when offered BI by an trained nurse from HP Clinic Nelbom et al 2004, Backer et al 2007

49 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

50 Patient preference Staff expertise Best Evidence (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000) Patient experiences

51 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

52 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

53 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

54 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

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56 Thank you very much for your attention


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