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. 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)
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)
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

8. WHO: Terms of references
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

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. Why is HP important in health care?
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

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-related physical and psychosocial damage
Smoking abuse
Aggravation of other diseases & conditions, outcome & prognoses
Reduced smoking-related damage
Intervention
No abuse
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. How much is too much?
Dose response curve for anastomosis leakage after colorectal resection 2 4 6 8
1 - 7
8 - 14
>35 OR
Units per week
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. 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
+ Quality
(Eccles M BMJ 1998)

31. Quit smoking before surgery (OBS)
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)
(DO Warner Anaest 1984)

32. Evidence degree: Pyramid
Meta-analyses Syst reviews
RCT (intervention)
DO Warner
CCT (intervention)
Cohorts, Case-Control studies (Obs)
Cases (Obs)
Editorial papers and Consensus (’GOBSAT’)
Animal Studies
In Vitro studies

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. Postop complications 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)

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

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

39. Evidence degree: Pyramid
Møller SørensenLindström
Thomsen
Thomsen
Meta-analyses Syst reviews
RCT (intervention)
DO Warner
CCT (intervention)
Cohorts, Case-Control studies (Obs)
Cases (Obs)
Editorial papers and Consensus (’GOBSAT’)
Animal Studies
In Vitro studies

40. Alcohol

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

42. Evidence degree: Pyramid
Oppedal
Tønnesen
Meta-analyses Syst reviews
RCT (intervention)
Shourie
CCT (intervention)
Cohorts, Case-Control studies (Obs)
Cases (Obs)
Editorial papers and Consensus (’GOBSAT’)
Animal Studies
In Vitro studies

43. Alcohol intake in units/day RCT: 4 weeks abstinence program before colorectal resection
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
1 no OP
From this study we now know that patients can change their life stile before surgery.
42 patients were included and radomisesd to either alcohol abstinence supported by disulfiram (antabus) or to te routine procedure, which was to do nothing.
As you can see, al the patient in the intervention group stopped drinking before…..
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 complications
(Lancet 2002)
Smoking cessation int.
Hip/Knee Replacement
Postop recovery
(BMC Health Serv Res 2008)
Physical exercise int.
Spine Surgery

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

51. 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

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)
Intervenstion 22%
Controll 3%

56. Thank you very much
for your attention