1. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Clinical Research Professor Hanne Tønnesen

2. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Contents Best evidence based practice –Background The randomized trials –Example –Evidence: score for level and quality Patient preferences –Example

3. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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 Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Clinical relevant, patient focused research concerning –diagnostic –prognosis –treatment –care –health promotion –disease prevention –Rehabilitation New evidence replaces earlier accepted procedures by new, more effective with less side-effects Best Evidence-Based HP Best available evidence

5. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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 (Eccles M BMJ 1998)

6. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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)

7. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Postop complications (RCT) 6-8 wks, knee and hip replacement surgery Møller et al: Lancet 2002 3-4 wks, gall bladder, herniation, knee and hip surgery Lindström et al. Ann Surg 2008 1-2 wks, colorectal resection Sørensen et al. Colorect Dis 2003

8. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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 SørensenLindst röm DO Warner

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

10. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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 Moller 2002

11. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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 Today –Eradiation of Helicobacter + emergency surgery, exclusively To morrow ? Another example The history of peptic ulcer intervention

12. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Quality Management Evaluation and improvement by using standards and indicators Research EB practiceQuality M Clinical quality database with consecutive patients = CCT, correlates to evidence level 2

13. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Evidence level 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 Clinical Databases

14. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Forskningstræning 2009 Commonly utilized methods –Two researchers read and evaluate. –In case of disagreement a third researcher makes the decision. Many different point score systems –Some invented for the occasion –Few validated Quality: RCT

15. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital How to balance different shortcomings? –Better to describe each shortcoming individually –But this does not solve the problem of balancing Quality: RCT

16. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Quality: RCT Evaluation of –Research question (and if it is answered) –Material / Trial profile In- and exclusion criteria Patient characteristics: are the groups comparable Trial profile: has account been made of all included patients, number of drop-outs, >80% completeness

17. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Quality: RCT Evaluation of –Randomization Hidden randomization list? Envelopes sealed, intransparant, continously numbered? Blinding of patient / doctor, blinded follow-up / analyses ? –Results: ITT or per protocol (only the completed) –Outcomes

18. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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

19. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital 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 nurses 97 of 100 accepted when offered BI by an experienced nurse from another department Nelbom et al 2004, Backer et al 2007

20. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Especially 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 period –5 to 10% stopped for at least a year Nelbom et al 2004, Backer et al 2007, Tonnesen et al 2008 submitted

21. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Individual preferences, wishes and expectations from each patient contacting a health care system Best Evidence-Based HP Patient preferences

22. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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

23. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS 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

24. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Patient experiences Being randomised to the control group instead of 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

25. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Ex: High compliance in surgical settings 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

26. WHO Collaborating Centre Evidence-Based Health Promotion in Hospitals & HS Bispebjerg University Hospital Contents Best evidence based practice Background The randomized trials Example Evidence: score for level and quality Patient preferences Example