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

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)

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)

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: 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

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

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)

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

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

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

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

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

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)

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 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

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 smoking Alcohol shows a dose respons relationship

How much is too much? Dose response curve for anastomosis leakage after colorectal resection 2 4 6 8 1 - 7 8 - 14 15 - 21 22 - 35 >35 OR Units per week 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 smoking 200% increase in posoperative morbidity

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

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

Smoking

Effect of intervention on postop morbidity What is the documentation?

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)

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)

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

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 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)

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)

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

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

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

Alcohol

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

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

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

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)

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 … 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

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

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

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) Intervenstion 22% Controll 3%

Thank you very much for your attention