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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 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
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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)
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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)
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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
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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
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Evidence-Based Clinical Health Promotion
Prof. Hanne Tønnesen MD PhDCEO at the International HPH secretariat, WHO-CC Copenhagen
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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
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Distribution of members by April 2014
>950 member Hospitals and Health Services world wide
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Best HP PracticeIncludes all three parts
Patient preference
Staff expertise
BestEvidence
(Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)
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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
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What is CHP? HPH
CHP bridges clinical treatment and public health - thus helping patients, families, community and society
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• 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?
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Facts about Clin HP
Poor lifestyle
+ Treatment
-----------------------------------------
= Poor outcomes
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Facts about Clin HP
Poor lifestyle
+ Clinical Health Promotion
+Treatment-----------------------------------------
= Better treatment results
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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
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Factors of importance for the outcome in patient path-ways
Disease / diagnosisInterventionOrganisationIndividual patient-related factors
– Health• Diet and nutrition • Smoking • Alcohol • Physical activity
– Co-morbidity (chronic diseases)
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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
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Cont.Smokers and drinkers are over-represented in hospitals compared to the general population
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The surgical agenda
Focus on a clear risk reductionChanging to a better risk group
Fixed day for surgeryShort preoperative periodLong postoperative stay for complicated patients
Patient expectationComplication-free surgerySupport of motivation to doing their “home-work”
Window of opportunity
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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
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How much is too much?Daily smokingAlcohol shows a dose respons relationship
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0
2
4
6
8
0 1 - 7 8 - 14 15 - 21 22 - 35 >35
OR
Units per week
How much is too much? Dose response curve for anastomosis leakage after colorectal resection
Sørensen LT: Ann Surg 2002
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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
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Daily smoking200% increase in posoperative morbidity
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The most frequent compl.
Alcohol
Wound rupture & infectionsCardiac complPulmonary complBleeding episodes
Smoking
Wound rupture & infections
Pulmonary compl
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Increased risk for postoperative compl.
All types of surgical interventionsAll types of surgical settings
Br J Anaesth 2009
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Smoking
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Effect of intervention on postop morbidity
What is the documentation?
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+ 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-analysesSyst reviews
(Eccles M BMJ 1998)
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Quit smoking before surgery (OBS)
0
20
40
60
80
100Cont < 8 weeks> 8 weeksNever
*
%
(DO Warner Anaest 1984)
ConclusionIt 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)
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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-analysesSyst reviews
DO Warner
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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)
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Periop. SCI 6 included complications
(T Thomsen, Cochrane 2014)
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Postop complications
All complicationsBrief intervention incl. Q
– RR = 0.96 (0.74 – 1.25)
Intensive programmer = Gold Standard
Programs (GSP)– RR = 0.42 (0.27 – 0.65)
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Wound complBrief 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
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0
20
40
60
80
100
All compl Infections
SmokingReduced smokingStopped smoking
*
%
*AM Møller et al: Lancet 2002
Effect on postop complication 6-8 week intensive prior to knee and hip replacement
surgery
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0
20
40
60
80
100
Completers Q 6 w FU Q 6m Satisfied
%
Is smoking cessation >50% possible ?RSB Standard: > 80 000 ptt
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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-analysesSyst reviews
Møller SørensenLindströmThomsen
DO Warner
Thomsen
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Alcohol
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Postoperative complications
(BMJ 1999)
0
20
40
60
80
100 WithoutIntervention
Intervention
*
%
0
20
40
60
80
100%
(Pilot project)
0
20
40
60
80
100 WithoutIntervention
Intervention
*
%
(Alc Alc 1999)
(K Oppedal, Cochrane 2012)
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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-analysesSyst reviews
Tønnesen
Shourie
Oppedal
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42 alc patients7 (5-40)
n = 20 7 (5-40)
n = 226 (5-40)
Rn = 1
withdrawn:polyneurop
n = 200 (0-0)
n = 216 (5-40)
0-4w
OP
n = 4withdrawn:2 no OP1 laparosc1 delayed
n = 2withdrawn:1 no OP1 laparosc
Alcohol intake in units/day RCT: 4 weeks abstinence program before colorectal resection
n = 160 (0-7)
n = 191 (0-11)
4-8w
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4 weeks preop program - aimed at abstinence from alcohol
Prophylaxis: B-vitamins + thiamine Clordiazepoxide 10x10 mg tabletsControlled Disulfiram 2 x 200 mg/ wk Psychosocial: Weekly visits at surgical dept Open hotline Measurements of organ functions
(BMJ 1999)
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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
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Even physical exercise …
0
20
40
60
80
100 WithoutIntervention
Intervention
*
%
Postop complications(BMJ 1999)
Alcohol cessation int.Colorectal Resection
0
2
4
6
8
10 WithoutIntervention
Intervention
*
days
Postop recovery(BMC Health Serv Res 2008)
Physical exercise int.Spine Surgery
0
20
40
60
80
100 WithoutIntervention
Intervention
*
%
Postop complications(Lancet 2002)
Smoking cessation int.Hip/Knee Replacement
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Staff expertise
Patient preference
Staff expertise
BestEvidence
(Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)
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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 nurses97 of 100 accepted when offered BI by an trained nurse from HP Clinic
Nelbom et al 2004, Backer et al 2007
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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
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Patient preference
Staff expertise
Best Evidence
(Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)
Patient experiences
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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
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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
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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
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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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Thank you very muchfor your attention