The Effect of Systematic Clin HP Lower costs; Higher patient satisfaction; Reduced morbidity; Shorter treatment period; Improved lifestyle

Transcription

1 The Effect of Systematic Clin HP Lower costs; Higher patient satisfaction; Reduced morbidity; Shorter treatment period; Improved lifestyle Hanne Tønnesen, Professor MD PHD FCHPS Specialist in surgery CEO International HPH Secretariat, Director WHO-CC: Evidence-Based HP in Hosp&HS

2 Clinical treatment + Clinical Health Promotion Better results Immediately

3 Overview Definitions: Clin HP and E-B HP Interaction of Clin HP & Treatment Internal Medicine Surgery Psychiatry Costs Implementation

4 Definitions Clin HP Clinical activities that involve prevention, health promotion and rehabilitation performed together with the patient in the clinical setting (Nat Board Health DK Clin HP 2011) Evidence Meta-A Syst reviews RCT (intervention) CCT (intervention) Cohorts, Case-Control studies (Obs) Cases (Obs) Editorial papers and Consensus ( GOBSAT ) Animal Studies In Vitro studies

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

6 Clinical expertise The influence of specially trained nurses Emergency patients Smokers / Alcohol abusers 47 /100 accepted HP dialog when asked by staff nurses 97 /100 accepted it when asked by a trained GSP nurse Nelbom et al. 2004, Backer et al. 2007, Clin Resp Jour

7 Clinical expertise Nurses trained in manual-based guidelines 193 hospitalised smokers (veterans) 48% advised to quit - and of those were: 45% assisted to quit 62% advised to quit - and of those were: 70% assisted to quit Katz DA et al; J Gen Intern Med 2013

8 Patient preferences We are afraid that the patients are not motivated for smoking cessation Knowledge 80% want support from the hospital to change lifestyle prior to surgery 80% find it relevant to talk about lifestyle, including tobacco, alcohol drinking and overweight and physical activity Boel T et al. Ugeskr Laeger 2004 Tønnesen H et al: Swedish National Board of Health and Welfare 2014

9 Patient preferences We are afraid that we invade privacy when recommending lifestyle changes before surgery! Knowledge All hip/knee patients wanted to be offered the possibility to change smoking habits before surgery Quitters Smokers All fracture patients found it relevant to offer alcohol intervention in relation to surgery Very heavy drinkers Risky drinkers Møller & Villebro Ugeskr Laeger 2004 Pedersen & Tønnesen: Open Ort Clinica 2011

10 Patients in Region Skåne, Sweden: High accept of Clin HP Tobacco Alcohol Ph. Act Food Use the patients experiences Follow-up in the effect of clin HP Tönnesen H et al SOS-report 2014

11 Inter-actions HPH Unhealthy lifestyle Lifestyle-related illness and problems Aggravation of treatment outcome of diseases Intervention Better lifestyle Reduced lifestyle-related illness and problems Improved treatment outcome of diseases

12 Inter-actions HP policy for staff Mortality rate among patients was 5% lower in ICUs» Martin McKee 2000; HPH Conference in Copenhagen DK The clinical staff Key persons for the patients also in relation to HP Lack of knowledge + own smoking are major barriers» Willaing I et al; Scand J Public Health 2003 The management Key persons for the patients also in relation to HP Managers' knowledge, attitude and practices vary by their smoking status» Zabeen S. Int J Soc Psychiatry 2015

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14 Swedish Physicians demand: No smoking for surgical patients

15 Internal medicine Heavy knowledge on the effect of lifestyle on development of NCD (non-communicable diseases) Heavy knowledge on the extreme effect of Clin HP on treatment results in NCD Included in all treatment programs from WHO and others Global Burden of disease and injuries; Lancet 2012

16 Ex from Diabetes: Tob+Alc-Nutr+Phys and medication Gaede P et al: NEMJ 2008

17 Surgery and Clin HP Tobacco Alcohol Nutrition Physical activity NCDs

18 Perioperative SCI: RCTs Controls Interv 60 (Thomsen T et al Cochrane 2014) wks Møller wks Lindström postop Nåsell wks Sørensen BI+NRT Sørensen 2007 BI+NRT Thomsen VAR Wong 2012

19 Reducing smoking? % Smoking Reduced smoking Stopped smoking * All compl * Infections AM Møller et al: Lancet 2002

20 How much is too much? Over or per day double the complications Over or triples the complications

21 What patients? Everybody drinking too much Even without alcoholic cirrhosis!

22 Ex: Adding HP to surgery Alcohol cessation int. Colorectal Resection Smoking cessation int. Hip/Knee Replacement Physical exercise int. Spine Surgery 100 % Without Intervention 100 % Without Intervention 10 days Without Intervention 80 Intervention 80 Intervention 8 Intervention * 40 * 4 * Postop complications (BMJ Cochrane 2012) 0 Postop complications (Lancet Cochrane 2014) 0 Postop recovery (Clin Rehabil Cochrane 2012)

23 Ankle fracture surgery in alcohol abusers 1992: Compliation rate of 33% Tönnesen et al J Bone Joint Surg : Complication rate of 35% Aalykke M et al Clin Health Promot 2015

24 What is true about mental health and smoking? Smoking reduces emotional problems, level of anxiety and depression? Quitting is followed by irritability, anxiety and depression? Re-uptake of smoking reduces those immediately?

25 Psychiatry and Clin HP

26 Meta-analyses: Significant improvements After withdrawal symptoms quitting is associated with lower levels of: Anxiety OR: -0,37 Depression OR: -0,25 Mixed anxiety + depr OR: -0,31 Stress OR: -0,23 And higher levels of QoL OR: +0,22 Positive feelings OR: +0,68 Tayler at al; BJM 2014

27 Psychiatry Nordic psychiatric patients die years prior to the background population Primarily due to lifestyle related diseases We need more Clin HP in Psychiatry Br J Psyc 2012

28 VIP Model in Psychiatry Better functionality by habilitation before, during and after treatment Before Under After

29 Costs: Surgery Ankle fracture surgery the first 6 weeks Examinations, surgery, 1-2 days hospital stay and follow-up visit Average costs 5,000 per patient (DRG data) + alcohol intake 21 drinks/week: Costs 16,000 per patient (DRG data) + alcohol quitting (incl 1,000 for GSP-A) Costs 11,000 per patient (DRG data) Pedersen B; Clin Health Promot 2014 (PhD Thesis)

30 Implementation of Clin HP The only way to reduce the extra lifestyle-related poor treatment results Many hospitals and health care units do not give clin HP activities the sufficient attention Systematic implementation Few patients are offered clin HP activities in relation to their treatment Teaching and training of staff and administration Lack of know-how and focus and missing support from management, decision makers, health planners and policy levels

31 Use cost-effective programs: GSP % quitter after 6 months OBS: 3-7% lower in heavy and disadvantaged smokers Neumann T et al Tobacco Contr % lower in depressive smokers Klinge M et al Master Thesis 2015 Ghith N et al. Clin HP 2012 Number of meetings

32 Implementation Use the free tools tested by WHO and HPH Exchange guidelines and results via HPH Participate in the HPH Summer Schools & Master Class on implementation Join the International Fast Track Implementation WHO-HPH Project; 12 months process

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34 Meet the future patient Professional: - Leader of own health and disease intervention - New partnerships: networks, patient organizations - Education (internet, self-help groups etc) - Focus on health gain, not just survival - Demanding, not grateful - Requiring evidence-based HP as part of clinical pathway (otherwise complaining)

35 Overview Definitions: Clin HP and E-B HP Interaction of Clin HP & Treatment Internal Medicine Surgery Psychiatry Costs Implementation

36 Warm regards to you from the HPH World

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