Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Clinical Research
Professor Hanne Tønnesen
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Contents
• Best evidence based practice
– Background
• The randomized trials
– Example
– Evidence: score for level and quality
• Patient preferences
– Example
Best Evidence-Based HP
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Includes all three parts
Best
Evidence
Staff
expertise
Patient
preference
(Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based
medicine. Churcill Livingstone 2000)
Best Evidence-Based HP
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Best available evidence
• 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
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Evidence degree: Pyramid
(Eccles M BMJ 1998)
+ Quality
Meta-analyses
Syst reviews
RCT (intervention)
CCT (intervention)
Cohorts, Case-Control studies (Obs)
Cases (Obs)
Editorial papers and Consensus (’GOBSAT’)
Animal Studies
In Vitro studies
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Smoking before surgery (OBS)
%
100
80
Cont
< 8 weeks
> 8 weeks
Never
60
40
20
0
*
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)
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Postop complications (RCT)
%
100
100
100
80
No interv
Intervention
80
80
60
60
60
40
40
40
*
*
20
20
20
0
0
0
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
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Evidence degree: Pyramid
Møller
SørensenLindst
röm
Meta-analyses
Syst reviews
DO Warner
RCT (intervention)
CCT (intervention)
Cohorts, Case-Control studies (Obs)
Cases (Obs)
Editorial papers and Consensus (’GOBSAT’)
Animal Studies
In Vitro studies
6-8 weeks intervention before knee / hip replacement
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Effect upon postop compl
%
Smoking
Reduced smoking
Stopped smoking
100
80
60
40
20
*
0
All compl
AM Møller et al. Lancet 2002
*
Infections
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Evidence degree: Pyramid
Møller
Sørensen
Meta-analyses
Syst reviews
Lindström
Moller 2002
RCT (intervention)
CCT (intervention)
Cohorts, Case-Control studies (Obs)
Cases (Obs)
Editorial papers and Consensus (’GOBSAT’)
Animal Studies
In Vitro studies
The history of peptic ulcer intervention
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Another example
• Previously
– Egg, milk and biscuits + major surgery
– Antacida + selective surgery
– H-2 Blockers and Inhibiters of the protonpump + super-selective surgery
• Today
– Eradiation of Helicobacter + emergency
surgery, exclusively
• To morrow ?
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Quality: RCT
• 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
Forskningstræning 2009
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Quality: RCT
• How to balance different
shortcomings?
– Better to describe each shortcoming
individually
– But this does not solve the problem of
balancing
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
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
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
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
Best Evidence-Based HP
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Clinical expertise
• Use of clinical expertise and
experiences in relation to
– intervention
– meet the patients’ needs and wishes
The influence of especially trained nurses
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Clinical expertise
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
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
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
Best Evidence-Based HP
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Patient preferences
• Individual preferences, wishes
and expectations from each
patient contacting a health care
system
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
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
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
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
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
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
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Ex: High compliance in
surgical settings
Alcohol cessation int.
Colorectal Resection
%
100
Without
Intervention
Smoking cessation int.
Hip/Knee Replacement
%
100
Intervention
Without
Intervention
Physical exercise int.
Spine Surgery
days
10
Intervention
Intervention
80
80
8
60
60
6
40
*
40
*
4
20
20
2
0
0
0
Postop complications
(BMJ 1999)
Postop complications
(Lancet 2002)
Without
Intervention
*
Postop recovery
(BMC Health Serv Res 2008)
Bispebjerg University Hospital
Evidence-Based Health Promotion in Hospitals & HS
WHO Collaborating Centre
Contents
Best evidence based practice
Background
The randomized trials
Example
Evidence: score for level and quality
Patient preferences
Example