Back to resultsMunicipality-based Post-discharge Follow-up Visits
Primary Purpose
Frailty, Readmission, Transition
Status
Completed
Phase
Not Applicable
Locations
Denmark
Study Type
Interventional
Intervention
Receive municipality-based follow-up visit
Sponsored by
About this trial
This is an interventional prevention trial for Frailty focused on measuring frailty, readmission, transition, discharge, primary care
Eligibility Criteria
Inclusion Criteria:
- Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.)
- Discharged from medical ward Holbæk Sygehus.
- Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.)
Exclusion Criteria:
- Not discharged to home (If the patient are not discharged to home.)
- No written consent (If the patient does not wish to participate / written consent are not signed.)
Sites / Locations
- Medicinsk Afdeling, Holbæk Sygehus
Arms of the Study
Arm 1
Arm 2
Arm Type
Experimental
No Intervention
Arm Label
Follow-up visit
Usual care
Arm Description
Receive municipality-based follow-up visit including primary physician.
Does not receive follow-up visit
Outcomes
Primary Outcome Measures
Re-admission
The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret).
Secondary Outcome Measures
Long-term hospitalization rate
Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).
Full Information
NCT ID
NCT02094040
First Posted
March 12, 2014
Last Updated
March 19, 2014
Sponsor
Holbaek Sygehus
Collaborators
Region Sjælland, Danish Institute for Public Health
1. Study Identification
Unique Protocol Identification Number
NCT02094040
Brief Title
Municipality-based Post-discharge Follow-up Visits
Official Title
Effect of Municipality-based Post-discharge Follow-up Visit Including the Primary Physician on Early Re-hospitalization in High Risk People of 65+ Years. A Randomised Controlled Trial.
Study Type
Interventional
2. Study Status
Record Verification Date
March 2014
Overall Recruitment Status
Completed
Study Start Date
February 2012 (undefined)
Primary Completion Date
December 2013 (Actual)
Study Completion Date
December 2013 (Actual)
3. Sponsor/Collaborators
Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Holbaek Sygehus
Collaborators
Region Sjælland, Danish Institute for Public Health
4. Oversight
Data Monitoring Committee
No
5. Study Description
Brief Summary
The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.
6. Conditions and Keywords
Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Frailty, Readmission, Transition, Primary Care
Keywords
frailty, readmission, transition, discharge, primary care
7. Study Design
Primary Purpose
Prevention
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
Investigator
Allocation
Randomized
Enrollment
531 (Actual)
8. Arms, Groups, and Interventions
Arm Title
Follow-up visit
Arm Type
Experimental
Arm Description
Receive municipality-based follow-up visit including primary physician.
Arm Title
Usual care
Arm Type
No Intervention
Arm Description
Does not receive follow-up visit
Intervention Type
Behavioral
Intervention Name(s)
Receive municipality-based follow-up visit
Other Intervention Name(s)
Intervention group
Intervention Description
Systematic electronic referral from hospital to municipality of high risk people at discharge from a medical ward. Contact from municipality service to primary physician and citizen, to arrange first home visit within 7 days with focus on: medication, rehabilitation plan and health care appointments, functional level and need for further health care initiatives. The visit is concluded by planning of further visits (up till tree) and division of responsibilities between primary physician and the municipality service.
Primary Outcome Measure Information:
Title
Re-admission
Description
The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret).
Time Frame
Within 30 days from discharge
Secondary Outcome Measure Information:
Title
Long-term hospitalization rate
Description
Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).
Time Frame
Within 180 days from discharge
Other Pre-specified Outcome Measures:
Title
Long-term death rate
Description
Other pre-specified outcome concerns death rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).
Time Frame
Within 180 days from discharge
Title
Long-term use of primary health care services
Description
Other pre-specified outcome concerns the use of primary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of primary health care in Denmark (Sygesikringsregistret) and registration from 3 Danish municipalities.
Time Frame
Within 180 days from discharge
Title
Long-term use of secondary health care services
Description
Other pre-specified outcome concerns the use of secondary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret).
Time Frame
Within 180 days from discharge
10. Eligibility
Sex
All
Minimum Age & Unit of Time
65 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria:
Patient geography (The participant live in; Holbæk Kommune, Odsherred Kommune or Kalundborg Kommune.)
Discharged from medical ward Holbæk Sygehus.
Frailty (Rated by following criterion: dementia or a minimum of two of the following conditions; two or more hospitalisations within 12 month prior to follow up, los of physical function, treatment of two or more concurrent medical and/or surgical conditions, psychiatric disease, multi-pharmacy of more than 6 prescription medication, suspicious of congenital disturbances, substance abuse problem, disadvantaged social network, need for increasing home care following index hospitalization.)
Exclusion Criteria:
Not discharged to home (If the patient are not discharged to home.)
No written consent (If the patient does not wish to participate / written consent are not signed.)
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Thomas Gjørup
Organizational Affiliation
Medicinsk Afdeling, Holbæk Sygehus
Official's Role
Principal Investigator
Facility Information:
Facility Name
Medicinsk Afdeling, Holbæk Sygehus
City
Holbæk
ZIP/Postal Code
4300
Country
Denmark
12. IPD Sharing Statement
Citations:
PubMed Identifier
26059872
Citation
Thygesen LC, Fokdal S, Gjorup T, Taylor RS, Zwisler AD; Prevention of Early Readmission Research Group. Can municipality-based post-discharge follow-up visits including a general practitioner reduce early readmission among the fragile elderly (65+ years old)? A randomized controlled trial. Scand J Prim Health Care. 2015 Jun;33(2):65-73. doi: 10.3109/02813432.2015.1041831. Epub 2015 Jun 10.
Results Reference
derived
Learn more about this trial
Municipality-based Post-discharge Follow-up Visits
We'll reach out to this number within 24 hrs