Follow-up Study Clinical Trial
Official title:
A Randomised Controlled Trial of an Integrated Post-discharge Transitional Care Package for General Medical In-patients in Cape Town, South Africa
The post discharge time is a vulnerable time for general medical in-patients, with high
rates of adverse events that may cause unnecessary readmissions and even death. A recent
study of 415 patients discharged from the general medical wards at Groote Schuur Hospital,
demonstrated a very high 12 month mortality of 35%. The majority of these deaths were
classified as "unexpected". The reasons for this were not further examined, but it was
speculated, given the authors' knowledge of the public sector in Cape Town, that three
related factors contribute significantly to this early mortality: i) a lack of continuity of
care, with patients not necessarily accessing the primary care support treatment that they
need or being able to access early post discharge follow-up (for example for anti-retroviral
or anti-tuberculous care); ii) the inability of primary care to deal with the complex nature
of the discharged patients, most whom have significant co-morbid disease; iii) A lack of
optimisation of therapy for chronic disease after acute discharge.
The investigators hypothesise that an integrated post-discharge transitional care package,
which includes an early medical specialist follow-up in the first 3 months after hospital
discharge will decrease the 6- and 12-month mortality and re-admission rate amongst general
medical hospital admissions in Cape Town, South Africa. Our study will compare an integrated
package, suitable to implementation if effective, with current standard discharge packages.
n/a
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Caregiver), Primary Purpose: Health Services Research
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