Enhanced Primary Care for Elderly

Frail Elderly Syndrome Clinical Trial

Official title:

Enhanced Primary Care for Elderly: A Multicenter Pragmatic Clinical Trial Where Older People With Great Needs Are Predicted and Given Personalized Primary Care

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03180606
• Other study ID #: Elderly care 2016-347-31
• Status: Completed
• Start date: September 27, 2017
• Est. completion date: December 31, 2019

Study information

• Verified date: June 2020
• Source: Region Östergötland
• Contact: n/a
• Is FDA regulated: No
• Study type: Observational

Clinical Trial Summary

The present health care situation for the elderly in many countries is insufficient and not designed according to the health care needs of the aged population. In a pragmatic multicenter primary care setting (n= 1600), the investigators use an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization and apply a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc). The project has high potential impact on the development of future care of elderly.

In addition to the intervention study, several academic sub-studies focusing on patient's perspective, professional roles, equality, implementation and governance management of health care will be performed.

Description:

The current project is a multidisciplinary research project covering several aspects of a shift in elderly care, with outcome measures not only related to primary medical or functional measures. The analyses will widen the view to overall societal costs and effects of changes in key institutions of social security as well as to hidden mechanisms in the governance system of care and health care of elderly.

The primary aim of the present study is to investigate the extent to which a differentiated (personalized) and targeted primary care intervention provided to a statistically predicted risk population of elderly, results in care that is more effective and of higher quality than that of a control group receiving standard care. In a pragmatic multicenter primary care setting (n= 1600), an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization is used followed by a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc).

The investigators also aim to study the care model in a broader sense; experiences of the elderly, their social networks and diversity. Finally, the project will also investigate how the health care system, from specific health care professionals (primary care nurses, doctors, para-medical staff) to management levels and politicians influence the implementation of the present and future care models. One specific subproject focuses on the mechanisms behind the inability of steak holders/politicians and top administrative executives to find efficient governance principals for elderly care and health care, despite already available knowledge sources.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 1304
• Est. completion date: December 31, 2019
• Est. primary completion date: December 31, 2019
• Gender: All
• Age group: 75 Years to 110 Years

Eligibility

Inclusion Criteria:

• Age 75 years and older living in county of Östergötland

Exclusion Criteria:

• No exclusion criteria

Related Conditions & MeSH terms

• Frail Elderly Syndrome

Intervention

Other:
• Multi-disciplinary and personalized primary care
Team-based primary care where nurse, GP, social-worker, physiotherapist, occupational therapist evaluate and give treatment

Locations

Country	Name	City	State
Sweden	Primary Care of Östergötland	Linköping	Östergötland
Sweden	Region Östergötland/Linköping University	Linköping	Östergötland

Sponsors (1)

Lead Sponsor	Collaborator
Region Östergötland

Country where clinical trial is conducted

Sweden, 

References & Publications (1)

Marcusson J, Nord M, Johansson MM, Alwin J, Levin LÅ, Dannapfel P, Thomas K, Poksinska B, Sverker A, Olaison A, Cedersund E, Kelfve S, Motel-Klingebiel A, Hellström I, Kullberg A, Böttiger Y, Dong HJ, Peolsson A, Wass M, Lyth J, Andersson A. Proactive healthcare for frail elderly persons: study protocol for a prospective controlled primary care intervention in Sweden. BMJ Open. 2019 May 22;9(5):e027847. doi: 10.1136/bmjopen-2018-027847. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Hospital care days	The number of days in hospital	January 1st 2018 - December 31st 2019
Secondary	Hospital care occasions	Number of occasions in hospital care	January 1st 2018 - December 31st 2019
Secondary	Health related quality of life	Measured as EQ-5D scores	January 1st 2018 - December 31st 2019
Secondary	Costs for health care	The total costs for health care measured in USD	January 1st 2018 - December 31st 2019
Secondary	Mortality	Number of deaths during the study period	January 1st 2018 - December 31st 2019

External Links

•   Study protocol article