Clinical Trial Details
— Status: Completed
Administrative data
| NCT number |
NCT04796701 |
| Other study ID # |
FH2017-2019 |
| Secondary ID |
|
| Status |
Completed |
| Phase |
N/A
|
| First received |
|
| Last updated |
|
| Start date |
February 1, 2017 |
| Est. completion date |
December 31, 2019 |
Study information
| Verified date |
February 2021 |
| Source |
University of Aarhus |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Interventional
|
Clinical Trial Summary
The objective of this study is to evaluate the effect of a transitional care intervention on
readmissions among older medical patients.
The proportion of older people is rapidly growing. These changes represent a challenge for
healthcare systems. 20% of all hospital admitted patients ≥ 65 years are readmitted within
the first 30 days after discharge. Prior transitional care research has mainly focused on
either hospital-based or community-based interventions with no or little intervention
elements in both settings. The results show different effects on readmission rates. This
calls for new research on trans-sectorial interventions with both pre- and post-discharge
elements.
Description:
Design:
Non-randomized controlled trial.
Participants For eligibility criteria - see elsewhere. Intervention group • Patients living
in Odder, Skanderborg or Hedensted municipality
Control group
• Patients living in Horsens municipality
Follow-Home Intervention
The intervention group receives following intervention:
If possible, all included participants are physically followed home by a hospital-based
project worker on the day of discharge. During the visit, the focus is on: basic human needs,
medication review reconciliation, and a comprehensive geriatric assessment. Problems,
challenges and concerns are discussed. Finally, a conference for the following working day is
arranged either as a physical visit or a video conference. The patient, relatives,
community-based nurse and project worker are invited to participate and health status and
challenges are discussed They are recommended to contact the project worker about health and
practical issues up to 7 days after discharge where the intervention ends. Subsequently, the
responsibility for treatment and care is assigned to the GP and home healthcare provider.
Usual care
Patients in the control group recieves the following usual discharge procedure:
On the day of discharge, the hospital-based nurse digitally sends a summery of the hospital
stay and a treatment and care plan to the community-based nurse. If needed, the
hospital-based nurse contacts the community-based nurse by phone as a supplement to the plan.
Finally, a discharge letter conducted by the hospital-based doctor is digitally sent to the
GP.
Method:
Inclusion of participants is consecutive. Inclusion period was between 01/02/17 to 31/12/19.
In total, approximately 1200 patients were included .
Data collection Outcome data will be retrieved from CROSS-TRACKS database at 30 days after
discharge from index admission.
Analysis
Intervention and Control group will be matched on 3 variables on individual level:
- CCI
- Index admission period: +/- 3-4 weeks
- Sex
All readmissions are included in the analysis (not only first time readmissions). That means
that one patient can be included several times.
Logistic regression adjusted for possible confounders will be used when analysing the
outcomes. Confounders are chosen through a study specific DAG.
Sub-group analysis will be conducted according to:
- Age
- Sex
- Housing
- Civil status
- Social status
- Length of hospital stay in index admission
- Comorbidity
- Diagnosis
- Ect.
