Municipality-based Post-discharge Follow-up Visits

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.

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.

Study Overview

• Status: Completed
• Conditions: Frailty; Readmission; Primary Care; Transition
• Intervention / Treatment: Behavioral: Receive municipality-based follow-up visit

• Study Type: Interventional
• Enrollment (Actual): 531
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Denmark
  • Holbæk, Denmark, 4300
    • Medicinsk Afdeling, Holbæk Sygehus

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 65 years and older (Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

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.)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Follow-up visit; Receive municipality-based follow-up visit including primary physician.	Behavioral: Receive municipality-based follow-up visit; 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.; Other Names: Intervention group
No Intervention: Usual care; Does not receive follow-up visit

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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).	Within 30 days from discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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).	Within 180 days from discharge

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Long-term death rate	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).	Within 180 days from discharge
Long-term use of primary health care services	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.	Within 180 days from discharge
Long-term use of secondary health care services	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).	Within 180 days from discharge

Collaborators and Investigators

• Sponsor: Holbaek Sygehus
• Collaborators: Region Sjælland; Danish Institute for Public Health
• Investigators: Principal Investigator: Thomas Gjørup, Medicinsk Afdeling, Holbæk Sygehus

Publications and helpful links

General Publications

• 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.

Study record dates

Study Major Dates

• Study Start: February 1, 2012
• Primary Completion (Actual): December 1, 2013
• Study Completion (Actual): December 1, 2013

Study Registration Dates

• First Submitted: March 12, 2014
• First Submitted That Met QC Criteria: March 19, 2014
• First Posted (Estimate): March 21, 2014

Study Record Updates

• Last Update Posted (Estimate): March 21, 2014
• Last Update Submitted That Met QC Criteria: March 19, 2014
• Last Verified: March 1, 2014

More Information

Terms related to this study

• Keywords: frailty; primary care; transition; discharge; readmission
• Additional Relevant MeSH Terms: Pathologic Processes; Frailty
• Other Study ID Numbers: 3800H0.52-0059