- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02202096
A Pilot Randomized Trial of a Comprehensive Transitional Care Program for Colorectal Cancer Patients
June 13, 2016 updated by: Lillian Kao, The University of Texas Health Science Center, Houston
A Pilot Randomized Trial of the Comprehensive Transitional Care Program for Medically Underserved Colorectal Cancer Surgery Patients
The primary hypothesis is that a comprehensive transitional care program based on the premise of a patient-centered medical home versus routine care reduces emergency room visits and hospital readmissions without increasing costs among cancer patients undergoing surgery at a large safety-net hospital.
Study Overview
Status
Withdrawn
Intervention / Treatment
- Other: Patient education: One-on-one visit
- Other: Discharge planning: Assessment of barriers to discharge
- Other: Medication reconciliation: Patient medication review
- Other: Appointment before discharge: Additional measure to ensure awareness of next clinic visit
- Other: Transition coach
- Other: Patient-centered discharge instructions: Enhanced
- Other: Provider continuity: Specific surgeons responsible for coordinating care with medical/radiation oncology
- Other: Timely follow-up: Barriers to clinic follow-up visits will be discussed
- Other: Timely PCP communication
- Other: Follow-up telephone call
- Other: Patient hotline: 24 hour follow-up following call to Ask My Nurse number
Study Type
Interventional
Phase
- Not Applicable
Contacts and Locations
This section provides the contact details for those conducting the study, and information on where this study is being conducted.
Study Locations
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Texas
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Houston, Texas, United States, 77026
- Lyndon B. Johnson General Hospital
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Participation Criteria
Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.
Eligibility Criteria
Ages Eligible for Study
18 years and older (ADULT, OLDER_ADULT)
Accepts Healthy Volunteers
No
Genders Eligible for Study
All
Description
Inclusion Criteria:
- Diagnosis of colorectal cancer
- Adults, Age 18 years or older
- Undergoing surgery for either palliative cure or palliation
Exclusion Criteria:
- Patients not expected to survive hospital based on the operating surgeon's opinion
- Children under the age of 18 years
Study Plan
This section provides details of the study plan, including how the study is designed and what the study is measuring.
How is the study designed?
Design Details
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Intervention (plus usual care)
Patient education: One-on-one visit Discharge planning: Assessment of barriers to discharge Medication reconciliation: Patient medication review Appointment before discharge: Additional measure to ensure awareness of next clinic visit Transition coach Patient-centered discharge instructions: Enhanced Provider continuity: Specific surgeons responsible for coordinating care with medical/radiation oncology Timely follow-up: Barriers to clinic follow-up visits will be discussed Timely PCP communication Follow-up telephone call Patient hotline: 24 hour follow-up following call to Ask My Nurse number
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The navigator or surgeon will have a one-on-one visit with he patient to answer any questions.
Case management will be consulted on the day of surgery.
The navigator will perform an assessment of barriers to discharge based on one-on-one interviews with the patient.
The navigator will review the patient's medications with him/her prior to discharge.
Additional measures to ensure that patients are aware of the date, time, and place of their clinic visit(s) may include a phone calls or text messages to patients and their caregivers by the navigator, surgeon or clinic nurse.
The navigator will assist with coordination of care and tracking follow-up appointments and tests.
Enhanced, language-specific, discharge instructions will be developed and provided to all patients verbally and in a written format designed for patients with limited literacy skills.
Drs. Stefanos Millas (colorectal surgery) and Curtis Wray (surgical oncology) will be responsible for coordinating care with medical and radiation oncology as well as consulting when patients are readmitted to the hospital (if not admitted to the surgical service).
Changes will be made to the clinic scheduling process for colorectal cancer surgery patients to minimize wait times, to allow them to be seen on a "walk-in" basis, and to prioritize visits for patients with urgent problems as identified by follow-up calls or inquiries to the Ask My Nurse hotline.
Patients will be queried about financial barriers to clinic follow-up such as lack of money for parking and/or lack of transportation; parking vouchers and taxi/bus vouchers may be provided.
The operating surgeon will phone the PCP prior to and upon discharge to discuss concerns and follow-up care plans.
Communication via the electronic medical record (EPIC) will also be sent.
If the patient does not have a PCP, a referral will be made prior at the initial clinic visit and one provided.
Patients will be contacted by phone by the navigator or surgeon on post-discharge day 1 to identify and address any concerns.
If there are concerns, calls may be made on subsequent post-operative days.
Follow-up will occur within 24 hours of calling the Ask My Nurse number.
Patients with emergent problems will be seen immediately by the surgical oncology team if available or the on call surgery team.
Patients with non-urgent matters will be called by a member of the surgical oncology team.
Arrangements will be made to see the patient in clinic or the ER within the next 8-16 hours depending upon severity and time of day.
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No Intervention: Usual Care
Usual care-Standard of care that all colorectal cancer patients normally receive
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Number of post-operative ER visits and readmissions
Time Frame: up to 30 days postoperatively
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The number of times the patient returned to the ER and/or was readmitted to the hospital withing 30 days following their surgery
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up to 30 days postoperatively
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Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Study record dates
These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.
Study Major Dates
Study Start
February 1, 2015
Primary Completion (Anticipated)
February 1, 2016
Study Registration Dates
First Submitted
May 19, 2014
First Submitted That Met QC Criteria
July 24, 2014
First Posted (Estimate)
July 28, 2014
Study Record Updates
Last Update Posted (Estimate)
June 14, 2016
Last Update Submitted That Met QC Criteria
June 13, 2016
Last Verified
June 1, 2016
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- HSC-MS-13-0336
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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