- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03613064
Addressing Social Vulnerabilities in Cardiovascular Disease
June 4, 2021 updated by: University of California, San Francisco
Addressing Social Vulnerabilities to Prevent Hospital Readmissions in Adults With Cardiovascular Disease
The investigators will conduct a feasibility study of an enhanced transitional care intervention, that will: 1) automate identification and risk-stratification of patients with CHF and IHD with social vulnerabilities; 2) incorporate a new standardized social vulnerabilities screening tool into clinical care; 3) enable electronic referrals to community resources; and 4) add novel community-based interventions to the existing medically-oriented transitional care intervention that is the standard of care at the study hospital (Parkland Hospital in Dallas, Texas) and other hospitals nationwide.
Study Overview
Status
Not yet recruiting
Conditions
Intervention / Treatment
Detailed Description
The investigators plan to develop, pilot and evaluate the feasibility of an existing medically oriented transitional care intervention enhanced to also address social vulnerabilities, to prevent readmissions in congestive heart failure (CHF) & ischemic heart disease (IHD).
The intervention design will be based on the Andersen Behavior Model of Health Services Use, highlighting pathways for clinical linkages to community resources to facilitate individual behavior change.
To summarize, although existing interventions have largely focused on individual- and health system-level factors such as optimizing medication regimens, discharge education, and post-discharge follow-up, much of the risk for readmission in patients with CHF and IHD is also driven by social vulnerabilities that are currently not addressed in medical settings.
Community-based organizations are a valuable but untapped resource to ameliorate key social vulnerabilities (i.e., food/housing insecurity, behavioral health needs) that are major barriers to effective medication and visit adherence, self-management and lifestyle modification in patients with heart disease.
Thus, the investigators propose an enhanced transitional care intervention that uses the Dallas Information Exchange Portal, a health information technology platform, to link patients to local community organizations at discharge.
Addressing social vulnerabilities to enable better adherence, self-management, and lifestyle behaviors can in turn prevent readmissions and improve downstream health outcomes.
The investigators will conduct a feasibility study of an enhanced transitional care intervention, that will: 1) automate identification and risk-stratification of patients with CHF and IHD with social vulnerabilities; 2) incorporate a new standardized social vulnerabilities screening tool into clinical care; 3) enable electronic referrals to community resources; and 4) add novel community-based interventions to the existing medically-oriented transitional care intervention that is the standard of care at Parkland and other hospitals nationwide.
The investigators will assess feasibility and acceptability of our intervention using measures derived from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation science framework.
Study Type
Interventional
Enrollment (Anticipated)
50
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 Contact
- Name: Oanh K Nguyen, MD
- Phone Number: 415-206-3755
- Email: Oanh.Nguyen@ucsf.edu
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 to 120 years (ADULT, OLDER_ADULT)
Accepts Healthy Volunteers
No
Genders Eligible for Study
All
Description
Inclusion Criteria:
- patients hospitalized with CHF and IHD at high-risk for readmission
Exclusion Criteria:
- none
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
- Primary Purpose: HEALTH_SERVICES_RESEARCH
- Allocation: NON_RANDOMIZED
- Interventional Model: PARALLEL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
EXPERIMENTAL: Congestive Heart Failure (CHF)
The CHF arm will include adults hospitalized with CHF who have been identified as being at high risk for readmission (in the top quintile of risk) by our readmission risk prediction algorithms, and who also have social vulnerabilities present.
All subjects in the CHF arm will receive the Socially Enhanced Transitional Care Intervention.
|
Components: 1) Standardized social vulnerabilities assessment tool, to be developed and incorporated into admission workflows.
2) Electronic community service referrals to existing community resources (i.e.
food banks, shelters, community rehab), via the Dallas IEP or other information technology platform, for material (food, housing) and psychosocial needs (mental health/drug treatment).
3) Community-based cardiovascular self-management interventions, to be developed and piloted in conjunction with #3 - e.g., customized 'heart healthy' food baskets for CHF/IHD; risk factor monitoring (i.e., weight and blood pressure measurement at food banks, shelters, churches, modeled on the barber shop hypertension intervention); and 'heart buddy' support groups for CHF and IHD at community sites.
|
EXPERIMENTAL: Ischemic Heart Disease (IHD)
The IHD arm will include adults hospitalized with IHD who have been identified as being at high risk for readmission (in the top quintile of risk) by our readmission risk prediction algorithms, and who also have social vulnerabilities present.
All subjects in the IHD arm will receive the Socially Enhanced Transitional Care Intervention.
|
Components: 1) Standardized social vulnerabilities assessment tool, to be developed and incorporated into admission workflows.
2) Electronic community service referrals to existing community resources (i.e.
food banks, shelters, community rehab), via the Dallas IEP or other information technology platform, for material (food, housing) and psychosocial needs (mental health/drug treatment).
3) Community-based cardiovascular self-management interventions, to be developed and piloted in conjunction with #3 - e.g., customized 'heart healthy' food baskets for CHF/IHD; risk factor monitoring (i.e., weight and blood pressure measurement at food banks, shelters, churches, modeled on the barber shop hypertension intervention); and 'heart buddy' support groups for CHF and IHD at community sites.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Reach of the intervention ('R' of the RE-AIM Implementation Science Framework)
Time Frame: Up to 12 months
|
Proportion of individuals enrolled, of those who are eligible for the intervention
|
Up to 12 months
|
Effectiveness of the intervention ('E' of the RE-AIM Implementation Science Framework) - Referrals
Time Frame: Up to 12 months
|
Proportion of referrals to community-based service programs that are completed, of referrals that are sent.
'Completed' will be defined as individuals arriving in-person at a community-based service program after a referral is placed.
|
Up to 12 months
|
Effectiveness of the intervention ('E' of the RE-AIM Implementation Science Framework) - Health Services Utilization
Time Frame: Up to 12 months
|
Changes in acute health services use (composite of emergency department visits, hospitalizations) before and after the intervention using interrupted time series
|
Up to 12 months
|
Effectiveness of the intervention ('E' of the RE-AIM Implementation Science Framework) - Satisfaction
Time Frame: Up to 12 months
|
Patient satisfaction with the intervention program using brief verbal questionnaires
|
Up to 12 months
|
Adoption of the intervention ('A' of the RE-AIM Implementation Science Framework)
Time Frame: Up to 12 months
|
Number of community organizations active in referral and information exchange intervention
|
Up to 12 months
|
Implementation of the intervention ('I' of the RE-AIM Implementation Science Framework)
Time Frame: Up to 12 months
|
Acceptability, feasibility, and fidelity to intervention, ascertained through semi-structured interviews of research subjects, discharge planners, case managers, community program directors with thematic analysis of interview findings.
We will ascertain perspectives on all three constructs during interviews and identify common themes across constructs to understand barriers and facilitators to implementation in aggregate
|
Up to 12 months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Readmission rate
Time Frame: Up to 12 months
|
Rate of 30-day readmissions among research subjects.
We anticipate that we will be underpowered to detect a difference with our limited planned enrollment during this pilot feasibility study
|
Up to 12 months
|
Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Collaborators
Investigators
- Principal Investigator: Oanh K Nguyen, MD, University of California, San Francisco
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 (ANTICIPATED)
January 1, 2022
Primary Completion (ANTICIPATED)
December 1, 2022
Study Completion (ANTICIPATED)
December 1, 2022
Study Registration Dates
First Submitted
May 31, 2018
First Submitted That Met QC Criteria
July 27, 2018
First Posted (ACTUAL)
August 2, 2018
Study Record Updates
Last Update Posted (ACTUAL)
June 8, 2021
Last Update Submitted That Met QC Criteria
June 4, 2021
Last Verified
June 1, 2021
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- STU 022016-033
- 1K23HL133441 (NIH)
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
NO
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
No
Studies a U.S. FDA-regulated device product
No
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.
Clinical Trials on Coronary Artery Disease
-
Elixir Medical CorporationIstituto Clinico HumanitasActive, not recruitingCoronary Artery Disease | Chronic Total Occlusion of Coronary Artery | Multi Vessel Coronary Artery Disease | Bifurcation of Coronary Artery | Long Lesions Coronary Artery DiseaseItaly
-
Fundación EPICActive, not recruitingCoronary Artery Disease | Left Main Coronary Artery Disease | Left Main Coronary Artery Stenosis | Restenosis, CoronarySpain
-
Peking Union Medical College HospitalNot yet recruitingCoronary Artery Disease | Inflammation | Coronary Artery Disease Progression | Coronary Artery Stenosis | Coronary Artery Restenosis | Inflammatory Disease | Inflammation VascularChina
-
Peking Union Medical College HospitalRecruitingCoronary Artery Disease | Inflammation | Coronary Artery Disease Progression | Coronary Artery Stenosis | Coronary Artery Restenosis | Inflammatory Disease | Inflammation VascularChina
-
IGLESIAS Juan FernandoUniversity of BernNot yet recruiting
-
National Institutes of Health Clinical Center (CC)National Heart, Lung, and Blood Institute (NHLBI)CompletedCoronary Arteriosclerosis | Coronary Artery Disease (CAD) | Obstructive Coronary Artery DiseaseUnited States
-
Barts & The London NHS TrustImperial College London; Brunel UniversityNot yet recruitingCORONARY ARTERY DISEASE
-
Fundación EPICRecruitingCoronary Artery Disease | Coronary Disease | Coronary Occlusion | Left Main Coronary Artery Disease | Coronary Artery StenosisSpain
-
Abbott Medical DevicesCompletedCoronary Artery Disease | Coronary Disease | Coronary Occlusion | Chronic Total Occlusion of Coronary Artery | Coronary Restenosis | Coronary Artery Stenosis | Coronary Artery RestenosisBelgium
-
China National Center for Cardiovascular DiseasesRecruitingLeft Main Coronary Artery DiseaseChina
Clinical Trials on Socially Enhanced Transitional Care Intervention
-
Rush University Medical CenterCompletedPatient Discharge | Patient AdmissionUnited States
-
Mayo ClinicCompletedPalliative Care | Transitional CareUnited States
-
Duke UniversityUniversity of North Carolina, Chapel HillCompletedBrain Injuries, Traumatic | Patients | Family Members | Transitional CareUnited States
-
McMaster UniversityHamilton Health Sciences Corporation; Ontario Ministry of Health and Long Term... and other collaboratorsCompleted
-
Radboud University Medical CenterUniversity of Pecs; University Hospital, Bonn; University of Navarra; Lancaster... and other collaboratorsNot yet recruiting
-
Institute for Clinical Evaluative SciencesCompleted
-
University of Massachusetts, WorcesterCompleted
-
The Hong Kong Polytechnic UniversityHospital Authority, Hong KongCompletedPalliative Care | Renal Failure, End-stageHong Kong
-
Baylor College of MedicineM.D. Anderson Cancer Center; Harris County Hospital District; Texas A&M University and other collaboratorsCompleted
-
Assistance Publique - Hôpitaux de ParisNot yet recruitingHospital Readmissions of Elderly PatientsFrance