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.
Studieoversigt
Status
Status
Betingelser
Betingelser
Intervention / Behandling
Intervention / Behandling
Undersøgelsestype
Undersøgelsestype
Tilmelding (Faktiske)
Tilmelding
Fase
Fase
- Ikke anvendelig
Kontakter og lokationer
Studiesteder
-
-
-
Holbæk, Danmark, 4300
- Medicinsk Afdeling, Holbæk Sygehus
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-
Deltagelseskriterier
Berettigelseskriterier
Berettigelseskriterier
Aldre berettiget til at studere
Tager imod sunde frivillige
Køn, der er berettiget til at studere
Beskrivelse
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.)
Studieplan
Hvordan er undersøgelsen tilrettelagt?
Design detaljer
- Primært formål: Forebyggelse
- Tildeling: Randomiseret
- Interventionel model: Parallel tildeling
- Maskning: Enkelt
Antal våben
Våben og indgreb
Deltagergruppe / ArmDeltagergruppe / Arm |
Intervention / BehandlingIntervention / Behandling |
|---|---|
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Eksperimentel: Follow-up visit
Receive municipality-based follow-up visit including primary physician.
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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.
Andre navne:
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Ingen indgriben: Usual care
Does not receive follow-up visit
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Hvad måler undersøgelsen?
Primære resultatmål
Primære resultatmål
Resultatmål |
Foranstaltningsbeskrivelse |
Tidsramme |
|---|---|---|
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Re-admission
Tidsramme: Within 30 days from discharge
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The primary outcome is re-hospitalisation rate within 30 days from discharge.
Data is obtained from the official register of danish patients (Landspatientregistret).
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Within 30 days from discharge
|
Sekundære resultatmål
Sekundære resultatmål
Resultatmål |
Foranstaltningsbeskrivelse |
Tidsramme |
|---|---|---|
|
Long-term hospitalization rate
Tidsramme: Within 180 days from discharge
|
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
|
Andre resultatmål
Andre resultatmål
Resultatmål |
Foranstaltningsbeskrivelse |
Tidsramme |
|---|---|---|
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Long-term death rate
Tidsramme: Within 180 days from discharge
|
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).
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Within 180 days from discharge
|
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Long-term use of primary health care services
Tidsramme: Within 180 days from discharge
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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.
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Within 180 days from discharge
|
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Long-term use of secondary health care services
Tidsramme: Within 180 days from discharge
|
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
|
Samarbejdspartnere og efterforskere
Sponsor
Sponsor
Samarbejdspartnere
Samarbejdspartnere
Efterforskere
Efterforskere
- Ledende efterforsker: Thomas Gjørup, Medicinsk Afdeling, Holbæk Sygehus
Publikationer og nyttige links
Datoer for undersøgelser
Studer store datoer
Studiestart
Studiestart
Primær færdiggørelse (Faktiske)
Primær færdiggørelse
Studieafslutning (Faktiske)
Studieafslutning
Datoer for studieregistrering
Først indsendt
Først indsendt
Først indsendt, der opfyldte QC-kriterier
Først indsendt, der opfyldte QC-kriterier
Først opslået (Skøn)
Først opslået
Opdateringer af undersøgelsesjournaler
Sidste opdatering sendt (Skøn)
Sidste opdatering sendt
Sidste opdatering indsendt, der opfyldte kvalitetskontrolkriterier
Sidste opdatering indsendt, der opfyldte kvalitetskontrolkriterier
Sidst verificeret
Sidst verificeret
Mere information
Begreber relateret til denne undersøgelse
Yderligere relevante MeSH-vilkår
Andre undersøgelses-id-numre
Andre undersøgelses-id-numre
- 3800H0.52-0059
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