Triage of frail elderly with reduced exercise tolerance in primary care (TREE). A clustered randomized diagnostic study

Abstract

Background: Exercise reduced tolerance and breathlessness are common in the elderly and can result in substantial loss in functionality and health related quality of life. Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common underlying causes, but can be difficult to disentangle due to overlap in symptomatology. In addition, other potential causes such as obesity, anaemia, renal dysfunction and thyroid disorders may be involved.We aim to assess whether screening of frail elderly with reduced exercise tolerance leads to high detection rates of HF, COPD, or alternative diagnoses, and whether detection of these diseases would result in changes in patient management and increase in both functionality and quality of life.

Methods/design: A cluster randomized diagnostic trial. Primary care practices are randomized to the diagnostic-treatment strategy (screening) or care as usual.

Patient population: Frail (defined as having three or more chronic or vitality threatening diseases and/or receiving five or more drugs chronically during the last year) community-dwelling persons aged 65 years and older selected from the electronic medical files of the participating general practitioners. Those with reduced exercise tolerance or moderate to severe dyspnoea (≥2 score on the Medical Research Counsel dyspnoea scale) are included in the study.The diagnostic screening in the intervention group includes history taking, physical examination, electrocardiography, spirometry, blood tests, and echocardiography. Subsequently, participants with new diagnoses will be managed according to clinical guidelines. Participants in the control arm receive care as usual. All participants fill out health status and other relevant questionnaires at baseline and after 6 months of follow-up.

Discussion: This study will generate information on the yield of screening for previously unrecognized HF, COPD and other chronic diseases in frail elderly with reduced exercise tolerance and/or exercise induced dyspnoea. The cluster randomized comparison will reveal whether this yield will result in subsequent improvements in functional health and/or health related quality of life.

Trial registration: ClinicalTrials.gov NCT01148719.

Figures

Figure 1

Study scheme. S = small (2400 patients), M = medium (4800 patients), L = large (7200 patients), COPD = chronic obstructive pulmonary disease, HF = heart failure, MDS = Minimal Data Set, SF36 = 36 Item Short-Form Health status questionnaire, PE = physical examination, ECG = electrocardiogram, VAS = visual analog scale, MRC = Medical Research Council dyspnoea questionnaire, GP = general practitioner, #other includes cognitive problems (like dementia) and unable to travel to the general practice, *after sending 2 written invitations.