Alice Springs Hospital Readmission Prevention Project: Analysis of a multi-dimensional transitional care program in patients frequently admitted to hospital

Not Applicable

• Conditions: chronic non-communicable diseases; Frequent hospital readmission; Aboriginal Australian health; Cardiovascular - Coronary heart disease; Respiratory - Chronic obstructive pulmonary disease; Public Health - Health service research

• Registration Number: ACTRN12615000808549
• Lead Sponsor: Baker IDI Heart and Diabetes Institute

Brief Summary

Not available

Detailed Description

Not available

Study Timeline

• Results First Posted: 1900-01-01
• Study Start: 2015-08-04
• Last Update Posted: 13 January 2020

Recruitment & Eligibility

• Status: Stopped early
• Sex: All
• Target Recruitment: 210

Inclusion Criteria

4 or more adult medical/surgical admissions over the preceding 12 months OR more than 7 admissions over the past 24 months
-A surgical admission is deemed appropriate if related to a patient's chronic disease eg. diabetic foot infections, chronic pancreatitis, cellulitis
2. Resident of Central Australia (including the cross border regions of Western Australia and
South Australia and extending north to Elliot in the Northern Territory).

Exclusion Criteria

1. Median life expectancy of 12 months or less based on independent specialist (including
subspecialist physician) assessment
2. Stage 5 chronic kidney disease (eGFR < 15ml/min or receiving renal replacement therapy)
3. Solid organ transplant (including renal transplant)
4. Ongoing palliative care service review
5. Previous enrollment in the study (such subjects will have on-going care as per original
study allocation)

Study & Design

• Study Type: Interventional
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
Rate of all-cause readmission (calculated as readmissions/month follow-up)<br>-This will be assessed using data linkage with hospital medical records[12 months following enrolment]