Models of Care in the Transition From the Secondary to the Primary Sector Among the Frailest Elderly

Not Applicable

Completed

• Conditions: Frail Elderly Syndrome; Frailty; Readmission; Transitional Care; Aging; Elderly
• Interventions: Other: Early follow-up visit after discharge; Other: Possible follow-up visit from GP; Other: Comprehensive geriatric assessment (CGA); Other: Continued geriatric care

• Registration Number: NCT03796923
• Lead Sponsor: University of Aarhus

Brief Summary

In most Western countries the elderly population increases rapidly. In Denmark, the population of elderly aged 75 years or older may amount to nearly 15 % of the entire population in 2050 compared to 9 % today (2017). A large part of the elderly population is at high risk of hospitalization including more admissions and increased morbidity and mortality. The number of hospital beds is declining persistently, calling for shorter lengths of stay (LOS). Increasingly complex treatments now take place outside hospital. Presently, many Danish regional hospitals establish geriatric wards and other geriatric in-hospital and outpatient services to overcome these challenges. The aim of the present PhD-study is to investigate the effects of different models of transitional care among the frailest elderly patients.

Detailed Description

Design Population: The frailest acutely admitted geriatric patients aged +75. Intervention: Early follow-up visits after discharge. Comparison: Usual care follow-up. Outcomes: The primary outcome is readmission within 30 days after discharge. Secondary outcomes are: mortality 30 days after discharge and 90 days after admission, length of stay (LOS), direct discharge from the Emergency Department, time at home before readmission, duration of readmission and physical functional status 30 days after discharge.

Methods The first study is conducted as a randomized controlled trial (RCT) using two different degrees of intervention. The second study is a cohort study of an unexposed control group. The third study is sub-group analyses of the RCT data according to frailty status and type of dwelling.

A focus group comprised of included patients and relatives will be set to identify additional patient related outcome measures (PROMs) and to participate in an advisory group throughout the remaining project.

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations

Study Timeline

• Study Start: 2018-01-01
• Study First Submitted: 2019-01-02
• Study First Submitted QC: 2019-01-04
• Study First Posted: 2019-01-08
• Primary Completion: 2020-09-16
• Study Completion: 2020-11-16
• Status Verified: 2021-04
• Last Update Submitted: 2021-04-29
• Last Update Posted: 2021-04-30

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 3340

Inclusion Criteria

Not provided

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Exclusion Criteria

Not provided

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Intervention I	Early follow-up visit after discharge	Intervention (I): early follow-up visit from the community nurse within 24 hours after discharge
Intervention I	Comprehensive geriatric assessment (CGA)	Intervention (I): early follow-up visit from the community nurse within 24 hours after discharge
Intervention II	Comprehensive geriatric assessment (CGA)	Intervention (II): early follow-up by the geriatric team within 24 hours after discharge
Intervention II	Continued geriatric care	Intervention (II): early follow-up by the geriatric team within 24 hours after discharge
Control	Possible follow-up visit from GP	Usual care: individualized follow-up performed by the GP and municipality services
Intervention II	Early follow-up visit after discharge	Intervention (II): early follow-up by the geriatric team within 24 hours after discharge

Primary Outcome Measures

Name	Time	Method
Readmission	30 days	Readmission within 30 days after discharge

Secondary Outcome Measures

Name	Time	Method
Length of stay (LOS)	30 days after primary discharge	Length of stay during primary admission and total length of stay including following readmissions
Mortality	90 days after admission and 30 days after primary discharge	Mortality within 90 days after admission and 30 days after discharge

Trial Locations

Locations (1)

Aarhus University; 🇩🇰 Aarhus, Denmark