Impact of Pharmacist-led Care Navigation Mediated by Digital Health Tools on Hospital Readmissions After Discharge: a Randomized Clinical Trial.
试验速览
- 阶段
- 不适用
- 状态
- 尚未招募
- 入组人数
- 3,220
- 试验地点
- 1
- 主要终点
- Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge
研究概览
简要总结
Hospitalizations for Primary Care-Sensitive Conditions (PCSCs) are potentially avoidable hospital admissions that may be prevented when Primary Health Care provides effective and timely care through prevention, early diagnosis, appropriate management of chronic conditions, and control of acute episodes.
This study proposes an open-label, pragmatic, cluster-randomized clinical trial to evaluate the effectiveness of continuous telecare, supported by digital health tools, in the post-discharge follow-up of patients hospitalized for PCSCs.
The main outcome will be the occurrence of non-elective hospital readmissions and urgent or emergency care visits within 180 days after discharge, compared with usual care.
The intervention will include pharmacist-led teleconsultations, a communication channel through a messaging app, and the development of an individualized care plan. Participants in the control group will receive the usual care provided by the healthcare network.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Other
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Individuals aged 18 years or older;
- •Residing in the municipality of Porto Alegre;
- •Hospitalized at Hospital de Clínicas de Porto Alegre for selected Primary Care-Sensitive Conditions (PCSCs): respiratory diseases (such as asthma, chronic obstructive pulmonary disease, and tuberculosis), cardiovascular diseases (such as arterial hypertension, angina, and heart failure), cerebrovascular diseases (such as stroke), and metabolic diseases (such as diabetes mellitus).
排除标准
- •Individuals who are unable to be contacted by telephone;
- •Individuals with language or cognitive barriers that cannot be overcome with the assistance of a caregiver or legal representative;
- •Individuals participating in another clinical trial that conflicts with the present study.
研究组 & 干预措施
Pharmacist-led teleconsultations
Continuous pharmacist-led care program supported by digital health tools, which will include: three pharmacist teleconsultations, with the first consultation within 15 days after hospital discharge, the second within 30 days, and the third within 90 days; an open communication channel through a messaging app; an individualized care plan; and referrals to Primary Health Care professionals, when necessary.
干预措施: Pharmacist-led teleconsultations (Behavioral)
Usual care
Usual care provided by the hospital and Primary Health Care services, without implementation of the structured pharmacist-led care program supported by digital health tools.
结局指标
主要结局
Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge
时间窗: From enrollment until 180 days after hospital discharge
Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge, assessed through patient/caregiver reports during follow-up visits and electronic medical records.
次要结局
- Proportion of participants who died within 180 days after hospital discharge(From enrollment until 180 days after hospital discharge)
- Proportion of participants who fully or predominantly completed the actions outlined in the individualized care plan(From enrollment until 180 days after hospital discharge)
- Satisfaction with continuous pharmacist-led care(From enrollment until 180 days after hospital discharge)