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One of the most cost effective intervention is to avoid unnecessary hospitalizations in the national health system. These unnecessary admissions are increasing for several years, reaching rates of over 30% in patients with chronic obstructive pulmonary disease (COPD) or heart failure at two months of hospital discharge. There is scientific evidence suggesting that a multidisciplinary intervention consisting in controling disease and stress associated with disease, and modifying eating habits could reduce the number of hospitalizations due to disease decompensation.
The main objective of the study is to assess the rate of readmissions at year of multidisciplinary intervention in patients with COPD and / or heart failure.
We will select 144 patients who will be randomized to two groups (control and intervention group) and they will be followed for 12 months through 4 visits (1 month, 3 months, 6 months and 12 months of hospital discharge).
Patients assigned to the intervention group will be receive three educational sessions (one of them will be imparted by nursing, another by the nutritionist and the last one by the psychologist). In addition, patients with a BMI <20 and / or> 30 will receive a closer monitoring by the nutritionist).
Patients assigned to the control group will receive usual care in clinical practice.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Control group | No Intervention | Habitual Clinical Practice | |
| Intervention Group | Experimental | Multidisciplinary intervention consisting in controlling disease and stress associated to it, and modifying eating habits. A Nurse, nutritionist and a psychologist will be the responsible of these educational sessions. it will be three educational sessions. Patients with a BMI lower than 20 or bigger than 30 will be receive a closer follow up by nutritionist. In addition, patients with a score of 9 or more in the Patients Health Questionnaire-9 questionnaire will be also a closer follow up with the psychologist. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Multidisciplinary Intervention | Behavioral | Health education sessions consisting in controlling disease and stress asociated to it, and modifying eating habits |
|
| Measure | Description | Time Frame |
|---|---|---|
| Readmission rate | in the twelve months following the intervention, according to the electronic record of the hospital | 12 months |
| Measure | Description | Time Frame |
|---|---|---|
| Number of admissions to emergency service or number of visits to general practitioner's office or number of visits to emergency service | 12 months | |
| time until the first admission to the hospital | it wil be measured at 12 months |
| Measure | Description | Time Frame |
|---|---|---|
| HbA1c | glycated hemoglobin | at month, 3, 6 and 12 months |
| Type B natriuretic peptide (BNP), blood pressure | At month, 3, 6 and 12 months of discharge |
Inclusion Criteria:
Exclusion Criteria:
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Araba Universitary Hospital (Txagorritxu) | Recruiting | Vitoria-Gasteiz | Alava | 01009 | Spain |
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| ID | Term |
|---|---|
| D029424 | Pulmonary Disease, Chronic Obstructive |
| D006333 | Heart Failure |
| ID | Term |
|---|---|
| D008173 | Lung Diseases, Obstructive |
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
| D002908 | Chronic Disease |
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| time until first visit to general practitioner's office | it will be measured at 12 months |
| time until the first visit to emergency service | it will be measured at 12 months |
| Health related quality of life through several questionnaires | COPD Assessment Test (CAT), self efficacy scale in COPD patients, SORT Form-36, Patient Health Questionnaire-9, Minnesota Living with Heart Failure Questionnaire (MLHFQ), Physical Activity Questionnaire (IPAQ), Barthel Index, European heart failure self-care behaviour scale. | At month, 3, 6 and 12 months after discharge |
| APACHE III INDEX, Functional Category of New York Heart Association (NYHA) | 1 day |
| D020969 |
| Disease Attributes |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D006331 | Heart Diseases |
| D002318 | Cardiovascular Diseases |