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| Name | Class |
|---|---|
| Region Sjælland | OTHER |
| Danish Institute for Public Health | OTHER |
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The purpose of this study is to determine whether discharge follow-up visit by primary physician and community-based nurse affects the risk of early re-hospitalisation among high risk older people discharged from a medical ward.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Follow-up visit | Experimental | Receive municipality-based follow-up visit including primary physician. |
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| Usual care | No Intervention | Does not receive follow-up visit |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Receive municipality-based follow-up visit | Behavioral | Systematic electronic referral from hospital to municipality of high risk people at discharge from a medical ward. Contact from municipality service to primary physician and citizen, to arrange first home visit within 7 days with focus on: medication, rehabilitation plan and health care appointments, functional level and need for further health care initiatives. The visit is concluded by planning of further visits (up till tree) and division of responsibilities between primary physician and the municipality service. |
| Measure | Description | Time Frame |
|---|---|---|
| Re-admission | The primary outcome is re-hospitalisation rate within 30 days from discharge. Data is obtained from the official register of danish patients (Landspatientregistret). | Within 30 days from discharge |
| Measure | Description | Time Frame |
|---|---|---|
| Long-term hospitalization rate | Secondary outcome concerns hospitalization rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret). | Within 180 days from discharge |
| Measure | Description | Time Frame |
|---|---|---|
| Long-term death rate | Other pre-specified outcome concerns death rate measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret). | Within 180 days from discharge |
| Long-term use of primary health care services |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Thomas Gjørup | Medicinsk Afdeling, Holbæk Sygehus | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Medicinsk Afdeling, Holbæk Sygehus | Holbæk | 4300 | Denmark |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 26059872 | Derived | Thygesen LC, Fokdal S, Gjorup T, Taylor RS, Zwisler AD; Prevention of Early Readmission Research Group. Can municipality-based post-discharge follow-up visits including a general practitioner reduce early readmission among the fragile elderly (65+ years old)? A randomized controlled trial. Scand J Prim Health Care. 2015 Jun;33(2):65-73. doi: 10.3109/02813432.2015.1041831. Epub 2015 Jun 10. |
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| ID | Term |
|---|---|
| D000073496 | Frailty |
| ID | Term |
|---|---|
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
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Other pre-specified outcome concerns the use of primary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of primary health care in Denmark (Sygesikringsregistret) and registration from 3 Danish municipalities. |
| Within 180 days from discharge |
| Long-term use of secondary health care services | Other pre-specified outcome concerns the use of secondary health care services measured at 30 and 180 days post discharge. Data is obtained from the official register of Danish patients (Landspatientregistret). | Within 180 days from discharge |