Patients at Risk of Hospital Admission
Conditions
Brief summary
Proactive Health Support is a randomized controlled trial of telephone-based self-management support. The primary aim of the intervention is to reduce hospital admissions and improve quality of life in patients with a high risk of hospital admission.
Detailed description
Participants are identified through an algorithm, that assigns each patient with a risk score of 0-100%. Patients with the highest risk in each of the five regions of Denmark are invited to participate.
Interventions
BEHAVIORALProactive Health Support
Active listening, coaching and counselling
Sponsors
Frederiksberg University Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
NONE
Intervention model description
Randomized controlled trial with 1:1 randomization stratified for risk of hospital admission and region
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Persons with a hospital contact within the last year caused by ≥ 1 of the following diagnoses: heart diseases (DI110, DI130, DI132, DI50), connective tissue diseases (DD86, DM05, DM06, DM08, DM09, DM30, DM31, DM32, DM33, DM34, DM35, DM36), pulmonary diseases (DJ40, DJ41, DJ42, DJ43, DJ44, DJ45, DJ46, DJ47, DJ60, DJ61, , DJ62, DJ63, DJ64, DJ65, DJ66, DJ67, DJ684, DJ701, DJ703, DJ841, DJ842, DJ843, DJ848, DJ849, DJ920, DJ961, DJ982, DJ983) or diabetes (DE10, DE11, DE14) Or * Persons ≥ 18 years and ≥ three unplanned hospital admissions in the last six months Or * Persons ≥ 65 years with a preventable hospital admission (predefined diagnoses: dehydration, constipation, lower respiratory tract infections, urinary tract infections, gastroenteritis, fractures, nutrition deficiency anemia, social causes and pressure ulcers) or a readmission (within 30 days)
Exclusion criteria
* Selected psychiatric diagnoses: substance abuse disorder (DF1), schizophrenia (DF2) or dementia (DF00, DF01, DF02, DF03, DF051) * Metastatic cancer (DC77, DC78, DC79, DC80) * Assisted living Facility * Documented terminal illness or life expectancy \< one year * Assessment of dementia * Major surgery planned within 6 months * Hearing impairment * Not speaking Danish * Cognitive impairment * Substance abuse, that impairs adherence * No telephone * Receiving similar trial intervention * Other (including intervention not suitable)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Hospital admissions | 6 months | — |
| Quality of life | 6 months | Questionnaire SF 36 - Mental Health Composite Score (Norm-based T-score of 45-55 is considered normal) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Use of primary healthcare | 3, 6 and 12 months | — |
| Use of prescription medication | 3, 6 and 12 months | — |
| Survival | 1 year | — |
| Patient education | 3, 6 and 12 months | Questionnaire Hei-Q - all 8 subscales (health-directed activities, positive and active engagement in life, emotional distress, self-monitoring and insight, constructive attitudes and approaches, skill and technique acquisition, social integration and support, health service navigation, range 1-4) |
| Incremental cost effectiveness ratio by comparison of costs with quality adjusted life years | 3, 6 and 12 months | — |
| Regional differences in resource use and costs | 3, 6 and 12 months | — |
| Resource use in primary care and rehabilitation | 3, 6 and 12 months | — |
| Quality of life | 3, 6 and 12 months | Questionnaire SF36: All eight subscales (physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, mental health and health transition, range 0-100. Furthermore, norm-based T-scores are reported, 45-55 is considered normal) and two composite scores (mental and physical health, norm-based T-score of 45-55 is considered normal) |
| Outpatient consultations | 3, 6 and 12 months | — |
Countries
Denmark
Outcome results
None listed