Arthritis, Chronic Kidney Disease, Chronic Liver Diseases, Cognitive Impairment, Coronary Artery Disease, Depression - Major Depressive Disorder, Diabetes Mellitus, Dyslipidemia, Hypertension, Multimorbidity, Stroke
Conditions
Keywords
management service package, multimorbidity, quality of life, intrinsic capacity
Brief summary
This study aims to test a new comprehensive management service package for older adults with two or more chronic conditions (multimorbidity). The package includes digital health tools, personalized guidance, and long-term management support. Researchers will compare the service package with usual care to see whether it reduces hospital readmissions, improves quality of life, and supports daily functioning. About 394 participants will be randomly assigned to either the service package group or the usual care group. Participants will be followed for 6 months to measure health outcomes, treatment adherence, and safety.
Detailed description
The goal of this clinical trial is to learn if a new comprehensive management service package can help improve health outcomes for older adults who have two or more chronic conditions (multimorbidity). It will also learn about the safety, acceptability, and cost-effectiveness of the service package. The main questions it aims to answer are: 1. Does the service package lower the number of hospital readmissions in older adults with multimorbidity? 2. Does it improve quality of life, daily function (intrinsic capacity), and treatment adherence? 3. What are the costs and potential risks of using the service package compared to usual care? Researchers will compare the service package to usual care (no service package). Participants will: 1. Be randomly assigned to either the service package group or the usual care group 2. Use the digital tools and health management support included in the service package (such as apps, monitoring devices, and personalized health guidance) 3. Receive regular follow-up visits and surveys over 6 months to track their health, hospital use, and satisfaction
Interventions
DEVICEService Package Group
patients receive comprehensive multimorbidity management service package (digital tools, MDT decision support, lifestyle interventions, long-term management tools).
Sponsors
Xuanwu Hospital, Beijing
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Age ≥65 years 2. Diagnosed with ≥2 chronic diseases or geriatric syndromes (e.g., hypertension, diabetes, frailty, depression) 3. Willing to provide informed consent
Exclusion criteria
1. Life expectancy \<1 year due to severe illness (e.g., cardiogenic shock) 2. Currently participating in other clinical trials
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Hospital readmission rate | 6 months | Hospital readmission rate |
Contacts
Primary ContactYin Chun Lin, PhD
Outcome results
None listed