Ambulatory Care Sensitive Conditions
Conditions
Keywords
Transitional Care, Ambulatory Care Sensitive Conditions, Remote Patient Monitoring, Patient Readmission, Patient Discharge
Brief summary
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.
Interventions
BEHAVIORALPharmacist-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 other Primary Health Care professionals, when necessary.
Sponsors
Hospital de Clinicas de Porto Alegre
Institute of Artificial Intelligence in Health
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
OTHER
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* 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).
Exclusion criteria
* 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.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge | 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. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of participants who died within 180 days after hospital discharge | From enrollment until 180 days after hospital discharge | Proportion of participants who died within 180 days after hospital discharge, assessed through caregiver reports and medical records. |
| Proportion of participants who fully or predominantly completed the actions outlined in the individualized care plan | From enrollment until 180 days after hospital discharge | Proportion of participants who fully or predominantly completed the actions outlined in the individualized care plan, as documented in pharmacist teleconsultations and medical records. An individualized care plan will be developed for each participant based on the Clinical Protocols and Therapeutic Guidelines of the Brazilian Ministry of Health and will include agreed-upon actions. Throughout the follow-up period, completion of the planned actions will be documented. Participants will be considered adherent to the care plan if there is documentation that they completed all planned actions or at least 75% of them within the defined period. |
| Satisfaction with continuous pharmacist-led care | From enrollment until 180 days after hospital discharge | Satisfaction with continuous pharmacist-led care will be assessed using the Net Promoter Score (NPS), based on the standard question: "On a scale from 0 to 10, how likely are you to recommend pharmacist-led telecare to a friend or family member?". Respondents will be classified as promoters (score 9-10), passives (score 7-8), or detractors (score 0-6). The NPS will be calculated as the difference between the percentage of promoters and the percentage of detractors, resulting in a score ranging from -100 to +100 (NPS = % Promoters - % Detractors). |
Countries
Brazil
Contacts
CONTACTBianca V Bianchini, PhD
STUDY_CHAIRDiego Gnatta, PhD
Federal University of Rio Grande do Sul
Outcome results
None listed