chronische ziekten frailty multimorbidity
Conditions
Interventions
1. Periodic (quarterly) Risk Identification of frailty and Monitoring of care
to older people (UPRIM) in electronic medical records of the general practice.
2. UPRIM plus the introduction of a specia
Sponsors
Universitair Medisch Centrum Utrecht
Eligibility
Age
18 Years to 99 Years
Inclusion criteria
Inclusion criteria: Potentially frail older people; patients of 60 years and older in general practice setting with one or more of the following three criteria: - multimorbidity (defined as a frailty index score of 0.20 or higher, for eleborate details see chapter 5 of the protocol), AND/OR - polypharmacy (5 or more different drugs in actual chronic use), AND/OR - care gap (more than three years no contact with the general practice, except for the yearly influenzae vaccination)
Exclusion criteria
Exclusion criteria: - terminally ill patients - patients living in an elderly care home or nursing home - patients on a waiting list for an elderly care home or nursing home
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| The primary outcome parameter is change in daily functioning. Daily functioning (ADL) is measured with the Katz 15 questionnaire which is embedded in the Minimal Data Set questionnaire. | — |
Secondary
| Measure | Time frame |
|---|---|
| Secondary outcome parameters are: 1. Quality of life (RAND-36, EQ5D, both embedded in the Minimal Data Set) 2. Care use (number of referrals, admittances, prescriptions, diagnoses and visits) expressed in: a) number of *elective* interventions in secondary care (planned admittances); b) number of *emergency* admittances in secondary care, nursing homes and older people homes homes; c) number of contacts with the general practitioner*s surgeries, outside the regular hours; d) number of contacts with the healthcare assistant, the general practitioner, the general practice assistant and GNPC; e) medication use, dysfunctional and functional polypharmacy; f) consultation with other primary carers (AMW (General Social Work), physiotherapy, homecare); 3. Mortality 4. Cost-effectiveness analysis (CEA) For the CEA, the ratio of differences in the main outcome measure - (I)ADL - between the three groups and differences in costs will be analyzed. 5. Patient satisfaction Patient satisfaction will be measured in the Minimal Data Set. 6. Comparison of frailty index courses between groups, with particular attention to the proportion of patients with polypharmacy, multimorbidity and a care gap of > 3 years. Secondly, focus on the correlation of frailty index scores with daily functioning and quality of life as reported in the Minimal Data Set. 7. Time spent on informal caring and burden of this care for the informal carer; health status and quality of life of informal carer. The secundary outcome parameters are partly measured with the extraction of routine care data by UPRIM, and partly with data acquired in the Minimal Data Set questionnaires (the MDS for the participants as well as for the informal carers). | — |
Countries
Netherlands
Outcome results
None listed