NCT02815462

Brief Summary

In an earlier study using electronic health records (EHR), the investigators have identified nine factors to be significantly associated with FA risk. These nine predictors include Furosemide intravenous 40 milligrams or more; Admissions in the past one year; Medifund status; Frequent emergency department use; Anti-depressants treatment in past one year; Charlson comorbidity index; End Stage Renal Failure on dialysis; Subsidized ward stay and Geriatric patient. The investigators have combined these nine predictors into the FAM-FACE-SG score for FA risk (defined as 3 or more inpatient admissions in the following 12 months). The FAM-FACE-SG risk score has the advantage of being deployed in our hospital's enterprise data repository known as Electronic Health Intelligence System or eHINTs for short, on a real-time or near real-time basis. On a daily basis, data from multiple data sources are extracted, transformed and loaded onto the eHINTS system. The system can be programmed to run every midnight to provide risk scores the following morning for patients admitted the previous day. In this trial, the intervention is to combine the FAM-FACE-SG risk score in addition to a decision making algorithm to guide referrals to various transitional care services based on needs assessment on nursing and function. The primary objective is to evaluate the impact of our intervention in improving healthcare utilization (hospital readmissions, emergency department (ED) attendances, length of stay up to 90 days post-discharge).

Trial Health

30
At Risk

Trial Health Score

Automated assessment based on enrollment pace, timeline, and geographic reach

Trial has exceeded expected completion date
Timeline
Completed

Started Aug 2016

Geographic Reach
1 country

1 active site

Status
withdrawn

Health score is calculated from publicly available data and should be used for screening purposes only.

Trial Relationships

Click on a node to explore related trials.

Study Timeline

Key milestones and dates

First Submitted

Initial submission to the registry

June 20, 2016

Completed
8 days until next milestone

First Posted

Study publicly available on registry

June 28, 2016

Completed
1 month until next milestone

Study Start

First participant enrolled

August 1, 2016

Completed
1 year until next milestone

Primary Completion

Last participant's last visit for primary outcome

August 1, 2017

Completed
Same day until next milestone

Study Completion

Last participant's last visit for all outcomes

August 1, 2017

Completed
Last Updated

April 28, 2023

Status Verified

April 1, 2023

Enrollment Period

1 year

First QC Date

June 20, 2016

Last Update Submit

April 26, 2023

Conditions

Patient Readmission

Keywords

Frequent hospital admissionsRisk stratificationReadmissions

Outcome Measures

Primary Outcomes (1)

  • 90-day readmission rate

    90 days

Secondary Outcomes (9)

  • 30-day readmission rate

    30 days

  • 30-day ED attendance rate

    30 days

  • 90-day ED attendance rate

    90 days

  • index hospital admission length of stay

    90 days

  • cumulative length of stay 90 days after index hospital discharge

    90 days

  • +4 more secondary outcomes

Study Arms (2)

Intervention

EXPERIMENTAL

FAM-FACE-SG risk score + decision making algorithm

Other: FAMFACESG

Control

ACTIVE COMPARATOR

Usual Care

Other: Control

Interventions

FAMFACESGOTHER

\- PNs will receive the FAM-FACE-SG FA risk scores for frequent admitters admitted to their ward.

Intervention
ControlOTHER

\- Usual hospital Care

Control

Eligibility Criteria

Age21 Years+
Sexall
Healthy VolunteersNo
Age GroupsAdult (18-64), Older Adult (65+)

You may qualify if:

  • Singapore General Hospital wards with patient navigators
  • Patients who are frequent admitters (defined as 3 or more hospital admissions in the preceding 12 months)

You may not qualify if:

  • Haematology, Oncology, Emergency department, obstetrics and neonatology wards

Contact the study team to confirm eligibility.

Sponsors & Collaborators

Study Sites (1)

Singapore General Hospital

Singapore, 486838, Singapore

Location

Related Publications (5)

  • Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-85. doi: 10.1146/annurev-med-022613-090415. Epub 2013 Oct 21.

    PMID: 24160939BACKGROUND

  • Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. doi: 10.1056/NEJMsa0803563.

    PMID: 19339721RESULT

  • Robst J. Developing Models to Predict Persistent High-Cost Cases in Florida Medicaid. Popul Health Manag. 2015 Dec;18(6):467-76. doi: 10.1089/pop.2014.0174. Epub 2015 Jun 23.

    PMID: 26102363RESULT

  • Longman JM, I Rolfe M, Passey MD, Heathcote KE, Ewald DP, Dunn T, Barclay LM, Morgan GG. Frequent hospital admission of older people with chronic disease: a cross-sectional survey with telephone follow-up and data linkage. BMC Health Serv Res. 2012 Oct 30;12:373. doi: 10.1186/1472-6963-12-373.

    PMID: 23110342RESULT

  • Low LL, Vasanwala FF, Ng LB, Chen C, Lee KH, Tan SY. Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study. BMC Health Serv Res. 2015 Mar 14;15:100. doi: 10.1186/s12913-015-0750-2.

    PMID: 25888830RESULT

Study Officials

  • Lian Leng Low

    Singapore General Hospital

    PRINCIPAL INVESTIGATOR
0

Study Design

Study Type
interventional
Phase
not applicable
Allocation
RANDOMIZED
Masking
NONE
Purpose
HEALTH SERVICES RESEARCH
Intervention Model
PARALLEL
Sponsor Type
OTHER
Responsible Party
SPONSOR

Study Record Dates

First Submitted

June 20, 2016

First Posted

June 28, 2016

Study Start

August 1, 2016

Primary Completion

August 1, 2017

Study Completion

August 1, 2017

Last Updated

April 28, 2023

Record last verified: 2023-04

Locations

SG(1)