Enhanced Primary Care for Elderly

NCT03180606 | Completed

• 1 other identifier: Elderly care 2016-347-31
• Study Type: observational
• Target: 1,304
• Locations: 1 country
• Sites: 2

Brief Summary

The present health care situation for the elderly in many countries is insufficient and not designed according to the health care needs of the aged population. In a pragmatic multicenter primary care setting (n= 1600), the investigators use an evidence based prediction model to find elderly (75+) with high risk for complex medical care or hospitalization and apply a differentiated and directed medical and social care to this risk group, in comparison to usual care. The intervention will include all the latest evidence based tools in the care of elderly (multi-professional team, social support, medical care home-visits, telephone support, general practitioner visits, etc). The project has high potential impact on the development of future care of elderly. In addition to the intervention study, several academic sub-studies focusing on patient's perspective, professional roles, equality, implementation and governance management of health care will be performed.

Conditions

Frail Elderly Syndrome

Keywords

Elderly; Frail; Primary care

Outcome Measures

Primary Outcomes (1)

• Hospital care days

  The number of days in hospital

  January 1st 2018 - December 31st 2019

Secondary Outcomes (4)

• Hospital care occasions

  January 1st 2018 - December 31st 2019

• Health related quality of life

  January 1st 2018 - December 31st 2019

• Costs for health care

  January 1st 2018 - December 31st 2019

• Mortality

  January 1st 2018 - December 31st 2019

Study Arms (2)

Predicted and personalized primary care

Elderly 75 years of age and older in primary care with high risk of being fragile and future risk of needing hospital care that receives personalized primary care

Other: Multi-disciplinary and personalized primary care

Predicted but with treatment as usual

Elderly 75 years of age and older in primary care with high risk of being fragile and future risk of needing hospital care that receives treatment as usual

Interventions

Multi-disciplinary and personalized primary care OTHER

Team-based primary care where nurse, GP, social-worker, physiotherapist, occupational therapist evaluate and give treatment

Predicted and personalized primary care

Eligibility Criteria

• Age: 75 Years - 110 Years
• Sex: all
• Age Groups: Older Adult (65+)
• Sampling Method: Probability Sample

Study Population

People 75 years and older in the county of Östergötland with a high risk of being fragile and in need of hospital care. This risk group of 1600 out of 24000 is detected by a digital/statistical method depending on previous health care consumption and specific diagnoses

You may qualify if:

• Age 75 years and older living in county of Östergötland

Sponsors & Collaborators

• Region Östergötland: lead

Study Sites (2)

Region Östergötland/Linköping University

Linköping, Östergötland County, 58183, Sweden

Location

Primary Care of Östergötland

Linköping, Östergötland County, 58185, Sweden

Location

Related Publications (7)

• Marcusson J, Nord M, Johansson MM, Alwin J, Levin LA, Dannapfel P, Thomas K, Poksinska B, Sverker A, Olaison A, Cedersund E, Kelfve S, Motel-Klingebiel A, Hellstrom I, Kullberg A, Bottiger Y, Dong HJ, Peolsson A, Wass M, Lyth J, Andersson A. Proactive healthcare for frail elderly persons: study protocol for a prospective controlled primary care intervention in Sweden. BMJ Open. 2019 May 22;9(5):e027847. doi: 10.1136/bmjopen-2018-027847.

  PMID: 31122995 BACKGROUND

• Hansen K, Lyth J, Segernas A, Alwin J, Nord M. Self-rated health as a predictor of mortality and healthcare use in older adults at high risk of hospitalisation: a prospective cohort study in Sweden. BMJ Open. 2025 Sep 1;15(9):e091787. doi: 10.1136/bmjopen-2024-091787.

  PMID: 40889980 DERIVED

• Dong HJ, Yang J, Johansson MM, Peolsson A, Barbero M, Nord M. Association between frailty and pain in older people at high risk of future hospitalization. Front Pain Res (Lausanne). 2025 Apr 28;6:1576691. doi: 10.3389/fpain.2025.1576691. eCollection 2025.

  PMID: 40386744 DERIVED

• Dong HJ, Peolsson A, Johansson MM. Effects of proactive healthcare on pain, physical and activities of daily living functioning in vulnerable older adults with chronic pain: a pragmatic clinical trial with one- and two-year follow-up. Eur Geriatr Med. 2024 Jun;15(3):709-718. doi: 10.1007/s41999-024-00952-9. Epub 2024 Mar 6.

  PMID: 38446408 DERIVED

• Lundgren M, Segernas A, Nord M, Alwin J, Lyth J. Reasons for hospitalisation and cumulative mortality in people, 75 years or older, at high risk of hospital admission: a prospective study. BMC Geriatr. 2024 Feb 20;24(1):176. doi: 10.1186/s12877-024-04771-2.

  PMID: 38378482 DERIVED

• Kammerlind AS, Peolsson A, Johansson MM. Dizziness in older persons at high risk of future hospitalization: prevalence, differences between those with and without dizziness, and effect of a proactive primary care intervention. BMC Geriatr. 2022 Apr 10;22(1):315. doi: 10.1186/s12877-022-02910-1.

  PMID: 35399055 DERIVED

• Nord M, Lyth J, Alwin J, Marcusson J. Costs and effects of comprehensive geriatric assessment in primary care for older adults with high risk for hospitalisation. BMC Geriatr. 2021 Apr 21;21(1):263. doi: 10.1186/s12877-021-02166-1.

  PMID: 33882862 DERIVED

Related Links

• Study protocol article

Study Officials

• Jan Marcusson, MD, PhD

  Linkoeping University

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: observational
• Observational Model: CASE CONTROL
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: MD, senior consultant, professor

Study Record Dates

• First Submitted: May 31, 2017
• First Posted: June 8, 2017
• Study Start: September 27, 2017
• Primary Completion: December 31, 2019
• Study Completion: December 31, 2019
• Last Updated: June 5, 2020

Record last verified: 2020-06

Locations

SE (2)