A Multidisciplinary Outpatient Pathway

NCT04258176 | Completed

• 1 other identifier: 634802
• Study Type: observational
• Target: 270
• Locations: 1 country
• Sites: 1

Brief Summary

Patients with complex chronic multiple illnesses constitute an increasing challenge and more evidence-based knowledge of effective practice is required. In Denmark and the rest of the world, improved health care, public health, and increased focus on early diagnosis have led to increases in life expectancy resulting in a growing population of older people living with multiple long-term conditions (multimorbidity). Today, every fourth Dane suffers from more than one concomitant chronic or severe disease, estimated to rise to 60% for those over 65 years. National and international health care is organised and targeted as specialised, mono-diagnostic efforts for single diseases leading to lack of coordination and failure to integrate multidisciplinary patient trajectories. Danish research shows that general practice is challenged by insufficient collaboration between professionals involved in the treatment. Despite this, there exists limited evidence of initiatives aiming to improve care for multimorbid patients. This study aims to:

1. 1.identify chronic multimorbid patients and to analyse their use of two or more outpatient clinics, their general use of health care utilisations and their disease pattern and characteristics (Cross-sectional study using national registers).
2. 2.develop an innovative organisational structure around a multidisciplinary outpatient pathway for multimorbid patients and to pilot-test it (feasibility study)
3. 3.phase-III test a multidisciplinary outpatient pathway and to preliminarily evaluate the effects in patients and health professionals and on resource utilisations (effect study)

Conditions

Multimorbidity

Keywords

outpatient; multimorbidity

Outcome Measures

Primary Outcomes (3)

• PREM - PACIC

  Patient reported outcome measures: questionaires incl. The Patient Assessment of Chronic Illness Care (PACIC). This is a 20-item scale with a 5-point scale from (1(never) to 5 (allways). PACIC is reported as an avarage of the 20 items.

  August 2018 - August 2020 (approximately)

• PREM - MTBQ

  Patient reported outcome measures: questionaires incl. The Multimorbidity Treatment Burden Questionnaire. This is a 10-item scale with a 6-point scale. The Multimorbidity Treatment Burden Questionnaire (MTBQ) questionnaire is designed to measure treatment burden (the effort of looking after one's health) in patients with multimorbidity (multiple long term conditions). You calculate the average score from the questions answered. Multiple the average score by 25 to give a global MTBQ score from 0-100

  August 2018 - August 2020 (approximately)

• Attendance in outpatient clinics

  Number of times patients are coming to the hospital for outpatient visits

  August 2018 - August 2021 (approximately)

Study Arms (2)

Intervention group

Patients seen in the multidisciplinary pathway

Other: Multidisciplinary outpatient pathway

Comparison group

Multimorbid patients seen several outpatient clinics who did not undergo the trajectory

Interventions

Multidisciplinary outpatient pathway OTHER

Coordinators, assigned to improve the care flow, review and align the patient's appointments and tests in agreement with the patient's wishes. Outpatient consultations are arranged to take place the same day and schedules for care providers are coordinated. The patients' attendance in outpatient clinics are planned sequentially where the delivering specialty writes a summary to the subsequent specialty. Afterwards, the involved physicians and nurses attend an interdisciplinary conference, resulting in a joint treatment plan, with feedback and notice of modifications, which is delivered to the patient and general practice.

Intervention group

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Multimorbid patients who have several trajectories and appointments in outpatient clinics

You may qualify if:

• Patients seen on two or more outpatient Clinics at Silkeborg Regional Hospital
• years old or older
• Specialties involved: Nephrology, rheumatology, cardiology, endocrinology, pulmonology
• Listed for future appointments in two or more outpatient clinics
• Days between appointments less than 43

You may not qualify if:

• Patients only undergoing patient education
• Appointments in relation to science or diagnosing

Sponsors & Collaborators

• Central Jutland Regional Hospital: lead

Study Sites (1)

University Research Clinic for Innovative Patient Pathways, Diagnostic Centre, Silkeborg Regional Hospital

Silkeborg, Central Jutland, 8600, Denmark

Location

Study Officials

• Peter Vedsted

  Diagnostic Center, University Research Clinic for Innovative Patient Pathways

  STUDY DIRECTOR

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Target Duration: 1 Year
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: February 4, 2020
• First Posted: February 6, 2020
• Study Start: August 15, 2018
• Primary Completion: March 31, 2021
• Study Completion: March 31, 2021
• Last Updated: August 30, 2021

Record last verified: 2021-08

Locations

DK (1)