Development and Validation of a Comprehensive Management Service Package for Older Adults With Multimorbidity

NCT07151430 | Not Yet Recruiting DMC

• 2 other identifiers: XWH-MULTICOMORB-2024-0012023YFC3605003
• Study Type: interventional
• Target: 358
• Locations: 0 countries
• Sites: N/A

Brief Summary

This study aims to test a new comprehensive management service package for older adults with two or more chronic conditions (multimorbidity). The package includes digital health tools, personalized guidance, and long-term management support. Researchers will compare the service package with usual care to see whether it reduces hospital readmissions, improves quality of life, and supports daily functioning. About 394 participants will be randomly assigned to either the service package group or the usual care group. Participants will be followed for 6 months to measure health outcomes, treatment adherence, and safety.

Conditions

Multimorbidity; Hypertension; Diabetes Mellitus; Coronary Artery Disease; Dyslipidemia; Stroke; Arthritis; Cognitive Impairment; Depression - Major Depressive Disorder; Chronic Kidney Disease; Chronic Liver Diseases

Keywords

management service package; multimorbidity; quality of life; intrinsic capacity

Outcome Measures

Primary Outcomes (1)

• Hospital readmission rate

  Hospital readmission rate

  6 months

Study Arms (2)

Experimental Arm

EXPERIMENTAL

Comprehensive multimorbidity management service package (digital tools, MDT decision support, lifestyle interventions, long-term management tools).

Device: Service Package Group

Control Arm

NO INTERVENTION

Standard of care without the service package.

Interventions

Service Package Group DEVICE

patients receive comprehensive multimorbidity management service package (digital tools, MDT decision support, lifestyle interventions, long-term management tools).

Experimental Arm

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• Age ≥65 years
• Diagnosed with ≥2 chronic diseases or geriatric syndromes (e.g., hypertension, diabetes, frailty, depression)
• Willing to provide informed consent

You may not qualify if:

• Life expectancy \<1 year due to severe illness (e.g., cardiogenic shock)
• Currently participating in other clinical trials

Sponsors & Collaborators

• Xuanwu Hospital, Beijing: lead

MeSH Terms

Conditions

Hypertension; Diabetes Mellitus; Coronary Artery Disease; Dyslipidemias; Stroke; Arthritis; Cognitive Dysfunction; Renal Insufficiency, Chronic

Condition Hierarchy (Ancestors)

Vascular Diseases; Cardiovascular Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases; Endocrine System Diseases; Coronary Disease; Myocardial Ischemia; Heart Diseases; Arteriosclerosis; Arterial Occlusive Diseases; Lipid Metabolism Disorders; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Joint Diseases; Musculoskeletal Diseases; Cognition Disorders; Neurocognitive Disorders; Mental Disorders; Renal Insufficiency; Kidney Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urogenital Diseases; Male Urogenital Diseases; Chronic Disease; Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Central Study Contacts

Yin Chun Lin, PhD

CONTACT

8613552566227; yinclmail@163.com

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Director of Department of Cardiology

Study Record Dates

• First Submitted: August 19, 2025
• First Posted: September 3, 2025
• Study Start: December 1, 2025
• Primary Completion (Estimated): June 1, 2026
• Study Completion (Estimated): December 1, 2026
• Last Updated: September 3, 2025

Record last verified: 2025-08

Data Sharing

• IPD Sharing: Will not share