Acute Internal Medicine and Geriatrics and Departmentof Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
Family Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
BMJ Open. 2019 May 22;9(5):e027847. doi: 10.1136/bmjopen-2018-027847.
The provision of healthcare services is not dedicated to promoting maintenance of function and does not target frail older persons at high risk of the main causes of morbidity and mortality. The aim of this study is to evaluate the effects of a proactive medical and social intervention in comparison with conventional care on a group of persons aged 75 and older selected by statistical prediction.
In a pragmatic multicentre primary care setting (n=1600), a prediction model to find elderly (75+) persons at high risk of complex medical care or hospitalisation is used, followed by proactive medical and social care, in comparison with usual care. The study started in April 2017 with a run-in period until December 2017, followed by a 2-year continued intervention phase that will continue until the end of December 2019. The intervention includes several tools (multiprofessional team for rehabilitation, social support, medical care home visits and telephone support). Primary outcome measures are healthcare cost, number of hospital care episodes, hospital care days and mortality. Secondary outcome measures are number of outpatient visits, cost of social care and informal care, number of prescribed drugs, health-related quality of life, cost-effectiveness, sense of security, functional status and ability. We also study the care of elderly persons in a broader sense, by covering the perspectives of the patients, the professional staff and the management, and on a political level, by using semistructured interviews, qualitative methods and a questionnaire.
Approved by the regional ethical review board in Linköping (Dnr 2016/347-31). The results will be presented in scientific journals and scientific meetings during 2019-2022 and are planned to be used for the development of future care models.
NCT03180606.
医疗服务的提供并不是专门为了促进功能维持，也不是针对那些患有高发病率和死亡率主要病因的体弱老年人。本研究旨在评估与常规护理相比，对通过统计预测选择的一组 75 岁及以上老年人进行积极的医疗和社会干预的效果。
在一个实用的多中心初级保健环境中（n=1600），使用预测模型来寻找患有复杂医疗或住院风险高的老年（75+）患者，然后进行积极的医疗和社会护理，与常规护理进行比较。该研究于 2017 年 4 月开始，经过 2017 年 12 月的运行期，随后进入为期 2 年的持续干预阶段，持续到 2019 年 12 月结束。干预措施包括多项工具（康复多专业团队、社会支持、家庭医疗访问和电话支持）。主要结局指标是医疗保健费用、住院次数、住院天数和死亡率。次要结局指标是门诊就诊次数、社会和非正式护理费用、处方药物数量、健康相关生活质量、成本效益、安全感、功能状态和能力。我们还从更广泛的角度研究老年人的护理，涵盖了患者、专业人员和管理层的观点，以及从政治角度，使用半结构化访谈、定性方法和问卷调查。
得到了林雪平地区伦理审查委员会的批准（编号 2016/347-31）。结果将在 2019-2022 年期间在科学期刊和科学会议上公布，并计划用于未来护理模式的开发。
NCT03180606。
