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A Multidisciplinary Outpatient Pathway

NCT04258176 · Status: COMPLETED · Type: OBSERVATIONAL · Enrollment: 270

Last updated 2021-08-30

No results posted yet for this study

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. 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. develop an innovative organisational structure around a multidisciplinary outpatient pathway for multimorbid patients and to pilot-test it (feasibility study)
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

Interventions

OTHER

Multidisciplinary outpatient pathway

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.

Sponsors & Collaborators

  • Central Jutland Regional Hospital

    lead OTHER

Principal Investigators

  • Peter Vedsted · Diagnostic Center, University Research Clinic for Innovative Patient Pathways

Eligibility

Min Age
18 Years
Sex
ALL
Healthy Volunteers
No

Timeline & Regulatory

Start
2018-08-15
Primary Completion
2021-03-31
Completion
2021-03-31

Countries

  • Denmark

Study Locations

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Read the full study record

This page highlights key information. For complete eligibility criteria, study locations, investigator contacts, and the full protocol, visit the original record on ClinicalTrials.gov.

View NCT04258176 on ClinicalTrials.gov