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Scandinavian Journal of Primary Health Care Volume 33, 2015 - Issue 2
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ORIGINAL ARTICLE

Can municipality-based post-discharge follow-up visits including a general practitioner reduce early readmission among the fragile elderly (65+ years old)? A randomized controlled trial

Lau Caspar ThygesenNational Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
,
Sara FokdalDepartment of Health Development, Municipality of Holbæk, Holbæk, Denmark
,
Thomas GjørupDepartment of Medicine, Holbæk University Hospital, Holbæk, Denmark
,
Rod S. TaylorNational Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark;Institute of Health Research, University of Exeter Medical School, Exeter, UK
,
Ann-Dorthe ZwislerNational Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark;Department of Medicine, Holbæk University Hospital, Holbæk, DenmarkCorrespondence[email protected]
& on behalf of the Prevention of Early Readmission Research Group
Pages 65-73 | Received 16 Sep 2014, Accepted 13 Mar 2015, Published online: 10 Jun 2015

Figures & data

Figure 1. Flow diagram. Note: *Inclusion criteria were patients aged 65 years or older discharged alive from the Department of Internal Medicine of Holbæk University Hospital, Denmark and living in one of the three surrounding municipalities and who had dementia or two of the following conditions: two or more hospital admissions within the 12 months before the index admission, loss of physical functioning, treatment of two or more concurrent medical or surgical conditions, mental disorder, six or more prescription medications, symptoms of cognitive disturbance, substance abuse problem, disadvantaged social network, or need for increasing home care following the index admission.
Figure 1. Flow diagram. Note: *Inclusion criteria were patients aged 65 years or older discharged alive from the Department of Internal Medicine of Holbæk University Hospital, Denmark and living in one of the three surrounding municipalities and who had dementia or two of the following conditions: two or more hospital admissions within the 12 months before the index admission, loss of physical functioning, treatment of two or more concurrent medical or surgical conditions, mental disorder, six or more prescription medications, symptoms of cognitive disturbance, substance abuse problem, disadvantaged social network, or need for increasing home care following the index admission.

Table I. Baseline characteristics of the included patients.

Table II. Reasons for selecting patients for the intervention and numbers and types of home visits and contacts during the intervention period (numbers [percentages] unless stated otherwise).

Figure 2. Time to (A) first readmission, (B) first unplanned readmission, and (C) first readmission to a department of medicine.
Figure 2. Time to (A) first readmission, (B) first unplanned readmission, and (C) first readmission to a department of medicine.

Table III. Admissions, contacts with general practitioner, and deaths at 30 and 180 days and referred municipal services (home care, nursing home, and nursing) 1–6 months after the index admission.

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