Self-care Program in the Prevention of Admissions of Patients

Basque Health Service144 enrolled

Overview

One of the most cost effective intervention is to avoid unnecessary hospitalizations in the national health system. These unnecessary admissions are increasing for several years, reaching rates of over 30% in patients with chronic obstructive pulmonary disease (COPD) or heart failure at two months of hospital discharge. There is scientific evidence suggesting that a multidisciplinary intervention consisting in controling disease and stress associated with disease, and modifying eating habits could reduce the number of hospitalizations due to disease decompensation. The main objective of the study is to assess the rate of readmissions at year of multidisciplinary intervention in patients with COPD and / or heart failure. We will select 144 patients who will be randomized to two groups (control and intervention group) and they will be followed for 12 months through 4 visits (1 month, 3 months, 6 months and 12 months of hospital discharge). Patients assigned to the intervention group will be receive three educational sessions (one of them will be imparted by nursing, another by the nutritionist and the last one by the psychologist). In addition, patients with a BMI \<20 and / or\> 30 will receive a closer monitoring by the nutritionist). Patients assigned to the control group will receive usual care in clinical practice.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

PREVENTION

Masking

NONE

Enrollment

144

Conditions

Pulmonary Disease, Chronic Obstructive

Eligibility

Sex: ALL

Medical Language ↔ Plain English

Inclusion Criteria: * COPD * Heart failure: heart failure in clinically stable with ≥ II degree of NYHA . 1 or more emergency admissions for the same diagnosis in the prior year Exclusion Criteria: * Mental states that make difficult the self-care: Class 295, 296, 297, 298, 300, 301, 304 and 316 (schizophrenic disorders, episodic mood, delusional other nonorganic psychosis, anxiety, dissociative and somatoform, personality, alcohol and drug dependencies) * Congenital respiratory diseases or presence of other obstructive pulmonary diseases * Patients participating in other research studies. * Other diseases that can affect patients' medium-term survival * Moderate to severe cognitive impairment.

Outcomes

Primary Outcomes

Readmission rate

in the twelve months following the intervention, according to the electronic record of the hospital

Time frame: 12 months

Secondary Outcomes

Number of admissions to emergency service or number of visits to general practitioner's office or number of visits to emergency service

Time frame: 12 months

time until the first admission to the hospital

Time frame: it wil be measured at 12 months

time until first visit to general practitioner's office

Time frame: it will be measured at 12 months

time until the first visit to emergency service

Time frame: it will be measured at 12 months

Health related quality of life through several questionnaires

COPD Assessment Test (CAT), self efficacy scale in COPD patients, SORT Form-36, Patient Health Questionnaire-9, Minnesota Living with Heart Failure Questionnaire (MLHFQ), Physical Activity Questionnaire (IPAQ), Barthel Index, European heart failure self-care behaviour scale.

Time frame: At month, 3, 6 and 12 months after discharge