Older patients account for around 10% of the population, of which 57% have a long-term illness, and 33% were admitted in the past year. Geriatric assessment (GA) is a multidimensional assessment of general health status that can help identifying deficiencies and followed by a personalized care plan. Assessment and management of elderly patients is a daily concern for the general practitioner (GP) but conflicting results have been reported so far relating to the clinical impact of GA when applied in the primary care setting. This study protocol aims to assess the effect on morbi-mortality of a complex intervention in patients aged ≥70 years with chronic conditions in primary care. It aims to demonstrate that a GA adapted to primary care, followed by a personalized care plan and combined with successful interprofessional collaboration can improve clinically relevant outcomes in elderly patients with chronic conditions such as one-year overall mortality, unplanned hospital admission, emergency visits, or institutionalization. The CEPIA study will also help addressing the issue of whether an improved benefit could be achieved from a systematic nurse-led or a case-by-case GP-led GA.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
750
Nurse-led or GP-led Geriatric assessment combined with an educational seminar focused on GA and personalized care-plan as well as a dedicated hotline for general practitioners seeking a geriatric advice Interactive educational seminar Primary care
Faculté de Médecine, Université Paris Est Créteil (UPEC)
Créteil, France
Primary composite endpoint combined with: - Percentage of all-cause mortality - Percentage of Unplanned hospital admission - Percentage of Emergency visits. - Percentage of Institutionalization
Time frame: At 12 months
Percentage of all-cause mortality
Time frame: At 12 months
Percentage of Unplanned hospital admission
Time frame: At 12 months
Percentage of Emergency visits
Time frame: At 12 months
Percentage of Institutionalization
Time frame: At 12 months
Quality of life (Duke profile score)
Time frame: At Day 0 and 12 months
Autonomy by KATZ ALD score
Time frame: At Day 0 and 12 months
Number of medication prescription (polypharmacy)
Time frame: Up to 12 months
Percentage of Geriatric assessment performed
Time frame: Up to 12 months
Percentage of personalized care plan performed
Time frame: Up to 12 months
Percentage of geriatric phone advices requested by GPs
Time frame: Up to 12 months
Percentage of health care actions planned
Time frame: Up to 12 months
Percentage of satisfied general practitioner with the intervention
self-assessment
Time frame: 27months after the beginning of the study
Satisfaction of general practitioners and nurses after completion of intervention
interview of general practionners and nurses by independant investigator
Time frame: 12 months after the beginning of the study
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