title: 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.
abstract: OBJECTIVE
  To evaluate how municipality-based post-discharge follow-up visits including a general practitioner and municipal nurse affect early readmission among high-risk older people discharged from a hospital department of internal medicine.
  
  
  METHODS
  Centrally randomized single-centre pragmatic controlled trial comparing intervention and usual care with investigator-blinded outcome assessment.
  
  
  METHODS
  The intervention was home visits with a general practitioner and municipal nurse within seven days of discharge focusing on medication, rehabilitation plan, functional level, and need for further health care initiatives. The visit was concluded by planning one or two further visits. Controls received standard health care services.
  
  
  METHODS
  People aged 65 + years discharged from Holbæk University Hospital, Denmark, in 2012 considered at high risk of readmission.
  
  
  METHODS
  The primary outcome was readmission within 30 days. Secondary outcomes at 30 and 180 days included readmission, primary health care, and municipal services. Outcomes were register-based and analysis used the intention-to-treat principle.
  
  
  RESULTS
  A total of 270 and 261 patients were randomized to intervention and control groups, respectively. The groups were similar in baseline characteristics. In all 149 planned discharge follow-up visits were carried out (55%). Within 30 days, 24% of the intervention group and 23% of the control group were readmitted (p = 0.93). No significant differences were found for any other secondary outcomes except that the intervention group received more municipal nursing services.
  
  
  CONCLUSIONS
  This municipality-based follow-up intervention was only feasible in half the planned visits. The intervention as delivered had no effect on readmission or subsequent use of primary or secondary health care services.
authors.affiliation: National Institute of Public Health, University of Southern Denmark , Copenhagen , Denmark.
authors.forename: Lau Caspar
authors.initials: LC
authors.lastname: Thygesen
authors.forename: Sara
authors.initials: S
authors.lastname: Fokdal
authors.forename: Thomas
authors.initials: T
authors.lastname: Gjørup
authors.forename: Rod S
authors.initials: RS
authors.lastname: Taylor
authors.forename: Ann-Dorthe
authors.initials: AD
authors.lastname: Zwisler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D003695:Delivery of Health Care / Q000379:methods*; D003718:Denmark; D005260:Female; D016330:Frail Elderly; D058005:General Practitioners; D006299:Health Services for the Aged; D006699:Home Care Services; D006761:Hospitals; D006792:House Calls; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D009726:Nurses; D010351:Patient Discharge; D010359:Patient Readmission; D015397:Program Evaluation; D012017:Referral and Consultation; D012306:Risk; D059039:Standard of Care
keywords: Community health nursing; Denmark; frail elderly; patient readmission; population register; primary health care; quality of health care; randomized controlled trial