N/A
Completed N=2,158
Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence
Care Transitions
Source: ClinicalTrials.gov NCT02354482 ↗
Enrolled (actual)
2,158
Serious AEs
—
Results posted
Nov 2019
Primary outcomePrimary: Hospital Readmission — .956; .949; .698; .972 odds ratio
Summary
Funded by the Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in health care and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S.
Outcome Measures
| Outcome | Result | p-value |
|---|---|---|
| PRIMARY Hospital Readmission |
.956; .949; .698; .972; 1.56; .964 | — |
| PRIMARY Emergency Department (ED) Visit |
.946; 1.031; .803; 1.091; 1.524; .983 | — |
Eligibility Criteria
Inclusion Criteria
- diverse high risk patient populations, including those with:
- multiple chronic conditions
- mental health issues
- rural area domicile
- limited English proficiency or low health literacy
- low socioeconomic status
- Medicare and Medicaid dual eligible
- disabled and younger than 65.
Exclusion Criteria
- children
- non-Medicare patients
- Under police custody
- Under suicide watch
- In-hospital death
- Transferred (not discharged) to another acute care hospital
- Discharged against medical advice
- Admission for primary diagnosis of psychiatric conditions
- Admission for rehabilitation
- Admission for medical treatment of cancer
Data sourced from ClinicalTrials.gov (NCT02354482). Outcome figures and adverse-event rates are extracted automatically from the registry's posted results and are provided for clinician reference, not as a substitute for the primary publication. Informational only — not medical advice.