N/A
N=400
Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination
Cardiovascular Diseases · Myocardial Infarction · Atrial Fibrillation · Diabetes Mellitus · Heart Failure
Bottom Line
View on ClinicalTrials.gov: NCT05820295 ↗Enrolled (actual)
400
Serious AEs
0.0%
Results posted
Sep 2025
Primary outcome: Primary: Number of Emergency Department Visits or Hospital Admissions — 0.25; 0.21 events per 100 person-days alive
Study Design & Population
- Study type
- Interventional
- Phase
- N/A
- Interventions
- Care coordination delivered based on perceived need (Behavioral); Care coordination delivered based on usual care (e.g. discharge from hospital) (Behavioral)
- Age
- Older Adult · 65+ yrs
- Sex
- All
- Sponsor
- Weill Medical College of Cornell University
- Primary completion
- May 2024
Outcome Measures
| Outcome | Result | p-value |
|---|---|---|
| PRIMARY Number of Emergency Department Visits or Hospital Admissions |
0.25; 0.21 | — |
| SECONDARY Acceptability |
13; 17 | — |
| SECONDARY Appropriateness |
13; 17 | — |
| SECONDARY Fidelity |
13; 17 | — |
| SECONDARY Efficiency |
52; 45 | — |
Summary
This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to older adults at risk for cardiovascular outcomes. The hypothesis is that assigning care coordinators to older adults based on perceived need will be more effective at preventing emergency department visits and hospitalizations compared to usual care.
Eligibility Criteria
Inclusion Criteria
- Medicare beneficiaries 65 years and older,
- Attributed to the NewYork Quality Care accountable care organization,
- Are community-dwelling,
- Have cardiovascular disease or 1 or more cardiovascular risk factors, and
- Had highly fragmented ambulatory care in the prior year (defined as a reversed Bice-Boxerman Index greater than or equal to 0.85)
Exclusion Criteria
- Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims)
- Enrolled in home hospice
- Dementia (as measured in claims using the Bynum Standard 1-year definition)
Data sourced from ClinicalTrials.gov (NCT05820295). 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.