Structured decision support to prevent hospitalisations of community-dwelling older adults in Denmark (PATINA) an open-label, stepped-wedge, cluster-randomised controlled trial

Background Ageing populations and health-care staff shortages encourage efforts in primary care to recognise and prevent health deterioration and acute hospitalisation in community-dwelling older adults. The PATINA algorithm and decision-support tool alerts home-based-care nurses to older adults at risk of hospitalisation. The study aim was to test whether use of the PATINA tool was associated with changes in health-care use. Methods An open-label, stepped-wedge, cluster-randomised controlled trial was done in three Danish municipalities, covering 20 area teams providing home-based care to around 7000 recipients. During a period of 12 months, area teams were randomly assigned to an intervention crossover for older adults (aged 65 years or older) who received care at home. The primary outcome was hospitalisation within 30 days of identification by the algorithm as being at risk of hospitalisation. Secondary outcomes were hospital readmission and other hospital contacts, outpatient contacts, contact with primary care physicians (PCPs), temporary care, and death, within 30 days of identification. This study was registered at ClinicalTrials.gov (NTC04398797). Findings In total, 2464 older adults participated in the study: 1216 (49 center dot 4%) in the control phase and 1248 (50 center dot 6%) in the intervention phase. In the control phase, 102 individuals were hospitalised within 30 days during 33 943 days of risk (incidence 0 center dot 09 per 30 days), compared with 118 individuals within 34 843 days of risk (0 center dot 10 per 30 days) during the intervention phase. The intervention was not associated with a reduction in the number of first hospitalisations within 30 days (incidence rate ratio [IRR] 1 center dot 10 [90% CI 0 center dot 90-1 center dot 40]; p=0 center dot 28). Furthermore it was not associated with reduced rates of other hospital contacts (IRR 1 center dot 10 [95% CI 0 center dot 90-1 center dot 40]; p=0 center dot 28), outpatient contacts (1 center dot 10 [0 center dot 88-1 center dot 40]; p=0 center dot 42), or mortality (0 center dot 82 [0 center dot 58-1 center dot 20]; p=0 center dot 25). The intervention was associated with a 59% reduction in readmissions within 30 days of hospital discharge (IRR 0 center dot 41 [95% CI 0 center dot 24-0 center dot 68]; p=0 center dot 0007), a 140% increase in contacts with PCPs (2 center dot 40 [1 center dot 18-3 center dot 20]; p < 0 center dot 0001), and a 150% increase in use of temporary care (2 center dot 50 [1 center dot 40-4 center dot 70]; p=0 center dot 0027). Interpretation Despite having no effect on the primary outcome, the PATINA tool showed other benefits for older adults receiving home-based care. Such algorithms have the potential to shift health-care use from secondary to primary care but need to be tested in other home-based care settings. Implementation of algorithms in clinical practice should be informed by analysis of cost-effectiveness and potential harms as well as the benefits.

Automated summary

This study aimed to test whether the use of the PATINA tool was associated with changes in health-care use. The results showed that despite having no effect on the primary outcome, the PATINA tool showed other benefits for older adults receiving home-based care.