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Table 1 Case report form

From: A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission

 

Study period

 

Baseline

Day 3

Day 5

1 month

6 month

12 month

ENROLMENT

 Eligibility screen

X

     

Informed consent

X

     

Screening log

X

     

 Randomisation

X

     

ASSESSMENT

 Assessment form

X

X

X

X

X

X

Demographics

X

     

Presenting problem

X

     

Place of assessment

X

X

X

X

X

X

Patient status (‘living at home’)

 

X

X

X

X

X

Subsequent admissions

   

X

X

 

 Adverse event log

 

X

X

X

X

X

QUESTIONNAIRES

 Barthel Index of Activities of Daily Living

X

   

X

 

 Confusion Assessment Method (CAM)

X

X

X

X

  

 Charlson Co-morbidity Index

X

   

X

 

 Health Service Use Questionnaire

X

   

X

 

 Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE)

X

     

 Montreal Cognitive Assessment (MoCA)

X

   

X

 

 EuroQol five-dimension five-level (EQ-5D-5 L)

X

   

X

 

 Patient feedback form

   

X

  

 Difficulties in Questionnaire completion Form

X

X

X

X

X

 

MISCELLANEOUS

 Death form

Completed on patient death

 Discontinuation form

Completed when a patient withdraws or is lost to follow-up