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Trial registered on ANZCTR


Registration number
ACTRN12625000844448p
Ethics application status
Submitted, not yet approved
Date submitted
1/07/2025
Date registered
6/08/2025
Date last updated
6/08/2025
Date data sharing statement initially provided
6/08/2025
Type of registration
Prospectively registered

Titles & IDs
Public title
Supportive Care for Chronic Disease: An audit to evaluate the existing Supportive Care for Chronic Disease services program in the Hunter New England Health District.
Scientific title
Supportive Care for Chronic Disease: An audit to evaluate the existing Supportive Care for Chronic Disease services program in the Hunter New England Health District.
Secondary ID [1] 314592 0
Nil known.
Universal Trial Number (UTN)
Trial acronym
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Advanced Liver Disease 337707 0
Heart Failure 337708 0
Motor Neurone Disease 337710 0
Movement Disorders 337711 0
Voluntary Assisted Dying 337712 0
Other chronic diseases 337829 0
Chronic Obstructive Pulmonary Disease 337835 0
Condition category
Condition code
Oral and Gastrointestinal 334043 334043 0 0
Other diseases of the mouth, teeth, oesophagus, digestive system including liver and colon
Cardiovascular 334086 334086 0 0
Coronary heart disease
Neurological 334087 334087 0 0
Neurodegenerative diseases
Neurological 334088 334088 0 0
Parkinson's disease
Public Health 334089 334089 0 0
Health service research
Respiratory 334168 334168 0 0
Chronic obstructive pulmonary disease

Intervention/exposure
Study type
Observational
Patient registry
False
Target follow-up duration
Target follow-up type
Description of intervention(s) / exposure
An audit to evaluate the existing Supportive Care for Chronic Disease (SCCD) service program will be undertaken by clinicians or medical students or allied health students with access to Hunter New England Health District (HNELHD) medical records. The SCCD program delivers holistic and person-centred care for patients and their carers alongside existing health care (standard care). SCCD involves chronic disease care plus implementation of palliative care principles for adults living with advanced liver disease, heart failure, motor neurone disease, Parkinson’s disease, chronic obstructive pulmonary disease and Aboriginal people with advanced non-malignant comorbidities (ICCAPP), with estimated life expectancy two years or less.
The SCCD service offers a 12-week program to patients and their nominated carers provided by social work, dietitian, speech pathology and occupational therapy via in-person, telehealth or virtual care. Additional psychosocial and emotional support is provided on a need’s basis by a psychiatrist for individuals assessed by the SCCD team to have elevated levels of disease related burden or distress, carer burden or psychiatric illness. Patients receive a minimum of four occasions of service and carers three occasions across the 12-week program. Patient/Carer-Reported Measures are completed electronically within 48 hours of each scheduled contact. The outcomes of these measures guide the focus of the planned consultations as well as the expressed concerns of patients and carers during consultations. Clinical care and advice are provided during consultations with additional care co-ordination and support undertaken between planned consultations according to patient and carer need.

This study will be an audit of existing service data with no patient participation. Patients and carers will complete the SCCD program regardless of their involvement in this study. The audit will involve data collected from 25th August 2025 to 30 June 2032, from patient medical records (HNELHD clinical systems and databases); SCCD service data (Excel spreadsheet and progress notes populated with patient/carer demographics, scheduled appointments, attendance, referrals, interventions and planned/unplanned health service utilisations); patient/carer reported measures [Integrated Palliative Outcomes Scale (IPOS), Euroqol (EQ)-5D-5L, Malnutrition Screening Tool (MST), EAT-10 Swallowing Screening tool (EAT-10), Carer Experience Scale (CES), Carer Support Needs Assessment Tool (CSNAT) ]; and questionnaires (post service completion feedback survey). Data collection will be completed at a at a single timepoint, 6 months after completion of the SCCD program. Data will be analysed retrospectively with a focus on three timeframes, 6 months pre-referral to SCCD, during the SCCD program and 6 months after SCCD program completion. Direct identifiers will not be collected. The database will be held on HNELHD servers.
Intervention code [1] 331217 0
Not applicable
Comparator / control treatment
Standard care for all SCCD participants is conducted in multidisciplinary outpatient settings. Depending on diagnosis, patient participants receive care from a specialist physician (e.g. cardiologist) with additional support from allied health clinicians according to resourcing of each disease specific multidisciplinary team. This support may be planned or on an ad hoc basis. Participants are referred to the SCCD program by a member of their treating specialist team according to disease specific referral criteria. Participants will act as their own controls with data compared at 3 timeframes at 6 months pre-referral to SCCD, during the SCCD program and 6 months after SCCD program completion. The reference comparator will be the 6 months pre-referral to SCCD program.
Control group
Active

Outcomes
Primary outcome [1] 341707 0
Change in unplanned health service utilisation across the 3 timeframes.
Timepoint [1] 341707 0
Reported monthly and compared at 3 timeframes: during the 6 months pre referral to SCCD, at completion of the SCCD program and during 6 months following completion of SCCD program.
Secondary outcome [1] 448445 0
Disease Related Burden
Timepoint [1] 448445 0
Existing data collected at each patient contact, baseline and weeks 4, 8 and 12.
Secondary outcome [2] 448446 0
Change in Advanced Care Planning practices
Timepoint [2] 448446 0
Reported at completion of the SCCD program.
Secondary outcome [3] 448447 0
The impact of SCCD mode of care delivery upon HSU.
Timepoint [3] 448447 0
Reported monthly. Surveys sent via mail with replied paid envelope or emailed electronically to participants within 2 weeks of discharge from SCCD program.
Secondary outcome [4] 448791 0
Financial impact related to any benefit in HSU with consideration of costs associated to deliver the intervention.
Timepoint [4] 448791 0
At completion of the SCCD program.
Secondary outcome [5] 450147 0
Carer burden
Timepoint [5] 450147 0
Existing data collected at each carer contact, baseline and weeks 6 and 12.
Secondary outcome [6] 450148 0
The impact of mode of SCCD care delivery upon carer experience of health care.
Timepoint [6] 450148 0
Reported monthly. Surveys sent via mail with replied paid envelope or emailed electronically to participants within 2 weeks of discharge from SCCD program.
Secondary outcome [7] 450338 0
The impact of SCCD mode of care delivery upon patient experience of health care.
Timepoint [7] 450338 0
Reported monthly. Surveys sent via mail with replied paid envelope or emailed electronically to participants within 2 weeks of discharge from SCCD program.

Eligibility
Key inclusion criteria
Adults living with advanced liver disease, heart failure, motor neurone disease, Parkinson’s disease, chronic obstructive pulmonary disease, and Aboriginal people with advanced comorbidities (ICCAPP), with estimated life expectancy 2 years or less, who have attended the SSCD program in Hunter New England Health District.
Minimum age
18 Years
Maximum age
No limit
Sex
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
Malignant conditions without a concurrent diagnosis of chronic disease.
Anyone under 18 years of age.

Study design
Purpose
Natural history
Duration
Longitudinal
Selection
Defined population
Timing
Both
Statistical methods / analysis

Recruitment
Recruitment status
Not yet recruiting
Date of first participant enrolment
Anticipated
Actual
Date of last participant enrolment
Anticipated
Actual
Date of last data collection
Anticipated
Actual
Sample size
Target
Accrual to date
Final
Recruitment in Australia
Recruitment state(s)
NSW
Recruitment hospital [1] 28006 0
John Hunter Hospital - New Lambton
Recruitment postcode(s) [1] 44209 0
2305 - New Lambton

Funding & Sponsors
Funding source category [1] 319139 0
Charities/Societies/Foundations
Name [1] 319139 0
John Hunter Hospital Charitable Trust
Country [1] 319139 0
Australia
Funding source category [2] 319142 0
Other Collaborative groups
Name [2] 319142 0
Hunter Medical Research Institute
Country [2] 319142 0
Australia
Primary sponsor type
Individual
Name
Professor Katie Wynne, John Hunter Hospital, New Lambton Heights.
Address
Country
Australia
Secondary sponsor category [1] 321608 0
None
Name [1] 321608 0
Address [1] 321608 0
Country [1] 321608 0

Ethics approval
Ethics application status
Submitted, not yet approved
Ethics committee name [1] 317732 0
Hunter New England Human Research Ethics Committee
Ethics committee address [1] 317732 0
Ethics committee country [1] 317732 0
Australia
Date submitted for ethics approval [1] 317732 0
27/06/2025
Approval date [1] 317732 0
Ethics approval number [1] 317732 0

Summary
Brief summary
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 141966 0
Prof Katie Wynne
Address 141966 0
John Hunter Hospital, Locked Bag 1, New Lambton Heights, NSW 2305.
Country 141966 0
Australia
Phone 141966 0
+61429995896
Fax 141966 0
Email 141966 0
Contact person for public queries
Name 141967 0
Shaye Ludlow
Address 141967 0
John Hunter Hospital, Locked Bag 1, New Lambton Heights, NSW 2305.
Country 141967 0
Australia
Phone 141967 0
+61249213686
Fax 141967 0
Email 141967 0
Contact person for scientific queries
Name 141968 0
Prof Katie Wynne
Address 141968 0
John Hunter Hospital, Locked Bag 1, New Lambton Heights, NSW 2305.
Country 141968 0
Australia
Phone 141968 0
+61429995896
Fax 141968 0
Email 141968 0

Data sharing statement
Will the study consider sharing individual participant data?
No


What supporting documents are/will be available?

No Supporting Document Provided


Results publications and other study-related documents

Documents added manually
No documents have been uploaded by study researchers.

Documents added automatically
No additional documents have been identified.