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Trial registered on ANZCTR
Registration number
ACTRN12624000795594
Ethics application status
Approved
Date submitted
28/05/2024
Date registered
27/06/2024
Date last updated
13/10/2024
Date data sharing statement initially provided
27/06/2024
Type of registration
Prospectively registered
Titles & IDs
Public title
Feasibility and acceptability of a transitional care intervention for frail older adults returning home from hospital: The TRANSFER-II Study
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Scientific title
Feasibility and acceptability of a transitional care intervention for frail older adults returning home from hospital: The TRANSFER-II Study
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Secondary ID [1]
312184
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None
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Universal Trial Number (UTN)
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Trial acronym
The TRANSFER-II Study
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Linked study record
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Health condition
Health condition(s) or problem(s) studied:
frailty
333939
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transitional care
333940
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Condition category
Condition code
Public Health
330610
330610
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0
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Health service research
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Intervention/exposure
Study type
Interventional
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Description of intervention(s) / exposure
The TRANSFER-II Study will include the provision of patient centred discharge communication when leaving hospital. Once the participant is recruited, consented and the baseline assessments completed, the intervention commences. The intervention is in addition to standard clinical practice and usual patient care will continue. The Nurse Navigator (intervention nurse) will meet with the patient in hospital before discharge and discuss the plan for home and make any appropriate referrals. At this time the Nurse Navigator will identify 3 patient-centred priorities for home as derived by the discharge summary Plan/Recommendation of care and medical team. These will be determined through discussion with the patient around what is important to them from the list of activities written on the discharge summary plan and then prioritised in a list of 1 to 3 in consultation with the Nurse Navigator. Once discharged, the Nurse Navigator will contact the patient within one week and then again the following week to provide support and answer questions about the discharge summary and follow up plan, and discuss progress of the 3 patient-centred priorities. During this contact the nurse will make any appropriate referrals, facilitate GP review where needed, provide virtual education and resources as necessary.
The intervention is as follows:
• Contact during admission (initial 30 minute consultation) by the Nurse Navigator and discuss with the patient the plan for discharge. Provide the patient the ‘Nurse Navigator Flyer’ (designed by the research team for this study).
• Medical staff complete the discharge summary as usual routine practice.
• Nurse Navigator sets three patient-centred priorities with the patient from the discharge summary plan/recommendations of care, three things to do when the patient returns home, these will be discussed verbally and written down in simple language on the ‘Plan for Home’ sheet (designed by the research team for this study). This may have to be completed over the phone if patient is discharged afterhours or non-working days of the intervention nurse and posted if this is requested by participant (approximately 15-30 minutes).
• The nurse will help to organise and facilitate these patient-centred priorities prior to discharge. At this time, will also help to identify any unmet needs and ensure safety on discharge.
• The nurse will then follow up with a telehealth contact (using a hospital landline) within 1 week of discharge to discuss these 3 patient-centred priorities, then again the following week with a total of 2 points of contact within the intervention. These telehealth contacts will approximately be 30 minutes in duration, and on average 1 week apart.
• Provide support and answer questions about the discharge summary and follow up requirements. Ensuring there is clear communication to the patient about the discharge plan in language that they will understand. During these contacts the intervention nurse will help to facilitate further community support where possible, e.g. organise GP/clinician review or referral to CareFinder.
• These intervention calls may generate additional calls within these points of contact to organise follow up or update the participant with appointment details. For example the participant states they were unable to call their GP for follow up, the intervention nurse calls the GP and books this appointment, then calls the participant back to update appointment time and details. This would be considered one point of contact. Every participant will receive a minimum of 2 contacts approximately 1 week apart,
• These calls and any additional will be tracked and documented within study feasibility data collection through REDCap. Study adherence will also be tracked through REDCap data collection on patients' ability to set and achieve priorities and, through Electronic Medical Records documentation.
All included participants will receive usual care as well as the intervention. Standard practice for discharge is that all patients are assessed during admission for issues returning home and referred to relevant services (e.g. Hospital in the Home) where appropriate. All patients on discharge are given a Discharge Summary as written by the medical team. Currently there is no patient-centred discharge communication or post-discharge follow-up of this nature that exists within the hospital.
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Intervention code [1]
328688
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Treatment: Other
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Comparator / control treatment
No control group
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Control group
Uncontrolled
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Outcomes
Primary outcome [1]
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Feasibility
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Assessment method [1]
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Proportion of participants who achieved 1,2 or all 3 priorities as determined by documentation and audit of study materials as recorded in REDCap.
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Timepoint [1]
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At conclusion of the study.
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Primary outcome [2]
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Acceptability
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Assessment method [2]
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Proportion of participants who were able to agree to 3 priorities as determined by documentation and audit of study materials as recorded in REDCap.
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Timepoint [2]
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At conclusion of the study.
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Secondary outcome [1]
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Unplanned readmissions
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Assessment method [1]
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Hospital readmissions as per Electronic Medical Records and patient reported.
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Timepoint [1]
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1-, 3-, 6-, and 12-months post-discharge from hospital.
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Secondary outcome [2]
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Mortality
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Assessment method [2]
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Electronic Medical Records.
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Timepoint [2]
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1-, 3-, 6-, and 12-months post-discharge from hospital.
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Secondary outcome [3]
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Institutionalisation
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Assessment method [3]
435626
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Patient reported and Electronic Medical Records
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Timepoint [3]
435626
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1-, 3-, 6-, and 12-months post-discharge from hospital.
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Secondary outcome [4]
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Quality of Life
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Assessment method [4]
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EQ-5D-5L
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Timepoint [4]
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Baseline and then 1 month post-discharge from hospital.
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Secondary outcome [5]
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Anxiety and Depression, this will be assessed as a composite outcome as determined by the HADS scale.
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Assessment method [5]
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Hospital Anxiety and Depression Scale (HADS)
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Timepoint [5]
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Baseline and then 1 month post-discharge from hospital.
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Eligibility
Key inclusion criteria
• Older adults aged 65 years and above.
• Admitted under the Rehabilitation and Aged Care Services at Blacktown and included in the Western Sydney Clinical Frailty Registry.
• Discharging from hospital and returning home.
• Australian permanent resident.
• Have access to a phone and able to participate in intervention requirements.
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Minimum age
65
Years
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Maximum age
No limit
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Sex
Both males and females
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Can healthy volunteers participate?
No
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Key exclusion criteria
• Living in Residential Aged Care or permanent institutionalisation.
• Participants admitted under other specialties outside Geriatrics.
• Participants under ongoing legal guardianship.
• Patients with a diagnosis of dementia or those without the capacity to consent.
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Study design
Purpose of the study
Treatment
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Allocation to intervention
Non-randomised trial
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Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
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Methods used to generate the sequence in which subjects will be randomised (sequence generation)
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Masking / blinding
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Who is / are masked / blinded?
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Intervention assignment
Single group
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Other design features
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Phase
Not Applicable
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Type of endpoint/s
Safety/efficacy
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Statistical methods / analysis
This study uses a feasibility sample size, and the nature of this study is to determine proof of construct related to patient experiences and safety during transition from hospital to home. With a minimum of 100 participants, the 95% CI for any estimated proportion will be no wider than +/- 10%, hence this sample size has been chosen based on a sample size calculation conducted with the primary outcomes.
Statistical analysis will include descriptive statistics (mean, median, number) and estimates of those proportions using a 95% CI. Repeat measures will be reported for continuous and categorical variables. Inferential statistics will be used on remaining outcome measures to compare differences at various timepoints, including Paired t-test and Wilcoxon test.
Qualitative thematic analysis will be conducted on the qualitative question asked to intervention participants at follow up timepoints as per methods established by Braun and Clarke.. Themes will be produced from the responses through the development of codes and relationships of core commonality. There will be consultation within the investigator team to develop key themes that accurately represent the responses of participants.
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Recruitment
Recruitment status
Recruiting
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Date of first participant enrolment
Anticipated
2/09/2024
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Actual
20/08/2024
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Date of last participant enrolment
Anticipated
3/02/2025
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Actual
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Date of last data collection
Anticipated
2/02/2026
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Actual
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Sample size
Target
100
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Accrual to date
38
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Final
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Recruitment in Australia
Recruitment state(s)
NSW
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Recruitment hospital [1]
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Blacktown Hospital - Blacktown
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Recruitment hospital [2]
26608
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Mount Druitt Hospital - Mount Druitt
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Recruitment postcode(s) [1]
42649
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2148 - Blacktown
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Recruitment postcode(s) [2]
42650
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2770 - Mount Druitt
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Funding & Sponsors
Funding source category [1]
316554
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Government body
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Name [1]
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Western Sydney Local Health District
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Address [1]
316554
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Country [1]
316554
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Australia
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Primary sponsor type
Government body
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Name
Western Sydney Local Health District
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Address
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Country
Australia
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Secondary sponsor category [1]
318800
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None
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Name [1]
318800
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Address [1]
318800
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Country [1]
318800
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Other collaborator category [1]
283058
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University
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Name [1]
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University of Wollongong
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Address [1]
283058
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Country [1]
283058
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Australia
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Ethics approval
Ethics application status
Approved
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Ethics committee name [1]
315346
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Western Sydney Local Health District Human Research Ethics Committee
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Ethics committee address [1]
315346
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https://www.wslhd.health.nsw.gov.au/Education-Portal/Research/ethics-governance
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Ethics committee country [1]
315346
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Australia
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Date submitted for ethics approval [1]
315346
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16/05/2024
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Approval date [1]
315346
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03/07/2024
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Ethics approval number [1]
315346
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2024/ETH01032
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Summary
Brief summary
This is a feasibility and acceptability study investigating the use of a transitional care intervention for frail older adults discharging from hospital and returning home. All participants recruited will be given the intervention. Primary outcomes look at feasibility and acceptability of the intervention. Comparison of secondary outcome measures will be conducted for quality of life and anxiety and depression scores at baseline and 1-month. With further follow up of readmissions, institutionalisation and mortality at 1-month, 3-months, 6-months, and 12-months. This project proposes that setting 3 patient-centred priorities with telehealth follow up on these priorities is found to be a feasible and acceptable transitional care intervention for frail older adults within Blacktown and Mount Druitt Hospitals.
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Trial website
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Trial related presentations / publications
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Public notes
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Contacts
Principal investigator
Name
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Prof Caleb Ferguson
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Address
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University of Wollongong, 33 Moore St, Liverpool NSW 2170
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Country
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Australia
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Phone
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+61242214078
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Fax
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Email
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[email protected]
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Contact person for public queries
Name
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Kirsten Parker
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Address
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University of Wollongong, 33 Moore St, Liverpool NSW 2170
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Country
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Australia
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Phone
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+61403226275
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Fax
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Email
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[email protected]
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Contact person for scientific queries
Name
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Kirsten Parker
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Address
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University of Wollongong, 33 Moore St, Liverpool NSW 2170
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Country
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Australia
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Phone
134412
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+61403226275
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Fax
134412
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Email
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[email protected]
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Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
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What data in particular will be shared?
De-identified data related to the outcome measures published from this study will be shared only.
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When will data be available (start and end dates)?
Start date: Immediately after the outcomes from this study has been published in the peer review journals.
End date: Data will be stored securely for a minimum of 5 years following completion of the research or the last publication as per Section 2.1, Australian Code for the Responsible Conduct of Research.
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Available to whom?
Researchers and academics at the discretion of the principal investigator.
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Available for what types of analyses?
Systematic review and meta analysis
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How or where can data be obtained?
Please contact Kirsten Parker with any requests -
[email protected]
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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.
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