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NCT Number: NCT05823805

Approaches For ThE pRioritization of Patients in priMAry Care Post-COVID To Reduce Health Inequities (AFTERMATH)

The COVID-19 pandemic significantly impacted primary care across Canada. Inequities in prevention activities and chronic disease management likely increased but the extent is unknown. Pragmatic interventions are required to prioritize patients and improve the quality of primary care post-COVID. In AFTERMATH, the investigators will conduct a pragmatic cluster randomized controlled trial (cRCT) at the largest primary care Practice-Based Research Network (PBRN) in Ontario, focused on a highly marginalized population: adults living with mental illness and one or more additional chronic diseases. The investigators will test an intervention that builds on the investigators' past work and combines data and supports to primary care providers to improve quality of life, reduce gaps in prevention activities and improve chronic disease management. The investigators' project will result in new evidence on ways to improve access to care and reduce inequities, and inform future efforts to use data beyond COVID-19.

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Key information

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

A. Family physicians: Any family physician in a University of Toronto DFCM academic site with 10+ community-dwelling patients living with schizophrenia or bipolar disorder plus one or more additional chronic disease (COPD, diabetes, hypertension, osteoarthritis, dementia, epilepsy and Parkinson's).

B. Patients: Patients from the included family physician practices living with schizophrenia or bipolar disorder plus one or more additional chronic disease (COPD, diabetes, hypertension, osteoarthritis, dementia, epilepsy and Parkinson's).

Exclusion criteria

A. Family Physicians: None

B. Patients: Patients under 18

Treatment and study plan

Community Health Worker

Other

Physicians will work with a Community Health Worker (CHW) to review the data presented in their Quality Improvement reports, and triage patients for proactive outreach (e.g. "No action necessary", "Call patient to check-in", "Arrange BP, weight and labs", "Book for phone appointment", "Book for in-person appointment").

Primary outcomes

  1. health-related quality of life

    Time frame: 9 months

    We will assess health-related quality of life using the World Health Organization WHO QOL-BREF scale

Secondary outcomes

  1. Preventive care activities and chronic disease management outcomes

    Time frame: 9 months

    Preventive care activities up-to-date and chronic disease management outcomes, which reflect the goals of primary care teams, and health services outcomes (primary care visits, emergency department visits, hospitalizations, and total health services costs).

Study contacts

Contact information is provided by the study sponsor or research team.

Andrew Pinto, MD MSc

CONTACT

[email protected]

416-864-6060 ext. 76148

Danial Behzad, BSc

CONTACT

[email protected]

416-864-6060 ext. 71307

Sponsors and collaborators

Lead sponsor

Unity Health Toronto

Other

Registry information

Official study title

Approaches For ThE pRioritization of Patients in priMAry Care Post-COVID To Reduce Health Inequities (AFTERMATH): Cluster Randomized Controlled Trial

Acronym: AFTERMATH

Important dates

Study start
2025
Primary completion
2027
Study completion
2027
First posted
Apr 21, 2023
Registry last updated
Aug 15, 2025

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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