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. 2018 Jun 28;18(1):508.
doi: 10.1186/s12913-018-3301-9.

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

L Verweij  1   2 , P Jepma  3   4 , B M Buurman  3   5 , C H M Latour  3 , R H H Engelbert  3   6 , G Ter Riet  7 , F Karapinar-Çarkit  8 , S Daliri  4   8 , R J G Peters  4 , W J M Scholte Op Reimer  3   4
Affiliations

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

L Verweij et al. BMC Health Serv Res. .

Abstract

Background: After hospitalization for cardiac disease, older patients are at high risk of readmission and death. Although geriatric conditions increase this risk, treatment of older cardiac patients is limited to the management of cardiac diseases. The aim of this study is to investigate if unplanned hospital readmission and mortality can be reduced by the Cardiac Care Bridge transitional care program (CCB program) that integrates case management, disease management and home-based cardiac rehabilitation.

Methods: In a randomized trial on patient level, 500 eligible patients ≥ 70 years and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Included patients will receive a Comprehensive Geriatric Assessment (CGA) at admission. Randomization with stratified blocks will be used with pre-stratification by study site and cognitive status based on the Mini-Mental State Examination (15-23 vs ≥ 24). Patients enrolled in the intervention group will receive a CGA-based integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) before discharge and four home visits post-discharge. The CCRNs collaborate with physical therapists, who will perform home-based cardiac rehabilitation and with a pharmacist who advices the CCRNs in medication management The control group will receive care as usual. The primary outcome is the incidence of first all-cause unplanned readmission or mortality within 6 months post-randomization. Secondary outcomes at three, six and 12 months after randomization are physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden.

Discussion: This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care.

Trial registration: NTR6316 . Date of registration: April 6, 2017.

Keywords: Cardiology; Case management; Disease management; Rehabilitation; Transitional care.

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Conflict of interest statement

Ethics approval and consent to participate

The CCB program has been approved by the Medical Ethics Committee of the AMC in the Netherlands (Protocol ID: MEC2016_024). Any relevant adjustments to the study protocol will be communicated to the Medical Ethics Committee of the AMC and to the Netherlands Trial Register. The study will be conducted in accordance with the Dutch Medical Research Involving Human Subjects and the WMA Declaration of Helsinki (1964). All patients will provide written informed consent before the start of the study. Netherlands Trial Register number: NTR6316, version 1 April 6th 2017.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flowchart of patient selection and randomization
See this image and copyright information in PMC

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