Centre of Expertise Urban Vitality

The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial


Background<br/>after hospitalisation for cardiac disease, older patients are at high risk of readmission and death.<br/><br/>Objective<br/>the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality.<br/><br/>Design<br/>single-blind, randomised clinical trial.<br/><br/>Setting<br/>the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge.<br/><br/>Subjects<br/>cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months.<br/><br/>Methods<br/>the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months.<br/><br/>Results<br/>in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care.<br/><br/>Conclusion<br/>in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.<br/><br/>Trial registration<br/>Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

Reference Jepma, P., Verweij, L., Buurman, B. M., Terbraak, M. S., Daliri, S., Latour, C. H. M., ter Riet, G., Karapinar-Çarkit, F., Dekker , J., Klunder , J. L., Liem, S.-S., Moons, A. H. M., Peters, R. J. G., & Scholte op Reimer, W. J. M. (2021). The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial. Age and Ageing, 50(6), 2105-2115. Article afab146. https://doi.org/10.1093/ageing/afab146
Published by  Urban Vitality 10 November 2021

Publication date

Nov 2021


Patricia Jepma
Lotte Verweij
Bianca M. Buurman
Sara Daliri
Fatma Karapinar-Çarkit
Jill Dekker
José L. Klunder
Su-San Liem
Arno H.M. Moons
Ron J.G. Peters
Wilma J.M. Scholte op Reimer


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