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  1. Page 6 | Alexander Street, a ProQuest Company
  2. Copyright:
  3. Departmental Publications List 2011

Verdehr Trio. Birds of Paradise. CD CD Set. CD Stark. Americana Wind Quintet. Westwood Wind Quintet. Weiss Family Woodwinds. Telemann, Georg Philipp; Heldenmusik. David Hickman, trumpet; William Neil, organ. Carol Rodland, viola. Children of Light. CD Tomasi, Henri. CD trad. Concertino for Flute, Oboe, Clarinet, and Bassoon. Members Westwood Wind Quintet. Anthony Plog, trumpet; Sharon Davis,piano. Dallas Symphony Orchestra Brass Quintet. Fred Sautter, trumpet; Roger Sherman, organ.

Trio for Violin, Claroinet, and Piano. Solaris Wind Quintet. Warhol Appassionata. CD Yong, Kam Kee. And the Fallen Petals. This is due to the limit on physical therapy sessions funded by Dutch healthcare insurance policies. Patients in the control group will receive usual care during hospitalization and after discharge. During hospitalization, other disciplines are consulted as needed. After discharge, care as usual may include medical care by a cardiologist according to the national cardiovascular guidelines and a cardiac nurse specialist, if available.

Also, control group patients can be referred to center-based cardiac rehabilitation. According to the Dutch multidisciplinary guideline of cardiac rehabilitation, center-based cardiac rehabilitation consists two one-hour exercise sessions per week during 6 weeks [ 32 ]. However, it is expected that only a small number of patients in the control group will receive center-based cardiac rehabilitation due to their age, illness and clinical complexity.

Standard primary care will be provided in both the intervention and the control group.

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Page 6 | Alexander Street, a ProQuest Company

For non-cardiovascular problems, the GP is the primary healthcare provider. Optional care provision in the GP practice includes secondary prevention, medication titration, regular evaluations of physical health status and referral to other disciplines. In both groups the GP will be informed about the hospitalization by a discharge letter from the medical specialist.

During the intervention, the CCRN will be an extra liaison between care providers in case of medical, mental or social issues. In the Netherlands virtually all citizens have basic healthcare insurance, which includes coverage of primary care visits, hospital outpatient visits, hospitalizations and prescribed medication. Dutch citizens can also purchase optional supplementary insurance, which includes physical therapy and other services.

The CCB program combines case management, disease management and home-based cardiac rehabilitation, which require additional skills of healthcare providers.

The participating CRNs and CCRNs will therefore follow a 5-day training program focussing on case management and disease management which addresses geriatric conditions, the performance of the CGA, development of an integrated care plan, pathophysiology of common cardiac diseases, early detection of physical deterioration and complications, pharmaceutical treatments and cardiac rehabilitation, including lifestyle counselling [ 9 , 10 , 11 , 12 , 13 ].

We performed a feasibility process in six participating hospitals from June until May to check for potential inclusion rates to implement the study protocol and to train CRNs in data collection.

In total 45 patients were included in this pilot phase. After successful implementation, we started the official inclusion stepwise per hospital with the first hospitals starting in June Secondary outcomes will be measured at three, 6 and 12 months. Data will be collected by telephone at three and 12 months and at 6 months by a home visit of a blinded research nurse. Table 3 provides an overview of the data collection on different time points.

The secondary outcomes are the following:. The incidence of the first all-cause unplanned hospital readmission or mortality within 3 months and 12 months after randomization triangulated by self-reporting and hospital data management system.

Functional capacity at 6 months after randomization Short Physical Performance Battery [ 36 ] and 2-min step test [ 37 ]. Medication adherence questionnaire and pharmacy dispensing records at 3 , 6 and 12 months after andomization.

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All analyses will be performed according to a predefined statistical analysis plan, which is published in the Netherlands Trial Register NTR The primary analyses will be performed according to the intention-to-treat principle. Adjusted analyses using multivariable logistic or linear regression models, as appropriate, will focus on the incidence proportion of the composite endpoint of readmission and mortality up to 6 months. All analyses will be adjusted for the following potential confounders: age, sex, Charlson Comorbidity Score, MMSE, cardiovascular diagnosis, length of stay and living arrangement.

In addition, subgroup analyses will be performed for cardiac diagnosis, frailty status with the VMS screening tool, cognitive status with the MMSE and social economic status. Data will be collected by an electronic Case Record Form in Research Manager [ 25 ], a web-based data management program.

Multiple imputation will be used as a sensitivity analysis to assess the impact of missing values. We will perform a cost-effectiveness analysis from a societal perspective. The uncertainty surrounding the ICERS will be estimated with non-parametric bootstrapping replications. The intention to treat principle will be applied to analyse the data. Missing values for cost and effect data will be predicted by multiple imputation. Quantitative data will be collected by using pre-defined process indicators to measure study performance and adherence to the intervention by the patient, CRN, CCRN and PT.

Process indicators will be used to study fidelity and adherence to the study protocol. Process indicators are focussed on documentation, communication between healthcare providers, consultation of disciplines, referral to healthcare providers and medication issues. All process indicators will be quantified by nominator and denominator and collected through existing resources.

Usual care will be documented to be able to assess the difference between the intervention and control group. In addition, qualitative data will be collected during the intervention by focus groups with healthcare providers and in semi-structured interviews with patients and informal caregivers to evaluate satisfaction with the intervention.

These data will be analysed to identify factors that promote or impede future implementation of the CCB care program. After 12 weeks, the intervention has stopped. Therefore, serious adverse events after this period are not expected to be caused by the study and will only be recorded during the annual security reports. Older patients who are discharged after hospitalization for a cardiac disease are at high risk of adverse outcomes, in particular early readmission and mortality [ 42 , 43 ]. This vulnerable patient population is currently underrepresented in medical research, resulting in a lack of evidence on how to improve their outcomes [ 44 , 45 , 46 ].

In this paper we describe the study protocol of the CCB care program in which we combine three care components: case management, disease management and home-based cardiac rehabilitation that will be provided during and after hospitalization for cardiac disease. Multidisciplinary collaboration between the in-hospital cardiac team, including the CRN and the cardiologist, the clinical nurse specialist in geriatrics and the pharmacist, CCRN and PT in primary care, is an important part of the study intervention.

Current literature on transitional care and cardiac rehabilitation in older high risk patients focuses mainly on the separate components of case management, disease management and home-based cardiac rehabilitation. However, there was less impact on time to first hospitalization, HR 1. However, most of these were pilot studies with limited power.

The Korinna trial [ 49 ] combined both case management and disease management in older patients after a myocardial infarction, but did not find a relevant effect on hospital readmission HR 1. Compared to the intervention in the Korinna trial [ 49 ], the CCB program is focussed on a broader cardiac patient population instead of patients after acute myocardial infarction only.


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Other differences are the emphasis of the CCB program on the first period after hospitaization with a first home visit within 2 days after discharge and the additional home based cardiac rehabilitation program. The first strength of this study is that it includes a wider variety of the cardiac patient population than previous studies. This is because it selects patients based on their risk of readmission and mortality, instead of diagnosis, and because it selects from six hospitals in both an urban and a rural area.

Second, this study has a robust design and includes a postponed informed consent procedure, which assures high internal validity. Third, a comprehensive geriatric assessment is used to develop a personalized care plan, including cardiac and geriatric care, that is transferrable across settings and healthcare providers.

Fourth, due to the comprehensive nature of the intervention, it will not be possible to evaluate separate intervention components on their effectiveness but by use of process indicators we will collect data on the execution of the components of the intervention and performance of the involved healthcare providers to support interpretation of the study results. Finally, the intervention has been designed in multi-disciplinary collaboration between nurses, physical therapists, pharmacists and physicians.

This study also has some limitations. First, we exclude patients with delirium and dementia. These patients are at risk for readmission [ 50 ] and mortality [ 51 , 52 ] and therefore could potentially benefit from this intervention. However, it is not possible to include these patients in the CCB program because of ethical considerations.

Secondly, the face-to-face handover between de CRN and CCRN is a promising intervention but also challenging due to logistical difficulties as, for example, the sometimes unpredictable discharges from the hospital. An alternative handover was introduced by video call via tablets.

In summary, the CCB program aims to significantly reduce the primary composite endpoint of unplanned hospital readmission and mortality in older cardiac patients. Heart disease and stroke Statistics update: a report from the American Heart Association.

Departmental Publications List 2011

Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: a prospective cohort study. PLoS One. Geriatric conditions in heart failure.

Curr Cardiovasc Risk Rep. What to expect from the evolving field of geriatric cardiology. J Am Coll Cardiol. Prevalence of geriatric syndromes and impact on clinical and functional outcomes in older patients with acute cardiac diseases. Components of comprehensive and effective transitional care. J Am Geriatr Soc. The care span: the importance of transitional care in achieving health reform. Health Aff. Older adults' use of postacute and cardiac rehabilitation services after hospitalization for a cardiac event.

Rehabil Nurs. Changes in health-related quality of life in older patients with acute myocardial infarction or congestive heart failure: a prospective study. A trial of a comprehensive nursing rehabilitation program for nursing home residents post-hospitalization. Res Gerontol Nurs. Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors.

Predictors of drop-out from an outpatient cardiac rehabilitation programme. Clin Rehabil. Effectiveness of cardiac rehabilitation among older patients after acute myocardial infarction. Am Heart J. Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. Comprehensive geriatric assessment and transitional Care in Acutely Hospitalized Patients - the transitional care bridge randomized clinical trial.

Effect of a nurse-coordinated prevention programme on cardiovascular risk after an acute coronary syndrome: main results of the RESPONSE randomised trial. Predictive value of the VMS theme 'Frail elderly': delirium, falling and mortality in elderly hospital patients. Ned Tijdschr Geneeskd. Optimal screening for increased risk for adverse outcomes in hospitalised older adults. Age Ageing. Patterns of weight change preceding hospitalization for heart failure.

Characterization of acute heart failure hospitalizations in a Portuguese cardiology department. Rev Port Cardiol. Recurrent readmissions in medical patients: a prospective study. J Hosp Med. Research Manager. Accessed 12 Jan A modified informed-consent procedure in which the complete information is given retrospectively: no objection from participating patients. Are randomized clinical trials good for us in the short term?

J Clin Epidemiol. The Hawthorne effect: a randomised, controlled trial. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. Recognition of drug related problems by home healthcare employees: a Dutch observational study with self reports. J Nurs Educ Pract. Dutch Society for Cardiology. Multidisciplinary guideline for cardiac Rehabilitation Accessed 21 June Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale.

Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. Health Qual Life Outcomes. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission.

J Gerontol. Rikly R, Jones C. Functional fitness normative scores for community residing older adults ages J Aging Phys Act. An evaluation of two self-report screening measures for mood in an out-patient chronic heart failure population. Int J Geriatr Psychiatry. Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness.

Qual Life Res. National Care for the Elderly Program.

Publication details

Accessed 07 Nov Trajectories of risk for specific readmission diagnoses after hospitalization for heart failure, acute myocardial infarction, or pneumonia. Diagnoses and timing of day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. Moving from disease-centered to patient goals-directed care for patients with multiple chronic conditions. JAMA Cardiol. Underrepresentation of elderly people in randomised controlled trials. The example of trials of 4 widely prescribed drugs. Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.