Importance Older adults acutely hospitalized are at risk of disability. Trials on comprehensive geriatric assessment (CGA) and transitional care present inconsistent results.Objective To test whether an intervention of systematic CGA, followed by the transitional care bridge program, improved activities of daily living (ADLs) compared with systematic CGA alone.Design, Setting, and Participants This study was a double-blind, multicenter, randomized clinical trial conducted at 3 hospitals with affiliated home care organizations in the Netherlands between September 1, 2010, and March 1, 2014. In total, 1070 consecutive patients were eligible, 674 (63.0%) of whom enrolled. They were 65 years or older, acutely hospitalized to a medical ward for at least 48 hours with an Identification of Seniors at Risk–Hospitalized Patients score of 2 or higher, and randomized using permuted blocks stratified by study site and Mini-Mental State Examination score (<24 vs ≥24). The dates of the analysis were June 1, 2014, to November 15, 2014.Interventions The transitional care bridge program intervention was started during hospitalization by a visit from a community care registered nurse (CCRN) and continued after discharge with home visits at 2 days and at 2, 6, 12, and 24 weeks. The CCRNs applied the CGA care and treatment plan.Main Outcomes and Measures The main outcome was the Katz Index of ADL at 6 months compared with 2 weeks before admission. Secondary outcomes were mortality, cognitive functioning, time to hospital readmission, and the time to discharge from a nursing home.Results The study cohort comprised 674 participants. Their mean age was 80 years, 42.1% (n = 284) were male, and 39.2% (n = 264) were cognitively impaired at admission. Intent-to-treat analysis found no differences in the mean Katz Index of ADL at 6 months between the intervention arm (mean, 2.0; 95% CI, 1.8-2.2) and the CGA-only arm (mean, 1.9; 95% CI, 1.7-2.2). For secondary outcomes, there were 85 deaths (25.2%) in the intervention arm and 104 deaths (30.9%) in the CGA-only arm, resulting in a lower risk on the time to death within 6 months after hospital admission (hazard ratio, 0.75; 95% CI, 0.56-0.99; P = .045; number needed to treat to prevent 1 death, 16). No other secondary outcome was significant.Conclusions and Relevance A systematic CGA, followed by the transitional care bridge program, showed no effect on ADL functioning in acutely hospitalized older patients.Trial Registration Netherlands Trial Registry: NTR2384
Background: after hospitalisation for cardiac disease, older patients are at high risk of readmission and death. Objective: 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. Design: single-blind, randomised clinical trial. Setting: 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. Subjects: 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. Methods: 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. Results: 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. Conclusion: in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.
Background: Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients’ participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients. Methods: A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed. Results: Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants’ recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention. Conclusion: Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients’ needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.
