Verweij L, Jepma P, Buurman B M, Latour C H M, Engelbert R H H, Ter Riet G, Karapinar-Çarkit F, Daliri S, Peters R J G, Scholte Op Reimer W J M
ACHIEVE Center of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands.
Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands.
BMC Health Serv Res. 2018 Jun 28;18(1):508. doi: 10.1186/s12913-018-3301-9.
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.
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.
This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care.
NTR6316 . Date of registration: April 6, 2017.
心脏病住院治疗后，老年患者再次入院和死亡的风险很高。尽管老年疾病会增加这种风险，但老年心脏病患者的治疗仅限于心脏病的管理。本研究的目的是调查心脏护理桥梁过渡护理计划（CCB计划）是否能降低计划外住院再入院率和死亡率，该计划整合了病例管理、疾病管理和家庭心脏康复。
在一项患者层面的随机试验中，荷兰六家医院将招募500名年龄≥70岁、再入院和死亡风险高的符合条件的患者。纳入的患者将在入院时接受综合老年评估（CGA）。将采用分层区组随机化，根据研究地点和基于简易精神状态检查的认知状态（15 - 23分与≥24分）进行预分层。干预组的患者将接受基于CGA的综合护理计划，出院前与社区护理注册护士（CCRN）进行面对面交接，并在出院后进行四次家访。CCRN与物理治疗师合作，物理治疗师将进行家庭心脏康复，CCRN还与药剂师合作，药剂师在药物管理方面为CCRN提供建议。对照组将接受常规护理。主要结局是随机分组后6个月内首次全因计划外再入院或死亡的发生率。随机分组后3个月、6个月和12个月的次要结局包括身体功能、功能能力、抑郁、焦虑、药物依从性、健康相关生活质量、医疗保健利用和照顾者负担。
本研究将提供有关老年护理和心脏护理整合有效性的新知识。
NTR6316。注册日期：2017年4月6日。
