{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T13:52:50Z","timestamp":1790949170909,"version":"4.1.0"},"reference-count":37,"publisher":"Oxford University Press (OUP)","issue":"6","license":[{"start":{"date-parts":[[2021,7,25]],"date-time":"2021-07-25T00:00:00Z","timestamp":1627171200000},"content-version":"vor","delay-in-days":1,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001826","name":"Netherlands Organisation for Health Research and Development","doi-asserted-by":"publisher","award":["520002002"],"award-info":[{"award-number":["520002002"]}],"id":[{"id":"10.13039\/501100001826","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100003246","name":"Dutch Research Council","doi-asserted-by":"publisher","award":["023.008.024"],"award-info":[{"award-number":["023.008.024"]}],"id":[{"id":"10.13039\/501100003246","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100003246","name":"Dutch Research Council","doi-asserted-by":"publisher","award":["023.009.036"],"award-info":[{"award-number":["023.009.036"]}],"id":[{"id":"10.13039\/501100003246","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,11,10]]},"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n after hospitalisation for cardiac disease, older patients are at high risk of readmission and death.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Design<\/jats:title>\n single-blind, randomised clinical trial.<\/jats:p>\n <\/jats:sec>\n \n Setting<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Subjects<\/jats:title>\n cardiac patients\u2009\u2265\u200970\u00a0years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6\u00a0months.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n 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\u00a0months.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n 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 \u22124.7 to 18%], risk ratios 1.14 [95% CI 0.91\u20131.42], P\u2009=\u20090.253). The study was discontinued prematurely due to implementation activities in usual care.<\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6\u00a0months.<\/jats:p>\n <\/jats:sec>\n \n Trial registration<\/jats:title>\n Netherlands Trial Register 6,316, https:\/\/www.trialregister.nl\/trial\/6169<\/jats:p>\n <\/jats:sec>","DOI":"10.1093\/ageing\/afab146","type":"journal-article","created":{"date-parts":[[2021,6,18]],"date-time":"2021-06-18T19:12:53Z","timestamp":1624043573000},"page":"2105-2115","source":"Crossref","is-referenced-by-count":32,"title":["The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial"],"prefix":"10.1093","volume":"50","author":[{"given":"Patricia","family":"Jepma","sequence":"first","affiliation":[{"name":"Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands"},{"name":"Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lotte","family":"Verweij","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands"},{"name":"Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bianca M","family":"Buurman","sequence":"additional","affiliation":[{"name":"Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands"},{"name":"Amsterdam UMC, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michel S","family":"Terbraak","sequence":"additional","affiliation":[{"name":"Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Daliri","sequence":"additional","affiliation":[{"name":"OLVG Hospital, Department of Clinical Pharmacy, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Corine H M","family":"Latour","sequence":"additional","affiliation":[{"name":"Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerben","family":"ter Riet","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands"},{"name":"Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatma","family":"Karapinar - \u00c7arkit","sequence":"additional","affiliation":[{"name":"OLVG Hospital, Department of Clinical Pharmacy, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jill","family":"Dekker","sequence":"additional","affiliation":[{"name":"Bovenij Medical Centre, Department of Cardiology, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose L","family":"Klunder","sequence":"additional","affiliation":[{"name":"OLVG Hospital, Department of Cardiology, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Su-San","family":"Liem","sequence":"additional","affiliation":[{"name":"Amstelland Hospital, Department of Cardiology, Amstelveen, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arno H M","family":"Moons","sequence":"additional","affiliation":[{"name":"OLVG Hospital, Department of Cardiology, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ron J G","family":"Peters","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wilma J M","family":"Scholte op Reimer","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands"},{"name":"HU University of Applied Sciences Utrecht, Research Group Chronic Diseases, Utrecht, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2021,7,24]]},"reference":[{"key":"2021111107292437500_ref1","doi-asserted-by":"crossref","first-page":"e139","DOI":"10.1161\/CIR.0000000000000757","article-title":"Heart disease and stroke statistics-2020 update: a report from the American Heart Association","volume":"141","author":"Virani","year":"2020","journal-title":"Circulation"},{"key":"2021111107292437500_ref2","doi-asserted-by":"crossref","first-page":"1333","DOI":"10.1056\/NEJMoa1406656","article-title":"Demographic and epidemiologic drivers of global cardiovascular mortality","volume":"372","author":"Roth","year":"2015","journal-title":"N Engl J Med"},{"key":"2021111107292437500_ref3","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.118.005320","article-title":"Thirty-day readmission risk model for older adults hospitalized with acute myocardial infarction","volume":"12","author":"Dodson","year":"2019","journal-title":"Circ Cardiovasc Qual Outcomes"},{"key":"2021111107292437500_ref4","doi-asserted-by":"crossref","first-page":"1299","DOI":"10.1002\/ejhf.1611","article-title":"Heart Failure Association\/European Society of Cardiology position paper on frailty in patients with heart failure","volume":"21","author":"Vitale","year":"2019","journal-title":"Eur J Heart Fail"},{"key":"2021111107292437500_ref5","doi-asserted-by":"crossref","first-page":"1286","DOI":"10.1016\/j.jacc.2015.07.048","article-title":"What to expect from the evolving field of geriatric cardiology","volume":"66","author":"Bell","year":"2015","journal-title":"J Am Coll Cardiol"},{"key":"2021111107292437500_ref6","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1111\/jgs.14782","article-title":"Components of comprehensive and effective transitional care","volume":"65","author":"Naylor","year":"2017","journal-title":"J Am Geriatr Soc"},{"key":"2021111107292437500_ref7","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1097\/PTS.0000000000000067","article-title":"Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity","volume":"10","author":"Schoonover","year":"2014","journal-title":"J Patient Saf"},{"key":"2021111107292437500_ref8","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1093\/geront\/gnx192","article-title":"\"I Feel Worn Out, as if I Neglected Myself\": older patients' perspectives on post-hospital symptoms after acute hospitalization","volume":"59","author":"Seben","year":"2019","journal-title":"Gerontologist"},{"key":"2021111107292437500_ref9","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1016\/j.cger.2019.07.001","article-title":"Never too old for cardiac rehabilitation","volume":"35","author":"O'Neill","year":"2019","journal-title":"Clin Geriatr Med"},{"key":"2021111107292437500_ref10","doi-asserted-by":"crossref","first-page":"2315","DOI":"10.1093\/eurheartj\/ehw106","article-title":"European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)","volume":"37","author":"Piepoli","year":"2016","journal-title":"Eur Heart J"},{"key":"2021111107292437500_ref11","doi-asserted-by":"crossref","first-page":"1597","DOI":"10.1111\/jgs.14828","article-title":"Impact of transitional care services for chronically ill older patients: a systematic evidence review","volume":"65","author":"Le Berre","year":"2017","journal-title":"J Am Geriatr Soc"},{"key":"2021111107292437500_ref12","doi-asserted-by":"crossref","first-page":"1531","DOI":"10.1377\/hlthaff.2014.0160","article-title":"Transitional care interventions prevent hospital readmissions for adults with chronic illnesses","volume":"33","author":"Verhaegh","year":"2014","journal-title":"Health Aff"},{"key":"2021111107292437500_ref13","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1001\/jamainternmed.2015.8042","article-title":"Comprehensive geriatric assessment and transitional care in acutely hospitalized patients - the transitional care bridge randomized clinical trial","volume":"176","author":"Buurman","year":"2016","journal-title":"JAMA Intern Med"},{"key":"2021111107292437500_ref14","doi-asserted-by":"crossref","first-page":"1427","DOI":"10.1002\/ejhf.765","article-title":"Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis","volume":"19","author":"Van Spall","year":"2017","journal-title":"Eur J Heart Fail"},{"key":"2021111107292437500_ref15","doi-asserted-by":"crossref","first-page":"774","DOI":"10.7326\/M14-0083","article-title":"Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis","volume":"160","author":"Feltner","year":"2014","journal-title":"Ann Intern Med"},{"key":"2021111107292437500_ref16","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1001\/jama.2019.0710","article-title":"Effect of patient-centered transitional care services on clinical outcomes in patients hospitalized for heart failure: the PACT-HF randomized clinical trial","volume":"321","author":"Van Spall","year":"2019","journal-title":"JAMA"},{"key":"2021111107292437500_ref17","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1186\/1471-2318-13-115","article-title":"Effects of a nurse-based case management compared to usual care among aged patients with myocardial infarction: results from the randomized controlled KORINNA study","volume":"13","author":"Meisinger","year":"2013","journal-title":"BMC Geriatri"},{"key":"2021111107292437500_ref18","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-018-3301-9","article-title":"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","volume":"18","author":"Verweij","year":"2018","journal-title":"BMC Health Serv Res"},{"key":"2021111107292437500_ref19","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/j.jclinepi.2010.03.004","article-title":"CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials","volume":"63","author":"Moher","year":"2010","journal-title":"J Clin Epidemiol"},{"key":"2021111107292437500_ref20","volume-title":"Dutch Safety Management Program Practical guide for frail older patients [in Dutch]","year":"2009"},{"key":"2021111107292437500_ref21","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1093\/ageing\/afu187","article-title":"Optimal screening for increased risk for adverse outcomes in hospitalised older adults","volume":"44","author":"Heim","year":"2015","journal-title":"Age Ageing"},{"key":"2021111107292437500_ref22","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2016-011060","article-title":"Utility of models to predict 28-day or 30-day unplanned hospital readmissions: an updated systematic review","volume":"6","author":"Zhou","year":"2016","journal-title":"BMJ Open"},{"key":"2021111107292437500_ref23","first-page":"29","article-title":"A modified informed-consent procedure in which the complete information is given retrospectively: no objection from participating patients","volume":"149","author":"Boter","year":"2005","journal-title":"Ned Tijdschr Geneeskd"},{"key":"2021111107292437500_ref24","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1016\/S0895-4356(00)00305-X","article-title":"Are randomized clinical trials good for us (in the short term)? Evidence for a ``trial effect''","volume":"54","author":"Braunholtz","year":"2001","journal-title":"J Clin Epidemiol"},{"key":"2021111107292437500_ref25","first-page":"41","article-title":"Recognition of drug related problems by home healthcare employees: a Dutch observational study with self reports","volume":"3","author":"Sino","year":"2013","journal-title":"J Nurs Educ And Pract"},{"key":"2021111107292437500_ref26","volume-title":"Multidisciplinary guideline for cardiac rehabilitation","author":"Dutch Society for Cardiology","year":"2011"},{"key":"2021111107292437500_ref27","volume-title":"What information is in the Personal Records Database?","author":"Government of the Netherlands"},{"key":"2021111107292437500_ref28","doi-asserted-by":"crossref","first-page":"1690","DOI":"10.1001\/jama.280.19.1690","article-title":"What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes","volume":"280","author":"Zhang","year":"1998","journal-title":"JAMA"},{"key":"2021111107292437500_ref29","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1177\/1536867X1301300405","article-title":"Flexible parametric illness-death models","volume":"13","author":"Hinchliffe","year":"2013","journal-title":"Stata J"},{"key":"2021111107292437500_ref30","doi-asserted-by":"crossref","first-page":"4719","DOI":"10.1002\/sim.7448","article-title":"Parametric multistate survival models: flexible modelling allowing transition-specific distributions with application to estimating clinically useful measures of effect differences","volume":"36","author":"Crowther","year":"2017 20","journal-title":"Stat Med"},{"key":"2021111107292437500_ref31","doi-asserted-by":"crossref","first-page":"2498","DOI":"10.1111\/jan.14786","article-title":"The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: a mixed-methods process evaluation","volume":"77","author":"Verweij","year":"2021","journal-title":"J Adv Nurs"},{"key":"2021111107292437500_ref32","volume-title":"Comprehensive geriatric care in hospitals: the role of inpatient geriatric consultation teams \u2013 Synthesis","author":"Deschodt","year":"2015"},{"key":"2021111107292437500_ref33","doi-asserted-by":"publisher","DOI":"10.1186\/1741-7015-11-48","article-title":"Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis","volume":"11","author":"Deschodt","year":"2013","journal-title":"BMC Med"},{"key":"2021111107292437500_ref34","doi-asserted-by":"crossref","first-page":"673","DOI":"10.7326\/0003-4819-156-10-201205150-00003","article-title":"A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial","volume":"156","author":"Fan","year":"2012","journal-title":"Ann Intern Med"},{"key":"2021111107292437500_ref35","doi-asserted-by":"crossref","first-page":"891","DOI":"10.1002\/ejhf.592","article-title":"ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC","volume":"18","author":"Ponikowski","year":"2016","journal-title":"Eur J Heart Fail"},{"key":"2021111107292437500_ref36","doi-asserted-by":"crossref","first-page":"1539","DOI":"10.1177\/0269216318801162","article-title":"Does advance care planning in addition to usual care reduce hospitalisation for patients with advanced heart failure: A systematic review and narrative synthesis","volume":"32","author":"Kernick","year":"2018","journal-title":"Palliat Med"},{"key":"2021111107292437500_ref37","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1007\/s40520-019-01172-z","article-title":"Factors associated with refusal or acceptance of older patients (\u2265\u200965 years) to provide consent to participate in clinical research in cardiology: a qualitative study","volume":"32","author":"Ecarnot","year":"2020","journal-title":"Aging Clin Exp Res"}],"container-title":["Age and Ageing"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ageing\/article-pdf\/50\/6\/2105\/41119577\/afab146.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ageing\/article-pdf\/50\/6\/2105\/41119577\/afab146.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,11,11]],"date-time":"2021-11-11T07:30:10Z","timestamp":1636615810000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ageing\/article\/50\/6\/2105\/6326075"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,24]]},"references-count":37,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,7,24]]},"published-print":{"date-parts":[[2021,11,10]]}},"URL":"https:\/\/doi.org\/10.1093\/ageing\/afab146","relation":{},"ISSN":["0002-0729","1468-2834"],"issn-type":[{"value":"0002-0729","type":"print"},{"value":"1468-2834","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2021,11]]},"published":{"date-parts":[[2021,7,24]]}}}