Referral to home-based cardiac rehabilitation (HBCR) is low among older and frailer patients due to low expectations regarding adherence by healthcare professionals. The aim of this study was to determine adherence to HBCR when old and frail patients are referred, and to explore any differences in baseline characteristics between adherent and nonadherent patients. Data of the Cardiac Care Bridge were used (Dutch trial register NTR6316). The study included hospitalized cardiac patients ≥ 70 years old and at high risk of functional loss. Adherence to HBCR was confirmed when two-thirds of the intended nine sessions were followed. Of the 153 patients included (age: 82 ± 6 years, 54% female), 29% could not be referred due to death before referral, not returning home, or practical problems. Of the 109 patients who were referred, 67% adhered. Characteristics associated with non-adherence were older age (84 ± 6 vs. 82 ± 6, p = 0.05) and higher handgrip strength in men (33 ± 8 vs. 25 ± 11, p = 0.01). There was no difference in comorbidity, symptoms, or physical capacity. Based on these observations, most older cardiac patients who return home after hospital admission appear to adhere to HBCR after referral, suggesting that most older cardiac patients are motivated and capable of receiving HBCR.
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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.
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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.
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Aim: To evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse-coordinated transitional care intervention in older cardiac patients to understand and interpret the study results. Design: A mixed-methods process evaluation based on the Medical Research Council Process Evaluation framework. Methods: Quantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi-structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data-analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence. Results: The overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in-hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention. Conclusion: Although involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non-significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population. Impact: In addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.
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Aim: The aim of this study is to explore patients' and (in)formal caregivers' perspectives on their role(s) and contributing factors in the course of unplanned hospital readmission of older cardiac patients in the Cardiac Care Bridge (CCB) program. Design: This study is a qualitative multiple case study alongside the CCB randomized trial, based on grounded theory principles. Methods: Five cases within the intervention group, with an unplanned hospital readmission within six months after randomization, were selected. In each case, semi-structured interviews were held with patients (n = 4), informal caregivers (n = 5), physical therapists (n = 4), and community nurses (n = 5) between April and June 2019. Patients' medical records were collected to reconstruct care processes before the readmission. Thematic analysis and the six-step analysis of Strauss & Corbin have been used. Results: Three main themes emerged. Patients experienced acute episodes of physical deterioration before unplanned hospital readmission. The involvement of (in)formal caregivers in adequate observation of patients' health status is vital to prevent rehospitalization (theme 1). Patients and (in)formal caregivers' perception of care needs did not always match, which resulted in hampering care support (theme 2). CCB caregivers experienced difficulties in providing care in some cases, resulting in limited care provision in addition to the existing care services (theme 3). Conclusion: Early detection of deteriorating health status that leads to readmission was often lacking, due to the acuteness of the deterioration. Empowerment of patients and their informal caregivers in the recognition of early signs of deterioration and adequate collaboration between caregivers could support early detection. Patients' care needs and expectations should be prioritized to stimulate participation. Impact: (In)formal caregivers may be able to prevent unplanned hospital readmission of older cardiac patients by ensuring: (1) early detection of health deterioration, (2) empowerment of patient and informal caregivers, and (3) clear understanding of patients' care needs and expectations.
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A growing number of older patients undergo cardiac surgery. Some of these patients are at increased risk of post-operative functional decline, potentially leading to reduced quality of life and autonomy, and other negative health outcomes. First step in prevention is to identify patients at risk of functional decline. There are no current published tools available to predict functional decline following cardiac surgery. The objective was to validate the identification of seniors at risk—hospitalised patients (ISAR-HP), in older patients undergoing cardiac surgery. A multicenter cohort study was performed in cardiac surgery wards of two university hospitals with follow-up 3 months after hospital admission. Inclusion criteria: consecutive cardiac surgery patients, aged ≥65. Functional decline was defined as a decline of at least one point on the Katz ADL Index at follow-up compared with preadmission status.
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BACKGROUND: 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.METHODS: 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.DISCUSSION: This study will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care.TRIAL REGISTRATION: NTR6316 . Date of registration: April 6, 2017.
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(A) BACKGROUND: Home-based cardiac rehabilitation (CR) is an attractive alternative for frail older patients who are unable to participate in hospital-based CR. Yet, the feasibility of home-based CR provided by primary care physiotherapists (PTs) to these patients remains uncertain.(B) OBJECTIVE: To investigate physiotherapists' (PTs) clinical experience with a guideline-centered, home-based CR protocol for frail older patients.(C) METHODS: A qualitative study examined the home-based CR protocol of a randomized controlled trial. Observations and interviews of the CR-trained primary care PTs providing home-based CR were conducted until data saturation. Two researchers separately coded the findings according to the theoretical framework of Gurses.(D) RESULTS: The enrolled PTs (n = 8) had a median age of 45 years (IQR 27-57), and a median work experience of 20 years (IQR 5-33). Three principal themes were identified that influence protocol-adherence by PTs and the feasibility of protocol-implementation: 1) feasibility of exercise testing and the exercise program; 2) patients' motivation and PTs' motivational techniques; and 3) interdisciplinary collaboration with other healthcare providers in monitoring patients' risks.(E) CONCLUSION: Home-based CR for frail patients seems feasible for PTs. Recommendations on the optimal intensity, use of home-based exercise tests and measurement tools, and interventions to optimize self-regulation are needed to facilitate home-based CR.
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Objectives: The primary objective was to determine the responsiveness of the Dutch version of the 13-item Tampa Scale for Kinesiophobia for cardiac patients (TSK-NL Heart). The secondary objective was to assess changes in kinesiophobia during cardiac rehabilitation.Methods: Kinesiophobia was measured pre- and post-cardiac rehabilitation using the TSK-NL Heart questionnaire in 109 cardiac patients (61 years; 76% men). The effect size of kinesiophobia score changes was calculated for the full population. A measure that is responsive to change should produce higher effects sizes in patients in whom kinesiophobia improves. Therefore, effect sizes were also calculated for patients who did or did not improve on selected external measures. For this step, the Cardiac Anxiety Questionnaire (CAQ) and the Hospital Anxiety and Depression Scale (HADS) were completed as external measures in a subsample of 58 patients.Results: The effect size of the TSK-NL Heart for the full study population was small (0.29). In line with the study hypothesis the effect size was higher (moderate) for patients with improved CAQ (0.52) and HADS scores (0.54). Prevalence of high kinesiophobia levels decreased from 40% pre-cardiac rehabilitation to 26% post-cardiac rehabilitation (p = 0.004).Conclusion: The TSK-NL Heart has moderate responsiveness and can be used to measure changes in kinesiophobia. Improvements in kinesiophobia were observed during cardiac rehabilitation. Nevertheless, high levels of kinesiophobia were still highly prevalent post-cardiac rehabilitation.
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Objectives: To determine the psychometric properties of a questionnaire to assess fear of movement (kinesiophobia): the Tampa Scale for Kinesiophobia (TSK-NL Heart), and to investigate the prevalence of kinesiophobia in patients attending cardiac rehabilitation.Methods: A total of 152 patients were evaluated with the TSK-NL Heart during intake and 7 days later. Internal consistency, test-retest reliability and construct validity were assessed. For construct validity, the Cardiac Anxiety Questionnaire (CAQ) and the Hospital Anxiety and Depression Scale (HADS) were used. The factor structure of the TSK-NL Heart was determined by a principal component analysis (PCA).Results: After removal of 4 items due to low internal consistency, the TSK-NL Heart showed substantial reliability (intraclass correlation coefficient; ICC: 0.80). A strong positive correlation was found between the TSK-NL Heart and the CAQ (rs: 0.61). Strong positive correlations were found between the TSK-NL Heart and de HADS (Anxiety) (rs: 0.60) and between the TSK-NL Heart and the CAQ (rs: 0.61). The PCA revealed a 3-factor structure as most suitable (fear of injury, avoidance of physical activity, perception of risk). High levels of kinesiophobia were found in 45.4% of patients.Conclusion: The 13-item TSK-NL Heart has good psychometric properties, and we recommend using this version to assess kinesiophobia, which is present in a substantial proportion of patients referred for cardiac rehabilitation.Keywords: Tampa Scale for Kinesiophobia; cardiac rehabilitation; exercise; fear of movement; physical activity; cardiovascular disease
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