The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial

Background<br/>after hospitalisation for cardiac disease, older patients are at high risk of readmission and death.<br/><br/>Objective<br/>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.<br/><br/>Design<br/>single-blind, randomised clinical trial.<br/><br/>Setting<br/>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.<br/><br/>Subjects<br/>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.<br/><br/>Methods<br/>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.<br/><br/>Results<br/>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.<br/><br/>Conclusion<br/>in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.<br/><br/>Trial registration<br/>Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169