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

Geriatricians' role in the management of aortic stenosis in frail older patients: a decade later

INTRODUCTION

Increasing evidence supports the implementation of geriatric assessment in the workup of older patients with aortic stenosis (AS). In 2012, an online European survey revealed that geriatricians were rarely involved in the assessment of candidates for transcatheter aortic valve implantation (TAVI). After a "call to action" for early involvement of geriatricians in AS evaluation, the survey was repeated in 2022. Our aim was to investigate whether geriatricians' role changed in the last decade.

METHODS

Online survey conducted between December 16th, 2021, and December 15th, 2022. All members of the European Geriatric Medicine Society were invited to participate. The survey included 26 questions regarding geriatricians' experience with AS and TAVI.

RESULTS

Among 193 respondents (79.8% geriatricians), 73 (38%) reported to be involved in AS evaluation at least once a week. During 2 years prior to the survey, 43 (22.3%) had referred > 50% of their patients with severe AS for TAVI. Age influenced TAVI referral in a considerable proportion of respondents (36.8%). TAVI candidates were mainly referred to specialised cardiac centres with multidisciplinary teams (91.8%), including (47.2%) or not including (44.6%) a geriatrician. A total of 38.9% of respondents reported to be part of a multidisciplinary heart team. Geriatricians were less frequently involved (37%) than cardiologists (89.6%) and surgeons (53.4%) in pre-procedural TAVI management. Cardiologists were more frequently involved (85.5%) than geriatricians (33.7%) and surgeons (26.9%) in post-procedural management.

CONCLUSIONS

Geriatricians' involvement in AS management and multidisciplinary heart teams remains scarce. More efforts should be devoted to implement geriatricians' role in AS decision-making.

Effectiveness of information and communication technology-based integrated care for older adults: a systematic review and meta-analysis

Background

Information and communication technology (ICT) is a key factor in advancing the implementation of integrated care for older adults in the context of an aging society and the normalization of epidemics. This systematic review aims to comprehensively evaluate the effectiveness of ICT-based integrated care for older adults to provide input for the construction of intelligent integrated care models suitable for the context of an aging population in China.

Methods

A systematic review and meta-analysis were conducted using PubMed, Web of Science Core Collection, Scopus, MEDLINE, EBSCO, EMBASE, CINAHL with full text, ProQuest, and Cochrane Library databases, along with the Google Scholar search engine, for papers published between January 1, 2000, and July 25, 2022, to include randomized controlled trials and quasi-experimental studies of ICT-based integrated care for older adults. Two reviewers independently performed literature screening, quality assessment (JBI standardized critical appraisal tool), and data extraction. The results were pooled using a random effects model, and narrative synthesis was used for studies with insufficient outcome data.

Results

We included 32 studies (21 interventions) with a total of 30,200 participants (14,289 in the control group and 15,911 in the intervention group). However, the quality of the literature could be improved. The meta-analysis results showed that ICT-based integrated care significantly improved the overall perceived health status of older adults (n=3 studies, MD 1.29 (CI 0.11 to 2.46), no heterogeneity) and reduced the number of emergency department visits (n=11 studies, OR 0.46 (CI 0.25 to 0.86), high heterogeneity) but had no significant effect on improving quality of life, mobility, depression, hospital admissions and readmissions, or mortality in older adults, with a high degree of study heterogeneity. Narrative analysis showed that the overall quality of care, primary care service use, and functional status of older adults in the intervention group improved, but the cost-effectiveness was unclear.

Conclusions

ICT-based integrated care is effective in improving health outcomes for older adults, but the quality and homogeneity of the evidence base need to be improved. Researchers should develop intelligent integrated care programs in the context of local health and care welfare provision systems for older adults, along with the preferences and priorities of the older adults.

Bridging the Gap: Impact of dedicated post-discharge services on readmission rates and emergency department visits for psychiatrically hospitalized youth

BACKGROUND

For psychiatrically hospitalized youth, discharge care coordination can reduce suicide risk and rehospitalization, but studies on effective interventions or programs are sparse. This study aimed to examine the impact of a dedicated post-discharge bridging service including case management and therapeutic supports on readmissions and emergency department presentations.

METHODS

This retrospective cohort study compared emergency department mental health visits (EDMH) and psychiatric hospitalizations in the 60 days before the hospitalization which included referral to the bridging service, and in the 60 days post-hospitalization.

RESULTS

This diagnostically heterogeneous group of 238 youth had a mean age of 14 years and were of similar racial and ethnic background as the broader inpatient population. There was a nominal decrease in hospitalizations (p = 0.251), and a significant decrease in EDMH (p < 0.001) in the 60 days following referral to this program compared to the 60 days prior. Further, the proportion of patients with at least one EDMH or hospitalization decreased significantly before and after linkage with this service from 42.4% to 27.3% (p < 0.001).

CONCLUSION

Dedicated post-discharge bridging services including family-centered, flexible case management and therapeutic supports can reduce EDMH visits and potentially lower readmission for children and adolescents.

Nurse-coordinated home-based cardiac rehabilitation for patients with heart failure: A scoping review

Objectives

This study aimed to review and summarize the studies of nurse-coordinated home-based cardiac rehabilitation for patients with heart failure.

Methods

The review was performed using Arksey and O'Malley's scoping review framework. A systematic search was conducted across eight databases, including PubMed, Embase, Web of Science, EBSCO, China Biomedical Literature Service System (SinoMed), China National Knowledge Infrastructure (CNKI), Wanfang Database, and Chinese Science and Technology Journals (CSTJ) Database, and Chinese Clinical Trial Registry, from inception to 30 April 2023. Articles relevant to the nurse-coordinated home-based cardiac rehabilitation for patients with heart failure were included.

Results

Eighteen studies were included in this review. These studies showed that nurses primarily focused on patient assessment, home-based cardiac rehabilitation planning and guidance, and follow-up. The studies also reported positive outcomes in patient safety, feasibility, and efficacy of the programs coordinated by nurses.

Conclusions

Home-based cardiac rehabilitation coordinated by nurses is beneficial to patients with heart failure. Future research will explore the potential of nurses in home-based cardiac rehabilitation for patients with heart failure, determine optimal evaluation criteria, and formulate safe, effective, and economical rehabilitation programs suitable for the patients.

Adherence of Older Cardiac Patients to a Home-Based Cardiac Rehabilitation Program

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.

Exploring barriers and facilitators of behavioural changes in dietary intake and physical activity: a qualitative study in older adults undergoing transcatheter aortic valve implantation

PURPOSE

The majority of older patients, scheduled for a cardiac procedure, do not adhere to international dietary intake and physical activity guidelines. The purpose of this study was to explore barriers and facilitators regarding dietary intake and physical activity behaviour change in older patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

We conducted a qualitative study using semi-structured interviews with patients undergoing TAVI. Interviews were analysed by two independent researchers using thematic analysis, the capability, opportunity and motivation behaviour model was used as a framework.

RESULTS

The study included 13 patients (82 ± 6 years old, 6 females) until data saturation was reached. Six themes were identified, which were all applicable to both dietary intake and physical activity. Three following themes were identified as barriers: (1) low physical capability, (2) healthy dietary intake and physical activity are not a priority at an older age and (3) ingrained habits and preferences. Three following themes were identified as facilitators: (1) knowledge that dietary intake and physical activity are important for maintaining health, (2) norms set by family, friends and caregivers and (3) support from the social environment.

CONCLUSION

Our study found that older patients had mixed feelings about changing their behaviour. The majority initially stated that dietary intake and physical activity were not a priority at older age. However, with knowledge that behaviour could improve health, patients also stated willingness to change, leading to a state of ambivalence. Healthcare professionals may consider motivational interviewing techniques to address this ambivalence.

Application of a nurse-led transitional care programme for patients discharged with T-tubes after biliary surgery

AIM

Nurse-led transitional care programmes (TCPs) have been shown to facilitate patient recovery in several illness settings, but its role among patients discharged with T-tubes remains uncertain. The aim of the study was to investigate the effects of a nurse-led TCP among patients discharged with T-tubes.

DESIGN

This retrospective cohort study was conducted at a tertiary medical centre.

METHODS

From January 2018 to December 2020, a total of 706 patients discharged with T-tubes after biliary surgery were included in the study. Patients were divided into a TCP group (n = 255) and a control group (n = 451) based on whether they participated in a TCP. The baseline characteristics, discharge readiness, self-care ability, transitional care quality and quality of life (QoL) were compared between the groups.

RESULTS

Self-care ability and transitional care quality were significantly higher in the TCP group. Patients in the TCP group also exhibited improved QoL and satisfaction. The results suggest that the incorporation of a nurse-led TCP among patients discharged with T-tubes after biliary surgery is feasible and effective. No Patient or Public Contribution.

Feasibility of home-based cardiac rehabilitation in frail older patients: a clinical perspective

(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.

Randomized Controlled Trial Comparing a Multidisciplinary Intervention by a Geriatrician and a Cardiologist to Usual Care after a Heart Failure Hospitalization in Older Patients: The SENECOR Study

Background: The prognosis of older patients after a heart failure (HF) hospitalization is poor. Methods: In this randomized trial, we consecutively assigned 150 patients 75 years old or older with a recent heart failure hospitalization to follow-up by a cardiologist (control) or follow-up by a cardiologist and a geriatrician (intervention). The primary outcome was all-cause hospitalization at a one-year follow-up. Results: All-cause hospitalization occurred in 47 of 75 patients (62.7%) in the intervention group and in 58 of 75 patients (77.3%) in the control group (hazard ratio, 0.67; 95% confidence interval, 0.46 to 0.99; p = 0.046). The number of patients with at least one HF hospitalization was similar in both groups (34.7% in the intervention group vs. 40% in the control group, p = 0.5). There were a total of 236 hospitalizations during the study period. The main reasons for hospitalization were heart failure (38.1%) and infection (14.8%). Mortality was 24.7%. Heart failure was the leading cause of mortality (54.1% of all deaths), without differences between groups. Conclusions: A follow-up by a cardiologist and geriatrician in older patients after an HF hospitalization was superior to a cardiologist’s follow-up in reducing all-cause hospitalization in older patients. (Funded by Beca Primitivo de la Vega, Fundación MAPFRE. ClinicalTrials.gov number, NCT03555318).

Effect of Exercise Prescription Implementation Rate on Cardiovascular Events

BACKGROUND

Exercise prescription of cardiac rehabilitation (CR) is vital in patients with cardiovascular diseases (CVDs) and those carrying high risk for CVDs. However, the relation between the implementation rate of exercise prescription and cardiovascular events (CVEs) is unclear.

DESIGN AND METHODS

In this retrospective study, using the administration data from the Rehabilitation Center in a hospital, patients aged ≥18 years with CVDs were consecutively enrolled from November 2018 to May 2021. Patients were divided into the high execution group (HEG) and low execution group (LEG) depending on whether they completed more than half the time of the exercise prescriptions. Baseline characteristics, ultrasonic cardiogram, cardiopulmonary exercise test, follow-up data, and CVEs were collected.

RESULTS

The mean age of the 197 CR patients was 61.8 ± 13.7 years and the mean follow-up duration was 10.9 ± 4.2 months. Among them, 15 patients suffered CVEs: 4 in the HEG and 11 in the LEG. The incidence of CVEs showed significant differences between HEG and LEG (chi-square test). Free-event survival analysis using Kaplan-Meier survival plots showed that patients in LEG had poor survival. Cox proportional hazards regression analysis revealed that the prescription implementation rate was an independent predictor of CVEs.

CONCLUSIONS

Our study suggested a significant effect of exercise prescription execution rate on the occurrence of CVEs. Further, the HEG of exercise prescription was associated with lower CVDs.

Transitional care from hospital to home for frail older adults: A systematic review and meta-analysis

Frail older adults are vulnerable to hospitalization and transitional care is needed to maintain care continuity; however, there exists no review regarding transitional care focusing on frailty. This study aimed to investigate transitional care for frail older adults and its effectiveness. Search terms were (P) frail older adults; (I) transitional care initiated before discharge; (C) usual care; (O) all health outcomes. Fourteen trials were identified. The most measured outcome was readmission (n = 13), followed by mortality (n = 9), function (n = 7), quality of life (n = 5), and self-rated health (n = 5). Statistical significance effects were reported in the followings: n = 6, readmission; n = 0, mortality; n = 3, function; n = 2, quality of life; and n = 4, self-rated health. The meta-analysis demonstrated that transitional care reduced readmission at six months but not other time points nor mortality or quality of life. The intervention effectiveness was inconclusive; therefore, an evidence-based yet novel approach is necessary to establish an adequate transitional care intervention for frail older adults.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial

AIMS

Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge.

METHODS

We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group.

RESULTS

For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (P_interaction  = .085). In total, 77.0% of the patients had at least one MRP post-discharge.

CONCLUSIONS

Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study

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.