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Terbraak M, Verweij L, Jepma P, Buurman B, Jørstad H, Scholte Op Reimer W, van der Schaaf M. Feasibility of home-based cardiac rehabilitation in frail older patients: a clinical perspective. Physiother Theory Pract 2023; 39:560-575. [PMID: 35068322 DOI: 10.1080/09593985.2022.2025549] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
(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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Affiliation(s)
- Michel Terbraak
- Department of Physical Therapy, Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Lotte Verweij
- Department of Physical Therapy, Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Patricia Jepma
- Department of Physical Therapy, Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Bianca Buurman
- Department of Physical Therapy, Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Harald Jørstad
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Wilma Scholte Op Reimer
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.,HU University of Applied Sciences Utrecht, Research Group Chronic Diseases, Utrecht, Netherlands
| | - Marike van der Schaaf
- Department of Physical Therapy, Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands.,Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam, Netherlands
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Verweij L, Petri ACM, MacNeil-Vroomen JL, Jepma P, Latour CHM, Peters RJG, Scholte op Reimer WJM, Buurman BM, Bosmans JE. The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial. PLoS One 2022; 17:e0263130. [PMID: 35085361 PMCID: PMC8794155 DOI: 10.1371/journal.pone.0263130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/09/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care. Methods The intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression. Results No significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained. Conclusion The CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care.
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Affiliation(s)
- Lotte Verweij
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | - Adrianne C. M. Petri
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Janet L. MacNeil-Vroomen
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Patricia Jepma
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Corine H. M. Latour
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Ron J. G. Peters
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wilma J. M. Scholte op Reimer
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Research Group Chronic Diseases, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - Bianca M. Buurman
- Centre of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Judith E. Bosmans
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Jepma P, Verweij L, Buurman BM, Terbraak MS, Daliri S, Latour CHM, ter Riet G, Karapinar - Çarkit F, Dekker J, Klunder JL, Liem SS, Moons AHM, Peters RJG, Scholte op Reimer WJM. The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial. Age Ageing 2021; 50:2105-2115. [PMID: 34304264 PMCID: PMC8581392 DOI: 10.1093/ageing/afab146] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Indexed: 12/28/2022] Open
Abstract
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. Trial registration Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169
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Affiliation(s)
- Patricia Jepma
- Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands
- Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands
| | - Lotte Verweij
- Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands
- Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands
| | - Bianca M Buurman
- Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands
- Amsterdam UMC, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, the Netherlands
| | - Michel S Terbraak
- Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands
| | - Sara Daliri
- OLVG Hospital, Department of Clinical Pharmacy, Amsterdam, the Netherlands
| | - Corine H M Latour
- Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands
| | - Gerben ter Riet
- Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands
- Amsterdam University of Applied Sciences, Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences,Amsterdam, the Netherlands
| | | | - Jill Dekker
- Bovenij Medical Centre, Department of Cardiology, Amsterdam, the Netherlands
| | - Jose L Klunder
- OLVG Hospital, Department of Cardiology, Amsterdam, the Netherlands
| | - Su-San Liem
- Amstelland Hospital, Department of Cardiology, Amstelveen, the Netherlands
| | - Arno H M Moons
- OLVG Hospital, Department of Cardiology, Amsterdam, the Netherlands
| | - Ron J G Peters
- Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands
| | - Wilma J M Scholte op Reimer
- Amsterdam UMC, Department of Cardiology, Amsterdam, the Netherlands
- HU University of Applied Sciences Utrecht, Research Group Chronic Diseases, Utrecht, the Netherlands
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Jepma P, Latour CHM, Ten Barge IHJ, Verweij L, Peters RJG, Scholte Op Reimer WJM, Buurman BM. Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study. BMC Health Serv Res 2021; 21:786. [PMID: 34372851 PMCID: PMC8353821 DOI: 10.1186/s12913-021-06719-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/29/2021] [Indexed: 12/17/2022] Open
Abstract
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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Affiliation(s)
- Patricia Jepma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
| | - Corine H M Latour
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Iris H J Ten Barge
- Nursing Sciences, Program of Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lotte Verweij
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Ron J G Peters
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wilma J M Scholte Op Reimer
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- HU University of Applied Sciences Utrecht, Research Group Chronic Diseases, Utrecht, The Netherlands
| | - Bianca M Buurman
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Rijpkema CJ, Verweij L, Jepma P, Latour CHM, Peters RJG, Scholte Op Reimer WJM, Buurman BM. The course of readmission in frail older cardiac patients. J Adv Nurs 2021; 77:2807-2818. [PMID: 33739473 PMCID: PMC8251632 DOI: 10.1111/jan.14828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/02/2021] [Accepted: 02/28/2021] [Indexed: 12/14/2022]
Abstract
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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Affiliation(s)
- Corinne J. Rijpkema
- Department of Internal MedicineSection of Geriatric MedicineAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lotte Verweij
- Department of CardiologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Center of Expertise Urban VitalityFaculty of HealthAmsterdam University of Applied ScienceAmsterdamThe Netherlands
| | - Patricia Jepma
- Department of CardiologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Center of Expertise Urban VitalityFaculty of HealthAmsterdam University of Applied ScienceAmsterdamThe Netherlands
| | - Corine H. M. Latour
- Center of Expertise Urban VitalityFaculty of HealthAmsterdam University of Applied ScienceAmsterdamThe Netherlands
| | - Ron J. G. Peters
- Department of CardiologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Wilma J. M. Scholte Op Reimer
- Department of CardiologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Research Group Chronic DiseasesUniversity of Applied Sciences UtrechtUtrechtThe Netherlands
| | - Bianca M. Buurman
- Department of Internal MedicineSection of Geriatric MedicineAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Center of Expertise Urban VitalityFaculty of HealthAmsterdam University of Applied ScienceAmsterdamThe Netherlands
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6
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Verweij L, Spoon DF, Terbraak MS, Jepma P, Peters RJG, Scholte Op Reimer WJM, Latour CHM, Buurman BM. The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: A mixed-methods process evaluation. J Adv Nurs 2021; 77:2498-2510. [PMID: 33594695 PMCID: PMC8048800 DOI: 10.1111/jan.14786] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/05/2021] [Accepted: 01/16/2021] [Indexed: 12/28/2022]
Abstract
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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Affiliation(s)
- Lotte Verweij
- Department of Cardiology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Denise F Spoon
- Department of Internal Medicine, Section of Geriatric Medicine, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Michel S Terbraak
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Patricia Jepma
- Department of Cardiology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Ron J G Peters
- Department of Cardiology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Wilma J M Scholte Op Reimer
- Department of Cardiology, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Research Group Chronic Diseases, HU University of Applied Sciences Utrecht, Utrecht, The Netherlands
| | - Corine H M Latour
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.,Department of Internal Medicine, Section of Geriatric Medicine, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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