Bridging the gap: Adapting transitional care to older cardiac patients' needs

Research output: PhD ThesisPhD-Thesis - Research and graduation internal


Hospital readmission and mortality rates of older cardiac patients are high. Multimorbidity and geriatric conditions are common in this population and increase this risk. In frail patients with cardiovascular disease, the risk of readmission and mortality is even 2-3 times higher. The identification of patients at risk is important to enable adequate treatment, based on patients’ individual risk factors and needs. Especially patients who are transferred between care settings or discharged from hospital to home, are at high risk of adverse events. The aims of this thesis are 1) to evaluate strategies to identify patients at high risk of readmission and mortality, 2) to evaluate a transitional care intervention in frail older cardiac patients and 3) to evaluate new approaches in cardiac rehabilitation.
Bridging the gap between hospital and home by combining disease management, case management and home-based cardiac rehabilitation did not lead to reduction of readmission and mortality in frail cardiac patients. The Cardiac Care Bridge (CCB) intervention is in its current form not recommended for implementation in clinical practice. If, with adequate risk assessment high-risk patients eligible for high-intensity preventive interventions can be identified, the CCB intervention may be reconsidered. For future purpose, interventions should as much as possible be integrated within existing care systems and should focus on patients’ own needs and preferences to achieve goals. Educational strategies focusing on interdisciplinary collaboration, system empowerment and identifying patients’ own drivers could improve the intervention quality to bridge the gap between current practice and older cardiac patients’ needs.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • University of Amsterdam, Netherlands
  • Scholte op Reimer, Wilma J. M., Supervisor
  • Peters, Ronaldus J. G., Supervisor
  • Buurman-van Es, Bianca, Co-supervisor
  • Latour, C. H. M., Co-supervisor, External person
Award date8 Jul 2021
Print ISBNs9789083102757
Publication statusPublished - 2021

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