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Table 3 Baseline assessment, outcome measures and time points in the Cardiac Care Bridge

From: The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

  CGA Question or instrument T0* T0 +  T1 T2§ T3||
Sociodemographic data
 Age   Date of birth X     
 Gender    X     
 Postal code    X     
 Living arrangement    X     
 Marital status    X     
 Ethnicity   Patients’ country of birth X     
 Education    X     
 Mortality   Date of death X   X X X
Medical data
 Diagnosis (and history) of cardiac disease    X     
 Comorbidities   CCI [55] X     
 Date of hospitalization    X     
 Hospitalization department    X     
Functional domain
 ADL- and iADL-functioning + ALDS [35] X   X X X
 Functional status   Specific Activity Scale [33] X    X  
 Hearing impairment + Do you experience difficulties with hearing, despite the use of a hearing aid? X     
 Visual impairment + Do you experience difficulties with your vision, despite the use of glasses? X     
 Fatigue + NRS X    X  
 Falls + Frequency X   X X X
 Fear of falling + NRS X   X X X
Physical domain
 Nutritional status + SNAQ [53] X   X X X
 Pain + NRS [56] X    X  
 Dizziness + Do you currently suffer from dizziness If yes, does this affect your daily living? X    X  
 Shortness of breath + Do you currently suffer from shortness of breath? If yes, does this affect your daily living? X    X  
 Angina pectoris + Do you currently suffer from angina pectoris If yes, does this affect your daily living? X    X  
 Heart palpitations + Do you currently suffer from heart palpitations? If yes, does this affect your daily living? X    X  
 Incontinence + Do you suffer from incontinence? If yes, do you suffer from incontinence of urine and/or defecation? X    X  
 Presence of urinary catheter + Do you have a urinary catheter? If yes, did you have the urinary catheter before hospitalization? X    X  
 Nycturia + Do you currently suffer from nycturia? If yes, does this affect your daily living? X    X  
 Handgrip strength + Jamar [57] X    X  
Psychological domain
 Cognitive status + MMSE [58] X    X  
 Depression & apathy + GDS-15[41] X    X  
 Anxiety + HADS-A [38] X   X X X
 Quality of life + EQ-5D-5 L [40] X   X X X
 Smoking status   Do you smoke or did you smoke in the past? If yes, how many cigarettes per day and for how many years? X   X X X
 Alcohol use   AUDIT-C [59] X   X X X
Social domain
 Caregiver burden   TOPIC-MDS [41] X    X X
Medication use
 Polypharmacy + Do you use five or more different medications? X    X  
 Medication adherence + Medication Adherence Questionnaire X   X X X
 Side effect of medication + Do you experience difficulties or side effects with medication use? X    X  
 Type of medication   Type, frequency and dose of medication X   X X X
Physical performance
 Physical performance   30-s chair stand test [60]   X   X  
 Mobility   SPPB [36] X    X  
 Physical capacity   2 MST [37] X X   X  
 Perceived exertion   Borg RPE scale [61] X X   X  
 Dyspnoea   MRC dyspnoea scale [62]   X   X  
Parameters
 BMI   Weight and length X    X  
 Waist circumference    X    X  
 Blood pressure   mmHg X    X  
 Heart frequency   BPM X    X  
 Respiratory rate    X    X  
 Blood parameters   Hemoglobin X   X X X
   Albumin X   X X X
   Creatinine X   X X X
   Total cholesterol X   X X X
   LDL-cholesterol X   X X X
   HDL-cholesterol X   X X X
   Triglyceride X   X X X
   Glucose / HbA1C X   X X X
Healthcare utilization   TOPIC-MDS [41]      
 Readmission   Have you been hospitalized in the last six months? If yes, what was the hospitalization diagnosis and in what hospital were you readmitted?    X X X
 Emergency visits   Have you visited the emergency or cardiac emergency room in the last six months? If yes, how many times and for what reason?    X* X* X*
 Nursing home admission   Have you been admitted to a nursing home in the last months? If yes, for how many weeks?    X X X
 General practice consult   Have you had a consult with your general practitioner in the last month? If yes, was this during office hours or during the evening, night or weekend and how many times in total?    X X X
 Home visit of GP   Have you had a home visit from your GP in last month? If yes, was this during office hours or during the evening, night or weekend, and how many times in total?    X X X
 Home care   Do you receive home care? If yes, is this care assistance and/or domestic help, and how many hours per week?    X X X
 Day care   Do you have day care? If yes, how many days per week?    X X X
 Cardiac rehabilitation use   Do you participate in cardiac rehabilitation in a rehabilitation center or outpatient clinic?    X X X
 Physical therapy   Do you participate in cardiac rehabilitation in a rehabilitation center or outpatient clinic?    X X X
  1. Abbreviations CCI Charlson comorbidity index, ALDS Amsterdam linear disability scale, NRS numeric rating scale, SNAQ short nutritional assessment questionnaire, MMSE mini mental state examination, GDS-15 geriatric depression Scale-15, HADS-A hospital anxiety and depression scale-anxiety subscale, EuroQol-5D Euroqol quality of life, MDS minimal dataset, SPPB short physical performance battery, 2MST 2 Minute step test, Borg RPE scale ratings of perceived exertion scale, MRC Dyspnea Scale Medical Research Council dyspnea scale, mmHg millimetre of mercury, BPM beats per minute
  2. *T0: baseline, ≤ 48 h after admission; T0+: within 2 weeks after hospitalization during home-based cardiac rehabilitation intake; T1: 3 months after hospitalization, follow-up by telephone; §T2: 6 months after hospitalization, follow-up by home visit; ||T3: 12 months after hospitalization, follow-up by telephone. Data will be obtained from the medical record