Coronary heart disease (CHD), myocardial infarction (MI) Circulatory System
Conditions
Interventions
Experimental intervention: Case management by trained nurse on the basis of telephone contacts and home visits
The study intervention will consist of an initial information session as well as physic
Sponsors
Federal Ministry of Education and Research (BMBF) (Germany)
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: All patients of the age group 70 years and older with a first or recurrent myocardial infarction during the recruitment period (September 2008 to December 2009) who are treated in the Augsburg Hospital.
Exclusion criteria
Exclusion criteria: 1. Patients who already live in institutionalised care or who are already receiving regular support by ambulatory care services. In addition, patients who already plan to move into institutional care or outside the study region within the next months. 2. Patients with severe comorbidity (e.g., terminal cancer) which makes rehospitalisation within the next months necessary or is associated with a life expectancy of less than one year 3. Patients who are not able to communicate in German language 4. Patients who are unable or unwilling to give written informed consent (e.g., patients with dementia) All consecutive patients screened for eligibility will be documented in a patient log with anonymous data on age, gender, comorbidity, and reasons for ineligibility.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Time from randomisation to first (unplanned) hospital readmission | — |
Secondary
| Measure | Time frame |
|---|---|
| 1. Activities of daily living: Barthel Index and Health Assessment Questionnaire Disability Index (HAQ-DI) (baseline and 1-year follow-up) 2. Instrumental activities of daily living (IADL) scale developed by Lawton/Brody (baseline and 1-year follow-up) 3. Mobility: Timed up and go (baseline and 1-year follow-up) 4. Hand grip strength measurement (baseline and 1-year follow-up) 5. Cognition: Mini Mental State Test (baseline and 1-year follow-up) 6. Nutrition: Seniors in the Community: Risk evaluation for eating and nutrition, Version II (SCREEN II) (baseline and 1-year follow-up) 7. Quality of life: EQ-5D (baseline and 3-/6-/9-/12-months follow-up) and World Health Organization (WHO) Five Well-being Index (baseline and 1-year follow-up) 8. Social network: Social Support Questionnaire (Fragebogen zur Sozialen Unterstützung [F-SozU]) (baseline and 1-year follow-up) 9. Depression: Geriatric depression Scale (baseline and 1-year follow-up) 10. Items on vision, hearing, chewing and swallowing from Geriatric Assessment (Lachs) (baseline and 1-year follow-up) 11. Baseline questionnaire including items on multimorbidity and physical examination (baseline and 1-year follow-up) 12. Health care utilisation (baseline and 3-/6-/9-/12-months follow-up) | — |
Countries
Germany
Outcome results
None listed