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

 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^¶

 Diagnosis (and history) of cardiac disease

X^¶

 Comorbidities

CCI [55]

X^¶

 Date of hospitalization

X^¶

 Hospitalization department

X

 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

 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

 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

 Caregiver burden

TOPIC-MDS [41]

X

X

X

 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

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

 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