Impact of home‐ and community‐based services in the long‐term care insurance system on outcomes of patients with acute heart failure: Insights from the Kitakawachi Clinical Background and Outcome of Heart Failure Registry

Developing Multidisciplinary Management of Heart Failure in the Super-Aging Society of Japan

The Japanese population is rapidly aging because of its long life expectancy and low birth rate; additionally, the number of patients with heart failure (HF) is increasing to the extent that HF is now considered a pandemic. According to a recent HF registry study, Japanese patients with HF have both medical and care-related problems. Although hospitalization is used to provide medical services, and institutionalization is used to provide care for frail older adults, it can be difficult to distinguish between them. In this context, multidisciplinary management of HF has become increasingly important in preventing hospital readmissions and maintaining a patient's quality of life. Academia has promoted an increase in the number of certified HF nurses and educators. Researchers have issued numerous guidelines or statements on topics such as cardiac rehabilitation, nutrition, and palliative care, in addition to the diagnosis and treatment of acute and chronic HF. Moreover, the Japanese government has created incentives through various medical and long-term care systems adjustments to increase collaboration between these two fields. This review summarizes current epidemiological registries that focus not only on medical but also care-related problems and the 10 years of multidisciplinary management experience in Japanese medical and long-term care systems.

Combination of low muscle strength and malnutrition is associated with longer length of hospital stay among older patients with heart failure

BACKGROUND

Muscle strength and nutritional status are associated with length of hospital stay (LOHS) in older patients with heart failure (HF).

OBJECTIVES

The purpose of the study was to examine the association of the combination of muscle strength and nutritional status on LOHS in older patients with HF.

METHODS

This retrospective cohort study included 414 older inpatients with HF (men, 57.2%; median age, 81 years; interquartile range, 75-86 years). Patients were categorized into four groups according to their muscle strength and nutritional status: group 1, high muscle strength and normal nutritional status; group 2, low muscle strength and normal nutritional status; group 3, high muscle strength and malnutrition; and group 4, low muscle strength and malnutrition. The outcome variable was the LOHS, and an LOHS of >16 days was defined as long LOHS.

RESULTS

Multivariate logistic regression analysis adjusted for baseline characteristics (reference, group 1) showed that group 4 was associated with a more significant risk of long LOHS (odds ratio [OR], 3.54 [95% confidence interval, 1.85-6.78]). In the subgroup analysis, this relationship was maintained for the first admission HF group (OR, 4.65 [2.07-10.45]) but not for the HF readmission group (OR, 2.80 [0.72-10.90]).

CONCLUSIONS

Our results suggest that the long LOHS for older patients with HF at first admission was associated with a combination of low muscle strength and malnutrition but not by either factor individually.

Risk Factors with 30-Day Readmission and the Impact of Length of Hospital Stay on It in Patients with Heart Failure: A Retrospective Observational Study Using a Japanese National Database

Heart failure is a major disease, and its 30-day readmission (readmission within 30-day after discharge) negatively impacts patients and society. Thus, we need to stratify the risk and prevent readmission. We aimed to investigate risk factors associated with 30-day readmission and examine the impact of length of hospital stay (LOS) on 30-day readmission. Using the Diagnosis-Procedure-Combination database from April 2018 to March 2021, we conducted multiple logistic regression to investigate risk factors with 30-day readmission. Also, we conducted subgroup analysis in the short LOS group. To examine the association between LOS and 30-day readmission, we performed propensity score matching between the short and middle LOS groups. As a result, we categorized 10,283 patients and 169,842 patients into the readmission group and the no-readmission group. We identified the following factors as the risk of readmission: short LOS, female, smoking, older age, lower body mass index, lower barthel index, artificial ventilator, beta-blockers, thiazides, tolvaptan, loop diuretics, carperitides, class Ⅲ antiarrhythmic agents, myocardial infarction, diabetes, renal disease, atrial fibrillation, dilated cardiomyopathy, and discharge to home. As a subgroup analysis in the short LOS group, we revealed that the short LOS group risk factors differed from overall. After propensity score matching in the short LOS group and middle LOS group, 37,199 pairs were matched, and we revealed that shorter LOS increases the risk of readmission. These results demonstrated that shortened LOS increases 30-day readmission, and risk factors are unique to each LOS. We suggest stratifying the readmission risk and being careful with early discharge.

Association between Rapid Dementia Screening Test score and clinical events in elderly patients with cardiovascular disease: a retrospective cohort study

AIMS

Cognitive decline is prevalent among patients with cardiovascular disease (CVD). Cognitive measurement has been considered as a standard assessment for secondary prevention; however, standard cognitive tests are sometimes infeasible due to time constraints. This study aimed to examine the association between the Rapid Dementia Screening Test (RDST), a brief screening tool for cognitive function, and clinical events in elderly patients with CVD.

METHODS AND RESULTS

This retrospective cohort study included 140 hospitalized patients with CVD who participated in inpatient cardiac rehabilitation (median age, 75 years; male, 67%). Cognitive function for each patient was assessed using the RDST and Montreal Cognitive Assessment (MoCA), a standard test of mild cognitive impairment. The clinical events assessed as outcomes included all-cause mortality and unplanned rehospitalization. Receiver-operating characteristic (ROC) curve analysis showed similar predictive accuracy for the study outcome (P = 0.337) between the RDST [area under the curve, 0.651; 95% confidence interval (CI), 0.559-0.743] and MoCA (0.625; 0.530-0.720). The ROC analysis identified a cut-off value of 9 points for the RDST (sensitivity, 77.8%; specificity, 50.5%). Patients with RDST ≤9 showed a poor survival rate compared with those with ≥10 points (log-rank test, P = 0.002; hazard ratio, 2.94, 95% CI, 1.46-5.94). This result was consistent even after adjusting for potential confounders.

CONCLUSION

The RDST was associated with clinical events in elderly patients with CVD and its predictive capability was comparable with that of MoCA, a standard cognitive test. The RDST may be useful in CVD as an alternative screening tool for cognitive decline.

Association among mild cognitive impairment, social frailty, and clinical events in elderly patients with cardiovascular disease

BACKGROUND

Social support is considered a key factor for secondary prevention in patients with cardiovascular disease (CVD) and mild cognitive impairment (MCI). Recent studies have suggested the clinical importance of social frailty in CVD.

OBJECTIVE

This study aimed to examine the association among coexistent MCI, social frailty, and clinical events in patients with CVD.

METHODS

This study included 184 hospitalized elderly patients with CVD who participated in inpatient cardiac rehabilitation (median age, 75 years; male, 66.3%). MCI was defined as a Montreal Cognitive Assessment score of ≤25 points at discharge. Social frailty was defined using the Makizako criteria. Lack of caregiver support was also assessed as an indicator of poor social support. The Kaplan-Meier survival curve analysis and Cox regression analysis were conducted to evaluate the combined impact of MCI and social frailty or the lack of caregiver support on the composite endpoint of all-cause mortality or unplanned rehospitalization.

RESULTS

The prevalence of MCI, social frailty, and lack of caregiver support were 65.2%, 70.7%, and 19.0%, respectively. There was a significant difference among subgroups by MCI and a lack of caregiver support (log-rank test, p = 0.018), and the MCI/non-caregiver group showed the worst prognosis (adjusted hazard ratio 3.96; 95% confidence interval 1.57-9.98). Likewise, MCI/social frailty group showed a significantly high event risk (3.94; 1.20-12.9) among the subgroups by MCI and social frailty.

CONCLUSION

Our results highlight the clinical importance of assessing the presence of caregiver support along with conventional social frailty for patients with CVD and MCI.

Discharge disposition and 1-year readmission in acute-phase hospitalized patients with heart failure: a retrospective observational multi-center study

Patients hospitalized for acute heart failure (HF) tend to experience declines in physical function and activities of daily living (ADL) due to bed rest and restricted mobilization. This could result in some patients being transferred to rehabilitation hospitals. This study aims to examine the relationship between discharge disposition and 1-year readmission and mortality rates in HF patients. Nine hundred fifty six consecutive HF patients who were hospitalized for acute decompensated HF and underwent rehabilitation were divided into two groups: home (returned home) or transfer (transferred to rehabilitative or long-term care hospital units due to decline in physical function and/or ADL) groups. The primary and secondary outcomes were 1-year readmission and mortality rates after discharge, respectively. Of the 956 patients, 8.6% (n = 82) were transferred to rehabilitative or long-term care hospital units. Over a 1-year follow-up period, all-cause and HF readmission rates were 50.1% (n = 479) and 27.2% (n = 260), respectively. The transfer group had significantly lower readmission rates compared to home group after adjusting for the pre-existing risk factors (hazard ratio for all-cause and HF readmission: 0.600 and 0.552, 95% CI 0.401-0.897 and 0.314-0.969; P = 0.013 and P = 0.038, respectively). There was no significant relationship between discharge disposition and all-cause mortality rate. Low ADL defined as Barthel index < 60 points was identified as a predictor of all-cause and HF readmission among the home group (odds ratio for all-cause and HF readmission rates: 2.156 and 1.847, 95% CI 1.026-4.531 and 1.036-2.931; P = 0.043 and P = 0.037, respectively). This multi-center study demonstrated that HF patients transferred to rehabilitative or long-term care hospital units after an acute hospitalization had a significantly decreased 1-year all-cause and HF readmission rates compared to patients who returned to their home. These findings may help in selecting a discharge disposition for older HF patients with ADL decline.

The International Classification of Functioning, Disabilities, and Health categories rated as necessary for care planning for older patients with heart failure: a survey of care managers in Japan

BACKGROUND

Establishing an information-sharing system between medical professionals and welfare/care professionals may help prevent heart failure (HF) exacerbations in community-dwelling older adults. Therefore, we aimed to identify the ICF categories necessary for care managers to develop care plans for older patients with HF.

METHODS

A questionnaire was administered to 695 care managers in Hiroshima, Japan, on ICF items necessary for care planning. We compared the care managers according to their specialties (medical qualifications and welfare or care qualifications). Furthermore, we created a co-occurrence network using text mining, regarding the elements necessary for collaboration between medical and care professionals.

RESULTS

There were 520 valid responses (74.8%). Forty-nine ICF items, including 18 for body functions, one for body structure, 21 for activities and participation, and nine for environmental factors, were classified as "necessary" for making care plans for older people with HF. Medical professionals more frequently answered "necessary" than care professionals regarding the 11 items for body functions and structure and three items for activities and participation (p < 0.05). Medical-welfare/care collaboration requires (1) information sharing with related organisations; (2) emergency response; (3) a system of cooperation between medical care and non-medical care; (4) consultation and support for individuals and families with life concerns, (5) management of nutrition, exercise, blood pressure and other factors, (6) guidelines for consultation and hospitalisation when physical conditions worsen.

CONCLUSIONS

Our findings showed that 49 ICF categories were required by care managers for care planning, and there was a significant difference in perception between medical and welfare or care qualifications qualifications.

Multidomain Frailty in Heart Failure: Current Status and Future Perspectives

PURPOSE OF REVIEW

With a worldwide aging population, frailty and heart failure (HF) have become issues that need to be addressed urgently in cardiovascular clinical practice. In this review, we outline the clinical implications of frailty in HF patients and the potential therapeutic strategies to improve the clinical outcomes of frail patients with HF.

RECENT FINDINGS

Frailty has physical, psychological, and social domains, each of which is a prognostic determinant for patients with HF, and each domain overlaps with the other, although there are no standardized criteria for diagnosing frailty. Frailty can be targeted for treatment with various interventions, and recent studies have suggested that multidisciplinary intervention could be a promising option for frail patients with HF. However, currently, there is limited data, and further research is needed before its clinical implementation. Frailty and HF share a common background and are strongly associated with each other. More comprehensive assessment and therapeutic interventions for frailty need to be developed to further improve the prognosis and quality of life of frail patients with HF.