論文ID: CJ-22-0675
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.
Heart failure (HF) is now a global pandemic that has become more common with increasingly aged populations. The mortality rate associated with HF is high despite new and increasingly effective drugs and non-pharmacological therapies.1 According to the Japanese Registry of All Cardiac and Vascular Diseases (JROAD) conducted by The Japanese Circulation Society (JCS), the annual number of patients hospitalized for HF has increased and the annual number of patients hospitalized for HF was 3.5-fold higher than that of patients hospitalized for acute myocardial infarction.2 Therefore, a Japanese strategic roadmap for HF management is urgently required.
In 2016, the JCS and the Japan Stroke Society jointly created a 5-year plan for overcoming stroke and cardiovascular disease, aiming to extend healthy life expectancy. HF is listed as 1 of the 3 major therapeutic targets.3 The JCS/Japanese Heart Failure Society (JHFS) provided a new, public definition of HF in 2017.4 The Cerebrovascular and Cardiovascular Disease Control Act of Japanese national law was enacted in December 2019, and the Ministry of Health, Labor, and Welfare, Japan, published the Japanese National Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular Disease (Japanese National Plan) in October 2020.5
Although progression of HF is a cause of rehospitalization, as the number of older patients increases, many socioeconomic weaknesses increase the risk of rehospitalization.6 These problems cannot be addressed by medical interventions alone and require a multidisciplinary team-based approach.
Since 1961, Japan has had a healthcare system with universal health coverage, which provides substantial benefits and the same quality of medical care to citizens of all income levels.7 Low-income people who are disabled because of illness, poverty, or unemployment can receive free medical care through public assistance. Indeed, Nishimoto et al recently reported that patients with acute HF who receive public assistance had no significant excess risk for all-cause death 1 year after discharge compared with those who did not receive public assistance.8
In addition, to medical insurance, the Japanese government initiated mandatory public long-term care insurance (LTCI) in 2000 to help older individuals live more independently and relieve the burden on family and caregivers.9 Because of the LTCI, recipients can take advantage of home-based and institutional care at a relatively affordable cost.
Although hospitalization is for providing medical services, and institutionalization is for providing long-term care services for frail older adults, it is sometimes difficult to distinguish between them. Therefore, multidisciplinary HF management in Japanese super-aging society should be considered in both the medical and LTCI systems.
Shiraishi et al reported that from 2007 to 2015, the mean age of patients with HF increased (71.6–77.0 years), while the length of hospital stay (26–16 days) and in-hospital mortality rate (7.5–4.7%) decreased in 3 large registry datasets for 9,075 patients with acute HF (Acute Decompensated Heart Failure Syndromes (ATTEND), West Tokyo Heart Failure (WET–HF), and very early presentation and treatment in the emergency department of Acute Heart Failure syndrome (REALITY–AHF)).10
However, in most previously reported Japanese registries, patient care problems have been poorly described. Recent Japanese registries have focused not only on traditional medical records such as ejection fraction and biomarkers, but also care- and social-related backgrounds (Table 1). The Kyoto Congestive Heart Failure (KCHF) registry is a prospective, observational, multicenter cohort study that enrolled consecutive patients with acute HF admitted to hospitals.11 The mean age of the 4,056 patients in the study was 80.0 years (age >85 years; 33%), which is significantly older than in previous Japanese registries. Most patients had social problems; for example, only 13% were employed, and 5.8% received public assistance; 21% were single, and 42% had a life partner. Activities of daily life (ADL) were performed with a wheelchair by 9.7% of the patients, and 4.3% were bedridden.11 Recent Japanese HF registries such as the Kitakawachi Clinical Background and Outcome of HF (KICKOFF),12 the registry and follow-up study of the medical and social conditions and outcomes of hospitalized patients with HF (REAL-HF),13,14 and the registry from the Sado-Niigata district15 reported similar home-based situations (Table 1). Therefore, almost 40% of patients with HF have LTCI, which is twice that reported in community-based studies.16 According to the prevalence and prognostic value of physical and social frailty in geriatric patients hospitalized for HF (FRAGILE-HF)17 and Kochi YOSACOI18 studies, half of the patients with HF have physical frailty, social isolation, and cognitive impairment, and these are independent prognostic risk factors. Therefore, in a super-aging society, Japanese patients with HF face both medical and care-related problems.
| Registries | ||||
|---|---|---|---|---|
| KCHF11 | KICKOFF12 | REAL-HF13 | Sado-Niigata15 | |
| n | 4,056 | 647 | 1,218 | 617 |
| Time frame | 2014–2016 | 2015–2016 | 2017–2018 | 2017–2018 |
| No. hospitals | 19 hospitals in Tokai, Kinki, Chugoku, and Kyushu districts |
13 hospitals in eastern Osaka Prefecture and southern end of Kyoto Prefecture |
8 hospitals participating Hiroshima Heart Health Promotion Project |
3 hospitals in the Niigata Prefecture |
| Inclusion criteria | All patients admitted for acute HF and those who underwent HF specific treatment ≤24 h after hospital presentation |
All patients admitted for acute HF |
All patients aged ≥20 years admitted for symptomatic HF |
All patients aged ≥65 years admitted for HF |
| HF definition | Framingham criteria | Framingham criteria | Framingham criteria or low output syndrome diagnosed by primary physicians |
Disease name in the Diagnosis Procedure Combination (DPC) system |
| Age (years) | 80 (72–86) | 78.2±11.5 | 79±13 | 84.7±8.1 |
| In-hospital mortality (%) | 6.7 | – | – | 16.9 |
| Length of hospital stay (days) | 21±18 | 25.4±21.4 | – | 21 (13–41) |
| Employed (%) | 13 | – | – | – |
| Public assistance (%) | 5.8 | – | – | – |
| Lifestyle | ||||
| Single (%) | 21 | 29.2 | 21.7 | 22.1 |
| With partner only (%) | 42 | 17.3 | 32.0 | 33.8 |
| ADL | ||||
| Use of wheelchair (%) | 9.7 | – | – | – |
| Bedridden (%) | 4.3 | – | – | – |
| Discharge destination | Follow-up cohort n=63214 |
|||
| Home (%) | 82 | – | 74.2 | 79.3 |
| Hospital (%) | 12 | – | 20.7 | 3.3 |
| Nursing facility (%) | 4.9 | – | – | 17.3 |
| Use of LTCI (%) | Follow-up cohort n=63213 |
57.7 | ||
| Support required (%) | 14 | 12 | Use of home-nursing care service 39% |
|
| Care required (%) | 34 | 31 | ||
ADL, activities of daily living; KCHF, Kyoto Congestive Heart Failure; KICKOFF, Kitakawachi Clinical Background and Outcome of Heart Failure; LTCI, long-term care insurance; REAL-HF, Registry and follow-up study of the medical and social conditions and outcomes regarding hospitalized heart failure patients.
Historical Western studies have reported that a variety of comprehensive multidisciplinary disease-management programs can reduce mortality rates, hospital readmissions, length of stay, potentially improve quality of life (QOL) and save funds.19–22
The first statement on multidisciplinary management of HF in the context of Japanese guidelines goes back to the JCS 2005 Guidelines for the treatment of chronic HF. The updated JCS 2017/JHFS 2017 guidelines on the diagnosis and treatment of acute and chronic HF clearly highlight the importance of multidisciplinary management and show the content of a disease-management program.4
Self-care is an overarching concept, formed by the 3 key concepts of self-care: maintenance, monitoring, and management. Improving self-care is a major focus of multidisciplinary HF management programs.23,24 Tools to support self-care monitoring at home are different from traditional paper-based tools and modern devices such as smartphones or iPads.25 Some Japanese hospitals have released HF patient diaries, including patient education (such as education on HF, pharmacy, and lifestyle modifications) and sections for monitoring health (e.g., weight and symptoms of congestion). The JHFS also released a HF patient diary in 2012.26
Nakane et al27 recently developed a self-management system using HF points for weight and clinical symptoms, and instructions to visit hospitals or clinics if the points exceeded prespecified levels. They found that the self-management system decreased hospitalization rates for HF while increasing unplanned visits and early intervention in the outpatient department.
In Japan, there are no reports that directly focus on Japanese members of a multidisciplinary HF team. However, a nationwide survey that focused on HF palliative care28 and the Japan Agency for Medical Research and Development-Congestive Heart Failure (AMED-CHF) study that focused on HF cardiac rehabilitation29 reported that members included cardiologists, nurses, physical therapists, dieticians, pharmacists, and medical social workers (MSWs). In 2020, the JCS started a “Heart Failure Educator” certification. Nurses, physical therapists, dieticians, pharmacists, and MSWs can apply for this; by 2021, 3,420 healthcare professionals were certified.30 The roles of team members are listed in Table 2.
| Team member | Roles and responsibility |
|---|---|
| Medical doctors | Making a diagnosis4 |
| Implementation of evidence-based treatment4 | |
| Setting the goals for a multidisciplinary team | |
| Collaborative communication with general practitioners31–33 | |
| Palliative and advance care planning4,73,74 | |
| Nurses | Coordinating the activities of multidisciplinary team members40 |
| Education and support to facilitate patient self-care24,26,27,42 | |
| Education and support for caregivers80 | |
| Facilitating transitions of care58,78 | |
| Palliative and advance care planning4,73,74 | |
| Physical therapists | Exercise and functional capacity testing45 |
| Exercise therapy based on exercise prescription45 | |
| Education for exercise training and regular physical activity45 | |
| Cardiac rehabilitation team should collaborate with the HF team | |
| Dieticians | Nutritional assessment50,51 |
| Nutritional management of patients with HF and malnutrition50,51 | |
| Nutritional counseling50,51 | |
| Nutritional support team should collaborate with the HF team | |
| Pharmacists | Patient education to improve medication adherence53 |
| Prevention of adverse drug reactions | |
| Suggestion of medications for palliative care and delirium54 | |
| Medical social worker | Assessment of social support and providing assistance |
| Discharge planning56 |
Cardiologists are expected to set the goals of the multidisciplinary team, solicit diverse opinions from each healthcare professional, and reach a team consensus. However, it is unclear whether outpatients with stabilized chronic HF should be followed up by cardiologists or general practitioners (GPs). For patients in a long-term outpatient setting, the burden of non-HF problems would increase. Therefore, a collaborative model in which GPs, cardiologists, and other professionals provide medical care together to optimize outcomes and QOL is needed.
Kinugasa et al conducted a survey of hospital cardiologists and GPs to assess the quality of community collaboration in HF. According to their survey hospital cardiologists prioritized medical intervention to prevent hospitalization and death because of HF, whereas GPs prioritized supporting patient-centered problems.31 To ensure relevant information is provided for GPs, the JHFS published pocket guides of the Guidelines for diagnosis and treatment of acute and chronic heart failure, and the AMED-CHF research group developed an HF guidebook that can be used by GPs and other medical and care staff in the community.32 From the KCHF registry, Washida et al reported that patients with collaborative follow-up after discharge (hospitals, clinics, or general hospitals) had a lower risk of hospitalization for HF.33
NursesNurses are integral to nearly all disease-management strategies. Moreover, they work in different sectors, from inpatient to outpatient, community, and home care. Therefore, transitioning these sectors is critical for implementing disease management throughout the patient’s life. Many studies in Western countries have found that nurse-led patient education, discharge planning, or hospital-to-home transitional interventions can improve health-related QOL and self-care behaviors, thereby decreasing HF hospitalization.34–37 The period after discharge from the hospital is a vulnerable stage; in some studies from Western countries, nurse-led HF clinics, home visits, or telemonitoring are used to optimize medication management, identify early signs of deterioration, and intensify medical follow-up as needed.38,39
The Japanese Nursing Association created a certification for chronic HF nursing in 2012 (the total number of nurses was 472 in 2020).40 In the future, nurse-led patient programs in both the in-hospital and outpatient setting will become essential.41,42
Physical TherapistsComprehensive cardiac rehabilitation (CR) is a strong recommendation for patients with HF because it improves functional capacity and QOL and reduces the risk of readmission of patients with HF and reduced left ventricular ejection fraction (LVEF).43 The concept of CR with exercise has recently included behavioral and lifestyle risk factor reduction, health education, and personal counseling.44,45 There should be close collaboration and communication among the CR team, HF team, and other team members involved in transition of care, especially post-discharge following hospitalization and acute-to-non-acute or long-term care facilities.
In 2000, the Japanese Association of Cardiac Rehabilitation established a certification program for registered CR instructors, and CR for HF was covered by health insurance in 2007, regardless of the patient’s LVEF, and as a result, participation rates have gradually increased.45 Kamiya et al reported that among 51,323 patients hospitalized for HF, the presence of nurses certified in chronic HF and registered CR instructors on staff was consistently associated with the implementation of inpatient and outpatient multidisciplinary HF care.29
DietitiansHistorically, dietary recommendations for HF management have primarily focused on sodium and fluid restrictions. However, malnutrition is common in patients with HF and approximately 5–15% of patients with HF develop cardiac cachexia.46 The benefits of high-calorie, protein-rich, oral nutritional supplements and amino acids have been reported in patients with HF.47,48 These interventions generally resulted in increased fat mass and improved exercise capacity in some patients. Recently, the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished inpatients (EFFORT), the largest randomized trial on nutritional support in patients with HF, reported that the mortality rate in the intervention group was 56% lower than that in the control group.49
Since 1999, when the Japanese Society for Parenteral and Enteral Nutrition first proposed them, academic interest in nutritional support teams (NSTs) has increased rapidly. By 2010, the full range of activities of NSTs was recognized as a necessary medical service in Japan, and the insurance system covered the total medical fees for NST activities.50 In 2018, the JHFS released scientific statements on the nutritional assessment and management of patients with HF,51 which include the pathophysiology of cardiac cachexia, nutritional assessment, and nutritional interventions based on multidisciplinary management and must be repeated and reinforced throughout HF care.
PharmacistsPharmacists are responsible for a variety of task related to the care of patients with HF, including patient medication education, pharmacotherapeutic recommendations, early identification and prevention of adverse drug reactions, improved medication adherence, and transition of care. A meta-analysis related to pharmacists’ activity found that there was a significant decrease in HF hospitalizations but no effect on HF deaths.52
In Japan, Suzuki et al reported that pharmacist-led HF drug recommendations during hospitalization as part of a multidisciplinary team approach for hospitalized patients with HF could increase β-blocker prescriptions and decrease non-preferred drug prescriptions.53 Moreover, pharmacists’ involvement in palliative care is rapidly increasing in Japan. According to the Japanese nationwide questionnaire on palliative care in patients with HF, dyspnea, pain, anxiety, delirium, and general fatigue are common in patients with endstage HF.28 Among the institutions that use drugs, morphine, dexmedetomidine, and midazolam are often administered.28 In addition, drug prescriptions for insomnia and delirium are common and pharmacists have frequently recommended these drugs. Therefore, the Japanese Society of Hospital Pharmacists released a statement on the pharmacological management of HF palliative care in 2021.54
Medical Social WorkersMSWs serve as mediators between medical services and social welfare, playing an essential role in supporting the utilization of social security systems based on the economic, psychiatric, and social issues raised by patients and families. MSWs are expected to share information with team members to resolve issues in the context of social welfare.
Transitional care services, including discharge planning and follow-up, are increasingly being used to prevent unnecessary readmissions. Phillips et al reported that comprehensive discharge planning plus post-discharge support for older patients with HF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.55
Although Japanese hospitals do not offer comprehensive transitional care programs under the health insurance system, discharge planning performed by nurses or MSWs belonging to specialized discharge planning departments is covered by medical insurance. A premium fee is paid to hospitals that hold conferences with community care workers before a patient’s discharge.56
Among the clinical endpoints, morbidity and mortality are the gold standards; however, an accurate assessment of the effects of multidisciplinary interventions on these endpoints is challenging, as patients present with complicated illnesses that often require multiple hospitalizations. Few studies have focused on reducing cardiac events in the Japanese medical and care environments.
Kinugasa et al57 used a single-center design to report on the effect of an inpatient HF multidisciplinary management program in rural Japanese areas. The incidence of composite endpoints of hospitalization for HF and all-cause death significantly decreased after the introduction of the program (hazard ratio [HR] 0.50). Tsuchihashi-Makaya et al58 reported in The Japanese HF Outpatients Disease Management and Cardiac Evaluation (J-HOMECARE) study that a nurse-led home-based disease-management program improved psychological status and reduced rehospitalization for HF in patients with HF. Hospitalization for HF was significantly lower in the intervention group than in the usual care group (HR 0.52). Recently, from the AMED-CHF study, Kamiya et al retrospectively reported an association between multidisciplinary outpatient CR participation and prognosis in 3,277 patients with HF at multiple centers. After propensity matching, the HR associated with CR participation was 0.77 for all-cause death and HF rehospitalization after discharge.59
As those studies were conducted in the early phase of implementing multidisciplinary interventions in Japan, the hazard risk reduction was quite good. However, it is possible that the high quality of usual care left little room for improvement with additional specific care; it can become difficult to earn such excellent results for hard endpoints, as these interventions have become normal.
The cost of multidisciplinary management under the Japanese insurance system should also be investigated.22 Kitagawa et al reported a positive correlation between hospitalization days and medical costs. After starting multidisciplinary management of the HF center at Hiroshima University Hospital, the frequency and length of hospitalization and costs for hospitalizations were significantly reduced. The implementation of multidisciplinary management for HF may reduce all-cause hospitalization and medical costs.60
There is little experience with multidisciplinary disease management of acute HF. However, many older adult patients experience delirium, progressive malnutrition, and physical frailty in the acute phase and these factors can prolong the hospital stay and are associated with death. In Japan, a unique acute-phase multidisciplinary management program is currently underway to prevent and treat these problems.
Early Assessment and Treatment of Delirium Patients treated in a cardiac intensive care unit (CICU) tend to develop delirium secondary to environmental and physiological factors, which prolongs the mechanical ventilation time and CICU stay, and leads to poor prognosis.61 Preventable actions, such as adequate control of pain and other symptoms (dyspnea, fever, and constipation), prevention of sensory impairment, orientation and reassurance, noise reduction strategies, sleep promotion, and minimization of the use of sedative drugs, should be evaluated by a multidisciplinary team.62 The statement regarding the pharmacological management of HF palliative care released by the Japanese Society of Hospital Pharmacists contains a section on delirium and recommends multidisciplinary management and drugs.54
Early-Start Cardiac Rehabilitation The adverse effects of skeletal muscle immobility manifest early with atrophic processes. According to the Japanese treatment guidelines for rehabilitation, patients with acute HF receiving intravenous inotropic drugs and stable hemodynamics can participate in CR under strict supervision.45 Takada et al reported that of 259 patients with acute HF, 11.6% commenced rehabilitation within 72 h after admission, and patients who received early rehabilitation had a higher rate of unassisted walking for at least 40 m by 30 days after admission.63 Kaneko et al64 reported that, with retrospective Diagnosis Procedure Combination (DPC) data analysis, among 430,216 eligible patients, 14.8% received acute-phase initiation of CR within 2 days of hospital admission. Propensity score-matching found that acute-phase initiation of CR was associated with fewer in-hospital deaths, shorter hospital stay, and lower incidence of 30-day readmission due to HF.
Early-Start Nutritional Support In acute HF, the patient’s nutritional condition is considered more likely to deteriorate than in the chronic phase.51 Early intervention with enteral nutrition (EN) is the standard of care in the ICU setting. However, few studies have addressed the use of early EN in critically ill patients in the CICU.
Nakayama et al65 reported the safety of early EN in patients admitted to the CICU. A multidisciplinary team discussed the daily energy and protein targets within 72 h of CICU admission. EN was initiated in hemodynamically stable patients because of mechanical support or catecholamine use. The results showed that 83% of the patients achieved the goal by hospital day 7, and no severe complications of EN developed. Saijo et al reported that early EN (within 48 h of intubation) in 86 patients with severe acute HF who required continuous invasive mechanical ventilation (IMV) was associated with reduced CICU length of stay, IMV time, and incidence of infection.66 Using retrospective DPC database analysis, Kaneko et al reported the effects of early feeding initiation. Propensity score-matching showed that delayed initiation of feeding was associated with higher in-hospital mortality rates, longer hospital stay, and higher incidence of pneumonia and sepsis.67
Prevention of ReadmissionThere is an increasing trend in the number of nuclear families owing to urbanization, and there are long waiting lists for nursing homes. Consequently, older patients sometimes remain in hospital not only for medical reasons but also because their families cannot care for them. Moreover, in 2009, 78% of the deaths in Japan occurred in hospitals, which was higher than in other countries.68 To prevent hospital readmission and death, the medical and care challenges in an aging society must be addressed.
Out-of-Hospital Multidisciplinary Diuretic Interventions to Prevent HF Readmission The management of HF is shifting toward treatment approaches outside the traditional hospital setting, and multidisciplinary outpatient treatment for worsening HF with intravenous or subcutaneous diuretics has been described in the literature.69 Buckley et al reported that short courses of intravenous diuretics in a multidisciplinary outpatient unit for volume management in patients with HF were safe and associated with significant urine output and weight loss.70 Nishi et al reported the effects of intermittent outpatient infusion (mean, 3 h) of low-dose inotropes or natriuretic peptides with furosemide injection under multidisciplinary management in Japan. This system was safe, and reduced the duration and number of hospitalizations and overall medical costs in selected patients.71 Further studies are necessary to develop more effective protocols for patient selection.
Palliative Care to Prevent Readmission Many patients diagnosed with HF experience symptoms that affect their QOL, so several professional organizations have recommended incorporating palliative care (PC) as a treatment option for patients with HF.4,54 A systematic review revealed that compared with usual care, PC interventions for patients with HF were associated with a substantial reduction in hospitalizations.72 Providing PC near the end of life may increase the likelihood of death outside the hospital.
In Japan, multidisciplinary team-based PC for HF was not reimbursed by April 2018, and only a few JCS-authorized cardiology training hospitals had a PC team for HF.28 In October 2019, the HF Palliative Care Training program for comprehensive care providers (HEPT) was officially approved by the JHFS,73 and the JCS/JHFS released a 2021 statement on palliative care for cardiovascular diseases.74
Creating a Community-Based Integrated Care Model to Prevent Readmission The Japanese government created incentives through various adjustments to the medical and long-term care systems to increase collaboration between these 2 fields. Community-based integrated care centers play a major role in the community, and have been increasingly established by municipalities since 2006. They should ultimately exist in every district (delimited by a school area that covers ≈20,000 inhabitants).75
Tomita et al reported that users of home and community-based services, such as respite care, rental services for assistive devices, and daycare, were less likely to be hospitalized or institutionalized than non-users.76 In patients with HF, Takabayashi et al reported from the KICKOFF registry data of older patients (65–85 years) that the rates of all-cause death and HF hospitalization were significantly lower among community-based service users than among non-users.16
Possibilities of Remote Monitoring The Home Telemonitoring Study for Japanese Patients with HF (HOMES-HF) was the first multicenter, open-label, randomized controlled trial to elucidate the effectiveness of home telemonitoring of physiological data, such as body weight, blood pressure, and pulse rate.77 Although the adherence rate of the study participants was maintained at approximately 90% at 2 months, there was no statistically significant difference in the primary endpoint (all-cause death or rehospitalization due to worsening HF) between the groups. The authors speculated that the lack of adequate interactive human-human communication might be a reason for the study’s failure.
Recently, some small studies of remote-monitoring have explored the effects of interactive communication and the frequency of examinations. Mizukawa et al investigated nurse-led interactive communication using telemonitoring and the intervention nurse arranged physician visits or contacted the patient care manager for care coordination as needed.78 Miyoshi et al conducted a study with remote monitoring of intrathoracic impedance (ITI) and reported the effects of repeated assessments of ITI.79 The results showed that a 1-week lifestyle modification and medication arrangement effectively increased ITI. Future studies are necessary to explore effective information and communications and the timing of monitoring to reduce readmissions.
In Japan, there is an urgent need for early multidisciplinary intervention during hospital admission for HF and the integration of medical and care systems to maintain patients’ ADL and QOL, reduce both the number of rehospitalizations and their duration, and increase the number of deaths at home if patients and caregivers agree.80 Many guidelines and statements have been released by academia, and the government has added incentives to the Japanese medical and care systems.
However, several problems still need to be addressed. First, as the number of certified HF nurses and educators is deficient only some hospitals have a multidisciplinary HF team.28,29 Therefore, efforts should be made to increase the number of nurses and educators familiar with HF. Second, even when multidisciplinary management is in place, it is often underused, and the actual number of patients who receive effective multidisciplinary management is unknown. To evaluate the effectiveness of disease-management programs, consensus-based performance measures should be used to improve the quality of care and outcomes. Finally, HF education presented by academia and the government to community members who may be patients or caregivers is necessary, because many community members are unaware of what HF is and its clinical course.81
