Implementing the Certified Heart Failure Educator System in Japan　― Initial Experience ―

Abstract

Background: The Japanese Circulation Society (JCS) launched a Certified Heart Failure Educator (CHFE) program in 2021. However, reports regarding this program are lacking. Here we describe the initial experience following implementation of CHFE program and assess its association with hospital quality measures.

Methods and Results: We performed a retrospective study using data from CHFE certification data for 2021–2024 and data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination in 2021. The cumulative number of CHFEs increased from 1,771 in 2021 to 6,603 in 2024. Various medical professionals joined the system, and almost all CHFEs were affiliated with hospitals. Of all 813 hospitals included, 416 (51.2%) had at least 1 CHFE in 2021, with a median number of 2 CHFEs per hospital. The group of hospitals with CHFEs had a higher proportion of JCS training hospitals and a higher number of annual heart failure (HF) hospitalizations and cardiology beds. Of 71,678 patients hospitalized for acute HF and discharged to home, 41,558 (58.0%) were hospitalized in facilities with CHFEs. After adjustment for baseline characteristics, hospital admission to a facility with a CHFE was associated with higher achievement of process measures and lower in-hospital mortality.

Conclusions: The CHFE system was successfully implemented and contributed to HF management primarily in high-quality hospitals. Our findings may provide insights for future strategies regarding this system.

Central Figure

Heart failure (HF) is a growing global health concern and remains a leading cause of hospitalizations worldwide.¹ The number of patients with HF, along with associated healthcare expenditures, is substantial and expected to increase with an aging population.^2,3 In Japan, the total number of HF hospitalizations has increased over the past few decades. Despite advances in treatment strategies, reductions in mortality and readmission rates have been modest.⁴ In addition, with the increasing number of hospitalizations for HF, the burden of HF per cardiologist has notably increased.⁵

HF is a multifaceted syndrome characterized by high mortality and reduced quality of life.⁶ To improve clinical outcomes, various interventions, such as nutritional guidance, cardiac rehabilitation, and medication management, are essential. Therefore, multidisciplinary team-based care for HF has been recognized as an effective approach to mitigate HF symptoms and reduce rehospitalizations.⁷ The Japanese Circulation Society (JCS) launched the Certified Heart Failure Educator (CHFE) program for healthcare professionals in 2021. To be certified, CHFEs must take educational courses, submit case reports, and pass an examination. In addition, to renew their qualification, they must obtain credits for education courses/lectures and the submission of case reports. The aim of the certification is to equip medical professionals with the knowledge and skills necessary to provide comprehensive support for patients with HF via a team-based approach and to address the increasing burden of HF on cardiovascular healthcare systems.

Despite the certification program being implemented, studies describing the current status of CHFEs and evaluating the actual roles of CHFE certification on clinical outcomes are lacking. The aims of this study were to clarify the characteristics and status of CHFEs and to assess the associations between CHFEs and quality measures in cardiovascular hospitals using a nationwide hospitalization database.

Methods

Data Sources

Data from 3 sources were used: registration data of CHFEs, Japanese Registry of All Cardiac and Vascular Diseases (JROAD) data, and JROAD–Diagnosis Procedure Combination (JROAD-DPC) data. The JCS provided data on CHFE certification in 2021 (the first examination was conducted in 2020), including information on affiliated institutions and categories of healthcare professionals. JROAD is a hospital-level database established by the JCS. It contains data from all JCS training hospitals and JCS-associated training hospitals, achieving a 100% response rate each year.^5,8 In this study, we extracted 2021 data on the annual number of hospitalizations for HF, the number of JCS-certified cardiologists, and the number of beds from JROAD. JROAD-DPC contains patient-level claims data for those hospitalized with cardiovascular diseases.⁹ We collected data for 817 JCS-training and JCS-associated training hospitals that admitted patients with HF from April 2021 to March 2022 (fiscal year 2021 in Japan). JROAD-DPC includes information on patient characteristics, such as diagnosis, age, sex, body mass index, Charlson Comorbidity Index, Japan Coma Scale, comorbidities, medications, medical treatments, in-hospital death, and length of hospital stay.

Study Design and Patients

This was a retrospective observational study. First, we described changes in the number of CHFEs from 2021 to 2024 and the characteristics of CHFEs certified in 2021. Second, we extracted data from JROAD-DPC for patients who were admitted because of HF. The definition of HF was based on the International Classification of Diseases, 10th revision codes I50, I110, I130, and I132, identified in the main diagnosis, admission-precipitating diagnosis, or the most or second-most resource-consuming diagnosis. Of patients with HF, we included those with an emergency admission and additional disease codes of acute HF (30101) or acute exacerbation of chronic HF (30102). Patients were excluded if they were hospitalized in hospitals that were not JCS certified or if they had missing variables. The positive predictive value of the diagnosis was 0.83 in a prior validation study.¹⁰

JROAD-DPC data were merged with JROAD hospital data and CHFE certification data to facilitate the analysis. Hospitals and patients were categorized into 2 groups according to the presence or absence of certificated CHFEs in 2021 (CHFE and no CHFE groups).

Study Outcomes

The outcomes of this study were the process and outcome measures related to HF hospitalization.¹¹ The process measures were indicators of medical support, such as: guidance regarding drug administration; nutritional guidance; admission and discharge support (coordinated discharge planning and patient flow management to support seamless transition from hospital to home or community care); cardiac rehabilitation; prescription of guideline-directed medical therapy, echocardiographic examination, and measurements of B-type natriuretic peptide (BNP) or N-terminal pro BNP (NT-proBNP). Outcome measures were in-hospital death and 30- and 90-day rehospitalizations at the same hospital.

Statistical Analysis

Patient clinical characteristics were summarized as numbers and percentages for categorical variables and as the median with interquartile range (IQR) for continuous variables. We described the characteristics of CHFEs and the baseline characteristics of patients hospitalized for acute HF according to CHFE group. We analyzed the association between the presence of CHFEs and patient outcomes using multivariable logistic or linear regression analysis. Because certain outcomes depended on the discharge status, analyses of the process measures and rehospitalizations were conducted only for patients discharged home. In-hospital mortality was analyzed for all hospitalized patients. The DPC dataset was collected annually, and rehospitalizations were analyzed for patients who were discharged home and rehospitalized in facilities participating in JROAD-DPC in both 2021 and 2022. Multivariable models were adjusted for age, sex, body mass index, Charlson Comorbidity Index, Barthel index, Japan Coma Scale at admission, comorbidities, respirator use, admission to an intensive care unit or high-care unit, length of hospital stay, annual number of hospitalizations for HF, number of cardiologists, and the number of hospital and cardiology beds. Statistical significance was set at two-sided P<0.05. Data were analyzed using Stata version 17 (StataCorp, College Station, TX, USA).

Ethics Statement

This study was conducted in accordance with the principles of the Declaration of Helsinki. The Ethics Committee of the National Cerebral and Cardiovascular Center (Registration no. R24025) approved the study protocol. All data were anonymized, and the requirement for informed consent was waived by the Ethics Committee.

Results

Characteristics of CHFEs

From the first CHFE certification in 2021 (examination conducted in 2020), the cumulative number of CHFEs increased from 1,771 in 2021 to 6,603 in 2024 (Figure 1A). In 2021, the number of CHFEs per 100,000 population was 1.4, with the highest number in the Kyushu/Okinawa region (2.3 per 100,000 population; Figure 1B). Of the CHFEs in 2021, 53.4% were nurses and 26.7% were therapists (Figure 1C). Almost all CHFEs were affiliated with hospitals (Figure 1D). The distribution of CHFEs per hospital is shown in Figure 1E, with a median number of 2 (IQR 1–3) CHFEs per hospital.

Figure 1.

Characteristics and distribution of Certified Heart Failure Educators (CHFEs). (A) Total number of CHFEs. (B) Number of CHFEs per population in different regions of Japan in 2021. (C) Professional occupations of CHFEs in 2021. (D) Workplace distribution of CHFEs in 2021. (E) Distribution of the number of CHFEs per hospital.

Hospital and Patient Characteristics According to the Presence of CHFEs

Of the 1,771 CHFEs certified in 2021, 1,094 were affiliated with JROAD-DPC-participating hospitals in 2021 and were analyzed in this study (Figure 2). Of the 813 hospitals included in the DPC data, 416 (51.2%) had at least 1 CHFE in 2021. The group of hospitals with CHFEs had a higher proportion of JCS training hospitals and a higher number of annual HF hospitalizations and cardiology beds (Table 1).

Figure 2.

Study flowchart showing inclusion of Certified Heart Failure Educators (CHFEs) and patients hospitalized for acute heart failure in this study. JROAD-DPC, Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination.

Table 1.

Hospital Characteristics According to the Presence of CHFEs

	No CHFE	CHFE
No. hospitals	397	416
No. JCS training hospitals (%)	307 (77.3)	375 (90.1)
No. HF hospitalizations	161 [101–237]	211 [147–313]
No. ADHF hospitalizations	60 [17–129]	114 [41–208]
No. JCS-certified cardiologists	4 [2–6]	6 [3–10]
No. hospital beds	347 [259–460]	429 [307–600]
No. cardiology beds	30 [24–41]	36 [30–46]
No. CHFEs	–	2 [1–3]

Unless indicated otherwise, data are given as the median [interquartile range]. ADHF, acute decompensated heart failure; CHFE, Certified Heart Failure Educator; HF, heart failure; JCS, Japanese Circulation Society.

Of the 191,410 patients hospitalized for HF in JROAD-DPC, 106,829 were hospitalized for acute HF with an emergency admission. Of these patients, we analyzed the 71,678 who were discharged home. Of the patients who were discharged home, 41,558 (58.0%) were hospitalized in facilities with CHFEs, and baseline patient characteristics, such as age, sex, body mass index, and comorbidities, were similar between the groups from facilities with and without CHFEs (Table 2). A higher proportion of patients in the CHFE group required a respirator or non-invasive positive pressure ventilation and were admitted to intensive or high-care units compared with the no CHFE group.

Table 2.

Patient Characteristics According to Hospitalization in Facilities With or Without CHFEs

	No CHFE	CHFE
No. patients	30,090	41,588
Age (years)	82 [73–88]	81 [73–88]
Female sex	13,324 (44.3)	18,139 (43.6)
Body mass index
<18.5 kg/m2	3,738 (12.4)	5,497 (13.2)
≥18.5, <25 kg/m2	16,360 (54.4)	22,507 (54.1)
≥25 kg/m2	8,357 (27.8)	10,806 (26.0)
Missing data	1,635 (5.4)	2,778 (6.7)
Charlson Comorbidity Index
1	9,587 (31.9)	13,055 (31.4)
2	8,180 (27.2)	11,649 (28.0)
≥3	12,323 (41.0)	16,884 (40.6)
Barthel index at admission
≤90	12,010 (39.9)	15,036 (36.2)
>90	9,594 (31.9)	13,819 (33.2)
Missing data	8,486 (28.2)	12,733 (30.6)
Japan Coma Scale at admission
Alert	25,592 (85.1)	35,449 (85.2)
Dizziness	3,864 (12.8)	5,326 (12.8)
Somnolence	409 (1.4)	536 (1.3)
Coma	225 (0.7)	277 (0.7)
Comorbidities associated with HF
Coronary artery disease	8,484 (28.2)	12,027 (28.9)
Valvular disease	3,753 (12.5)	5,433 (13.1)
Atrial fibrillation	11,400 (37.9)	15,878 (38.2)
Cardiomyopathy	1,092 (3.6)	1,760 (4.2)
Pulmonary hypertension	360 (1.2)	515 (1.2)
Congenital heart disease	160 (0.5)	270 (0.6)
Other comorbidities
Hypertension	17,374 (57.7)	24,326 (58.5)
Diabetes	9,821 (32.6)	14,160 (34.0)
Dyslipidemia	8,205 (27.3)	12,024 (28.9)
Dementia	1,617 (5.4)	2,253 (5.4)
Medications during hospitalization
ACE inhibitors	6,185 (20.6)	10,032 (24.1)
ARBs	11,211 (37.3)	15,584 (37.5)
ARNI	5,243 (17.4)	7,322 (17.6)
β-blockers	21,258 (70.6)	30,446 (73.2)
MRAs	15,888 (52.8)	22,999 (55.3)
SGLT2 inhibitors	7,764 (25.8)	12,097 (29.1)
Calcium channel blockers	12,567 (41.8)	17,390 (41.8)
Thiazide	2,103 (7.0)	3,213 (7.7)
Loop diuretics	28,133 (93.5)	38,912 (93.6)
Tolvaptan	14,175 (47.1)	19,046 (45.8)
Oral antidiabetic agents	6,273 (20.8)	8,995 (21.6)
Insulin	4,476 (14.9)	6,678 (16.1)
Statin	11,076 (36.8)	16,614 (39.9)
Respirator or NPPV	5,063 (16.8)	7,639 (18.4)
ICU or HCU	7,020 (23.3)	13,742 (33.0)
Length of hospital stay (days)	16 [11–23]	15 [11–22]

Unless indicated otherwise, data are given as the median [interquartile range] or n (%). ACE, angiotensin-converting enzyme; ARBs, angiotensin II receptor blockers; ARNI, angiotensin receptor-neprilysin inhibitor; CHFE, Certified Heart Failure Educator; HCU, high-care unit; HF, heart failure; ICU, intensive care unit; MRAs, mineralocorticoid receptor antagonists; NPPV, non-invasive positive pressure ventilation; SGLT2, sodium-glucose cotransporter 2.

Associations Between CHFEs and Hospital Outcomes

Process and outcome measures for patients from facilities with and without CHFEs are presented in the Supplementary Table. A larger proportion of the CHFE group received nutritional guidance, as well as admission and discharge support, underwent cardiac rehabilitation, and used HF medication. The crude in-hospital mortality was 10.4% in the CHFE group and 12.7% in the no CHFE group, and 7.6% of the CHFE group and 8.1% of the no CHFE group experienced rehospitalization within 30 days.

Multivariable logistic regression analysis revealed that hospitalization in facilities with CHFEs was associated with a higher rate of medical support, cardiac rehabilitation, sodium-glucose cotransporter 2 inhibitor use, transthoracic echocardiography, and BNP/NT-proBNP measurements (Table 3). The CHFE group had lower in-hospital mortality (odds ratio 0.90; 95% confidence interval 0.86–0.94) than the no CHFE group. However, no statistical associations were observed between the presence of CHFEs and 30- and 90-day rehospitalization.

Table 3.

Association Between the Presence of Certified HF Educators and Hospital Outcomes (Multivariable Analysis)

	OR/β coefficient	95% CI	P value
Process measures
Medical support
Drug administration guidance	1.01	0.97–1.05	0.53
Drug administration guidance at discharge	1.07	1.04–1.11	<0.001
Nutritional guidance	1.25	1.21–1.29	<0.001
Patient support at admission	1.17	1.13–1.21	<0.001
Patient support at discharge	1.16	1.13–1.20	<0.001
Patient referral document	1.06	1.03–1.10	<0.001
Rehabilitation
Cardiac rehabilitation	1.28	1.23–1.33	<0.001
Cardiac rehabilitation guidance at discharge	1.12	1.02–1.09	<0.001
Medications
β-blockers	1.00	0.97–1.04	0.83
ACE inhibitors/ARBs/ARNI	1.02	0.99–1.06	0.25
MRAs	1.01	0.98–1.04	0.59
SGLT2 inhibitors	1.09	1.05–1.13	<0.001
Transthoracic echocardiography	1.11	1.06–1.16	<0.001
BNP/NT-proBNP measurementsA	0.03	0.02–0.04	<0.001
Outcome measures
In-hospital death	0.90	0.86–0.94	<0.001
30-day rehospitalization	0.96	0.90–1.02	0.19
90-day rehospitalization	0.98	0.94–1.03	0.41

^AB-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) measurements were a continuous variable and were analyzed using a multivariable linear regression model. Other variables were analyzed using multivariable logistic regression model. CI, confidence interval; OR, odds ratio. Other abbreviations as in Table 2.

Discussion

This nationwide observational study of the initial phase of the CHFE program found that: (1) more than 6,000 medical professionals were certified as CHFEs during 2021–2024, with most working in hospitals; (2) facilities with CHFEs in 2021 tended to be larger facilities; and (3) being hospitalized for acute HF in a facility with CHFEs was associated with higher achievement of process measures and a lower risk of in-hospital mortality. To the best of our knowledge, this is the first study in which a nationwide claims database was used to describe the initial state of CHFE certification and to assess the association between the presence of CHFEs and in-hospital clinical outcomes. The results of this study provide insights into the implementation of the CHFE program and future strategies for medical institutions.

This study found that more than 90% of CHFEs were employed in hospitals. To overcome the increasing burden of HF in Japan, CHFEs are expected to contribute to the care of patients with HF in various settings, including hospitals, outpatient settings, and home care. Our study demonstrated that CHFEs were employed in large acute cardiovascular hospitals during the initial phase of certification. Expanding certification to medical staff affiliated with smaller hospitals and clinics will be necessary to enhance access to HF care. To increase the number of CHFEs in outpatient and home-care settings, establishing appropriate reimbursement policies and demonstrating the effectiveness of the CHFE system or a multidisciplinary approach are needed, but these remain insufficient in Japan.

In the present study, hospitalization in facilities with CHFEs was associated with higher achievement of process measures. A CHFE is expected to understand HF care better than other healthcare professionals, which may motivate them to participate in HF team management of patients. Although multivariable analysis demonstrated a positive association between the presence of CHFEs and medical support and cardiac rehabilitation, there was no statistically significant association with conventional HF medications, such as β-blockers. These results suggest that the decision-making process for prescriptions is primarily driven by physicians, with limited involvement of CHFEs. A previous study demonstrated that a large number of cardiologists per bed was associated with higher prescription rates of HF medications.¹² In real-world settings, the prescription rate of guideline-directed medical therapy is insufficient, and a multidisciplinary approach involving CHFEs may improve the prescription rate and adherence to these medications in the future.^13–15

In this study, admission to hospitals with CHFEs was associated with lower in-hospital mortality, but not with a reduction in HF readmission. Although few studies in the hospital setting have been published, prior studies have demonstrated the benefits of multidisciplinary team-based interventions on outcomes.^16–18 The current published guideline in Japan stresses the importance of transitional care after discharge and of the multidisciplinary team-based approach, including CHFEs.¹⁹ In our study, we examined only the first year of CHFE certification, during which there were relatively few CHFEs per facility (median 2), which may explain why their presence was not associated with readmission for HF. Previously, transitional care provided by specialists has proven beneficial in reducing readmissions.²⁰ In the present study, a few CHFEs were employed outside hospitals. In the future, strategies should be developed to increase the number of CHFEs in outpatient settings, thereby promoting seamless transition care after hospital discharge, which may lead to lower HF readmission rates.

Study Limitations

This study has several limitations. First, because of the observational nature of the study, the results cannot indicate causality in the favorable association between the presence of CHFEs and hospital outcomes. It remains unclear whether the better outcomes can be attributed to the direct effect of the presence of CHFEs, or whether such hospitals already had a strong cardiovascular care culture that encouraged staff to achieve CHFE certification. Second, we analyzed only the initial year of the certification program and did not assess long-term outcomes, including those in outpatient settings. Future studies are needed to determine whether CHFE systems affect the quality of the long-term management of patients with HF.

Conclusions

We clarified the initial status of the CHFE program in Japan. We revealed that hospitalization for HF in hospitals with CHFEs was associated with a higher achievement of process measures and lower in-hospital mortality. Although validation of our findings is required, this study provides information and insights for further improvements to this certification system in the future.

Acknowledgments / Sources of Funding

None.

Disclosures

The authors declare that they have no conflicts of interest with respect to this research study or paper. Y.K. is a member of Circulation Journal’s Editorial Team.

Author Contributions

K.K. contributed to the design of the project, data collection, analysis, and writing the draft of the manuscript. Y.I. and Y.M. contributed to the design of the project. M.N., T.N., S.M., and Y.K. contributed to project design and supervised the study. All authors contributed to data interpretation, revised the draft, and reviewed and approved the final version of the manuscript.

IRB Information

The study protocol was approved by the Ethics Committee of the National Cerebral and Cardiovascular Center (Registration no. R24025).

Data Availability

Data cannot be shared for privacy or ethical reasons.

Supplementary Files

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-25-0304

References

• 1.   GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392: 1789–1858, doi:10.1016/S0140-6736(18)32279-7.
• 2.   Dharmarajan K, Wang Y, Lin Z, Normand ST, Ross JS, Horwitz LI, et al. Association of changing hospital readmission rates with mortality rates after hospital discharge. JAMA 2017; 318: 270–278, doi:10.1001/jama.2017.8444.
• 3.   Desai AS, Stevenson LW. Rehospitalization for heart failure: Predict or prevent? Circulation 2012; 126: 501–506, doi:10.1161/CIRCULATIONAHA.112.125435.
• 4.   Kanaoka K, Iwanaga Y, Sumita Y, Nakai M, Miyamoto Y. Management and outcomes of acute heart failure hospitalizations in Japan. Circ J 2024; 88: 1265–1273, doi:10.1253/circj.CJ-23-0350.
• 5.   Kanaoka K, Iwanaga Y, Nakai M, Sumita Y, Saito Y, Miyamoto Y. Temporal trends and regional variations in cardiovascular care in Japan, 2010–2019. Int Heart J 2023; 64: 53–59, doi:10.1536/ihj.22-445.
• 6.   Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: A comprehensive and updated review of epidemiology. Cardiovasc Res 2023; 118: 3272–3287, doi:10.1093/cvr/cvac013
• 7.   Sokos G, Kido K, Panjrath G, Benton E, Page R 2nd, Patel J, et al. Multidisciplinary care in heart failure services. J Card Fail 2023; 29: 943–958, doi:10.1016/j.cardfail.2023.02.011.
• 8.   Nishi M, Miyamoto Y, Iwanaga Y, Kanaoka K, Sumita Y, Ishihara M, et al. Hospitalized patients, treatments, and quality of care for cardiovascular diseases in Japan: Outline of the nationwide JROAD investigation. Circ J 2025; 89: 1081–1086, doi:10.1253/circj.CJ-24-0704.
• 9.   Kanaoka K, Okayama S, Nakai M, Sumita Y, Nishimura K, Kawakami R, et al. Hospitalization costs for patients with acute congestive heart failure in Japan. Circ J 2019; 83: 1025–1031, doi:10.1253/circj.CJ-18-1212.
• 10.   Nakai M, Iwanaga Y, Sumita Y, Kanaoka K, Kawakami R, Ishii M, et al. Validation of acute myocardial infarction and heart failure diagnoses in hospitalized patients with the nationwide claim-based JROAD-DPC database. Circ Rep 2021; 3: 131–136, doi:10.1253/circrep.CR-21-0004.
• 11.   Kanaoka K, Iwanaga Y, Tsujimoto Y, Shiroshita A, Suzuki T, Nakai M, et al. Quality indicators for acute cardiovascular diseases: A scoping review. BMC Health Serv Res 2022; 22: 862, doi:10.1186/s12913-022-08239-0.
• 12.   Kanaoka K, Okayama S, Nakai M, Sumita Y, Onoue K, Soeda T, et al. Number of cardiologists per cardiovascular beds and in-hospital mortality for acute heart failure: A nationwide study in Japan. J Am Heart Assoc 2019; 8: e012282, doi:10.1161/JAHA.119.012282.
• 13.   Kanaoka K, Iwanaga Y, Takegawa K, Fujimoto W, Nishioka Y, Myojin T, et al. Current practice of guideline-directed medical therapy after acute heart failure hospitalization: A nationwide observational study. JACC Asia 2025; 5: 786–795, doi:10.1016/j.jacasi.2025.01.015.
• 14.   Suzuki M, Matsue Y, Izumi S, Kimura A, Hashimoto T, Otomo K, et al. Pharmacist-led intervention in the multidisciplinary team approach optimizes heart failure medication. Heart Vessels 2018; 33: 615–622, doi:10.1007/s00380-017-1099-8.
• 15.   Sandhu RK, Fradette M, Lin M, Youngson E, Lau D, Bungard TJ, et al. Stroke risk reduction in atrial fibrillation through pharmacist prescribing: A randomized clinical trial. JAMA Netw Open 2024; 7: e2421993, doi:10.1001/jamanetworkopen.2024.21993.
• 16.   Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: A meta-analysis. JAMA 2004; 291: 1358–1367, doi:10.1001/jama.291.11.1358.
• 17.   Parajuli DR, Kourbelis C, Franzon J, Newman P, Mckinnon RA, Shakib S, et al. Effectiveness of the pharmacist-involved multidisciplinary management of heart failure to improve hospitalizations and mortality rates in 4630 patients: A systematic review and meta-analysis of randomized controlled trials. J Card Fail 2019; 25: 744–756, doi:10.1016/j.cardfail.2019.07.455.
• 18.   Batchelor WB, Anwaruddin S, Wang DD, Perpetua EM, Krishnaswami A, Velagapudi P, et al. The multidisciplinary heart team in cardiovascular medicine: Current role and future challenges. JACC Adv 2023; 2: 100160, doi:10.1016/j.jacadv.2022.100160.
• 19.   Kitai T, Kohsaka S, Kato T, Kato E, Sato K, Teramoto K, et al. JCS/JHFS 2025 guideline on diagnosis and treatment of heart failure. Circ J 2025; 89: 1278–1444, doi:10.1253/circj.CJ-25-0002.
• 20.   Van Spall HGC, Rahman T, Mytton O, Ramasundarahettige C, Ibrahim Q, Kabali C, et al. Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: A systematic review and network meta-analysis. Eur J Heart Fail 2017; 19: 1427–14430, doi:10.1002/ejhf.765.