Prognostic Impact of Hospitalization-Associated Disability and Care Level in Older Heart Failure Patients　― Findings From the J-Proof HF Registry ―

Abstract

Background: Hospitalization-associated disability (HAD) is associated with poor prognosis in patients with heart failure (HF); however, the impact of HAD in older HF patients who require long-term care remains unclear. Therefore, the aim of this study was to determine the prognostic impact of the care level and HAD onset in older HF patients.

Methods and Results: This study included 9,973 patients (mean age 82.6±7.7 years; 50.8% male) out of 10,062 older HF patients enrolled in a nationwide multicenter registry (Japanese Physical Therapy Multicenter Registry of Older Frail Patients With Heart Failure) for analysis. Patients were classified into 4 groups according to the level of care required under long-term care insurance (LTCI) during hospitalization. The level of care required was a risk factor for all-cause mortality and composite outcomes. In the HAD group, the adjusted hazard ratio for all-cause mortality increased with care level severity There was no interaction between the level of care required and HAD in relation to the outcomes.

Conclusions: In older HF patients, both the level of care required and HAD are poor prognostic factors. In the HAD group, the level of care required is an important indicator for planning interventions to prevent poor outcomes under the LTCI system.

Population aging is a global social issue. In Japan, the number of people aged ≥65 years will have quadrupled by 2023 compared with 1960, and by 2024, the percentage of the population aged ≥65 years will be 29.1% of the total population.¹ The number of hospitalized heart failure (HF) patients is also increasing due to aging of the population.² Older HF patients have multimorbidity,³ and their physical functions can easily deteriorate due to bed rest and environmental factors during hospitalization, resulting in impaired independence in activities of daily living (ADL).⁴ Japanese Physical Therapy Multicenter Registry of Older Frail Patients With Heart Failure (J-Proof HF), a nationwide multi-center registry study of older HF patients who received physical therapy during hospitalization after the onset of HF, found that the prevalence of older HF patients with Hospitalization-associated disability (HAD), which indicates decreased ADL during hospitalization, was as high as 37.1%.⁵ Additionally, HAD in HF patients is an independent risk factor for adverse outcomes after discharge.^6,7

The Japanese government launched a long-term care insurance (LTCI) system in 2000 to support the independence of older people in Japan.⁸ All older people aged ≥65 are covered by LTCI and are classified into 5 levels of care according to their level of independence in ADL, taking into consideration both physical and cognitive dysfunction, and can use health care services. In other words, when planning strategies to improve the prognosis of older HF patients, the level of care required and the occurrence of HAD are considered important indicators for receiving social support through LTCI services. It has been reported that the level of care required, as classified by LTCI, is associated with poor prognosis in older HF patients.⁹ However, it remains unclear whether the prognostic impact of HAD differs according to the level of care required in older HF patients.

The purpose of this study was to clarify the prognostic impact of both the level of care required and the onset of HAD in older HF patients enrolled in J-proof HF, and to investigate whether there is an interaction between these 2 factors.

Methods

Study Design and Population

The study was based on the data from J-Proof HF, a nationwide multi-center registry study involving 96 facilities with physical therapist affiliations. J-Proof HF enrolled consecutive patients aged ≥65 years who were hospitalized for HF and prescribed physical therapy between December 2020 and March 2022. Exclusion criteria were as follows: death during hospitalization; transcatheter aortic valve implantation, MitraClip, or surgical procedures performed during hospitalization; acute coronary syndromes; and difficulty walking. Basic information about the J-Proof HF Registry, the study description, and the primary and secondary endpoints can be found in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (ID: UMIN000047893). J-Proof HF protocol was organised according to the Guidelines for the Epidemiological Research proposed by the Japanese Ministry of Health, Labour, and Welfare. Additionally, the study protocol was approved by the Ethics Committee of the Juntendo University School of Health Sciences, Tokyo, Japan (19-005). This investigation conforms with the principles outlined in the Declaration of Helsinki. Patient consent to participate in the study was obtained by either the opt-out or informed consent method, depending on the judgment of the ethics committees of the participating institutions.

Definition of HAD

We defined HAD as a decrease of at least 5 points in the Barthel Index (BI) at discharge from hospital compared with the BI in a stable state before hospitalization.⁵

Assessment of Need for Care

The LTCI system, launched in April 2000, is a nationwide system that uniformly guarantees the rights of citizens to access long-term care services. Eligibility for LTCI benefits is based on a 74-item questionnaire that assesses ADL and is classified into 7 levels using a computer algorithm. Additionally, the level of care is reviewed and finalized by a committee of experts.⁷ In the present study, the level of the need for care as certified during hospitalization was used, and classified into 4 groups: no LTCI certification; support required 1 and 2; care level 1 and 2; and care level 3–5.

Assessment of Post-Discharge Outcomes

The outcomes for this study were all-cause mortality, all-cause rehospitalization, and composite outcomes during the first year after discharge. These outcomes were retrieved from the medical records of the respective hospitals and from a mail survey.

Data Collection

Patient characteristics, including age, sex, clinical data (i.e., body mass index [BMI], HF aetiology, comorbidities, previous admissions due to HF, New York Heart Association class at admission, left ventricular ejection fraction [LVEF] assessed using transthoracic echocardiography at discharge, and medication use) were collected from medical records. Biochemical data included the levels of B-type natriuretic peptide (BNP), N-terminal pro BNP (NT-proBNP), serum albumin and haemoglobin, and the estimated glomerular filtration rate (eGFR). The Japanese Cardiovascular Health Study (J-CHS) Index was examined as a measure of physical frailty at admission.¹⁰ Grip strength was assessed at hospital discharge. Cognitive function at discharge was assessed using either the Hasegawa Dementia Scale (HDS-R),¹¹ the Mini-Mental State Examination (MMSE),¹² the Mini-Cognitive Assessment (Mini-Cog; https://mini-cog.com/download-the-mini-cog-instrument/), or the Japanese version of the Montreal Cognitive Assessment (MoCA-J).¹³ In this study, cognitive decline was defined as <21 points on the HDS-R, <24 points on the MMSE, <3 points on the MiniCog, and <26 points on the MoCA-J. We also examined the LTCI services (i.e., home-visit rehabilitation or commuting rehabilitation service, and other service) used before hospitalization, and living support (i.e., living alone, living alone with support people, living with others but difficult to care for, and living with a caregiver who is able). In addition, ADL (i.e., independent, needs assistance to go out, needs assistance for indoor living, needs assistance in all aspects of daily living) and exercise facilities (i.e., not used, commuting rehabilitation services or home-visit rehabilitation, outpatient rehabilitation, community or private exercise classes) were researched from a mail survey conducted 1 year after discharge.

Statistical Analysis

Continuous variables are reported using medians and interquartile ranges (IQR), and categorical variables are reported using counts and percentages according to the level of care. Continuous variable parameters were compared using 1-way analysis of variance, and categorical variables were analysed using the chi-square test. Cox proportional hazards regression analysis was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for all outcomes in the HAD-incidence and non-incidence groups, according to each level of care required. Additionally, the interaction of the level of care required and HAD on each of the adverse outcomes was analyzed. We also calculated the HRs and CIs of HAD for all outcomes, stratified by the level of care required. We adjusted for potentially confounding effects that were considered to be associated with the clinical outcomes, including age, sex, BMI, past HF hospitalisation, etiologies, comorbidities, serum albumin level, serum hemoglobin level, log-BNP level, prescription of angiotensin-converting enzyme, angiotensin II receptor blocker or angiotensin receptor neprilysin inhibitor, β-blocker, mineralocorticoid receptor antagonists, sodium-glucose cotransporter, and severity of frailty (J-CHS score: robust, prefrail, frail). NT-proBNP was converted to estimated BNP values from formulas reported in previous studies.¹⁴ A P value <0.05 was considered statistically significant, with a significant interaction indicated by P<0.1. Statistical analyses were performed using SPSS version 21 (IBM Corp., Armonk, NY, USA).

Results

From the 10,062 cases enrolled in J-Proof HF, we excluded patients who withdrew consent for data use (n=10) and patients whose level of LTCI was unknown (n=79). A total of 9,973 patients were eligible for the analysis (Figure 1). Patient characteristics by level of care required at discharge are shown in Table 1. Prevalence of the no LTCI certification, support required 1 and 2, care level 1 and 2, and care level 3–5 groups was 55.3%, 16.3%, 19.3%, and 8.3%, respectively. The incidence of HAD in the no LTCI certification, support required 1 and 2, care level 1 and 2, and care level 3–5 groups was 30.5%, 43.9%, 52.7%, and 46.7%, respectively. Groups with higher care needs were older, had fewer males, had more readmissions for HF, and showed more cognitive impairment and frailty. The rate of patients with hypertension, renal failure, diabetes, and musculoskeletal disease was more than 30% for the level-of-care group in the LTCI. The ratio of patients whose BI improved by ≥5 points at discharge compared with that before hospitalization was the highest in the care level 3–5 group.

Figure 1.

Patient selection flowchart. J-Proof HF, Japanese Physical Therapy Multicenter Registry of Older Frail Patients With Heart Failure; LTCI, long-term care insurance.

Table 1.

Baseline Patient Characteristics

	Total (n=9,973)	No LTCI certification (n=5,558; 55.3%)	Support required 1–2 (n=1,637; 16.3%)	Care levels 1–2 (n=1,943; 19.3%)	Care levels 3–5 (n=835; 8.3%)	P value
Age (years)	82.6±7.7	79.6±7.3	85.4±6.3	86.7±6.4	86.9±7.0	<0.01
Male	50.8	60.0	42.6	38.5	35.0	<0.01
BMI (kg/m2)	22.3 [19.8–25.0]	22.8 [20.4–25.4]	22.4 [19.7–25.0]	21.7 [19.2–24.3]	20.9 [18.1–23.9]	<0.01
Past HF hospitalization	39.0	33.2	45.9	45.6	48.9	<0.01
Etiology
Arrhythmia	49.2	48.8	50.5	48.9	50.5	0.58
Valve heart disease	38.3	35.6	40.9	42.5	41.8	<0.01
Ischemic heart disease	29.4	30.6	28.5	28.4	27.4	0.08
Cardiomyopathy	10.5	12.9	7.6	8.4	5.7	<0.01
NYHA class
I	3.6	4.5	2.3	2.5	3.0	<0.01
II	18.7	20.8	19.3	14.7	12.9
III	40.3	40.0	41.7	42.1	35.8
IV	37.1	34.7	36.7	40.7	48.3
Comorbidity
Hypertension	68.7	68.0	72.0	69.2	65.4	<0.01
CKD	40.8	37.4	44.7	45.3	44.7	<0.01
Diabetes	34.6	35.2	34.5	33.5	34.7	0.58
MSD	26.7	19.1	34.0	34.9	43.5	<0.01
CVA	16.0	11.9	16.8	22.3	26.0	<0.01
Medications
β-blocker	63.9	69.1	64.0	58.4	54.7	<0.01
ACEI/ARB/ARNI	54.0	59.5	50.0	48.1	39.6	<0.01
MRA	30.3	31.6	31.7	28.0	29.5	0.01
SGLT2	15.3	18.8	11.7	11.9	10.9	<0.01
LVEF (%)	48.0 [34.0–61.0]	45.0 [31.6–60.0]	52.0 [38.0–62.6]	51.0 [37.0–62.0]	50.0 [37.0–63.0]	<0.01
Albumin (g/dL)	3.5 [3.2–3.8]	3.6 [3.3–3.9]	3.5 [3.2–3.8]	3.4 [3.1–3.7]	3.3 [2.9–3.6]	<0.01
eGFR (mL/min/1.73 m2)	40.9 [27.5–55.4]	44 [30.0–57.5]	37.7 [26.0–51.0]	36.6 [25.5–51.5]	36.2 [24.3–51.7]	<0.01
Hemoglobin (g/dL)	11.4±2.2	11.9±2.3	10.9±1.9	10.8±2.0	10.7±1.9	<0.01
BNP (pg/mL)	561.0 [311.9–1,010.2]	547.7 [305.1–975.2]	535.9 [296.0–934.8]	588.1 [324.0–1,098.6]	632.0 [357.6–1,158.4]	<0.01
NT-proBNP (pg/mL)	4,918.0 [2,287.0–10,708.2]	4,336.8 [2,060.3–9,422.0]	5,077.0 [2,549.0–10,252.0]	6,184.0 [2,682.3–13,266.8]	6,481.0 [3,147.5–13,508.2]	<0.01
Cognitive dysfunction	36.5	27.1	36.0	54.3	57.8	<0.01
Grip strength (kg)	15.8 [9.3–22.3]	19.0 [12.8–26.0]	14.6 [10.0–19.6]	11.6 [6.0–16.9]	8.7 [0.0–13.0]	<0.01
J-CHS
Robust	2.2	3.8	0.2	0.2	0	<0.01
Prefrail	32.5	38.7	27.8	22.2	24.7
Frail	65.3	57.6	72.0	77.6	75.3
LTCI service before hospitalization
Home-visit rehabilitation or commuting rehabilitation service	11.5	0.5	20.8	27.3	29.7	<0.01
Other service	24.7	0.7	42.4	61.2	65.3	<0.01
Lifestyle
Living alone	10.9	10.9	10.7	6.9	5.0	<0.01
Living alone with support people	13.1	13.1	25.7	23.0	19.8
Living with others but difficult to care for	6.2	7.6	5.5	4.0	2.8
Living with an able caregiver	68.4	68.4	58.1	66.2	72.4
Length of hospital stay (days)	16 [11–23]	15 [11–22]	16 [11–23]	17 [12–25]	17 [12–25]	<0.01
Outpatient cardiac rehabilitation	3.9	6.3	2.3	0.5	0.3	<0.01
BI before hospital	100 [85–100]	100 [100–100]	95 [85–100]	85 [65–95]	55 [30–80]	<0.01
BI after hospital	90 [70–100]	100 [90–100]	90 [75–95]	70 [50–85]	45 [20–70]	<0.01
BI at discharge improved by ≥5 points compared with before the hospital	7.3	5.4	8.2	9.6	12.7	<0.01
HAD	38.4	30.5	43.9	52.7	46.7	<0.01

Data are presented as median [interquartile range], mean [SD] or n (%), as appropriate. ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; BI, Barthel Index; BMI, body mass index; BNP, B-type natriuretic peptide; CKD, chronic kidney disease; CVA, cerebrovascular disease; eGFR, estimated glomerular filtration rate; HAD, hospitalization-associated disability; HF, heart failure; J-CHS, Japanese Cardiovascular Health Study; LTCI, long-term care insurance; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonists; MSD, musculoskeletal disease; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; SGLT2, sodium-glucose cotransporter 2.

In the Cox proportional hazards regression analysis, a higher level of required care was associated with a higher risk of all-cause mortality (Table 2). All-cause mortality was also higher in both the care level 1 and 2 and care level 3–5 groups compared with the no certification group, regardless of the presence or absence of HAD. Among patients with HAD, more severe levels of required care were associated with higher HRs (care level 1 and 2 group: HR 1.48, 95% CI 1.08–2.05; care level 3–5 group: HR 1.85, 95% CI 1.24–2.76; Table 2). For the composite outcome, HRs were higher in both the care level 1 and 2 and care level 3–5 groups compared with the no certification group, both with and without HAD. In contrast, care levels showed no significant relationship with the risk of all-cause readmission. No significant interaction was observed between care levels and HAD for any of the outcomes. When stratified by care level, HAD was significantly associated with a higher risk of all-cause mortality across all groups (Table 3). A significant association between HAD and the composite outcome was also observed in the care level 1 and 2 and 3–5 groups. However, HAD was not significantly associated with the risk of rehospitalization in any care level group.

Table 2.

Hazard Ratios of the Level of Care Required Under LTCI for Each Outcome

	All patients			HAD (−)			HAD (+)
	HR	95% CI	P value	HR	95% CI	P value	HR	95% CI	P value
All-cause mortality
No certification	1 (Ref.)			1 (Ref.)			1 (Ref.)
Support required 1 and 2	1.10	0.83–1.47	0.47	1.12	0.73–1.70	0.59	1.08	0.73–1.60	0.67
Care level 1 and 2	1.78	1.40–2.27	<0.01	1.97	1.37–2.83	<0.01	1.48	1.08–2.05	0.01
Care level 3–5	1.76	1.30–2.38	<0.01	1.86	1.17–2.94	<0.01	1.85	1.24–2.76	<0.01
P for interaction*				0.27
All-cause rehospitalization
No certification	1 (Ref.)			1 (Ref.)			1 (Ref.)
Support required 1 and 2	1.09	0.92–1.31	0.23	1.15	0.92–1.44	0.20	1.05	0.78–1.40	0.74
Care level 1 and 2	1.02	0.86–1.22	0.74	1.03	0.82–1.29	0.78	1.07	0.82–1.39	0.58
Care level 3–5	1.16	0.93–1.46	0.17	1.21	0.90–1.63	0.19	1.23	0.86–1.76	0.24
P for interaction*				0.57
Composite endpoint
No certification	1 (Ref.)			1 (Ref.)			1 (Ref.)
Support required 1 and 2	1.06	0.93–1.25	0.45	1.13	0.90–1.37	0.31	1.01	0.77–1.32	0.90
Care level 1 and 2	1.23	1.05–1.44	<0.01	1.18	0.95–1.47	0.11	1.28	1.01–1.61	0.03
Care level 3–5	1.23	1.00–1.52	0.04	1.19	0.90–1.59	0.21	1.42	1.04–1.94	0.02
P for interaction*				0.68

*P for interaction between the presence or absence of HAD and level of care required. Cox hazard models were adjusted for age, male sex, BMI, past HF hospitalization, arrhythmia, valve heart disease, ischemic heart disease, cardiomyopathy as an etiology, diabetes, hypertension, CKD as comorbidities, serum albumin level, serum hemoglobin level, BNP level, ACEI or ARB or ARNI, β-blocker, MRA, SGLT2, and the J-CHS Index. CI, confidence interval; HR, hazard ratio. Other abbreviations as in Table 1.

Table 3.

Hazard Ratios for Each Outcome Associated With HAD, Stratified by the Level of Care Required Under LTCI

	All-cause mortality			All-cause rehospitalization			Composite endpoint
	HR	95% CI	P value	HR	95% CI	P value	HR	95% CI	P value
No certification
HAD (−)	1 (Ref.)			1 (Ref.)			1 (Ref.)
HAD (+)	1.80	1.31–2.46	<0.01	0.99	0.82–1.20	0.96	1.17	0.98–1.39	0.08
Support required 1 and 2
HAD (−)	1 (Ref.)			1 (Ref.)			1 (Ref.)
HAD (+)	1.75	1.07–2.86	0.02	0.90	0.66–1.23	0.52	1.08	0.81–1.45	0.56
Care level 1 and 2
HAD (−)	1 (Ref.)			1 (Ref.)			1 (Ref.)
HAD (+)	1.51	1.06–2.15	0.02	1.07	0.80–1.43	0.64	1.31	1.01–1.69	0.03
Care level 3–5
HAD (−)	1 (Ref.)			1 (Ref.)			1 (Ref.)
HAD (+)	1.88	1.12–3.14	0.01	1.09	0.72–1.67	0.66	1.53	1.05–2.24	0.02

Cox hazard models were adjusted for age, male sex, BMI, past HF hospitalization, arrhythmia, valve heart disease, ischemic heart disease, cardiomyopathy as an etiology, diabetes, hypertension, CKD as comorbidities, serum albumin level, serum hemoglobin level, BNP level, ACEI or ARB or ARNI, β-blocker, MRA, SGLT2, and the J-CHS index. CI, confidence interval; HR, hazard ratio. Other abbreviations as in Table 1.

The ADL and exercise facility surveys 1 year after discharge were completed by 67.6% (n=6,748; Figure 2) and 66.6% (n=6,651; Figure 3) of all eligible patients, respectively. The percentage of patients who reported that their ADLs were independent was lower for those who had a higher need for care at the time of discharge, and further decreased for those with HAD. Regardless of the level of care or the incident of HAD, the rate of patients using LTCI services or private facilities for exercise after discharge from hospital was lower than that of 50% of patients.

Figure 2.

Activities of daily living 1 year after discharge by level of care required at discharge. HAD, hospitalization-associated disability; LTCI, long-term care insurance

Figure 3.

Services for exercise 1 year after discharge by level of care required at discharge. HAD, hospitalization-associated disability; LTCI, long-term care insurance.

Discussion

This is the first nationwide, multicenter study in Japan to examine the impact of HAD – defined as a decline in ADL during hospitalization – and the level of care required under the LTCI system on post-discharge prognosis in older HF patients. The level of care required was a risk factor for poor prognosis in our study population, consistent with previous studies.^9,15–19 In addition, among patients with HAD, a more severe care level was associated with a higher risk of all-cause mortality. These findings suggest that, in older HF patients with HAD, prognosis can be stratified using the care level as an indicator. A previous study has reported a lower incidence of adverse outcomes in older HF patients who utilize LTCI services after discharge.¹⁹ Therefore, the results of this study indicate that the level of care required during hospitalization is an important factor to consider when planning post-discharge LTCI services, especially in patients with HAD.

The results of this study revealed that the occurrence of HAD in older HF patients, across all care levels, increased the risk of all-cause mortality within 1 year after discharge, and that the impact of HAD was similar regardless of care level severity. The mechanism by which the occurrence of HAD leads to poor prognosis remains unclear, based on the results of this study. However, aging, comorbidities, cognitive decline, frailty, and physical inactivity have been reported to be associated with the development of HAD, and these factors have also been suggested to contribute to a worse prognosis after discharge.^4,6,20 In our population, patients were older adults with multiple comorbidities, and many had cognitive decline and frailty. Furthermore, the proportion of patients with independent ADL 1 year after discharge was lower in the HAD group, suggesting that physical activity after discharge was also reduced in this group. These findings suggest that HAD increases the risk of all-cause mortality. Moreover, in the HAD group, a more severe level of care was associated with a higher risk of all-cause mortality, suggesting that prognosis can be stratified based on the level of care in older HF patients who develop HAD.

Among the patients in this study, the occurrence of HAD was not associated with a risk of rehospitalization, regardless of the level of care required. It has been reported that family support for diet and medication management may influence the risk of rehospitalization within 1 year after discharge among adults aged >85 years.¹⁶ In the group requiring long-term care in this study, the proportion of patients living alone was low, and even among those living alone, a high percentage had someone nearby to provide daily support. These findings suggest that family composition and lifestyle support systems – beyond LTCI services – may influence the risk of rehospitalization after discharge. Frailty, as well as the severity of HF, has been reported to be associated with decreased ADL during hospitalization in HF patients,²¹ which may have contributed to the increased rate of HAD in the care level 1 and 2 group. In contrast, the care level 3–5 group had a higher proportion of patients with low BI at admission and improved BI at discharge. Individualized ADL training is typically provided for patients with low ADL levels.²² Although the details of the ADL training in this study are not known, it is possible that the rehabilitation provided during hospitalization reduced the incidence of HAD in the care level 3–5 group compared with the care level 1 and 2 group. Further research is needed to determine how specific aspects of inpatient rehabilitation influence the occurrence of HAD across different levels of care.

In a mail survey 1 year after discharge, the proportion of patients with independent ADLs was lower with increasing LTCI levels, and the proportion of patients with independent ADLs was even lower when HAD occurred (no LTCI group [HAD no/yes]; 77.2/51.3%, required 1 and 2 group; 41.0/25.3%, care level 1 and 2 group; 22.5/13.9%, care level 3–5 group; 8.3/7.5%; Figure 2). One year after discharge from hospital, more than 60% of patients with high care needs were not using facilities for exercise therapy, and only approximately 30% of patients were using LTCI services, such as commuting rehabilitation services or home-visit rehabilitation, available for the purpose of providing exercise therapy (Figure 3). The rate of patients using commuting rehabilitation services or home-visit rehabilitation was approximately 20–30% in the care-requiring group (Table 1), and the rate of patients using services for exercise therapy after discharge did not increase, regardless of the occurrence of HAD. These results may indicate that physical functions and ADLs that declined during hospitalization are not sufficiently improved after discharge, and that patients in the care-requiring group also have fewer opportunities to implement exercise therapy, regardless of whether or not HAD occurred during hospitalization. In older HF patients, the difficulty to continue outpatient cardiac rehabilitation is one of the most important social issues in Japan, due to the decline in mobility caused by HF symptoms and physical function decline, cognitive decline, and the absence of a caregiver.²³ In contrast, it has been reported that physical rehabilitation tailored to the individualized needs of older HF patients by assessing balance, muscle strength, mobility, and endurance can improve physical function and prognosis,²⁴ and there is a strong need for continued physical rehabilitation for older HF patients after discharge from hospital. Additionally, regional collaboration based on a transitional care system between LTCI and medical insurance has been shown to potentially improve the prognosis of older HF patients.¹⁹ Therefore, based on the results of this study, we speculate that for older HF patients who have difficulty with outpatient rehabilitation, it is necessary to facilitate coordination between LTCI and medical insurance services and to implement post-discharge physical rehabilitation in order to improve ADL and prognosis.

Study Limitations

There are limitations associated with the present study. First, this study was conducted with the cooperation of 96 facilities in 37 prefectures throughout Japan, but it does not cover data from all regions of Japan or all cardiac rehabilitation facilities. Second, because this study included patients for whom rehabilitation was prescribed, the results of patients who were discharged from the hospital without inpatient rehabilitation were not validated. Last, this study did not investigate the timing of long-term care level certification, nor did it examine the level of care required or the detailed use of LTCI services after discharge from hospital, and therefore the results do not reflect these changes. Further studies are needed to determine whether changes in the level of care required influence the prognosis of HF patients who develop HAD. However, it takes approximately 1 month from the time of application for LTCI to the time of certification of the level of care in Japan.²⁵ Moreover, follow up is recommended within 1 week of discharge,²⁶ because most readmissions of HF patients occur within 2 weeks of discharge.²⁷ Consequently, it is meaningful that we have shown that the need for inpatient care and the occurrence of HAD are associated with poor prognosis and have proposed the need for early screening of the level of care during hospitalization.

Conclusions

Both care level and HAD incidence independently predict poor prognosis in older HF patients. Post-discharge care services may need to be planned with consideration of both the presence or absence of HAD and the level of care required, as the care level required is a useful measure for stratifying prognosis.

Acknowledgments

We thank the participants of this study for their contributions, without which these analyses would not have been possible. In addition, we thank all the facilities that participated in the J-Proof HF study.

Sources of Funding

This work was supported by research funding of Japanese Society of Cardiovascular Physical Therapy.

Disclosures

K. Kamiya, T.T. are members of Circulation Reports’ Editorial Team.

IRB Information

This study was approved by the Ethics Committee of the Juntendo University School of Health Sciences, Tokyo, Japan (reference no. 19-005).

Data Availability

The deidentified participant data will not be shared.

References

• 1.   Cabinet Office, Government of Japan. White Paper on Aging Society 2024 (Kourei syakai hakusyo). https://www8.cao.go.jp/kourei/whitepaper/w-2024/gaiyou/06pdf_indexg.html (accessed January 20, 2025).
• 2.   Sato Y, Kuragaichi T, Nakayama H, Hotta K, Nishimoto Y, Kato T, et al. Developing multidisciplinary management of heart failure in the super-aging society of Japan. Circ J 2024; 88: 2–9, doi:10.1253/circj.CJ-22-0675.
• 3.   Roger VL. Epidemiology of heart failure: A contemporary perspective. Circ Res 2021; 128: 1421–1434, doi:10.1161/CIRCRESAHA.121.318172.
• 4.   Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: She was probably able to ambulate, but I’m not sure”. JAMA 2011; 306: 1782–1793, doi:10.1001/jama.2011.1556.
• 5.   Takahashi T, Iwata K, Morisawa T, Kato M, Kono Y, Taya M, et al. Incidence of hospitalization-associated disability in older patients with heart failure. Circ J 2024; 88: 672–679, doi:10.1253/circj.CJ-23-0722.
• 6.   Saitoh M, Takahashi Y, Okamura D, Akiho M, Suzuki H, Noguchi N. Prognostic impact of hospital-acquired disability in elderly patients with heart failure. ESC Heart Fail 2021; 8: 1767–1774, doi:10.1002/ehf2.13356.
• 7.   Kato M, Sakurada K, Saitoh M, Morisawa T, Iida Y, Kamiya K. Hospitalization-associated disability and 1-year mortality risk in older patients with heart failure. J Am Med Dir Assoc 2025; 26: 105549, doi:10.1016/j.jamda.2025.105549.
• 8.   Tamiya N, Noguchi H, Nishi A, Reich MR, Ikegami N, Hashimoto H, et al. Population ageing and wellbeing: Lessons from Japan’s long-term care insurance policy. Lancet 2011; 378: 1183–1192, doi:10.1016/S0140-6736(11)61176-8.
• 9.   Takabayashi K, Iwatsu K, Ikeda T, Morikami Y, Ichinohe T, Yamamoto T, et al. Clinical characteristics and outcomes of heart failure patients with long-term care insurance: Insights from the Kitakawachi clinical background and outcome of heart failure registry. Circ J 2020; 84: 1528–1535, doi:10.1253/circj.CJ-20-0017.
• 10.   Satake S, Arai H. The revised Japanese version of the cardiovascular health study criteria (revised J-CHS criteria). Geriatr Gerontol Int 2020; 20: 992–993, doi:10.1111/ggi.14005.
• 11.   Katoh S, Shimogaki H, Onodera A, Ueda H, Oikawa K, Ikeda K, et al. Development of the revised version of Hasegawa’s dementia scale (HDS-R). Jpn J Geriatr Psychiatry 1991; 2: 1339–1347 (in Japanese).
• 12.   Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–198.
• 13.   Fujiwara Y, Suzuki H, Yasunaga M, Sugiyama M, Ijuin M, Sakuma N, et al. Brief screening tool for mild cognitive impairment in older Japanese: Validation of the Japanese version of the Montreal cognitive assessment. Geriatr Gerontol Int 2010; 10: 225–232.
• 14.   Ishihara S, Hiramitsu S, Kanaoka K, Taki M, Nakagawa H, Ueda T, et al. New conversion formula between B-type natriuretic peptide and N-terminal-pro-B-type natriuretic peptide: Analysis from a multicenter study. Circ J 2022; 25: 2010–2018.
• 15.   Takahashi K, Saito M, Inaba S, Morofuji T, Aisu H, Sumimoto T, et al. Contribution of the long-term care insurance certificate for predicting 1-year all-cause readmission compared with validated risk scores in elderly patients with heart failure. Open Heart 2016; 3: e000501, doi:10.1136/openhrt-2016-000501.
• 16.   Takabayashi K, Fujita R, IwatsuK, Ikeda T, Morikami Y, Ichinohe T, et al. 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. Geriatr Gerontol Int 2020; 20: 967–973, doi:10.1111/ggi.14013.
• 17.   Kase M, Fujiki S, Kashimura T, Okura Y, Kodera K, Watanabe H, et al. Relationship between medical therapy, long-term care insurance, and comorbidity in elderly patients with heart failure with systolic dysfunction. Circ J 2023; 87: 1130–1137.
• 18.   Tauchi Y, Ogino T, Morisawa T, Wada Y, Sakamoto R, Kanata Y, et al. Web-based questionnaire survey on heart failure in elderly patients using outpatient rehabilitation: Actual conditions of cardiac rehabilitation in long-term care insurance systems. Circ Rep 2023; 5: 133–143.
• 19.   Kinugasa Y, Nakamura K, Hirai M, Manba M, Ishiga N, Sota T, et al. Regional collaboration for heart failure patients certified as needing support or care in long-term care insurance system. Circ J 2024; 24: 109–119.
• 20.   Hao X, Zhang H, Zhao X, Peng X, Li K. Risk factors for hospitalization-associated disability among older patients: A systematic review and meta-analysis. Ageing Res Rev 2024; 101: 102516, doi:10.1016/j.arr.2024.102516.
• 21.   Dunlay, SM, Manemann SM, Chamberlain AM, Cheville AL, Jiang R, Weston SA, et al. Activities of daily living and outcomes in heart failure. Circ Heart Fail 2015; 8: 261–267.
• 22.   Kono Y, Sakurada K, Iida Y, Iwata K, Kato M, Kamiya K, et al. Real-world evidence of feasible assessment and intervention in cardiovascular physical therapy for older patients with heart failure: Insight from the J-Proof HF of the Japanese Society of Cardiovascular Physical Therapy. Circ Rep 2024; 6: 441–447.
• 23.   Kamiya K, Yamamoto T, Tsuchihashi-Makaya M, Ikegame T, Takahashi T, Sato Y, et al. Nationwide survey of multidisciplinary care and cardiac rehabilitation for patients with heart failure in Japan: An analysis of the AMED-CHF study. Circ J 2019; 83: 1546–1552.
• 24.   Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, et al. Physical rehabilitation for older patients hospitalized for heart Failure. N Engl J Med 2021; 385: 203–216.
• 25.   Japanese Ministry of Health, Labour and Welfare. Period of examination for certification of long-term care requirements (Youkaigonintei no ninteishinsakikan ni tsuite). https://www.mhlw.go.jp/stf/newpage_46380.html (accessed January 21, 2025).
• 26.   Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation 2022; 145: e895–e1032, doi:10.1161/CIR.0000000000001063.
• 27.   Fudim M, O’Connor CM, Dunning A, Ambrosy AP, Armstrong PW, Coles A, et al. Aetiology, timing and clinical predictors of early vs. late readmission following index hospitalization for acute heart failure: Insights from ASCEND-HF. Eur J Heart Fail 2018; 20: 304–314.