Impact of Tailored Multidisciplinary Cardiac Rehabilitation on Patients With Cardiovascular Diseases and Multimorbidity in Convalescent Rehabilitation Hospitals in Japan　― A Multicenter, Prospective Observational Study ―

Abstract

Background: Data on cardiac rehabilitation (CR) outcomes in patients with cardiovascular disease (CVD), frailty, and multimorbidity in post-acute settings are limited. This study aimed to evaluate the feasibility and efficacy of individualized, multidisciplinary CR in convalescent rehabilitation hospitals (cRHs).

Methods and Results: This multicenter, prospective, observational study included 72 consecutive patients transferred from acute care hospitals. Personalized CR programs were implemented in cRHs. Primary outcomes were changes in the Barthel Index (BI) and functional independence measure (FIM) scores. Secondary outcomes included assessments of physical and cognitive function, and nutritional status. Mean participant age was 78.6±11.8 years. Prior to admission, 51.4% experienced acute decompensated heart failure (ADHF). The average length of stay was 59.5±39.2 days. BI and FIM scores improved from admission to discharge. The following parameters improved: Short Physical Performance Battery, knee extensor strength, comfortable gait speed, 6-min walk distance, New York Heart Association classification, and cognitive function (Mini-Mental State Examination). Discharge dispositions included 53 (73.6%) home discharges, and 19 (26.4%) outpatient CR post-discharges. Patients with post-ADHF and patients with other conditions both showed functional improvements, but ∆BI and ∆FIM were lower in the post-ADHF group.

Conclusions: Tailored multidisciplinary CR in cRHs effectively improves daily living activities and physical and cognitive outcomes in patients with CVD with complex conditions. Expanded use of these hospitals may help address clinical challenges.

According to current guidelines, cardiac rehabilitation (CR) is a class I recommended intervention for patients with coronary artery disease and heart failure (HF).^1–3 However, the implementation rate of outpatient CR remains low, despite its benefits.^1,4,5 Notably, the attributes associated with non-CR participation include advanced age, Barthel Index (BI) scores <90 points, and the presence of comorbidities.⁵

Older patients with cardiovascular diseases (CVDs) often face additional challenges because of comorbidities.^6,7 During hospitalization, these patients frequently experience temporary care dependence because of their poor health status caused by comorbidities and other age-related issues. This necessitates a specific rehabilitation setting, including care and training for activities of daily living (ADL) and a smooth transition from hospital admission to rehabilitation.

Based on the Cerebrovascular and Cardiovascular Disease Control Act, the Ministry of Health, Labour and Welfare published the Japanese National Plan, which outlines 10 specific measures aimed at enhancing service provision systems related to health, medical care, and welfare services.⁸ One of these measures is “the development of a system to provide medical care and rehabilitation for patients with cerebrovascular and cardiovascular diseases”. Convalescent rehabilitation hospitals (cRHs) provide intensive and multidisciplinary rehabilitation therapy to patients with multimorbidity to improve their ADL and facilitate a smooth transition to home discharge. In Japan, the National Medical Insurance System covers CR as well as other rehabilitation programs for patients admitted to convalescent hospitals. However, despite recommendations to increase the use of cRHs, the clinical utilization of CR in these facilities remains low. One of the reasons is likely the paucity of evidence on the effectiveness of CR in cRHs for patients with CVD and multimorbidity.^9,10

Given the complex needs of older patients with CVD and multimorbidity, we hypothesized that the implementation of a multidisciplinary, tailored CR program in cRHs would be feasible and would be associated with improvements in ADL levels, frailty status, and discharge outcomes. Additionally, we anticipate that the findings will contribute to evidence supporting its broader adoption. Therefore, we conducted a multicenter, prospective observational study to evaluate the feasibility and efficacy of tailored multidisciplinary CR for patients with CVD with frailty and multimorbidity in cRHs and to explore the challenges that need to be addressed.

Methods

Study Design and Participants

This prospective, observational study was conducted at 3 convalescent hospitals (Showa Medical University Fujigaoka Rehabilitation Hospital, IMS Itabashi Rehabilitation Hospital, and Nishi Memorial Port Island Rehabilitation Hospital) between December 2022 and December 2023.

To verify the actual conditions and effects of CR in cRHs, we prospectively and sequentially included a series of patients who were transferred for the purpose of tailored multidisciplinary CR (cardiac rehabilitation with personalized rehabilitative therapy). Thus, cases aimed at rehabilitation after cerebral infarction, fractures, and other surgeries were not included. Indication of transferring the patients were discussed and decided by the heart teams in an acute care hospital depending on the disabling conditions in patients. The exclusion criteria were age <20 years and failure to provide consent to participate in this study. Patients who were unable to continue hospitalization or were transferred to an acute care hospital with unstable medical conditions were excluded from this study.

The Ethics Committee of Jichi Medical University Hospital (22-078) approved the present study, which was conducted in compliance with the Declaration of Helsinki and the ethical standards of the responsible institution for human participants.

Tailored Multidisciplinary CR

Tailored multidisciplinary CR involves the concurrent implementation of rehabilitation for the primary disease and for complications and comorbidities. The participants underwent a CR program based on the guidelines of the Japanese Circulation Society.¹ The CR program included exercise therapies, such as aerobic exercise and resistance training, and participant education on diet and self-management. The program conducted by physical therapists (PTs), occupational therapists (OTs), and speech-language-hearing therapists (STs) included aerobic exercise and resistance training, standing and walking training, balance training, conditioning, ADL training, instrumental ADL training, respiratory rehabilitation, upper limb training, behavior modification intervention, cognitive function training, higher brain function training for conditions such as aphasia, and swallowing function training, all tailored to the individual’s condition. Rehabilitation interventions were conducted in sessions of 20–60 min each, with a maximum of 3 sessions per day. In cRHs, multidisciplinary collaboration involves physicians, nurses, PTs, OTs, STs, medical social workers, registered dietitians, pharmacists, dentists, dental hygienists, and clinical laboratory technicians. Beyond scheduled rehabilitation sessions, nurses assist with ADL and conduct walking and ADL training in the wards as needed.

Data Collection

Baseline characteristics extracted from the medical records and interviews included age, sex, body mass index (BMI), diagnosis, length of stay in the acute care hospital, comorbidities, echocardiography findings, medication, biochemical test data, status of long-term care insurance (LTCI) certification level, presence of caregivers, and the frailty phenotype based on the Japanese version of the Cardiovascular Health Study¹¹ at admission: robust (0 points), pre-frail (1–2 points), and frail (≥3 points).¹² Additionally, the length of stay in the cRH, content of rehabilitation, discharge disposition, and status of rehabilitation after discharge were assessed.

Assessment of ADL

ADL assessment was performed by trained PTs and OTs using the BI¹³ and functional independence measure (FIM)¹⁴ assessment tools at the time of admission and discharge in the cRH. The BI comprises 10 items related to feeding, transfers, grooming, bathroom use, bathing, ambulation, stair climbing, dressing, and bowel and bladder care, with scores ranging from 0 to 100 (0=complete dependence, 100=complete independence). This evaluates the participant’s ability level in ADL tasks. The FIM comprises 18 items, including 13 motor and 5 cognitive items. Each item is scored on a 7-point scale ranging from completely dependent on assistance to completely independent. The scores range from 18 to 126 (18=complete dependence, 126=complete independence). The FIM evaluates the level at which a patient performs ADL.

Assessment of Physical Function and Exercise Capacity

Physical function was assessed by trained PTs and OTs at admission and discharge. The assessment tools were the Short Physical Performance Battery (SPPB), handgrip strength, knee extensor strength, gait speed, and timed up and go (TUG) test. The SPPB is the most reliable and valid evaluation battery for measuring physical function in older adults.¹⁵ The overall score was calculated from balance ability, 4-m walking time, and stand-up in 5-repetition times, as proposed by Guralnik et al.¹⁶ Handgrip strength was measured twice bilaterally, and the maximum value was used. Knee extensor strength was measured using a handheld dynamometer. Isometric knee extensor strength was measured at 90° knee flexion in a sitting posture, and 2 measurements were taken.¹⁷ The resultant value was divided by body weight (BW; kg) to calculate the %BW, and the maximum value was adopted. Gait speed was assessed using a comfortable walking speed over >5 m and converted to m/s.¹⁸ To perform the TUG test as described in the original derivation study, the participants were timed while they rose from a chair, walked at a comfortable and safe pace to a line on the floor 3 m away, turned and walked back to the chair, and sat down again.¹⁹

Exercise capacity was assessed using the 6-min walking distance (6MWD) test at admission and discharge.²⁰ The participants were instructed to walk at a comfortable pace to cover the maximum possible distance. The participants were also asked about their perceived breathlessness and classified using the Medical Research Council Dyspnea Scale,²¹ which was converted to the New York Heart Association (NYHA) classification based on the previous report.²²

Cognitive Function Assessment

Cognitive function was evaluated by trained PTs and OTs on admission and discharge. Cognitive function was assessed using the Japanese version of the Mini-Mental State Examination (MMSE).²³ Participants with scores >26 were diagnosed as having normal cognitive function.²⁴ Scores ≤26 were defined as cognitive decline.

Assessment of Swallowing Function

Swallowing function was assessed by trained PTs, OTs, and/or STs at admission and discharge, based on Fujishima’s Grade of Feeding and Swallowing Ability (Fujishima’s swallowing grade). The Fujishima grade classifies the severity of dysphagia.²⁵ This assessment tool is a 10-grade scale scored from 1 (difficult or impossible to swallow, not indicated for swallowing training) to 10 (normal swallowing function). Grades 1–3 indicated severe dysphagia, grades 4–6 moderate dysphagia, grades 7–9 mild dysphagia, and grade 10 normal swallowing function.

Nutritional Assessment

A nutritional assessment was conducted at admission and discharge using the Geriatric Nutritional Risk Index (GNRI),²⁶ which was calculated using the following formula: GNRI = 14.89 × serum albumin (g/dL) + 41.7 × BMI / 22. The group with moderate-to-severe malnutrition, defined as a GNRI of <92, was classified as the malnutrition group.

Statistical Analyses

All data are expressed as means±standard deviations or medians (interquartile ranges: 25th–75th percentile) for continuous variables, and as numbers and percentages for categorical variables. We used a paired t-test and Wilcoxon signed-rank test to compare each item at admission and discharge. Categorical variables were compared using the chi-squared test (χ² test) or Fisher’s exact test. In addition, the patients were divided into 2 subgroups of post-acute decompensated HF (ADHF; HF group) and other diseases (other group), and improvements in ADL, physical function, exercise tolerance, and cognitive function were assessed. All statistical analyses were performed using JMP® Pro17 (SAS Institute Inc., Cary, NC, USA). Differences were considered statistically significant at P<0.05.

Results

Patient Characteristics

Eighty patients were admitted to the cRH following acute CVD treatment within the entry period of the present study, but 1 patient did not provide consent. To verify the hypothesis regarding efficacy of CR, we also excluded 7 patients who were transferred to an acute care hospital because of acutely worsening conditions prior to achieving the goals of rehabilitation. Ultimately, we studied 72 patients (Figure). The clinical characteristics of the patients are shown in Table 1. The participants’ mean age was 78.6±11.8 years, and half (51.4%) of all the patients had ADHF. The patients exhibited multiple coronary risk factors, multimorbidity, polypharmacy, and hemoglobin and albumin levels lower than the standard range. Additionally, the frailty rate was high (75%).

Figure.

Flowchart of patient inclusion.

Table 1.

Baseline Characteristics (n=72)

Item
Age (years)	78.6±11.8
Sex, male	39 (54.2)
BMI (kg/m2)	20.3±4.0
Length of stay in the acute care hospital (days)	30.4±17.1
Diagnosis on admission at acute care hospital
ADHF	37 (51.4)
Open-heart surgery	26 (36.1)
Acute MI	5 (6.9)
Aortic diseases	4 (5.6)
Coronary risk factor
Diabetes	25 (34.7)
Hypertension	49 (68.1)
Dyslipidemia	32 (44.4)
Comorbidities
Chronic kidney disease	15 (20.8)
Chronic pulmonary disease	5 (6.9)
Orthopedic disease	26 (36.1)
Cerebrovascular disease	16 (22.2)
Lower extremity artery disease	4 (5.6)
Medication
β-blocker	56 (77.8)
ACE-I/ARB/ARNI	39 (54.1)
SGLT2 inhibitors	15 (20.8)
MRA	32 (44.4)
Diuretics	42 (58.3)
Antiplatelet agents	44 (61.1)
Anticoagulant agents	32 (44.4)
Total no. drugs	9.3±3.0
Echocardiography
LVEF (%)	50.2±12
LAD (mm)	37.0±7.4
E/e′	14.9±7.4
Laboratory data
Hb (g/dL)	11.3±1.8
Alb (g/dL)	3.2±0.4
eGFR (mL/min/1.73 m2)	56.4±23.8
CRP (mg/mL)	0.52 [0.23–1.99]
BNP (pg/mL)	198.4 [63.1–399.8]
Frailty phenotype (J-CHS)
Frailty	54 (75.0)
Pre-frailty	14 (19.4)
Robust	4 (5.6)
Social resources
LTCI certification level	43 (59.7)
With caregiver	45 (62.5)

Data are presented as mean±SD, median [interquartile range], or n (%). ADHF, acute decompensated heart failure; ACE-I, angiotensin-converting enzyme inhibitor; Alb, albumin; ARB, angiotensin II receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BMI, body mass index; BNP, B-type natriuretic peptide; Cr, creatinine; CRP, C-reactive protein; eGFR, estimated glomerular filtration rate; Hb, hemoglobin; J-CHS, Japanese version of the Cardiovascular Health Study criteria for frailty assessment; LAD, left anterior descending artery; LTCI, long-term care insurance; LVEF, left ventricular ejection fraction; MI, myocardial infarction; MRA, mineralocorticoid receptor antagonist; SGLT2, sodium-glucose cotransporter 2.

Efficacy of Tailored CR on Improvements of ADL, Functions, and Nutrition in Patients Admitted to cRHs

PT intervention was provided in all cases, while OT and ST interventions were implemented based on physician assessment (87.5% and 22.2% of the participants, respectively). The average daily intervention times were 59.0±28.4 min for PTs, 29.2±19.2 min for OTs, and 30.3±21.8 min for STs. The composition of the contents is listed in Table 2. The main component of exercise therapy was aerobic exercise (93.1%), followed by resistance training (90.3%), ADL training (86.1%), balance training (84.8%), standing and walking training (83.3%), conditioning (62.5%), and cognitive training (29.2%).

Table 2.

Details of Tailored CR in Convalescent Rehabilitation Hospitals (n=72)

Item
Length of hospital stay (days)	59.5±39.2
Rehabilitation training time (min/day)
Physical therapists (n=72)	59.0±28.4
Occupational therapists (n=63)	29.2±19.2
Speech-language-hearing therapists (n=16)	30.3±21.8
Contents of tailored multidisciplinary CR
Aerobic exercise	67 (93.1)
Resistance training	65 (90.3)
ADL training	62 (86.1)
Balance training	61 (84.8)
Standing and walking training	60 (83.3)
Conditioning	45 (62.5)
Upper limb training	32 (44.4)
Respiratory rehabilitation	26 (36.1)
Cognitive function training	21 (29.2)
IADL training	14 (19.4)
Swallowing training	10 (13.9)
Behavior modification intervention	6 (8.3)
Higher brain function training	3 (4.2)

Data are presented as mean±SD, or n (%). ADL, activities of daily living; CR, cardiac rehabilitation; IADL, instrumental activities of daily living.

The changes in key clinical indicators from admission to discharge at the cRH are summarized in Table 3. Significant improvements were observed in both the BI and FIM scores at discharge compared with those at admission (P<0.001). Similarly, scores for the SPPB, knee extensor strength as a percentage of BW, TUG test, and comfortable gait speed demonstrated significant enhancements at discharge compared with those at admission (P<0.001). In the exercise capacity domain, both the 6MWD and NYHA classifications exhibited marked improvements at discharge (P<0.001). Cognitive function, as measured using the MMSE, showed a significant increase at discharge (P<0.001). In particular, among participants with cognitive decline, the MMSE score significantly improved from admission to discharge (P<0.001). Regarding nutritional intake, 4 participants required nasogastric tube feeding at the time of admission, whereas 68 required oral intake. By discharge, 3 of the participants receiving nasogastric tube feeding transitioned to oral feeding. The severity of swallowing dysfunction, as assessed using the Fujishima swallowing grade, decreased from 4.2% at admission to 0% at discharge. Furthermore, the GNRI at discharge was significantly higher compared with that at admission (P<0.001), with participants in the malnutrition subgroup showing a marked improvement in GNRI scores, from 81.7±7.5 at admission to 87.2±10.3 at discharge (P<0.001).

Table 3.

Efficacy of Tailored CR on Multiple Functions and Nutritional Status in Patients With Cardiovascular Diseases Transferred to Convalescent Rehabilitation Hospitals

Item	Admission	Discharge	P value
ADL assessment
BI (points)	62.4±27.5	84.7±20.8	<0.001
FIM (points)	82.1±27.8	103.0±22.3	<0.001
Physical function
SPPB (points)	6.1±3.8	8.3±3.8	<0.001
Handgrip strength (kg)	19.1±8.6	19.7±8.4	<0.05
Knee extension strength %BW (kgf/kg)	33.9±16.2	40.5±16.9	<0.001
Gait speed (m/s)	0.8±0.3	0.9±0.3	<0.001
TUG(s) (n=53)	15.0±6.9	14.3±8.1	<0.001
Exercise capacity assessment
6MWD (m; n=36)	156.8±132.6	281±146.0	<0.001
NYHA classification			<0.001
Class I	5 (6.9)	5 (6.9)
Class II	8 (11.1)	21 (29.2)
Class III	54 (75.0)	44 (61.1)
Class IV	5 (7.0)	2 (2.8)
Cognitive assessment
MMSE (points)	24.6±5.3	25.8±4.6	<0.001
Cognitive decline (MMSE ≤26; n=34)	20.9±5.0	22.9±4.6	<0.001
Swallowing function assessment
Feeding status
Oral intake	68 (94.4)	71 (98.6)
Nasogastric tube feeding	4 (5.6)	1 (1.4)
Fujishima’s swallowing grade†			<0.05
Normal (grade 10)	52 (72.2)	54 (75.0)
Mild (grades 7–9)	14 (19.4)	15 (20.8)
Moderate (grades 4–6)	3 (4.2)	3 (4.2)
Severe (grades 1–3)	3 (4.2)	0 (0)
Nutritional assessment
GNRI	86.8±11.0	90.5±11.8	<0.001
Malnutrition (GNRI <92; n=47)	81.7±7.5	87.2±10.3	<0.001

^†Fujishima’s grade of feeding and swallowing ability. Data are presented as mean±SD, or n (%). 6MWD, 6-min walking distance; ADL, activities of daily living; BI, Barthel Index; CR, cardiac rehabilitation; FIM, functional independence measure; GNRI, Geriatric Nutritional Risk Index; MMSE, Mini-Mental State Examination; NYHA, New York Heart Association; SPPB, Short Physical Performance Battery; TUG, timed up and go.

The discharge dispositions were as follows (Table 4): 53 (73.6%) patients were discharged home, 17 (23.6%) were transferred to nursing homes, and 2 (2.7%) were transferred to other long-term care facilities. Notably, 19 (26.4%) patients were able to participate in outpatient CR post-discharge, underscoring the importance of continued CR in this cohort. Additionally, 18 (25.0%) participants received rehabilitation services through LTCI programs after discharge.

Table 4.

Discharge Disposition and Continuation of Rehabilitation Training After Discharge (n=72)

Item	n (%)
Discharge disposition
Home	53 (73.6)
Nursing homes	17 (23.6)
Convalescent/chronic hospital	2 (2.7)
Continuation of outpatient rehabilitation after discharge
Outpatient cardiac rehabilitation	19 (26.4)
Rehabilitation services of long-term care insurance	18 (25.0)

Impaired Functional Improvements in Post-ADHF Patients With Multimorbidity

Half of the transferred patients presented with post-ADHF conditions at admission. Thus, subgroups were classified into post-ADHF and other condition groups. Age, SPPB score, BI, and FIM scores at admission were not significantly different between the 2 groups (Table 5). In the comparison of data between admission and discharge, improvements were observed in BI, FIM, SPPB, 6MWD, MMSE, and GNRI scores in both groups. The difference in the BI scores at admission and discharge in the cRH was defined as ∆BI, and the difference in the FIM scores was defined as ∆FIM. ∆BI in the post-ADHF group was significantly lower than that in the other condition group (16.9±17.3 vs. 27.9±22.8; P<0.05). ∆FIM in the post-ADHF group was significantly lower than that in the other condition group (10.8±18.4 vs. 33.3±14.1; P<0.01).

Table 5.

Comparison of Efficacy of Tailored CR Between Patients With HF and Other Conditions

Item	HF group			Other group
	Admission	Discharge	P value	Admission	Discharge	P value
n	37			35
Age (years)	80.1±11.7			77.7±11.9
Sex, male	19 (51.4)			20 (57.1)
BMI (kg/m2)	20.3±4.1	19.7±4.0	<0.001	20.2±4.1	19.8±3.5	<0.05
BI (points)	62.3±29.7	79.2±23.1	<0.001	62.6±25.4	90.4±16.4†	<0.001
ΔBI (points)		16.9±17.3			27.9±22.8†
FIM (points)	87.4±29.5	98.2±25.6	<0.001	76.6±25.2	109.9±16.5	<0.001
ΔFIM (points)		10.8±18.4			33.3±14.1‡
SPPB (points)	5.3±4.1	7.0±4.1	<0.001	6.9±4.3	9.4±3.2†	<0.001
Handgrip strength (kg)	19.2±8.4	19.0±8.1	0.27	18.9±8.8	20.3±8.8	0.06
6MWD (m)	109.5±142.2	205.2±174.3	<0.05	183.5±121.9	321.0±113.9†	<0.001
MMSE (points)	24.6±4.9	25.4±4.4	0.06	24.5±5.8	26.3±4.8	<0.001
GNRI	86.7±10.5	90.1±11.7	<0.001	87.0±11.6	90.8±12.0	<0.001

^†P<0.05 vs. HF group. ^‡P<0.01 vs. HF group. Data are presented as mean±SD, or n (%). HF, heart failure; HF group, post ADHF group. Other abbreviations as in Tables 1,3.

Discussion

Limited data are available on the characteristics and CR outcomes of patients with CVD, frailty, and multimorbidity in post-acute care settings. Previous reports by our group^9,10 have demonstrated the positive impact of cooperation between acute care and rehabilitation hospitals on ADL and physical function in patients with CVD. To confirm and extend these observations, this multicenter, prospective cohort study was conducted, incorporating multiple evaluations and a larger patient cohort than that in previous studies.^9,10

We hypothesized that tailored multidisciplinary CR, which integrates interventions for comorbid conditions along with conventional CR, would improve functional outcomes in frail patients with CVD. Nearly all patients with CVD who were transferred to cRHs were of advanced age, exhibited frailty, had various risk factors and comorbidities, were malnourished, and were subject to polypharmacy. Supporting our hypothesis, significant improvements were observed in patients who underwent tailored multidisciplinary CR, including enhancements in ADL, physical function, exercise tolerance, swallowing function, nutritional status, and cognitive function. Some discharged patients showed sufficient improvement to participate in standard outpatient CR programs, demonstrating the effectiveness of the initial rehabilitation in preparing them for continued recovery.

The hospital environment, characterized by immobilization, fasting, sleep deprivation, and disorientation, can dramatically worsen physical frailty, leading to rapid and severe loss of muscle mass and function in older patients.²⁷ Recently, a condition known as hospitalization-associated disability (HAD) has been identified in which ADL decline and patients do not fully recover during hospitalization, irrespective of the underlying disease.²⁸ A significant proportion (10–20%) of older patients hospitalized for CVD exhibited HAD,^29–31 which is a significant predictor of poor prognosis. A complex exercise regimen for older patients with ADHF, comprising aerobic, resistance, balance, and flexibility exercises, improves physical function.³² Active rehabilitation from an early stage in acute care hospitals is necessary to prevent HAD. However, recovery of ADL and physical function during the short hospitalization period in acute care hospitals remains challenging. Thus, a seamless transition from hospital admission to rehabilitation settings in post-acute care services should be emphasized.

The insurance coverage for post-acute care facilities and services varies according to each country’s social security system. In the United States, most patients undergoing cardiac surgery are discharged to their homes, and skilled nursing facilities are the second most common destination.³³ In 2014, skilled nursing facilities improved patients’ ADL by 43.5%, transitioning from 37.3% to 47.3% of patients’ homes depending on efficiency.³⁴ A retrospective study in The Netherlands reported that geriatric rehabilitation in skilled nursing facilities reduced physical frailty in older patients with CVD as measured using the 6MWD and BI.³⁵ Standard modules in the geriatric rehabilitation program included daily physiotherapy (40 min), biweekly occupational therapy (30 min), weekly diet advice (30 min), patient education, and individual coaching by skilled nurses.

In Japan, both inpatient and outpatient CR are covered by insurance at cRHs that meet specific facility criteria. A multidisciplinary approach to CR is delivered by a collaborative team of healthcare professionals offering services. Occupational and speech-language-hearing therapies may also be provided depending on the disabling conditions of the patients with CVD. cRHs can provide more intensive rehabilitation than geriatric rehabilitation programs³⁵ in skilled nursing facilities. The present study demonstrated that rehabilitation training was conducted for more than 4 sessions (80 min) per day with additional support provided by other medical staff. Improvements of BI in our CR program were likely better than in the geriatric rehabilitation program. The effects of CR on physical function and exercise tolerance in this study also exceeded the previously reported minimal clinically important difference (MCID). The mean improvement in the SPPB score (2.2 points) was above the reported MCID (0.5–1.5 points).^36,37 A 6MWD extension of approximately 120 m showed greater improvement than both the reported MCID (30 m)³⁸ and the 85-m improvement reported by van Dam van Isselt et al.³⁵ This study also demonstrated that tailored multidisciplinary CR significantly ameliorated impaired cognitive function and malnutrition.

Tailored multidisciplinary CR incorporates individualized rehabilitation for comorbid conditions such as osteoarthritis and old cerebral infarction. For instance, exercise programs are adjusted based on joint pain and cognitive impairment. In contrast to acute care hospitals, where rehabilitation duration and frequency are limited, many patients in the present study benefited from extended rehabilitation in cRHs. Furthermore, among patients with heart failure and HAD, 37.1% were eligible for cRHs.³⁹ This suggests that timely transfer to such facilities is crucial for optimizing rehabilitation outcomes. Additionally, LTCI can facilitate structured heart failure management, information sharing, and monitoring, which may contribute to reducing readmissions.⁴⁰ However, obtaining certification for LTCI requires time. Therefore, early transfer to a cRH not only enhances motor and cognitive function but also allows for appropriate discharge planning, including environmental adjustments and nutritional support. Overall, our findings support the implementation of tailored multidisciplinary CR in cRHs to optimize recovery in frail patients with CVD and multimorbidity.

ADL at discharge from an acute care hospital following HF and cardiac surgery are prognostic factors for post-discharge mortality and unscheduled re-hospitalization.^41,42 Tailored CR in post-acute care significantly improved the BI and FIM scores in this study. However, the mean FIM score at discharge in this study was lower than that reported in our previous study (110 points).¹⁰ This discrepancy may be attributed to the higher proportion of patients following ADHF in our study. Half of the transferred patients in the present study presented with post-ADHF conditions at admission, compared with only 20% in the previous study. The present results demonstrate impaired ADL recovery in patients with HF compared with that in patients with other CVD. HF is a global pandemic that has become more common in increasingly aged populations.^6,43 Therefore, challenges in CR at rehabilitation hospitals remain for further improvement of ADL in older patients with HF, multimorbidity, and frailty.

Study Limitations

First, the number of patients in the rehabilitation hospitals was limited, even in this multicenter study. Nonetheless, this study included a larger number of patients than the previous study.¹⁰ Specifically, the number of patients with HF was approximately 3-fold higher in the present study. This could provide important information for current clinical practice. Second, a detailed evaluation of physical and cognitive function before admission was challenging, making it impossible to determine the extent to which the results at the time of transfer to a rehabilitation hospital were influenced by the pre-admission condition based on interviews. Third, regarding the detailed items of BI and FIM in ADL evaluation, only the total scores were available, so the breakdown is unknown. However, improvement in motor function was observed, and it is inferred that sufficient improvement was achieved in the motor function items. Last, the absence of a control group made it impossible to assess the effect of transfer to a rehabilitation hospital. However, because of the nature of rehabilitation hospitals, a randomized controlled trial is impractical, and a detailed evaluation, as in the present study, is difficult. Therefore, the protocol used in the present study was deemed appropriate.

Conclusions

Tailored multidisciplinary CR in cRHs in Japan is feasible and positively impacts patients with CVD, frailty, and multimorbidity, particularly in terms of recovering ADL and reducing disabling conditions. However, to enhance these benefits, further studies should focus on developing specialized CR programs tailored to the unique needs of patients with HF transferred to rehabilitation hospitals.

Acknowledgments

The authors thank Professor Hiroshi Suzuki, Cardiovascular Center, Showa Medical University Fujigaoka Hospital, and Associate Professor Takashi Ikeda, Showa Medical University School of Nursing and Rehabilitation Sciences, for their valuable contributions. We thank all those who contributed to this study.

Sources of Funding

This work was supported by Health and Labor Sciences Research Grants (22FA2001) from the Ministry of Health, Labour and Welfare of Japan.

Disclosures

T.T. is an Editorial Team member of Circulation Reports.

IRB Information

The Institutional Review Board of Jichi Medical University Hospital approved the study (approval no. 22-078).

Data Availability

The deidentified participant data will not be shared.

References

• 1.   Makita S, Yasu T, Akashi YJ, Adachi H, Izawa H, Ishihara S, et al. JCS/JACR 2021 guideline on rehabilitation in patients with cardiovascular disease. Circ J 2022; 87: 155–235.
• 2.   Thomas RJ. Cardiac rehabilitation – challenges and advances: Reply. N Engl J Med 2024; 390: 830–841.
• 3.   Taylor RS, Fredericks S, Jones I, Neubeck L, Sanders J, De Stoutz N, et al. Global perspectives on heart disease rehabilitation and secondary prevention: A scientific statement from the Association of Cardiovascular Nursing and Allied Professions, European Association of Preventive Cardiology, and International Council of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2023; 44: 2515–2525.
• 4.   Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K, Newlin K, et al. Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the million hearts cardiac rehabilitation collaborative. Mayo Clin Proc 2017; 92: 234–242.
• 5.   Kanaoka K, Iwanaga Y, Fukuma N, Nakai M, Sumita Y, Nishioka Y, et al. Trends and factors associated with cardiac rehabilitation participation: Data from Japanese nationwide databases. Circ J 2022; 86: 1998–2007.
• 6.   Gorodeski EZ, Goyal P, Hummel SL, Krishnaswami A, Goodlin SJ, Hart LL, et al.; Geriatric Cardiology Section Leadership Council, American College of Cardiology. Domain management approach to heart failure in the geriatric patient: Present and future. J Am Coll Cardiol 2018; 71: 1921–1936.
• 7.   Ijaz N, Buta B, Xue QL, Mohess DT, Bushan A, Tran H, et al. Interventions for frailty among older adults with cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2022; 79: 482–503.
• 8.   Kuwabara M, Mori M, Komoto S. Japanese national plan for promotion of measures against cerebrovascular and cardiovascular disease. Circulation 2021; 143: 1929–1931.
• 9.   Morisawa T, Ueno K, Fukuda Y, Kanazawa N, Kawaguchi H, Zaiki R, et al. Significance of sequential cardiac rehabilitation program through inter-hospital cooperation between acute care and rehabilitation hospitals in elderly patients after cardiac surgery in Japan. Heart Vessels 2017; 32: 1220–1226.
• 10.   Matsuo T, Morisawa T, Yamamoto S, Nyuba K, Maehata M, Fujii D, et al. Effect of in-patient cardiac rehabilitation at rehabilitation hospital for cardiology patients: Two-center trial. Heart Vessels 2024; 39: 75–85.
• 11.   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.
• 12.   Chen X, Mao G, Leng SX. Frailty syndrome: An overview. Clin Interv Aging 2014; 9: 433–441.
• 13.   Wade DT, Collin C. The Barthel ADL Index: A standard measure of physical disability? Int Disabil Stud 1988; 10: 64–67.
• 14.   Granger CV, Hamilton BB, Linacre JM, Heinemann AW, Wright BD. Performance profiles of the functional independence measure. Am J Phys Med Rehabil 1993; 72: 84–89.
• 15.   Freiberger E, de Vreede P, Schoene D, Rydwik E, Mueller V, Frändin K, et al. Performance-based physical function in older community-dwelling persons: A systematic review of instruments. Age Ageing 2012; 41: 712–721.
• 16.   Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994; 49: M85–M94.
• 17.   Hirano M, Katoh M, Gomi M, Arai S. Validity and reliability of isometric knee extension muscle strength measurements using a belt-stabilized hand-held dynamometer: A comparison with the measurement using an isokinetic dynamometer in a sitting posture. J Phys Ther Sci 2020; 32: 120–124.
• 18.   Wilson CM, Kostsuca SR, Boura JA. Utilization of a 5-meter walk test in evaluating self-selected gait speed during preoperative screening of patients scheduled for cardiac surgery. Cardiopulm Phys Ther J 2013; 24: 36–43.
• 19.   Mathias S, Nayak US, Isaacs B. Balance in elderly patients: The “get-up and go” test. Arch Phys Med Rehabil 1986; 67: 387–389.
• 20.   Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999; 54: 581–586.
• 21.   ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166: 111–117.
• 22.   Ahmadi Z, Igelström H, Sandberg J, Sundh J, Sköld M, Janson C, et al. Agreement of the modified Medical Research Council and New York Heart Association scales for assessing the impact of self-rated breathlessness in cardiopulmonary disease. ERJ Open Res 2022; 8: 00460-2021.
• 23.   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.
• 24.   Yokota J, Takahashi R, Chiba T, Matsushima K. Mild cognitive impairment in patients with acute heart failure does not limit the effectiveness of early phase II cardiac rehabilitation. Eur J Phys Rehabil Med 2022; 58: 470–477.
• 25.   Fujishima I. Rehabilitation for swallowing disorders associated with stroke [in Japanese], 2nd edn. Tokyo: Ishiyaku Publishers Inc., 1998.
• 26.   Bouillanne O, Morineau G, Dupont C, Coulombel I, Vincent JP, Nicolis I, et al. Geriatric Nutritional Risk Index: A new index for evaluating at-risk elderly medical patients. Am J Clin Nutr 2005; 82: 777–783.
• 27.   Krumholz HM. Post-hospital syndrome: An acquired, transient condition of generalized risk. N Engl J Med 2013; 368: 100–102.
• 28.   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.
• 29.   Yaku H, Kato T, Morimoto T, Inuzuka Y, Tamaki Y, Ozasa N, et al. Risk factors and clinical outcomes of functional decline during hospitalisation in very old patients with acute decompensated heart failure: An observational study. BMJ Open 2020; 10: e032674.
• 30.   Takabayashi K, Kitaguchi S, Iwatsu K, Morikami Y, Ichinohe T, Yamamoto T, et al. A decline in activities of daily living due to acute heart failure is an independent risk factor of hospitalization for heart failure and mortality. J Cardiol 2019; 73: 522–529.
• 31.   Morisawa T, Saitoh M, Otsuka S, Takamura G, Tahara M, Ochi Y, et al. Association between hospital-acquired functional decline and 2-year readmission or mortality after cardiac surgery in older patients: A multicenter, prospective cohort study. Aging Clin Exp Res 2023; 35: 649–657.
• 32.   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.
• 33.   Edgerton JR, Herbert MA, Mahoney C, Armstrong D, Dewey TM, Holper E, et al. Long-term fate of patients discharged to extended care facilities after cardiovascular surgery. Ann Thorac Surg 2013; 96: 871–877.
• 34.   Stoicea N, You T, Eiterman A, Hartwell C, Davila V, Marjoribanks S, et al. Perspectives of post-acute transition of care for cardiac surgery patients. Front Cardiovasc Med 2017; 4: 70.
• 35.   van Dam van Isselt EF, van Wijngaarden J, Lok DJA, Achterberg WP. Geriatric rehabilitation in older patients with cardiovascular disease: A feasibility study. Eur Geriatr Med 2018; 9: 853–861.
• 36.   Soubra R, Chkeir A, Novella JL. A systematic review of thirty-one assessment tests to evaluate mobility in older adults. BioMed Res Int 2019; 2019: 1354362.
• 37.   Rinaldo L, Caligari M, Acquati C, Nicolazzi S, Paracchini G, Sardano D, et al. Functional capacity assessment and minimal clinically important difference in post-acute cardiac patients: The role of Short Physical Performance Battery. Eur J Prev Cardiol 2022; 29: 1008–1014.
• 38.   Singh SJ, Puhan MA, Andrianopoulos V, Hernandes NA, Mitchell KE, Hill CJ, et al. An official systematic review of the European Respiratory Society/American Thoracic Society: Measurement properties of field walking tests in chronic respiratory disease. Eur Respir J 2014; 44: 1447–1478.
• 39.   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.
• 40.   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; 89: 109–119.
• 41.   Uemura Y, Shibata R, Takemoto K, Koyasu M, Ishikawa S, Murohara T, et al. Prognostic impact of the preservation of activities of daily living on post-discharge outcomes in patients with acute heart failure. Circ J 2018; 82: 2793–2799.
• 42.   Sato M, Mutai H, Yamamoto S, Tsukakoshi D, Takeda S, Oguchi N, et al. Decreased activities of daily living at discharge predict mortality and readmission in elderly patients after cardiac and aortic surgery: A retrospective cohort study. Medicine 2021; 100: e26819.
• 43.   Shimokawa H, Miura M, Nochioka K, Sakata Y. Heart failure as a general pandemic in Asia. Eur J Heart Fail 2015; 17: 884–892.