Association of a Transitional Heart Failure Management Program With Readmission and End-of-Life Care in Rural Japan

• Published in: Circulation Reports 2024/05/10, Vol.6(5), pp.168-177
• Main Authors: Kinugasa, Yoshiharu, Nakamura, Kensuke, Hirai, Masayuki, Manba, Midori, Ishiga, Natsuko, Sota, Takeshi, Nakayama, Natsuko, Ohta, Tomoki, Kato, Masahiko, Adachi, Toshiaki, Fukuki, Masaharu, Hirota, Yutaka, Mizuta, Einosuke, Mura, Emiko, Nozaka, Yoshihito, Omodani, Hiroki, Tanaka, Hiroaki, Tanaka, Yasunori, Watanabe, Izuru, Mikami, Masaaki, Yamamoto, Kazuhiro
• Format: Article
• Language: English
• Subjects: Discharge care planning; General practitioners; Heart failure handbook; Information sharing
• ISSN: 2434-0790; 2434-0790
• DOI: 10.1253/circrep.CR-24-0030

Background: Evidence on transitional care for heart failure (HF) in Japan is limited.Methods and Results: We implemented a transitional HF management program in rural Japan in 2019. This involved collaboration with general practitioners or nursing care facilities and included symptom monitoring by medical/nursing staff using a handbook; standardized discharge care planning and information sharing on self-care and advance care planning using a collaborative sheet; and sharing expertise on HF management via manuals. We compared the outcomes within 1 year of discharge among patients hospitalized with HF in the 2 years before program implementation (2017–2018; historical control, n=198), in the first 2 years after program implementation (2019–2020; Intervention Phase 1, n=205), and in the second 2 years, following program revision and regional dissemination (2021–2022; Intervention Phase 2, n=195). HF readmission rates gradually decreased over Phases 1 and 2 (P0.1 for interaction). Mortality rates remained unchanged, but significantly more patients received end-of-life care at home in Phase 2 than before (P