The Effects of Post-Acute Care in Patients with Heart Failure in Taiwan: A Single Center Experience

Abstract

Background

The National Health Insurance Administration in Taiwan has promoted the heart failure post-acute care (HF-PAC) program as a means to provide proactive integrated care within the optimal treatment timeframe to enhance functional recovery after acute decompensated heart failure (HF).

Objectives

The aim of this program was to reduce HF readmission rates, improved medication prescription rates, and improve the quality of life in HF patients.

Methods

Patients who had a reduced left ventricular ejection fraction (LVEF) of ≤ 40% were included and followed up for 6 months after discharge. They underwent cardiac rehabilitation and physiological, and nutritional status evaluations. The main clinical outcomes of the HF-PAC program were guideline-directed medical therapy prescription rate and 6-month readmission rate.

Results

A total of 122 patients were recruited from June 2018 to December 2020 at a medical center in southern Taiwan. The patients’ activities of daily living, nutritional status, quality of life and LVEF were significantly improved during the HF-PAC program. More than 95% of the patients received guideline-directed medical prescriptions at the end of the HF-PAC program. The cardiovascular-related 6-month re-admission rate after the HF-PAC program ended was 27.7%, and it could be predicted by the New York Health Association functional class [hazard ratio (HR) 95% confidence interval (95% CI) = 4.12 (1.36-12.46)], value of the Mini Nutritional Assessment - Short Form [HR (95% CI) = 0.46 (0.31-0.68)] and LVEF [HR (95% CI) = 0.95 (0.91-0.99)].

Conclusions

By incorporating multidisciplinary healthcare teams, the HF-PAC program improves the guideline- directed medical therapy prescription rate, thus improving patients’ cardiac function, physical activity recovery, the quality of life, and also reduces their readmission rate.

Abbreviations

ACC/AHA, American College of Cardiology/American Heart Association

ACEIs, Angiotensin-converting-enzyme inhibitors

ARBs, Angiotensin receptor blockers

ARNIs, Angiotensin receptor-neprilysin inhibitors

CI, Confidence interval

EQ-5D, EuroQol 5-Dimension Questionnaire

GDMT, Guideline-directed medical therapy

HF, Heart failure

HF-PAC, Heart failure post-acute care

HR, Hazard ratio

IADL, Instrumental Activities of Daily Living

INFs, Intermediate rehabilitation facilities

IRB, Institutional Review Board

LVD-36, The Left Ventricular Dysfunction Questionnaire

LVEF, Left ventricular ejection fractions

MNA*, The Mini Nutritional Assessment

MNA-SF, The Mini Nutritional Assessment - Short Form

MRAs, Mineralocortocoidmineralocorticoid receptor antagonists

NHIA, National Health Insurance Administration

NYHA, New York Health Association

PAC, Post-acute care

SGLT2is, Sodium-glucose cotransporter 2 inhibitors

SNFs, Skilled nursing facilities

VAS*, Visual analogue scale

6MWT, 6-minute walk test

* In the Supplementary.

INTRODUCTION

Heart failure (HF) is a highly prevalent major global public health issue.¹ Symptoms of deteriorating HF include reduced urine output, lower limb edema, weight gain, fatigue, loss of appetite, and cold extremities.² In Taiwan, the 6-month readmission and mortality rates of patients with HF are as high as 31.9% and 15.9%, respectively.³ To reduce the risk of developing complications in patients with HF, the United States introduced post-acute care (PAC) in the 1990s.⁴ Nearly 50% of patients with HF discharged from hospitals receive PAC at skilled nursing facilities (SNFs) or intermediate rehabilitation facilities (INFs).⁴ Patients who receive rehabilitative treatment (including physical, occupational, and speech therapy) are associated with significant reductions in readmission rates. Thus, the National Health Insurance Administration (NHIA) in Taiwan launched a PAC program in 2014 to provide proactive integrated care for patients based on their level of disability during the early phases of recovery.⁵

In Taiwan, PAC was first introduced for stroke patients, and it was shown to improve physical activity function and quality of life, thereby helping them return to their homes and communities.^6,7 Based on the success of the program with stroke patients, the NHIA extended the indications of PAC to include HF in 2017.⁵ Due to medical workforce and facility limitations in Taiwan, the Heart Failure Post-Acute Care (HF-PAC) program was implemented over 6 months and involved clinical integrated care as well as cardiac rehabilitation for patients hospitalized with acute HF. Patient-centered healthcare teams for HF with multidisciplinary teams including physicians, nurses, case managers, rehabilitation therapists, dieticians, pharmacists, social workers, and psychological therapists were created to provide patients with optimal treatment and education as well as enhance patients’ self-care capabilities. The aims of multidisciplinary disease management programs, such as the HF-PAC, are to reduce HF readmission rates, improve medication prescription rates and adherence, and improve quality of life.¹

METHODS

Research design

This program was conducted at a medical center in southern Taiwan and recruited hospitalized patients with acute decompensated HF. The program was approved by the Ethics Committee and Institutional Review Board (IRB, Approval number B-ER-109-094-T) of National Cheng Kung University Hospital, Taiwan. Since this was a retrospective cohort program that only involved the analysis of clinical medical records, the committee waived the requirement for written informed consent. Patients were evaluated by the HF case manager to determine whether they met the inclusion criteria for receiving HF-PAC prior to discharge. The healthcare team educated the patients and their families on HF, management of deteriorating symptoms, restrictions of low-sodium diet and water, body weight management, medication adherence, and enhanced self-care motivation strategies to improve their prognoses.⁸ The recruited patients were followed up as outpatients over 6 months after discharge and assessed at 1 week, 1 month, 3 months, 5 months and 6 months after discharge.⁵ As rehabilitation therapy is another important component of the HF-PAC program,⁹ the healthcare team referred patients to cardiac rehabilitation physicians to receive individualized cardiac rehabilitation therapy.

Participants

Patients who met the following inclusion criteria for the HF-PAC program were recruited: (1) patients hospitalized due to acute decompensated HF, with HF defined as a left ventricular ejection fraction (LVEF) ≤ 40% and American College of Cardiology/American Heart Association (ACC/AHA) Stages C or D, (2) age ≥ 18 years, (3) patients who would potentially benefit from a proactive integrated PAC program.⁵

We excluded individuals who (1) had an expected survival period of < 6 months due to non-HF-related diseases, (2) had been bed-ridden for > 3 months, (3) had severely limited neurological or musculoskeletal function and exhibited no potential for rehabilitation, (4) had serious consciousness, cognitive, or mental disorders, (5) were dependent on mechanical ventilation, (6) at the terminal HF stage, (7) were planned for coronary artery bypass surgery or heart valve surgery within a month, (8) had end-stage renal failure, (9) had severe lung disease requiring oxygen therapy, (10) previously closed cases, and (11) could not cooperate with the healthcare team during the HF-PAC program.⁵

Instruments

The NHIA requires that the following instruments are used to assess the HF-PAC program: Instrumental Activities of Daily Living (IADL) scale, the EuroQol 5-Dimension Questionnaire (EQ-5D), the Mini Nutritional Assessment - Short Form (MNA-SF), the 6-minute walk test (6MWT), and the Left Ventricular Dysfunction Questionnaire (LVD-36).⁵ The scoring method of each instrument is described in the Supplement.

Clinical indicators

Guideline-directed medical therapy prescription rate

Guideline-directed medical therapy (GDMT) is the most effective way to reduce mortality and morbidity in HF.¹⁰ The GDMT included prescription rates of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs)/angiotensin receptor-neprilysin inhibitors (ARNIs), β-blockers/I_f channel inhibitors, mineralocorticoid receptor antagonists (MRAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) at 1 week, 3 months and 6 months after discharge if the patients were not contraindicated.

Six-month readmission rate/one-year mortality/30-day emergency room visit

Six-month readmission rate, 1-year mortality rate, and 30-day emergency room visit rate were the clinical indicators used to measure the outcomes of the HF-PAC after the patients has completed the program.⁵

Statistical analysis

Demographic characteristics are presented as number and percentage or mean and standard deviation in the quantitative data. We used a mixed effects model to analyze differences in assessment outcomes of the HF-PAC over the program, and adjusted for age, sex, etiology of HF and comorbidities for the time effect. The predictors of 6-month readmission related to cardiovascular disease after the HF-PAC program ended were analyzed by Cox regression analysis. A multivariable Cox regression model was used to analyze variables with p < 0.05 in univariate Cox regression analysis and was estimated by Firth’s Penalized Likelihood; p < 0.05 indicated statistical significance.

RESULTS

A total of 122 patients were recruited from June 2018 to December 2020 and followed until June 2021. Eighty-one patients received the HF-PAC program for the full program period of 6 months, resulting in a HF-PAC program completion rate of nearly 50%. Figure 1 illustrates the recruitment process.

Figure 1.

Recruitment flowchart in heart failure post-acute care. HF-PAC, heart failure post-acute care; HFrEF, heart failure with reduced ejection fraction.

The demographic data of the participants are presented in Table 1. Overall, 82.7% of the participants who received the full 6-month period of care were male. The average age of the participants was 54.9 ± 13 years. The etiologies of HF were mainly ischemic cardiomyopathy and dilated cardiomyopathy, which accounted for 58.0% and 29.6% of the participants, respectively. The most common comorbidity was coronary artery disease (43.2%), follow by hypertension (38.3%) and diabetes mellitus (38.3%). The average hospitalization length of stay was 10.1 ± 9.1 days, and the average HF-PAC program length was 7.0 ± 0.8 months. Twenty-eight participants (34.6%) received cardiac rehabilitation at the beginning of the HF-PAC program, but only 8 participants (9.9%) completed the cardiac rehabilitation for 6 months during HF-PAC program. Most participants’ physical function was New York Health Association (NYHA) Functional Class II (55.6%) or III (39.5%) before undergoing the HF-PAC program. However, 18.5% and 76.5% of the participant improved to NYHA Functional Class I and II, respectively (Figure 2).

Table 1. Demographic characteristics of participants received heart failure post-acute care.

Variable	n (%) / mean ± SD
Sex
Male	67 (82.7)
Female	14 (17.3)
Age (years)	54.9 ± 13
Average length of hospital stay (days)	10.1 ± 9.1
Average HF-PAC period (months)	7.0 ± 0.8
Etiology of heart failure
Ischemic cardiomyopathy	47 (58.0)
Dilated cardiomyopathy	24 (29.6)
Valvular heart disease	3 (3.7)
Myocarditis	3 (3.7)
Others	4 (4.9)
Comorbidity
Coronary artery disease	35 (43.2)
Hypertension	31 (38.3)
Diabetes mellitus	31 (38.3)
Atrial fibrillation/atrial flutter	19 (23.5)
Chronic kidney disease	16 (19.8)
Clinical cardiac rehabilitation
Received during HF-PAC	28 (34.6)
Complete for six-month	8 (9.9)

HF-PAC, heart failure post-acute care.

Figure 2.

New York Health Association Functional Class status in patients received heart failure post-acute care.

The assessment outcomes for the HF-PAC program are shown in Table 2. The IADL score increased significantly in the female participants from 6.07 ± 1.79 to 7.57 ± 0.82 (β = 0.49; p < 0.001). The EQ-5D scores increased significantly both in objective score (TTO) and subjective score (VAS), 0.848 ± 0.09 to 0.877 ± 0.08 (p = 0.004) and 72.84 ± 12.49 to 91.8 ± 13.35.7 (p < 0.001), respectively. In addition, the MNA-SF score significantly improved from 11.74 ± 1.79 to 13.33 ± 1.04 (p < 0.001), and the LVEF increased from 28.84% ± 7.40% to 43.04% ± 15.10% (p < 0.001). However, the LVD-36 score and NT-pro-BNP level significantly decreased from 11.55 ± 6.74 to 6.11 ± 6.0 (p < 0.001) and 5791.07 ± 11611.20 to 1301.85 ± 3197.41 (p = 0.001), respectively.

Table 2. Assessment outcomes of heart failure post-acute care.

	1-week	1-month	3-month	5-month	6-month	Mixed effect model for trend
	Mean ± SD					β ± SE	p value
IADL (male)	4.37 ± 1.10	4.73 ± 0.78	4.77 ± 0.66	4.78 ± 0.72	4.84 ± 0.56	0.02 ± 0.02	0.295
IADL (female)	6.07 ± 1.79	6.71 ± 1.48	7.07 ± 1.49	7.40 ± 1.20	7.57 ± 0.82	0.49 ± 0.12	< 0.001*
EQ-5D (TTO)	0.848 ± 0.09	0.851 ± 0.09	0.876 ± 0.07	0.878 ± 0.08	0.877 ± 0.08	0.008 ± 0.002	0.004*
EQ-5D (VAS)	72.84 ± 12.49	75.89 ± 13.26	78.32 ± 13.84	77.83 ± 15.50	81.01 ± 13.35	1.88 ± 0.32	< 0.001*
MNA-SF	11.74 ± 1.79	NA	13.24 ± 1.22	NA	13.33 ± 1.04	0.50 ± 0.07	< 0.001*
6MWT	418.52 ± 101.38	NA	NA	NA	462.06 ± 85.52	59.09 ± 27.91	0.079
LVEF	28.48 ± 7.40	NA	NA	NA	43.24 ± 14.30	14.77 ± 1.70	< 0.001*
LVD-36	11.55 ± 6.74	NA	NA	NA	6.11 ± 6.00	-5.34 ± 0.65	< 0.001*
NT pro-BNP	5791.07 ± 11611.20	NA	NA	NA	1301.85 ± 3197.41	-4545.54 ± 1322.13	0.001*

EQ-5D, The EuroQol 5-Dimension Questionnaire; IADL, The Instrumental Activities of Daily Living; LVD-36, Left Ventricular Dysfunction Questionnaire; LVEF, left ventricular ejection fraction; MNA-SF, The Mini Nutritional Assessment Form; NT pro-BNP, N terminal pro B type natriuretic peptide; SD, standard deviation; SE, standard error; TTO, time trade-off; VAS, Visual Analogue Scale; 6MWT, 6-minute walk test.

Clinical outcomes for the HF-PAC program including GDMT prescription rate, 6-month readmission rate, 1-year mortality rate and 30-day emergency room visit rate are shown in Figure 3 and Figure 4. More than 95% of the patients had prescriptions for ACEIs/ARBs/ARNIs and β-blockers/I_f channel inhibitors at the end of the HF-PAC program. In addition, 78% of the patients received MRAs, but only about 20% received SGLT2is at the end of HF-PAC program. The 6-month readmission rate due to cardiovascular disease, 30-day ER-visit rate and mortality rate were 27.7%, 3.8%, and 3.2%, respectively, at the end of the HF-PAC program. The NYHA Functional class [hazard ratio (HR) (95% confidence interval (CI)) = 4.12 (1.36-12.46), p < 0.012], value of MNA-SF [HR (95% CI) = 0.46 (0.31-0.68), p < 0.001] and LVEF > 40% [HR (95% CI) = 0.35 (0.12-0.99), p = 0.049] at the end of HF-PAC program were the predictors of 6-month readmission rates after HF-PAC program, but only MNA-SF has significant in multivariable Cox regression analysis [HR (95% CI) = 0.53 (0.34-0.83), p < 0.005] (Table 3).

Figure 3.

Guideline-directed medical therapy prescription rate during heart failure post-acute care. ACEIs, angiotensin-converting-enzyme inhibitors; ARBs, angiotensin receptor blockers; MRA, mineralocortocoidmineralocorticoid receptor antagonist.

Figure 4.

Clinical outcome after heart failure post-acute care. CV, cardiovascular; ER, emergency room.

Table 3. Cox regression model for predictors of 6-month readmission after heart failure post-acute care ending.

Variables	Crude HR (95% CI)	p value	Adjusted HR (95% CI)#	p value
Male	0.52 (0.17-1.63)	0.264
Age	1.00 (0.97-1.04)	0.870
Etiology of heart failure
Ischemic cardiomyopathy	1.95 (0.25-15.38)	0.527
Dilated cardiomyopathy	1.53 (0.18-13.08)	0.699
Valvular heart disease	2.82 (0.18-45.08)	0.464
Others	Ref.
Coronary artery disease	1.36 (0.51-3.66)	0.538
Hypertension	0.64 (0.22-1.86)	0.416
Diabetes mellitus	1.10 (0.40-3.04)	0.849
Atrial fibrillation/atrial flutter	0.59 (0.17-2.06)	0.406
Chronic kidney disease	0.92 (0.26-3.23)	0.898
NYHA Fc class	4.12 (1.36-12.46)	0.012*	1.20 (0.38-4.16)	0.764
IADL	1.12 (0.73-1.72)	0.598
EQ-5D (TTO)	0.34 (0.00-345.94)	0.757
MNA-SF	0.46 (0.31-0.68)	< 0.001*	0.53 (0.34-0.82)	0.005*
6-minute walk test	1.00 (0.98-1.01)	0.631
LVEF	0.95 (0.91-0.99)	0.015*	0.96 (0.91-1.00)	0.097
LVD-36	1.04 (0.97-1.11)	0.283
NT-pro BNP
< 900	Ref.
≥ 900	2.62 (0.88-7.80)	0.084

^# Cox model estimate by Firth’s Penalized likelihood.

CI, confidence interval; EQ-5D, The EuroQol 5-Dimension Questionnaire; HR, hazard ratio; IADL, The Instrumental Activities of Daily Living; LVD-36, Left Ventricular Dysfunction Questionnaire; LVEF, left ventricular ejection fraction; MNA-SF, The Mini Nutritional Assessment Form; NT pro-BNP, N terminal pro B type natriuretic peptide; TTO, time trade-off.

DISCUSSION

The HF-PAC program in Taiwan is still in the early stages. This program is expected to reduce HF readmission rates, avoid disability and improve the quality of life of HF patients by integrating multidisciplinary team care.^1,5 To the best of our knowledge, most previous articles on HF-PAC programs have assessed readmission and mortality. However, our results demonstrated good efficacy in improving the patients’ functional capacity, nutritional status, LVEF and quality of life after completing the HF-PAC program. We also found that a better nutritional status and LVEF in HF patients were associated with a lower 6-month readmission rate due to cardiovascular disease.

The HF-PAC program in Taiwan primarily targets hospitalized patients with acute decompensated HF and LVEF ≤ 40%, and participants receive the PAC at an HF-integrated clinic for 6 months. At the end of 2019, 31 hospitals had HF healthcare teams in Taiwan, and 77.4% of them joined the HF-PAC program.¹¹ HF healthcare teams must be multidisciplinary, and educate the patients on self-care and adherence, dietary counseling, optimization of medications, psychosocial support, and exercise training.¹² Chen et al. reported that the readmission risk in HF patients who received multidisciplinary team care was lower than that in those who did not receive multidisciplinary team care, especially in those with ischemic cardiomyopathy.¹³ However, patients aged ≥ 65 years with a history of HF who are discharged from medical institutions are transferred to SNFs or INFs to receive PAC with support from the Medicare program in the United States.¹⁴ Among HF patients, 24.2% were readmitted to the hospital within 30 days after discharge from SNFs, and patients with a longer SNF stay had lower readmission rates.¹⁵ Differences between the healthcare systems are likely due to more limited human resources and medical facilities in Taiwan than in the United States. Nevertheless, the main goal of both systems is to reduce patient readmission rates and improve their functional recovery after HF.

The IADL, EQ-5D and MNA-SF scores of the participants are the main focus in our program, and they all improved during the HF-PAC program. Our participants had nearly maximum IADL scores at the end of the HF-PAC program. HF patients with impaired IADLs have been association with all-cause mortality,¹⁶ and impaired IADLs have also been associated with a longer average daily rehabilitation time in HF patients.¹⁷ In addition, nutritional status is also important for HF patients. We found that a higher MNA-SF score was associated with a significant decrease in 6-month readmission rate due to cardiovascular disease after the HF-PAC program. Poor nutrition is a known risk factor for cardiovascular mortality and HF readmissions, and dietary exposure may be a key driver of fluid and electrolyte imbalance.^18,19 A balanced diet and salt restriction are always recommended as lifestyle modifications in the management of HF.^18,20

Exercise training is recommended as being safe and effective for patients with HF.²¹ We admitted patients to clinical cardiac rehabilitation in accordance with the cardiopulmonary rehabilitation guidelines developed by the American College of Sports Medicine. Professionally trained cardiopulmonary rehabilitation physicians and therapists provided the patients with a series of aerobic and muscle-strengthening activities.^22,23 Bicycle and treadmill training methods were adopted to improve the patients’ cardiopulmonary function. If necessary, occupational therapy was also used to improve the patients’ muscle endurance to help facilitate their return to work after acute HF. Most patients received rehabilitation therapy after discharge but discontinued rehabilitation sessions after showing clinical improvements due to work commitments. Before the HF-PAC program was implemented in Taiwan, 15.8% of HF patients received phase II cardiac rehabilitation.¹³ In the current study, 34.6% of our patients received cardiac rehabilitation. Although only 9.9% of them completed the full cardiopulmonary rehabilitation program, we suggested that they maintain the daily rehabilitation by themselves depending on the their hemodynamic status, HF symptoms, rehabilitation needs, and endurance.¹⁷

The HF-PAC program in Taiwan was designed to provide patients with optimal treatment. In addition, all therapy processes must conform to the most recent European Society of Cardiology, ACC/AHA, and Taiwan Society of Cardiology (TSOC) guidelines.^1,24,25 According to the 2016 TSOC HF registry, the ratio of discharged patients with HF who received GDMT was approximately 60%.¹⁰ After the TSOC promoted the advantages of GDMT to cardiologists, 95% of the patients receiving the HF-PAC program were on ACEIs/ARBs/ARNIs or β-blockers/I_f channel inhibitors, and 78% were on MRAs. SGLT2is are new GDMT for HF, and they can reduce HF readmission and mortality rates.²⁶ About 20% of the patients in our program received SGLT2is because they had the comorbidity of diabetes mellitus, and our physicians did not prescribe SGLT2is regularly at the beginning of the HF-PAC program. We believe that prescriptions of SGLT2is in HF patients will gradually increase in the future.

The 6-month readmission rate for HF patients in Taiwan was 31.9% in 2016.³ Due to the high re-admission rates of HF patients, the NIHA integrated HF into the PAC program. In the present study, the 6-month HF readmission rate decreased from 21.05% to 20% after the HF-PAC program in 2019. Case managers played the most important role in the HF-PAC program, and they acted as a bridge between the healthcare team and HF patients to ensure that they received health education regarding HF, detailed care skills, and enhanced self-care motivation strategies to improve their prognoses.⁸

There are several limitations to this study. First, the results were obtained from a single medical center and a single group, and we hope that more general studies will be conducted to assess the efficiency of the HF-PAC program in the future. Second, selection bias was possible because we only included patients with HF who were treated at the Department of Cardiology. Third, the evaluation instruments were questionnaires mandated by the NHIA, so we suggest that future studies may consider using HF-specific questionnaires to evaluate patients.

CONCLUSIONS

The HF-PAC program has been successfully implemented in Taiwan for approximately 5 years. Our results support the contribution of the program and emphasize that by incorporating multidisciplinary healthcare teams, the HF-PAC program improved the guideline-directed medical therapy prescription rate, improved the patients’ cardiac function, physical activity recovery, and quality of life, and also reduced their readmission rates.

SUPPLEMENTARY MATERIALS

The instruments used for HF-PAC program assessment

Lawton-Brody Instrumental Activities of Daily Living scale

The Instrumental Activities of Daily Living (IADL) scale assess activities such as making phone calls, managing transportation, shopping, preparing meals, household chores, doing laundry, managing finances, and managing medications.^S1 Although the IADL scale is often used to evaluate the long-term care needs of older adults in Taiwan,^S2 it could assessed behavioral functional capacity for HF patients.^S3,S4 Scores range from 0-8 in male and 0-5 in female, with higher scores representing higher performance in IADLs.^S5 IADL was measured at each cardiology clinical outpatient visit.

EuroQol 5-Dimension Questionnaire

The EuroQol 5-Dimension Questionnaire (EQ-5D) is widely used for measuring individual health utilities.^S6 The EQ-5D can be used to evaluate the health status of patients from different countries, of different ethnicities, and with different diseases.^S7 The questionnaire comprises of two parts. The first part involves an objective assessment scale looking at 5 dimensions (mobility, self-care, daily living, pain or discomfort, and anxiety or depression). Each dimension is stratified into 3 levels and scores in each dimension are calculated and converted into utilities with a total score ranging from between 0 and 1. Higher scores represent a higher overall quality of life and health status. The second part involves a subjective visual analogue scale (VAS). Participants self-evaluate their daily health status using a scale from 0 to 100, where higher scores indicate better self-evaluated health statuses. EQ-5D was measured at each cardiology clinical outpatient visit.

Mini Nutritional Assessment - Short Form

The Mini Nutritional Assessment (MNA) was used to assess nutritional risk in older adults and develop nutritional care plans without laboratory tests. The MNA-Short Form (MNA-SF) contains only 6 items but retains the accuracy of the original MNA. The maximum MNA-SF score is 14; scores of ≤ 7, 8 to 11, and ≥ 12 points respectively represent malnutrition, risk of malnutrition, and suitable nutrition.^S8 MNA-SF was measured at 1-week, 3-month and 6-month after discharge.

Six-minute walk test

The 6-minute walk test (6MWT) is a simple and low-cost method of measuring cardiopulmonary endurance in patients with HF. The 6MWT can also assess patients’ subjective perceptions during exercise^S9 and was measured at 1-week and 6-month after discharge if patient received cardiac rehabilitation.

Left Ventricular Dysfunction Questionnaire

The Left Ventricular Dysfunction Questionnaire (LVD-36) developed by O’Leary and Jones (2000) and was used to measure the impact of left ventricular dysfunction on patient’s daily life.^S10 The questionnaire was translated into Chinese after obtaining approval from the original authors. The LVD-36 was used to assess the effects of HF symptoms on a patient’s daily life. It consists of 36 "yes" or "no" items assessing the patients’ recent condition. A lower number of "yes" results indicate a lower likelihood that the patient’s daily living is affect by HF symptoms.^S10 LVD-36 was measured at 1-week and 6-month after discharge.

DECLARATION OF CONFLICT OF INTEREST

All the authors declare no conflict of interest.

AUTHOR CONTRIBUTION

Program conception and design: Ping-Yen Liu, Ting-Hsing Chao, Chih-Hsin Hsu.

Data collection: Pei-Yi Wang, Wen-Chih Lin, Pei-Chun Hsieh.

Data analysis and interpretation: Pei-Yi Wang, Sheng-Hsiang Lin.

Drafting of the article: Pei-Yi Wang.

Critical revision of the article: Ping-Yen Liu, Chih-Hsin Hsu.