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Association Between The Discharge Process And Post-Discharge Events In Patients With Heart Failure


 Background: HF is a burden on healthcare resources due to the high cost of frequent readmissions. Predictive models have been reported for the post-discharge prognosis of HF. However, these models mostly included non-modifiable factors and their predictive accuracy was limited. This implies that potentially modifiable factors are needed, which could be attributed to the discharge process. This study aimed to explore the relationship between the discharge process and post-discharge events in patients with HF.Methods: Medical records were reviewed to identify patients who were admitted for HF exacerbation. Information related to the discharge process included post-discharge clinic appointments, educational contents before discharge, and family participation during patient education. HF-related events were defined as a composite of events, including emergency department visits, readmissions, or death. A multivariable Cox proportional hazards regression model was used to explore the association between the discharge process and HF-related events.Results: Of 201 patients, 41 had at least one HF-related event. Post-discharge clinic appointments were scheduled 8 days after discharge. Patients received their discharge education on average of one topic, and approximately the families of 70% of the patients participated in this educational activity. In the Cox regression model, family participation during education was independently associated with a longer time to HF events (hazard ratio: 2.105). However, and post-discharge follow-up appointments and the number of educational contents received were not associated with the time to HF events. Conclusion: We found that family participation during education is a protective factor for adverse prognosis in patients with HF. Our results highlight the importance of family engagement in HF management.

modi able factors should be considered to improve the predictive power for prognosis of patients with HF who are discharged from the hospital.
The intervention designed to prevent readmission among patients from one care setting to another is often called transitional care [7]. Potential factors, including transitional care that can be modi able, could be found in the discharge process, such as discharge education and post-discharge clinic appointments. Transitioning between inpatient and outpatient settings is critical for improving patient outcomes, such as reducing HF-related events [3]. Therefore, the purpose of this study was to explore the relationship between factors related to the discharge process and prognosis among patients who were admitted to the hospital due to HF exacerbation. In this study, prognosis was de ned as the composite end point of death, rehospitalization, or ED visits due to HF (i.e., HF event-free survival).

Study design and sample
A retrospective chart review was conducted using the data of patients discharged with a diagnosis of HF (International Classi cation of Disease-10 codes 150. 1-150.4, 150.9) from an academic medical center in Korea between January 2014 and March 2017. Eligible patients were admitted due to HF exacerbation and were discharged alive. We initially screened 818 records and excluded 516 because their primary reason for the index hospitalization was not related to HF or because they died during the index hospitalization. Of the 302 records retained, 101 were excluded as they did not include data on variables of interest (e.g., living status, post-discharge clinic appointments). As a result, 201 records were included in the study.

Data collection
Electronic medical records were reviewed to abstract the following information from the index hospitalization: demographic and clinical information and information related to the discharge process.
To identify patients' prognosis, their electronic medical records were reviewed for a median of 699 days (interquartile range: 441-789) after the index hospitalization. A data collection protocol was developed to consistently abstract the data. Any ambiguity among the research nurses was discussed by a principal investigator.
Information related to the discharge process. The discharge process factors included in this study were post-discharge clinic appointments, patient education for HF self-care, and family participation in patient education. According to a scienti c statement from the American Heart Association (AHA), systematic implementation of the principles of transitional care programs to prevent rehospitalizations was recommended for at-risk patients with HF [8]. The suggested components of the transition of care include medication reconciliation, early post-discharge contact and communication with patients and/or clinicians, patient education related to self-care, interdisciplinary care coordination, and communication of patient health information to patients and their post-discharge healthcare provider [8]. However, the systematic approach for the transition of care (e.g., care coordination) had not been implemented in Korea, including in the facility where this study was conducted. At the clinic, patients saw the same clinicians who evaluated them during the index hospitalization, and medication reconciliation was performed before discharge for all patients in Korea. Of the suggested components listed in the AHA scienti c statement, information about scheduling post-discharge clinic appointments and patient education on self-care was available in the medical records. The days of the patient's rst clinic visit after discharge were computed. The educational contents about HF before discharge were also abstracted from the medical records and categorized as follows: pathophysiology, medication, low sodium diet, symptom management, and exercise.
The signi cant role of caregivers in the self-care of patients with HF is well-known [9,10], and the American Association of Heart Failure Nurses' position paper clearly states the importance of family involvement in educating patients [11]. Therefore, information about the participation of family caregivers in patient education is also included as one of the discharge process factors. Patients with medical records indicating the participation of family members during patient education were considered to have the participation of family caregivers in their education.
HF event-free survival. The outcome of this study was de ned as the composite end point of time to the rst HF-related event, which was composed of HF-related death, rehospitalization, or ED visit due to HF exacerbation over 2 years after the index hospitalization. This information was abstracted from patients' electronic medical records after the index hospitalization was reviewed for up to 2 years.
Demographic and clinical information. For the demographic information, age, sex, education level, and living arrangement (living alone vs. living with others) were collected. For the clinical information, data on left ventricular ejection fraction, etiology of HF, changes in weight between admission and discharge, the number and names of the discharge medications, and comorbid conditions were collected. Comorbidity burden was measured using the Charlson comorbidity index (CCI) [12].

Data analysis
To compare the patients' demographic and clinical information and information related to the discharge process between patients with and without HF-related events, an independent t-test or chi-square test was conducted, as appropriate.
Multivariable Cox proportional hazards regression was used to examine whether HF event-free survival was predicted by discharge process factors (i.e., days of post-discharge clinic appointment, the number of educational contents about HF before discharge in which the patients received, and the participation of family members during patient education). Covariates included in the multivariable Cox proportional hazards regression model were age, education level, living arrangement, comorbidity burden measured with the CCI, and changes in weight between admission and discharge. All statistical analyses were performed using SPSS, version 20.0, software (IBM SPSS). Statistical signi cance was set at p < 0.05.

Sample characteristics
A total of 201 patients were included, with more women than men. The mean age was 70.8 years (SD= 13.6), and the majority had below high school education (67.2%) and lived with others (86.1%). The majority of the patients had a non-ischemic HF etiology with a reduced ejection fraction. Patients stayed on an average of 8.6 days ( Table 1). When comparing the characteristics between patients with and without HF-related events, patients with HF-related events were more likely to be older and have higher CCI scores than those without HF-related events (p <0.05). NT-pro BNP, N-terminal pro-brain natriuretic peptide; ACEi/ARB, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker †=The distribution was skewed, and p-values were obtained based on log-transformed values.
* The changes in weight between admission and discharge were computed by subtracting admission weights from discharge weights.

Discharge process factors
On average, the post-discharge clinic appointments were scheduled for approximately 8 days (SD= 2.9) after discharge ( Table 2). Approximately 60% of the patients were scheduled for post-discharge clinic appointments within one week of discharge. Almost all patients (99%) were scheduled within two weeks of discharge. All patients received HF education before discharge, except for 10 patients (5%). The HF educational content that was most frequently covered was related to medications (94.0%), followed by symptom management (41.8%), exercise (15.4%), low sodium diet (12.9%), and pathophysiology (1.5%). More than two-thirds of the patients (69.7%) were educated with their family members. When comparing the discharge process factors between patients with and without HF-related events, there were no differences, except that the patients with HF-related events received education about pathophysiology ( Table 2). During the follow-up period (a median of 699 days), one patient died due to HF-related reasons, and 40 patients had at least one of the following HF-related events: HF-related ED visits or readmissions.
In the Cox regression model, after adjustments were made for covariates, patients without family presence during the education were 2.1 times more likely to have a shorter length of HF event-free survival (hazard ratio, 2.105; 95% con dence interval, 1.004-4.412). Age and CCI were predictive of HF event-free survival among the covariates included in the Cox regression model. Older age and higher CCI were associated with an increased risk of HF-related events (Table 3).

Discussion
This study examined whether discharge process factors were associated with HF event-free survival. We found that the participation of families in patient education was related to HF event-free survival, but not in either the days of post-discharge clinic appointments or the number of educational contents about HF before discharge. This result implies that learning more about HF and its management is helpful for family members to help patients manage HF, which can contribute to preventing adverse prognosis.
The immediate post-discharge period has been termed as the "vulnerable phase" of hospitalization for HF [13]. A successful discharge process for this period as part of a transitional care program can help patients avoid preventable rehospitalization. In the United States, the Centers for Medicare and Medicaid Services have implemented several programs to decrease avoidable readmissions by improving the quality of care transitions when patients are discharged from the hospital [14]. One of the important quality measures for care transition is patient discharge education. According to a systematic review and meta-analysis by Fischer et al., the overall effect of providing HF discharge instructions on time during repeated hospitalizations in patients with HF was not signi cant. Similarly, in our study, the number of educational contents about HF before discharge was not associated with the time to HF-related events [15]. However, these results from our study and the study by Fischer and colleagues need to be cautiously interpreted. First, only three studies were included to estimate the pooled effect of discharge instructions in the study by Fischer et al. Second, the academic medical center where the data were collected for our study did not provide any guidelines to nurses on how to provide education for patients and with what contents. Nurses are in an ideal position to contribute to outcomes in the discharge process, especially in discharge education [3]. However, due to the lack of guidelines, patients in our study received HF education verbally in an inconsistent manner from their nurses. Previous studies have suggested the importance of a comprehensive understanding of HF, its symptoms, and self-care when providing patient education [16,17]. Therefore, the lack of a relationship between the number of educational contents and HF-related events in our study may be due to the poor quality of discharge education to patients.
The inclusion of families in discharge education and planning is required in some US states [18]. Investigators have described the important role of social support in HF management [9,10] and suggest the inclusion of informal caregivers in patient discharge education [11]. This claim is further supported by our nding that family members participate in patient discharge education. Living with others was not associated with event-free survival in our study. This nding appears to contradict the positive effect of family participation and HF management in that living with someone is often considered a proxy for social support. However, informal caregivers' negative effects on patients' self-care have been described when informal caregivers are not knowledgeable about HF management [19]. Therefore, our ndings further highlight the importance of family involvement in patient education for family members to adequately support patients' HF management after discharge.
An early post-discharge clinic appointment within the rst week of discharge is recommended according to a scienti c statement from the AHA [8]. Most of the patients in our study were scheduled to see their cardiologists within one week, and there were no differences in days to post-discharge clinic appointments between patients with and without HF-related events. This may have led to the nonsigni cant association between days to post-discharge clinic appointments after discharge and HFrelated events in our study.
This study has some limitations. Data were collected by reviewing medical records. Because information in the medical records depend on clinicians' documentation, certain information may not be available or incomplete. For example, information about the participation of family members during discharge education was available; however, their relationship with the patients was unavailable. This study was conducted in a single academic medical center, which may limit the generalizability of our ndings.

Conclusion
Our results suggest that family involvement in patient discharge education is important for improving the prognosis after discharge from the hospital. Family members may not be able to physically present during patient education, especially when a family is employed. To address this issue, nurses can create innovative strategies to promote family members' participation in patient education, such as using an online platform for video conferencing. Our results also showed that there was no relationship between the number of educational contents covered and patient prognosis. However, this result should be cautiously interpreted as the education given to patients is not evidence-based or guideline-based. Therefore, it is important to develop strategies for improving the quality of discharge education for patients with HF in Korea, where no system level supports (e.g., reimbursement) are available.