Polypharmacy and Clinical Outcomes in Hospitalized Patients With Acute Decompensated Heart Failure

BACKGROUND: Polypharmacy is a common problem among patients with acute decompensated heart failure (ADHF) who often have multiple comorbidities. OBJECTIVE: The aim of this study was to define the number of medications at hospital discharge and whether it is associated with clinical outcomes at 1 year. METHODS: We evaluated the number of medications in 2578 patients with ADHF who were ambulatory at hospital discharge in the Kyoto Congestive Heart Failure Registry and compared 1-year outcomes in 4 groups categorized by quartiles of the number of medications (quartile 1, ≤ 5; quartile 2, 6-8; quartile 3, 9-11; and quartile 4, ≥ 12). RESULTS: At hospital discharge, the median number of medications was 8 (interquartile range, 6-11) with 81.5% and 27.8% taking more than 5 and more than 10 medications, respectively. The cumulative 1-year incidence of a composite of death or rehospitalization (primary outcome measure) increased incrementally with an increasing number of medications (quartile 1, 30.8%; quartile 2, 31.6%; quartile 3, 39.7%; quartile 4, 50.3%; P < .0001). After adjusting for confounders, the excess risks of quartile 4 relative to those of quartile 1 remained significant (P = .01). CONCLUSIONS: In the contemporary cohort of patients with ADHF in Japan, polypharmacy at hospital discharge was common, and excessive polypharmacy was associated with a higher risk of mortality and rehospitalizations within a 1-year period. Collaborative disease management programs that include a careful review of medication lists and an appropriate deprescribing protocol should be implemented for these patients

Risk Factors and Clinical Outcomes of Nonhome Discharge in Patients With Acute Decompensated Heart Failure: An Observational Study

Background: No clinical studies have focused on the factors associated with discharge destination in patients with acute decompensated heart failure. Methods and Results: Of 4056 consecutive patients hospitalized for acute decompensated heart failure in the KCHF (Kyoto Congestive Heart Failure) registry, we analyzed 3460 patients hospitalized from their homes and discharged alive. There were 3009 and 451 patients who were discharged to home and nonhome, respectively. We investigated the factors associated with nonhome discharge and compared the outcomes between home discharge and nonhome discharge. Factors independently and positively associated with nonhome discharge were age ≥80 years (odds ratio [OR], 1.76; 95% CI, 1.28–2.42), body mass index ≤22 kg/m2 (OR, 1.49; 95% CI, 1.12–1.97), poor medication adherence (OR, 2.08; 95% CI, 1.49–2.88), worsening heart failure (OR, 2.02; 95% CI, 1.46–2.82), stroke during hospitalization (OR, 3.74; 95% CI, 1.75–8.00), functional decline (OR, 12.24; 95% CI, 8.74–17.14), and length of hospital stay >16 days (OR, 4.14; 95% CI, 3.01–5.69), while those negatively associated were diabetes mellitus (OR, 0.69; 95% CI, 0.51–0.94), cohabitants (OR, 0.62; 95% CI, 0.46–0.85), and ambulatory state before admission (OR, 0.25; 95% CI, 0.18–0.36). The cumulative 1‐year incidence of all‐cause death was significantly higher in the nonhome discharge group than in the home discharge group. The nonhome discharge group compared with the nonhome discharge group was associated with a higher adjusted risk for all‐cause death (hazard ratio, 1.66; P<0.001). Conclusions: The discharge destination of patients with acute decompensated heart failure is influenced by factors such as prehospital social background, age, body mass index, low self‐care ability, events during hospitalization (worsening heart failure, stroke, etc), functional decline, and length of hospital stay; moreover, the prognosis of nonhome discharge patients is worse than that of home discharge patients. Registration Information: clinicaltrials.gov. Identifier: NCT02334891

A comparison between hospital follow‐up and collaborative follow‐up in patients with acute heart failure

AIMS: There are no previous studies focusing on collaborative follow-ups between hospitals and clinics for patients discharged after acute heart failure (AHF) in Japan. The purpose of this study was to determine the status of collaboration between hospitals and clinics for patients with AHF in Japan and to compare patient characteristics and clinical outcomes using a large Japanese observational database. METHODS AND RESULTS: Of 4056 consecutive patients hospitalized for AHF in the Kyoto Congestive Heart Failure registry, we analysed 2862 patients discharged to go home, who were divided into 1674 patients (58.5%) followed up at hospitals with index hospitalization (hospital follow-up group) and 1188 (41.5%) followed up in a collaborative fashion with clinics or other general hospitals (collaborative follow-up group). The primary outcome was a composite of all-cause death or heart failure (HF) hospitalization within 1 year after discharge. Previous hospitalization for HF and length of hospital stay longer than 15 days were associated with hospital follow-up. Conversely, ≥80 years of age, hypertension, and cognitive dysfunction were associated with collaborative follow-up. The cumulative 1-year incidence of the primary outcome, all cause death, and cardiovascular death were similar between the hospital and collaborative follow-up groups (31.6% vs. 29.6%, P = 0.51, 13.1% vs, 13.9%, P = 0.35, 8.4% vs. 8.2%, P = 0.96). Even after adjusting for confounders, the difference in risk for patients in the hospital follow-up group relative to those in the collaborative follow-up group remained insignificant for the primary outcome, all-cause death, and cardiovascular death (HR: 1.11, 95% CI: 0.97-1.27, P = 0.14, HR: 1.10, 95% CI: 0.91-1.33, P = 0.33, HR: 0.96, 95% CI: 0.87-1.05, P = 0.33). The cumulative 1-year incidence of HF hospitalization was higher in the hospital follow-up group than in the collaborative follow-up group (25.5% vs. 21.3%, P = 0.02). The risk of HF hospitalization was higher in the hospital follow-up group than in the collaborative follow-up group (HR: 1.19, 95% CI: 1.01-1.39, P = 0.04). CONCLUSIONS: In patients hospitalized for AHF, 41.5% received collaborative follow-up after discharge. The risk of HF hospitalization was higher in the hospital follow-up group than in the collaborative follow-up, although risk of the primary outcome, all-cause death, and cardiovascular death were similar between groups

看護基礎教育にコミュニティ・オブ・プラクティスの考えを採り入れた「学びのグループゼミ」での学生の学び

　看護基礎教育カリキュラムの中に，学生がコミュニティを育みながら，看護実践を学び合えるしかけ（授業「学びのグループゼミ」）を組み入れた．本研究の目的は，「学びのグループゼミ」において学生の学習がどのように促進されたか，そのプロセスを明らかにすることである．2016 年度に「学びのグループゼミ」を受講した学生178 人（2 年生86 人，1 年生92 人）のうち，研究参加に同意が得られた学生162 人のなかから，同意が得られた26 名にインタビューを実施し，質的に分析を行った.　本研究の結果，「学びのグループゼミ」で学生は，以下1．～ 3．を学んでいたことが明らかになった．1．2 年生コアメンバーは，グループメンバーが参加しやすい＜場を創るために試行錯誤する＞，＜グループの変化をとらえる＞，＜グループの成長の役に立てたことを，自身の成長ととらえる＞という学びをしていた．2．2 年生アクティブグループメンバーと周辺グループメンバーは，グループメンバーを＜場に馴染ませ，相互交流を促進する＞，＜自らの実習経験を伝える＞ことを通してグループの役に立てていることを認識し，自らの＜実習経験を共有し，問い直す＞という学びをしていた．3．1 年生コアメンバーとアクティブグループメンバー・周辺グループメンバーは，＜学びのグループゼミへの戸惑いを感じつつ，参加のしかたを模索する＞＜緊張と戸惑いを乗り越え，学びのグループゼミで安心感と充実感を得る＞，＜ 2 年生と自身の体験を重ね合わせ，思考を広げる＞，＜教えられる対象としてだけではない，グループ内での自らの存在価値を見出す＞という学びをしていた．　「学びのグループゼミ」において学生の学びを促進した重要な相互作用として，次の2 点が考察できた．1 点目は，場を創るために試行錯誤したり，グループメンバーを場に馴染ませたり，経験を伝えるなどすることを通して，安心できる場を創ることを学んでいたこと．2 点目は，実習経験を問い直したり，学びのグループにおける存在価値を自ら見出したりすることによって，グループやグループメンバーの役に立てていることを学んでいたことである．学生が共同参加することで学習が促進するようなしかけを看護基礎教育カリキュラムに設けることができれば，知識提供型の学習とは異なる学習が促進される可能性が示唆された