The number of patients with Heart Failure (HF) continues to increase worldwide, and this number is expected to increase owing to the aging population and advances in medical treatment [1, 2]. However, despite improvements in HF therapy, HF-related events, such as rates of readmission and Emergency Department (ED) visits, remain high [3], with short-term readmission rates ranging from 20% to 25%[4]. In addition, because of the cost of repeated hospitalizations, HF is considered a burden on health-care resources [1, 2, 5].

Researchers have investigated the factors related to poor prognosis (e.g., readmission) in patients with HF. A recent systematic review of models was conducted to predict the risk of readmission in patients with HF [6]. The predictors included in the predictive models for HF were grouped into three categories: clinical (e.g., laboratory values and vital signs), administrative (e.g., demographic variables), and psychosocial (e.g., psychiatric comorbidities and substance abuse). However, the predictive accuracy of these models ranges from poor to acceptable. In addition, it should be noted that the factors included in the predictive models were non-modifiable. This finding implies that additional modifiable factors should be considered to improve the predictive power of the prognosis of patients with HF who are discharged from the index hospital.

Transitional care includes interventions designed to prevent readmission among patients from one care setting to another [7]. Potentially modifiable factors, including those related to transitional care, are often related to the discharge process, such as education and follow-up visits. In addition, transitioning between inpatient and outpatient settings is critical for improving patient outcomes in cases such as HF-related events [3]. Therefore, this study aims to explore the relationship between factors related to the discharge process and HF-related prognosis among patients admitted to the hospital because of HF exacerbation in two years. In this study, prognosis is defined as the composite endpoint of death, rehospitalization, or ED visits because of HF (i.e., HF event-free survival).

This study examined whether discharge process factors are associated with HF event-free survival. We found that the participation of family members in patient educational sessions was related to longer HF event-free survival but was not related to either the number of days to follow-up visits or educational contents received before discharge. This result implies that when learning more about HF and HF management, it is helpful for family members to be educated as well so that they can help patients manage HF and potentially prevent adverse prognoses.

The immediate post-discharge period is called 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 transition when patients are discharged from hospitals [14]. One of the most important quality measures in 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 the time during repeated hospitalizations in patients with HF was not significant [15]. Similarly, in our study, the amount of educational content on HF before discharge was not associated with time to HF-related events.

Despite the significance of having family members present during educational sessions, the results of our study and that by Fischer et al. should be interpreted with caution. First, only three studies were included in Fischer et al.’s study to estimate the pooled effect of the discharge instructions. Second, the academic medical center where the data were collected for our study had no guidelines for nurses on how to educate patients and what content should be included. Nurses are in an ideal position to contribute to the outcomes of the discharge process, particularly discharge education [3]. However, given the lack of guidelines, the patients in our study only received verbal HF education from their nurses in an inconsistent manner.

Previous studies have suggested the importance of providing patient education so that patients have a comprehensive understanding of HF, symptoms, and self-care [16, 17]. However, in our study, education about a low-sodium diet, symptom management, and exercise was not provided to the majority of patients with HF. Thus, the lack of association between the number of discharge educational content received and HF-related prognosis might be explained in part by the limited educational content or quality of teaching strategies. To improve the quality of discharge education, system-level support, such as developing and standardizing educational content and training nurses on how to teach patients the necessary knowledge and skills to manage HF, is required. Because nurses play a key role in patient education, they can take the initiative to improve transitional care for patients with HF in Korea. In particular, they should adapt the recommendations developed in the United States [8] for transitional care of patients with HF in Korea.

Including families in discharge education and planning sessions is mandatory in some areas of the United States [18]. Specifically, investigators have described the important role of social support in HF management [9, 10] and have suggested that informal caregivers should be included in inpatient discharge education [11]. Our findings further support the claim that family members who participated in inpatient discharge education usually had better outcomes. However, simply living with others was not associated with event-free survival in the present study, which appeared to contradict the positive effect of family caregivers’ presence during discharge education on HF management, as living with someone was often considered a proxy for social support. A few studies have found a negative effect on patients’ self-care when informal caregivers are not knowledgeable about HF management [19]. For example, in one study, when patients with HF informed others, including their family members, about their worsening symptoms, some family members suggested that the patient should relax and gave other inappropriate advice about the patients’ symptom status, which resulted in a delay in seeking care [20]. In addition, caregivers’ preparedness to meet patients’ physical and emotional needs was associated with their contribution to self-care in HF [21]. Our findings further highlight the importance of family caregivers’ presence in discharge education, along with patients, to be helpful for the better management of HF. However, the point estimate of the presence of family caregivers during discharge education may not be reliable given that the 95% confidence interval is relatively wide owing to the small number of HF-related events in our study.

An early follow-up appointment within the first week of discharge is recommended by the AHA [8]. Most patients in our study were scheduled to visit their cardiologists within one week, and there were no differences in the number of days to follow-up visits between patients with and without HF-related events. This finding demonstrates an overall high adherence rate to follow-up visit scheduling after hospital discharge in patients with HF.

Furthermore, we found that patients with HF-related events were more likely to be older than those without HF-related events. Numerous studies have identified age as a risk factor for poor HF-related prognosis after discharge from index hospitalization [22, 23, 24]. Given the significant relationship between age and an adverse prognosis in patients with HF, it may be more important to promote the participation of family members of older patients in discharge education, as older patients may experience difficulty understanding the content.

This study has some limitations. Data were collected only by reviewing medical records. Because the information in medical records depends on clinician documentation, certain information may not be available, or records may be incomplete. For example, detailed information about family members who participated in discharge education, such as their relationship with the patient, family members’ level of HF knowledge, and whether family members lived with the patients, was unavailable. The number or length of educational sessions was also unavailable in the medical records. Because there are no formal discharge education guidelines for HF in the study hospital (based on a review of medical records) and most hospitals in Korea, it is unknown whether nurses tailored the depth of educational content and the number of education sessions depending on the patient’s situation (e.g., de novo HF vs. chronic HF). The functional status level at hospital discharge (e.g., New York Heart Association functional class), which can be an important predictor of HF-related events, was also unavailable because the information was not routinely recorded in medical records. In addition, we did not collect information on whether the patients had acute de novo HF or chronic HF exacerbations associated with readmission. Finally, this study was conducted at a single academic medical center, which might limit the generalizability of the findings.

This study aimed to explore the factors associated with the discharge process of event-free survival in patients with HF. The presence of family caregivers in educational sessions was found to be a protective factor against adverse prognosis in patients with HF. Our results highlight the importance of family engagement in managing HF. Therefore, clinicians should develop strategies to increase the participation of family members in the discharge process. However, no relationship was found between the educational content and patient prognosis. This result should be interpreted with caution because critical information related to education (e.g., depth of content and education modalities) was unavailable in the medical records. Therefore, further studies are required to examine the relationship between the discharge process and prognosis of patients with HF.