Tohoku J. Exp. Med.

, 2019, 249, 163-171

Dysphagia Hinders Home Discharge in Heart Failure Patients 163

Dysphagia Hinders Hospitalized Patients with Heart Failure from

Being Discharged to Home
Junichi Yokota,1,2 Yoshiko Ogawa,3 Yoshimi Takahashi,4 Nobuhiro Yamaguchi,4
Noriko Onoue,4 Tsuyoshi Shinozaki4 and Masahiro Kohzuki1
1
Department of Internal Medicine and Rehabilitation Science Disability Science, Tohoku University Graduate
School of Medicine, Sendai, Miyagi, Japan
2
Department of Rehabilitation, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan
3
Department of Sport and Medical Sciences, Teikyo University, Hachioji, Tokyo, Japan
4
Department of Cardiology, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan

Dysphagia, defined as a dysfunction in any stage or process of eating, is common among heart failure (HF)
patients. In some diseases state, dysphagia hinders patients from being discharged to home. However, it
remains unclear whether dysphagia affects discharge disposition of HF patients. This study aimed to
identify the impact of dysphagia on discharge disposition of HF patients. A total of 323 patients,
hospitalized with acute exacerbation of HF, were eligible for the study (excluding patients who lived at
nursing care facilities before admission). Following the withdrawal of 37 patients, a total of 286 patients
were analyzed. Dysphagia was determined using the functional oral intake scale (FOIS), which evaluates
a patient’s ability to swallow. The FOIS is a 7-point scale, with a level of ≤ 5 indicating dysphagia. Of the
286 patients analyzed, 231 (80.8%) were discharged to home, and 55 were discharged to nursing care
facilities or rehabilitation hospitals (non-home). FOIS level was significantly lower, and dysphagia incidence
was significantly higher among patients discharged to non-home than among those discharged to home.
Multivariate analysis showed that FOIS level was an independent predictor of discharge disposition.
Additionally, after propensity score matching, which was performed to adjust for baseline characteristics,
FOIS level remained significantly lower in patients discharged to non-home than in those discharged to
home. In conclusion, dysphagia hinders patients hospitalized with HF from being discharged to home. We
conclude that evaluating dysphagia and its severity on admission is useful for predicting discharge
disposition in patients hospitalized with HF.

Keywords: discharge disposition; dysphagia; functional oral intake scale; heart failure; swallowing function
Tohoku J. Exp. Med., 2019 November, 249 (3), 163-171.  © 2019 Tohoku University Medical Press

In the broad sense, the term “dysphagia” refers to the

Introduction dysfunction in any stage or process of eating (the pre-oral,
Heart failure (HF) is a global problem and is defined oral, pharyngeal, and esophageal phase) (Clark et al. 2007).
by the inability of the heart to pump sufficient blood to the Eating is a complex activity that requires effective and
tissues of the body. In Japan, the number of HF patients is coordinated function of the motor, sensory, and cognitive
increasing due to the aging population (Shimokawa et al. systems. Therefore, dysphagia can be caused by neurologi-
2015). Some elderly patients hospitalized with cardiovas- cal, muscular, and cognitive impairment concomitant with
cular disorders, such as post-cardiac surgery, acute myocar- various disease states, aging, surgical intervention, intuba-
dial infarction, and peripheral artery disease, cannot be dis- tion, and other conditions. Elderly people often have vari-
charged to their homes and are forced to be admitted to ous physical and cognitive impairments associated with the
nursing care facilities or rehabilitation hospitals (Sansone et aging process, and dysphagia is a common and significant
al. 2002; Sasanuma et al. 2015). Previous studies have problem among this demographic group (Hansen et al.
reported that advanced age, lower body mass index (BMI), 2011).
a higher number of comorbidities, and lower levels of Patients with dysphagia can be screened for using a
activities of daily living (ADL) prevent patients with car- questionnaire (Belafsky et al. 2008), a repetitive saliva
diovascular disorders from being discharged to home swallowing test (RSST) (Oguchi et al. 2000a, b) and a
(Sansone et al. 2002; Sasanuma et al. 2015). water swallowing test (WST) (Tohara et al. 2003) and can
Received July 22, 2019; revised and accepted October 23, 2019. Published online November 14, 2019; doi: 10.1620/tjem.249.163.
Correspondence: Masahiro Kohzuki, M.D., Ph.D., Department of Internal Medicine and Rehabilitation Science Disability Science,
Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan.
e-mail: [email protected]

163
164 J. Yokota et al.

be diagnosed using videofluoroscopic and videoendoscopic ment in the study. After registration, the baseline characteristics of
evaluation of swallowing. However, depending on their the patients were collected. Swallowing function was evaluated when
clinical condition, not all patients are able to take these the attending physicians allowed patients to eat and drink. The dis-
examinations. The functional oral intake scale (FOIS) is an charge disposition (the final place to which the patient was dis-
evaluation method for swallowing (Crary et al. 2005). The charged) was recorded on the day of discharge. During the follow-up
period, 37 patients were withdrawn due to death, transfer to other
FOIS is a 7-point scale that measures the level of indepen-
departments, cardiovascular surgery, or stroke. This led to a final
dent functional oral intake (Table 1). Since the use of FOIS
analysis of 286 patients.
is non-invasive, it can be used in all patients regardless of
This study was approved by the Ethics Committee of Tohoku
their clinical condition. Moreover, the FOIS can evaluate University Graduate School of Medicine (Approval No. 2015-1-060)
the severity of dysphagia, with clinically significant dys- and the Ethics Committee of National Hospital Organization Sendai
phagia being defined as the requirement for modification of Medical Center (Approval No. 27-1). All participating patients pro-
an oral diet (FOIS level ≤ 5) (Maeda and Akagi 2015). vided written informed consent.
Dysphagia is a common comorbidity in patients with
HF, with 36.1% of patients hospitalized with acute exacer- Patient Characteristics on admission
bation of HF also showing symptoms of dysphagia (Yokota Clinical data, including age, sex, height, weight, BMI, medical
et al. 2016). Previous studies have demonstrated that dys- history, complications, medications, the number of people living
phagia hinders patients hospitalized with certain diseases together, New York Heart Association (NYHA) class, ejection frac-
from being discharged to home. In acute stroke patients tion (EF), and blood chemistry data were obtained on admission.
with dysphagia, compared with patients without dysphagia, NYHA class, an index of heart failure severity, was diagnosed by car-
the percentage of patients who were not discharged to home diologists.
was increased by 36% (Joundi et al. 2017). Moreover, in Cognitive function was evaluated using the mini-mental state
examination (MMSE) (Folstein et al. 1975). Physical function was
survivors of critical illness and critical illness with neuro-
evaluated by handgrip strength (Izawa et al. 2004), the modified spe-
logic impairment (Macht et al. 2011, 2013), the presence of
cific activity scale (MSAS; modified from the specific activity scale
post-extubation dysphagia has been found to increase the
(Goldman et al. 1981) to improve sensitivity and specificity) (Adachi
percentage of patients who are not discharged to home (by et al. 2009), and the Barthel index (BI) (an evaluation scale of ADL)
29% and 14%, respectively) in comparison with patients (Mahoney and Barthel 1965). Controlling nutritional status
without post-extubation dysphagia. However, it remains (CONUT) (Ignacio de Ulibarri et al. 2005), arm circumference (AC),
unclear whether dysphagia affects discharge disposition in and triceps skin fold (TSF) (Hosoya et al. 2001) were measured to
HF patients. This study aimed to identify the impact of evaluate nutritional status. CONUT is a nutritional assessment tool
dysphagia on the discharge disposition of hospitalized that assesses protein metabolism, lipid metabolism, and immune
patients with HF. function and is calculated using three parameters: serum albumin,
total cholesterol, and total lymphocyte count. CONUT consists of a
Materials and Methods 12-point scale; a score of 0-1 indicates normal nutrition, 2-4 indicates
Subjects and Study Design mild malnutrition, 5-8 indicates moderate malnutrition, and > 7 indi-
This study used a longitudinal design, as shown in the study cates severe malnutrition. AC and TSF data were standardized
protocol (Fig. 1). In total, 412 patients were hospitalized at the according to age and sex-stratified Japanese anthropometric reference
Department of Cardiology with acute exacerbation of HF from May data and expressed as percentage AC (%AC) and percentage TSF
2015 to October 2018. HF was diagnosed by cardiologists based on (%TSF) (Hosoya et al. 2001). Cognitive function, physical function,
the guidelines of the Japan Circulation Society (Tsutsui 2017). and nutritional status were evaluated by physiotherapists and occupa-
Patients excluded were those aged < 20 years (n = 0), those who lived tional therapists.
in nursing care facilities before admission (n = 19), and those unable
to follow instructions due to severe mental disorders, severe demen- Swallowing Function
tia, or agitation (n = 20). A further 50 patients did not provide con- Dysphagia was evaluated using FOIS. Based on a previous
sent to participate, leaving a total of 323 patients eligible for enroll- study, dysphagia was defined as a FOIS level ≤ 5 (Maeda and Akagi

Table 1. Functional Oral Intake Scale.

Level 1 Nothing by mouth.
Level 2 Tube dependent with minimal attempts of food or liquid.
Level 3 Tube dependent with consistent oral intake of food or liquid.
Level 4 Total oral diet of a single consistency.
Level 5 Total oral diet with multiple consistencies,
but requiring special preparation or compensations.
Level 6 Total oral diet with multiple consistencies without special preparation,
but with specific food limitations.
Level 7 Total oral diet with no restrictions.
 Dysphagia Hinders Home Discharge in Heart Failure Patients 165

Fig. 1. Study protocol.

A total of 412 patients were admitted to the Department of Cardiology with acute exacerbation of heart failure. Those
excluded from the study were patients aged < 20 years, those living in nursing care facilities before admission, and
those unable to follow instructions. A further 50 patients did not provide consent to participate. Thus, 323 patients were
eligible for the study. After registration, the baseline characteristics of these patients were collected. Swallowing func-
tion was evaluated when the attending physicians allowed patients to eat and drink. The discharge disposition was
recorded at discharge. Due to the withdrawal of 37 patients, 286 patients were analyzed.

2015). Additionally, swallowing function was evaluated using RSST Data and Statistical Analysis
and WST. These were performed to assess general pharyngeal func- Patients were divided into two groups based on their discharge
tion in swallowing. RSST assesses the ability to swallow saliva. The disposition: those discharged to home (home group), and those dis-
test was performed by counting the frequency of swallowing over 30 charged to nursing care facilities or rehabilitation hospitals (non-home
seconds. The swallowing function of the patients was judged as group). All data are expressed as the mean ± standard deviation for
abnormal when the number of dry swallows was less than 3 within 30 continuous variables, and as counts and percentages for categorical
seconds. The WST assessed the ability to swallow water. The WST variables. Comparisons between groups were made using an unpaired
was performed by placing cold water (3 ml) on the floor of the mouth two-tailed t-test for continuous variables and the chi-square test for
and instructing the patient to swallow. If the patient was unable to categorical variables. The independent predictors of discharge to
swallow, or experienced dyspnea, coughing, or wet-hoarse dysphonia home were assessed using logistic regression analysis. Variables that
after swallowing, the test was concluded and a score was judged (1 showed significant differences between groups in the univariate anal-
for inability to swallow, 2 for dyspnea, and 3 for cough or dysphonia). ysis were entered into a logistic regression model, and multicollinear-
Otherwise, the patient was asked to perform two dry swallows. If the ity was assessed using the variance inflation factor (VIF) (Glantz and
patient was unable to perform either of these, a score of 4 was Slinker 2001). VIF values exceeding 10 were considered indicative
assigned. If the patient was able to complete the dry swallowing of serious multicollinearity (Glantz and Slinker 2001). Predictors
challenge, a score of 5 was assigned. The entire procedure was were expressed as odds ratios with 95% confidence intervals.
repeated a total of three times. The swallowing function of the patient Moreover, the cut-off values were assessed using a receiver operating
was determined to be abnormal when the score was less than 4. characteristic (ROC) curve.
Swallowing function was evaluated by physicians, nurses, and Additionally, to adjust for significant differences in baseline
speech-language-hearing therapists. characteristics between the home and non-home groups, we con-
ducted propensity score matching by a logistic regression model
Rehabilitation Intervention based on the following variables: age, sex, height, weight, NYHA
The number of patients who had undergone physical therapy or class, EF, blood chemistry parameters (excluding albumin and trans-
swallowing therapy during hospitalization was checked using elec- thyretin), MMSE, handgrip strength, MSAS, BI, %AC, and %TSF.
tronic medical records. The discrimination capability of this model was evaluated using
166 J. Yokota et al.

c-statistics (0.887). The propensity score matching was performed in Predictors of discharge to home
a 1 to 1 manner, with a caliper width of 0.25. The clinical character- Table 4 shows the predictors for discharge to home.
istics of the two matched groups were compared. Variables that showed significant differences between
All analyses were performed using JMP version 13.1.0 (SAS groups in the univariate analysis were entered, and there
Institute, Cary, NC, USA). Statistical significance was determined as were no variables that had VIF values that exceeded 10.
a P value of < 0.05.
Significant differences were seen in FOIS level, handgrip
strength, and %TSF. Additionally, the cut-off values for
Results
predicting discharge to home were evaluated using a ROC
Patient Characteristics on admission curve. Values are shown in Table 5.
Among the 286 patients, 231 (80.8%) were discharged
to home (home group) and 55 were discharged to nursing Comparison between the groups after propensity score
care facilities or rehabilitation hospitals (non-home group). matching
Table 2 shows the patient characteristics on admission in After propensity score matching was performed, FOIS
both groups. Age and percentage of females were signifi- level remained significantly lower, and the percentage of
cantly higher while height, weight, and BMI were signifi- patients with FOIS level ≤ 5 remained significantly higher
cantly lower in the non-home group than in the home in the non-home group than in the home group. The per-
group. The percentage of patients with a medical history of centage of patients with a positive RSST was significantly
dementia was significantly higher in the non-home group higher, and WST scores were significantly lower in the non-
than in the home group. Albumin level was significantly home group than in the home group. Length of hospital
lower in the non-home group than in the home group. stay was significantly prolonged in the non-home group in
There were no significant differences in the number of peo- comparison with the home group. There were no signifi-
ple living together, NYHA class, EF, and blood chemistry cant differences in the other parameters between the groups
data (excluding albumin) between the two groups. In this (Tables 6 and 7).
study, 111 patients (38.8%) were diagnosed with HF with
preserved EF (≥ 50%), of which 88 patients were in the Discussion
home group (38.1%) and 23 were in the non-home group Dysphagia is a common comorbidity among heart fail-
(41.8%). ure patients and is believed to play a role in hindering
There were no significant differences between the patients from being discharged to home. This study aimed
groups in the days from hospitalization to evaluation in to identify the impact of dysphagia on the discharge dispo-
terms of cognitive function, physical function, and nutri- sition of patients with HF
tional status (home group, 3.5 ± 2.6 days vs non-home In the current study, the percentage of patients with
group, 4.1 ± 3.4 days, P = 0.232). All indexes of cognitive dysphagia was higher in hospitalized HF patients who were
function, physical function, and nutritional status (excluding discharged to nursing care facilities or rehabilitation hospi-
CONUT) were significantly lower in the non-home group tals than those who were discharged to home. Moreover,
than in the home group. this study clarified that FOIS level was an independent pre-
dictor of discharge to home in patients hospitalized with
Swallowing Function acute exacerbation of HF, with a FOIS level > 5 indicating
There was no significant difference in the number of a high chance of being discharged to home. In a previous
days between hospital admission and swallowing assess- study, dysphagia was defined as having a FOIS level ≤ 5
ment between the two groups (home group, 2.7 ± 1.9 days (Maeda and Akagi 2015). Therefore, this study demon-
vs non-home group, 3.0 ± 2.4 days, P = 0.403). The FOIS strates the correlation between dysphagia and discharge
level was significantly lower and the percentage of patients disposition and indicates that dysphagia hinders patients
with FOIS level ≤ 5 was significantly higher in the non- hospitalized with HF from being discharged to home.
home group than in the home group. The percentage of Based on multivariate analysis, handgrip strength and
patients with a positive RSST was significantly higher, and %TSF were also independent predictors of discharge to
the WST score was significantly lower in the non-home home in patients hospitalized with acute exacerbation of
group than in the home group (Table 2). HF. However, after propensity score matching, which was
performed to adjust for the baseline characteristics that can
Outcomes and Rehabilitation Intervention affect discharge disposition in HF, handgrip strength and
Length of hospital stay was significantly longer in the %TSF were not significantly different between HF patients
non-home group than in the home group. The percentage of either discharge disposition. On the other hand, FOIS
of patients provided with physical therapy or swallowing level was significantly lower in HF patients who discharged
therapy interventions was significantly higher in the non- to nursing care facilities or rehabilitation hospitals, and the
home group than in the home group (Table 3). percentage of patients with a FOIS level ≤ 5 remained sig-
nificantly higher after propensity score matching.
Additionally, the results of the evaluation of swallowing
 Dysphagia Hinders Home Discharge in Heart Failure Patients 167

Table 2. Patient characteristics on admission.

Home (n = 231) Non-home (n = 55) P value
Basic characteristics
Age (years) 79.3 ± 10.1 85.1 ± 9.4 < 0.001
Sex (male/female) 109 / 122 15 / 40 0.010
Height (cm) 155.6 ± 10.1 151.3 ± 10.0 0.004
Weight (kg) 58.8 ± 12.8 49.9 ± 11.8 < 0.001
BMI (kg/m2) 24.2 ± 4.4 21.8 ± 4.4 < 0.001
Medical history
Angina pectoris 60 (26.0) 9 (16.4) 0.162
Myocardial infarction 32 (13.9) 8 (14.5) 0.894
Valvular disease 52 (22.5) 12 (21.8) 0.912
Cerebrovascular disease 52 (22.5) 11 (20.0) 0.686
Neuromuscular disease 4 (1.7) 1 (1.8) 0.965
Respiratory disease 21 (9.1) 3 (5.5) 0.382
Cancer 44 (19.0) 8 (14.5) 0.437
Dementia 17 (7.4) 13 (23.6) < 0.001
Complication
Diabetes 103 (44.6) 22 (40.0) 0.538
Hypertension 175 (75.8) 37 (67.3) 0.197
Dyslipidemia 71 (30.7) 15 (27.3) 0.615
Medication
ACEI 61 (26.4) 10 (18.2) 0.204
ARB 96 (41.6) 22 (40.0) 0.833
Statin 55 (23.8) 10 (18.2) 0.106
Calcium antagonists 89 (38.5) 18 (32.7) 0.424
Diuretics 215 (93.1) 50 (90.9) 0.775
Beta-blockers 77 (33.3) 12 (21.8) 0.097
Coronary vasodilators 55 (28.2) 16 (28.1) 0.797
Psychotropic drug 13 (5.6) 6 (10.9) 0.222
Anti-dementia drug 14 (6.1) 2 (3.6) 0.482
Number of people living together 1.5 ± 1.2 1.3 ± 1.6 0.473
Clinical and laboratory findings
NYHA class (I /II / III / IV) 7 / 41 / 137 / 46 0 / 5 / 35 / 15 0.172
Ejection fraction (%) 50.9 ± 17.5 53.3 ± 17.8 0.368
NT-proBNP (pg/mL) 9,688.7 ± 13,154.7 12,591.8 ± 12,615.2 0.142
Hemoglobin (g/dL) 11.3 ± 2.4 10.8 ± 1.8 0.102
Total lymphocyte count (/μL) 1,367.7 ± 759.7 1,239.8 ± 758.1 0.263
eGFR (mL/min/1.73m2 ) 48.3 ± 25.3 41.2 ± 27.9 0.068
CRP (mg/dL) 1.8 ± 3.1 2.6 ± 4.1 0.162
Albumin (g/dL) 3.5 ± 0.5 3.4 ± 0.5 0.032
Transthyretin (mg/dL) 17.0 ± 5.5 16.3 ± 5.6 0.350
Total cholesterol (g/dL) 162.0 ± 40.8 167.1 ± 34.6 0.386
Cognitive function, physical function, and nutritional status
MMSE (score) 23.1 ± 4.9 17.9 ± 6.7 < 0.001
Handgrip strength (kg) 20.2 ± 7.7 12.8 ± 6.3 < 0.001
MSAS (METs) 2.2 ± 1.0 1.9 ± 0.5 0.001
BI (score) 56.6 ± 28.5 32.1 ± 24.6 < 0.001
CONUT (score) 3.6 ± 2.4 3.9 ± 2.3 0.479
%AC (%) 104.1 ± 18.9 96.0 ± 15.0 0.003
%TSF (%) 96.2 ± 49.6 70.1 ± 40.6 < 0.001
Swallowing function
FOIS (level) 6.1 ± 1.5 4.3 ± 2.0 < 0.001
Number of patients with FOIS level ≤ 5 51 (22.1) 34 (61.8) < 0.001
RSST positive 51 (22.1) 32 (58.2) < 0.001
WST (score) 4.4 ± 0.9 3.7 ± 0.9 < 0.001
Values are means ± standard deviation or numbers of subjects per group (n) with
percentages.
AC, arm circumference; ACEI, angiotensin converting enzyme inhibitor; ARB,
angiotensin receptor blocker; BI, barthel index; BMI, body mass index; CONUT,
controlling nutritional status; CRP, C-reactive protein; FOIS, functional oral
intake scale; eGFR, estimated glomerular filtration rate; METs, metabolic equiv-
alents; MMSE, mini-mental state examination; MSAS, modified specific activity
scale; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York
Heart Association; RSST, repetitive saliva swallowing test; TSF, triceps skin
fold; WST, water swallowing test.
168 J. Yokota et al.

Table 3. Outcomes and Rehabilitation Interventions.

Home (n = 231) Non-home (n = 55) P value
Outcomes
Length of hospital stay (day) 28.9 ± 15.2 45.4 ± 34.7 0.001
Discharge disposition < 0.001
Home 231 (100.0) 0 (0.0)
Nursing care facility 0 (0.0) 26 (47.3)
Rehabilitation hospital 0 (0.0) 29 (62.7)
Rehabilitation interventions
PT 188 (81.4) 52 (94.5) 0.017
ST 9 (3.9) 16 (29.1) < 0.001
Values are means ± standard deviation or numbers of subjects per group (n) with percentages.
PT, physical therapy; ST, swallowing therapy.

Table 4. Predictors of discharge to home.

β SE Wald P-value OR 95% CI
FOIS (level) –0.422 0.096 19.534 < 0.001 0.655 –0.610- –0.235
Handgrip strength (kg) –0.031 0.031 22.378 0.001 0.863 –0.208- –0.086
%TSF –0.014 0.004 10.654 < 0.001 0.986 –0.022- –0.006
CI, confidence interval; FOIS, functional intake oral scale; OR, odds ratio; SE, standard error; TSF,
triceps skin fold.

Table 5. Cut-off values of discharge to home.

AUC P-value Cut-off Sensitivity Specificity
FOIS (level) 0.749 < 0.001 > 5 level 81.4% 60.0%
Handgrip strength (kg) 0.783 < 0.001 > 12.6kg 87.0% 61.8%
%TSF 0.657 < 0.001 > 85.7% 52.8% 76.4%
AUC, area under curve; CI, confidence interval; FOIS, functional intake oral scale; TSF,
triceps skin fold.

function using RSST and WST were lower in HF patients muscle wasting in elderly patients in various disease states
who discharged to nursing care facilities or rehabilitation (Serra-Prat et al. 2012; Morley 2018). Malnutrition and
hospitals after propensity score matching. These results muscle wasting results in poor ADL, thereby preventing
suggest that dysphagia itself hinders patients hospitalized patients with certain disease states from being discharged to
with acute exacerbation of HF from being discharged to home (Sansone et al. 2002; Sasanuma et al. 2015; Isono et
home. Furthermore, it was demonstrated that the severity al. 2017).
of dysphagia positively correlated with the risk of discharge In this study, the percentage of patients with dysphagia
to nursing care facilities or rehabilitation hospitals in provided with physical therapy was relatively high, but the
patients with acute exacerbation of HF. These new findings percentage of patients provided with swallowing therapy
indicate that a FOIS level can be used for predicting dis- was relatively low. More active intervention to improve
charge disposition and may be valuable in identifying swallowing function may decrease the percentage of
patients who need special interventions. patients with poor ADL and increase the percentage of
The mechanisms by which dysphagia negatively patients with exacerbation of HF that discharge to home.
affects discharge disposition remain unclear. However, pre- This study has several limitations. Firstly, this study
vious studies have reported that in certain disease states, was conducted at a single center, and may not reflect the
dysphagia increases the percentage of patients who cannot findings of all other centers. Secondly, the state of patients
be discharged to home after hospitalization (Macht et al. at discharge, including severity of dysphagia, was not
2011, 2013; Joundi et al. 2017). In the context of this study, examined. Swallowing function may have changed during
dysphagia may cause aggravation of clinical outcomes in hospitalization, and changes in swallowing function may
patients with acute exacerbation of HF, through poor ADL have contributed to discharge disposition. Thirdly, the total
as a result of malnutrition and muscle wasting. Indeed, time and content of cardiac rehabilitation during hospital-
studies have shown that dysphagia causes malnutrition and ization were unclear. Therefore, further studies such as
 Dysphagia Hinders Home Discharge in Heart Failure Patients 169

Table 6. Patient characteristics on admission after propensity score matching.

Home (n = 41) Non-home (n = 41) P value
Basic characteristics
Age (years) 82.3 ± 7.3 84.2 ± 10.0 0.451
Sex (male/female) 11 / 30 13 / 28 0.627
Height (cm) 151.4 ± 9.2 151.7 ± 10.9 0.879
Weight (kg) 52.1 ± 9.8 50.1 ± 12.8 0.667
BMI (kg/m2) 22.8 ± 3.7 21.8 ± 4.4 0.450
Medical history
Angina pectoris 7 (17.1) 8 (19.5) 0.775
Myocardial infarction 6 (14.6) 4 (9.8) 0.500
Valvular disease 9 (22.0) 10 (24.4) 0.794
Cerebrovascular disease 4 (9.8) 8 (19.5) 0.211
Neuromuscular disease 0 (0.0) 1 (2.4) 0.314
Respiratory disease 1 (2.4) 3 (7.3) 0.305
Cancer 10 (24.4) 6 (14.6) 0.265
Dementia 8 (19.5) 8 (19.5) 1.000
Complication
Diabetes 17 (41.5) 16 (39.0) 0.821
Hypertension 32 (78.1) 27 (65.9) 0.219
Dyslipidemia 10 (24.4) 12 (29.3) 0.618
Medication
ACEI 11 (26.8) 7 (17.1) 0.286
ARB 15 (36.6) 18 (43.9) 0.499
Statin 4 (9.8) 7 (17.1) 0.331
Calcium antagonists 16 (39.0) 14 (34.2) 0.424
Diuretics 39 (95.1) 37 (90.2) 0.396
Beta-blockers 11 (26.8) 11 (26.8) 1.000
Coronary vasodilators 10 (24.4) 12 (29.3) 0.618
Psychotropic drug 2 (4.9) 5 (12.2) 0.236
Anti-dementia drug 3 (7.3) 0 (0.0) 0.078
Number of people living together 1.8 ± 1.3 1.5 ± 1.5 0.330
Clinical and laboratory findings
NYHA class (I /II / III / IV) 0 / 3 / 28 / 10 0 / 4 / 28 / 9 0.901
Ejection fraction (%) 50.1 ± 19.0 54.1 ± 18.4 0.344
NT-proBNP (pg/mL) 13,876.8 ± 16,470.7 13,064.5 ± 12,916.9 0.804
Hemoglobin (g/dL) 10.5 ± 2.2 11.0 ± 1.6 0.227
Total lymphocyte count (/μL) 1,233.9 ± 650.3 1,336.1 ± 822.0 0.534
eGFR (mL/min/1.73m2) 43.3 ± 27.5 41.3 ± 28.8 0.756
CRP (mg/dL) 2.2 ± 4.4 2.7 ± 4.5 0.653
Albumin (g/dL) 3.3 ± 0.6 3.4 ± 0.5 0.236
Transthyretin (mg/dL) 15.5 ± 6.1 16.8 ± 5.4 0.300
Total cholesterol (g/dL) 162.1 ± 47.2 170.2 ± 35.9 0.382
Cognitive function, physical performance, nutritional status
MMSE (score) 20.0 ± 5.6 19.1 ± 6.8 0.514
Handgrip strength (kg) 14.7 ± 5.4 14.1 ± 6.6 0.644
MSAS (METs) 2.1 ± 0.9 1.9 ± 0.5 0.258
BI (score) 39.6 ± 23.1 35.0 ± 24.8 0.384
CONUT (score) 4.6 ± 2.9 3.5 ± 2.2 0.061
%AC (%) 97.3 ± 11.5 97.7 ± 15.8 0.905
%TSF (%) 72.0 ± 35.2 73.5 ± 44.2 0.863
Swallowing function
FOIS (level) 5.8 ± 1.5 4.4 ± 2.0 0.001
Number of patients with FOIS level ≤ 5 13 (31.7) 25 (61.0) 0.008
RSST positive 14 (34.2) 24 (58.5) 0.026
WST (score) 4.2 ± 0.9 3.6 ± 0.9 0.003
Values are means ± standard deviation or numbers of subjects per group
(n) with percentages.
AC, arm circumference; ACEI, angiotensin converting enzyme inhibitor;
ARB, angiotensin receptor blocker; BI, barthel index; BMI, body mass
index; CONUT, controlling nutritional status; CRP, C-reactive protein;
FOIS, functional oral intake scale; eGFR, estimated glomerular filtration
rate; METs, metabolic equivalents; MMSE, mini-mental state examina-
tion; MSAS, modified specific activity scale; NT-proBNP, N-terminal
pro-B-type natriuretic peptide; NYHA, New York Heart Association;
RSST, repetitive saliva swallowing test; TSF, triceps skin fold; WST,
water swallowing test.
170 J. Yokota et al.

Table 7. Outcomes and Rehabilitation Interventions after propensity score matching.

Home (n = 41) Non-home (n = 41) P value
Outcomes
Length of hospital stay (day) 29.7 ± 14.1 45.9 ± 35.6 0.008
Discharge disposition < 0.001
Home 41 (100.0) 0 (0.0)
Nursing care facility 0 (0.0) 21 (51.2)
Rehabilitation hospital 0 (0.0) 20 (48.8)
Rehabilitation interventions
PT 36 (87.8) 38 (92.7) 0.457
ST 3 (7.3) 9 (22.0) 0.061
Values are means ± standard deviation or numbers of subjects per group (n) with percentages.
PT, physical therapy; ST, swallowing therapy.

multicenter trials and rehabilitation intervention studies are Glantz, S.A. & Slinker, B.K. (2001) Multicollinearity and what to
needed to clarify factors that affect discharge disposition in do about it. In Primer of applied regression and analysis of
variance, 2nd ed., edited by Glantz, S.A. & Slinker, B.K.
patients with acute exacerbation of HF. McGraw-Hill Education, New York, NY, pp. 185-240.
In conclusion, this study indicates that dysphagia hin- Goldman, L., Hashimoto, B., Cook, E.F. & Loscalzo, A. (1981)
ders patients with acute exacerbation of HF from being dis- Comparative reproducibility and validity of systems for
charged to home. Additionally, dysphagia and its severity assessing cardiovascular functional class: advantages of a new
specific activity scale. Circulation, 64, 1227-1234.
were independent predictors for discharge to home in Hansen, T., Kjaersgaard, A. & Faber, J. (2011) Measuring elderly
patients with acute exacerbation of HF. Thus, early detec- dysphagic patients’ performance in eating: a review. Disabil.
tion and active intervention for dysphagia may be important Rehabil., 33, 1931-1940.
in improving clinical outcomes in patients with acute exac- Hosoya, N., Okada, T. & Muto, Y. (2001) Japanese anthropometric
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Ignacio de Ulibarri, J., Gonzalez-Madrono, A., de Villar, N.G.,
Acknowledgments Gonzalez, P., Gonzalez, B., Mancha, A., Rodriguez, F. &
This research received no grant from any funding agency in Fernandez, G. (2005) CONUT: a tool for controlling nutri-
the public, commercial or not-for-profit sectors. The authors tional status. First validation in a hospital population. Nutr.
gratefully acknowledge the participation of all study patients and Hosp., 20, 38-45.
thank all colleagues in our department for their contribution to Isono, N., Imamura, Y., Ohmura, K., Ueda, N., Kawabata, S.,
the medical care of the patients. Also, we would like to thank Furuse, M. & Kuroiwa, T. (2017) Transthyretin concentra-
tions in acute stroke patients predict convalescent rehabilita-
Editage (https://www.editage.jp) for English language editing.
tion. J. Stroke Cerebrovasc. Dis., 26, 1375-1382.
Izawa, K., Hirano, Y., Yamada, S., Oka, K., Omiya, K. & Iijima, S.
Conflict of Interest (2004) Improvement in physiological outcomes and health-
The authors declare no conflict of interest. related quality of life following cardiac rehabilitation in
patients with acute myocardial infarction. Circ. J., 68, 315-
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