Association of an early multidisciplinary HF pathway and inpatient rehabilitation with 1-year survival: a four-group real-world analysis (2020–2025)

Background Heart failure (HF) care pathways and cardiac rehabilitation (CR) are recommended to standardize multidisciplinary management, yet real-world evidence describing how their implementation relates to long-term survival remains limited, particularly when both are considered jointly. Purpose To describe the association of an HF clinical pathway featuring early multidisciplinary involvement and inpatient CR with 1-year all-cause mortality after HF hospitalization. Methods We retrospectively analyzed HF hospitalizations between 1 April 2020 and 31 March 2025 in a Japanese hospital-based DPC dataset. The HF pathway targeted early coordinated multidisciplinary involvement (PT/OT, nursing, dietitians, and pharmacists), initiated as early as the day after admission whenever feasible. CR was defined as inpatient rehabilitation. Mortality included in-hospital deaths and follow-up deaths within 1 year. Patients were classified into four groups by pathway implementation (Path+/−) and CR exposure (Rehab+/−): Path−/Rehab−, Path−/Rehab+, Path+/Rehab−, and Path+/Rehab+. Time-to-event was defined from discharge to death (censored at 365 days). Unadjusted survival was assessed using Kaplan–Meier curves and the log-rank test. To account for baseline differences, we additionally performed propensity score–based inverse probability weighting using demographics, comorbidities, HF severity proxies (LVEF, BNP), acute care indicators (emergency admission, ICU/HCU, oxygen therapy, intravenous drug use), and prior HF admissions. Weighted Cox regression with robust variance was used to compare groups, and a global Wald test evaluated overall between-group differences. Results In unadjusted analyses (n=1,494; deaths=233), 1-year survival differed significantly across the four groups (log-rank χ²=22.16, p=0.0001; Figure 1). Observed deaths by group were: Path−/Rehab− 92, Path−/Rehab+ 94, Path+/Rehab− 16, and Path+/Rehab+ 31. In the weighted analysis (n=990; deaths=150), between-group differences remained (global Wald χ²=9.72, p=0.0211; Figure 2). Using Path−/Rehab− as reference, hazard ratios were lower for Path−/Rehab+ (HR 0.61, 95%CI 0.42–0.87, p=0.007) and Path+/Rehab− (HR 0.44, 95%CI 0.21–0.94, p=0.034), while Path+/Rehab+ showed a similar direction but did not reach statistical significance (HR 0.62, 95%CI 0.37–1.04, p=0.072). Conclusions In this real-world HF cohort, early multidisciplinary pathway implementation and inpatient CR were associated with better 1-year survival compared with neither intervention. The absence of statistical significance in the Path+/Rehab+ group despite a consistent direction underscores the need for further studies to confirm effectiveness and clarify which components, timing, and patient subgroups derive the greatest benefit.