Heart failure & cardiomyopathiesResearch article
Optimising Transitions of Care and Long-Term Management in Heart Failure: A Scoping Review of Strategies and Models
- Scoping review
- PRISMA extension for scoping reviews (PRISMA-ScR) checklist
- two systematic searches
- two independent reviewers
Authors' conclusion
Despite heterogeneity across healthcare systems and variability in programme designs, the evidence supports coordinated and patient-centred strategies for HF care transitions and long-term follow-up. These approaches reduce mortality and rehospitalisation, enhance patient engagement and quality of life, and provide a sustainable framework for healthcare systems.
Study context
- Population
- Patients with heart failure (HF); records published from January 2015 to June 2024 on transitional care and long-term follow-upstudies considered eligible, n=73 deemed most relevant synthesised qualitatively
- Participants
- 118 patients
Main finding
As reported in the abstract
Reduced 30-day rehospitalisation
20%-50%
Early follow-up
50%
Nursing coordination
30%
Pharmaceutical intervention
20%
Further findings
Hospitalisation and mortality with one nurse-led programme including calls and visits · six weeks (hospitalisation); nine months (mortality)
- Hospitalisation at six weeks decreased from 16.3% to 8.1%
- P = 0.048
- Mortality at nine months decreased from 13.8% to 4.1%
- P = 0.03
Death or rehospitalisation for cardiovascular events with risk-stratification-based management
- Reduced by 12%
- HR [hazard ratio]: 0.88; p=0.04
Rehospitalisation or death with an intensive programme with education, exercise, and close monitoring · 30 days and 90 days
- Lowered at 30 days
- 38%
- Lowered at 90 days
- 39%
Other strategies
- Multidisciplinary HF units, day care hospitals, and home hospitalisation improved adherence and outcomes
- Telemedicine and remote monitoring enabled early detection of decompensation
- Pharmacist- and nurse-led interventions enhanced medication safety and adherence
- Psychosocial and caregiver support improved self-management and quality of life
Characteristics of synthesised studies
- Published after 2020
- 53.4%
- Europe and North America
- 75.3%
- Intervention studies
- 32.9%
- Randomised controlled trials (of intervention studies)
- 45.8%
Original publication
Summarised from the published abstract; every number is checked against it