{
  "abstract": "Objective: Heart failure (HF) carries high rates of 30-day unplanned readmission. Multidisciplinary nurse-led transitional care (MNLTC) may bridge inpatient-to-community transitions, yet real-world evidence from non-Western settings remains limited.\n\nMethods: This retrospective cohort study enrolled 228 hospitalised HF patients. The primary outcome was 30-day all-cause readmission. Secondary outcomes included HF-specific readmission, emergency department visits, and all-cause mortality. Multivariable logistic regression, subgroup analyses, and sensitivity analyses (inverse probability of treatment weighting; complete case analysis) were performed.\n\nResults: The 30-day all-cause readmission rate was significantly lower with MNLTC ( p = 0.036), yielding an absolute risk difference of 11.40 percentage points and a number needed to treat of approximately 9. After adjustment for residual post-PSM imbalances in LVEF and Charlson Comorbidity Index, MNLTC remained independently associated with reduced readmission ( p = 0.049). No significant between-group differences were observed in secondary outcomes. Subgroup analyses showed consistent directional effects, with more pronounced estimates in HFrEF (OR 0.38; p = 0.030) and NYHA class III–IV (OR 0.47; p = 0.043). Both sensitivity analyses confirmed robustness.\n\nConclusions: MNLTC was independently associated with lower 30-day all-cause readmission in hospitalised HF patients, suggesting a role for structured transitional care in reducing preventable rehospitalisation. Prospective studies are needed to confirm these findings.",
  "abstract_shown": true,
  "affiliations": [
    "Department of the Second Cadre Ward, General Hospital of Northern Theater Command, Chinese People's Liberation Army",
    "Department of Oncology, Liaoning Chongwen Houde Hospital Co., Ltd.",
    "Department of the First Outpatient, General Hospital of Northern Theater Command, Chinese People's Liberation Army"
  ],
  "article_type": null,
  "arxiv": null,
  "author_total": 6,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Qiang Fan"
    },
    {
      "affs": [
        0
      ],
      "name": "Han Liu"
    },
    {
      "affs": [
        1
      ],
      "name": "Yang Yu"
    },
    {
      "affs": [
        2
      ],
      "name": "Qi Guo"
    },
    {
      "affs": [
        0
      ],
      "name": "Jing Li"
    },
    {
      "affs": [
        0
      ],
      "name": "Xiaoming Liu"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/69gq590wcmyxs.bib",
  "cited_by": 0,
  "doi": "10.3389/fcvm.2026.1963540",
  "fulltext_url": null,
  "id": "69gq590wcmyxs",
  "issns": [
    "2297-055X"
  ],
  "landing_url": "https://www.frontiersin.org/articles/10.3389/fcvm.2026.1963540/full",
  "language": null,
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [],
  "openalex": null,
  "pdf_url": null,
  "pmcid": null,
  "pmid": null,
  "published": "2026-11-03",
  "publisher": "Frontiers Media SA",
  "ris": "https://research.draconitic.com/paper/69gq590wcmyxs.ris",
  "sources": [
    {
      "first_seen": "2026-11-03T12:21:34Z",
      "native_id": "10.3389/fcvm.2026.1963540",
      "source": "crossref",
      "url": "https://www.frontiersin.org/articles/10.3389/fcvm.2026.1963540/full"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "issn:2297-055X",
      "subfield": "cardiovascular"
    }
  ],
  "title": "Multidisciplinary nurse-led transitional care and 30-day readmission in patients with heart failure: a retrospective cohort study",
  "title_text": "Multidisciplinary nurse-led transitional care and 30-day readmission in patients with heart failure: a retrospective cohort study",
  "type": "peer-reviewed",
  "updated_at": "2026-11-05T00:21:10Z",
  "url": "https://research.draconitic.com/paper/69gq590wcmyxs",
  "venue": "Frontiers in Cardiovascular Medicine",
  "versions": []
}