Multidisciplinary nurse-led transitional care and 30-day readmission in patients with heart failure: a retrospective cohort study
- 1Department of the Second Cadre Ward, General Hospital of Northern Theater Command, Chinese People's Liberation Army
- 2Department of Oncology, Liaoning Chongwen Houde Hospital Co., Ltd.
- 3Department of the First Outpatient, General Hospital of Northern Theater Command, Chinese People's Liberation Army
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.
Methods: 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.
Results: 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.
Conclusions: 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.
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BibTeX
@article{fan2026multidisciplinary,
title = {{Multidisciplinary nurse-led transitional care and 30-day readmission in patients with heart failure: a retrospective cohort study}},
author = {Qiang Fan and Han Liu and Yang Yu and Qi Guo and Jing Li and Xiaoming Liu},
journal = {Frontiers in Cardiovascular Medicine},
year = {2026},
month = nov,
doi = {10.3389/fcvm.2026.1963540},
url = {https://www.frontiersin.org/articles/10.3389/fcvm.2026.1963540/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Multidisciplinary nurse-led transitional care and 30-day readmission in patients with heart failure: a retrospective cohort study
AU - Qiang Fan
AU - Han Liu
AU - Yang Yu
AU - Qi Guo
AU - Jing Li
AU - Xiaoming Liu
PY - 2026
DA - 2026/11/03
JO - Frontiers in Cardiovascular Medicine
DO - 10.3389/fcvm.2026.1963540
UR - https://www.frontiersin.org/articles/10.3389/fcvm.2026.1963540/full
AB - 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. Methods: 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. Results: 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. Conclusions: 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.
SN - 2297-055X
ER -