Effectiveness and efficiency of a structured nurse-led follow-up programme in patients with heart failure: preliminary results of a multicentre study

Background Heart failure is a chronic condition with high prevalence, associated with significant morbidity and mortality, frequent hospital readmissions and substantial healthcare resource consumption. Structured nurse-led follow-up programmes have demonstrated improvements in clinical outcomes; however, evidence integrating both clinical effectiveness and economic efficiency, particularly in the context of Advanced Practice Nursing, remains limited. Aim To evaluate the effectiveness and efficiency of a structured nurse-led follow-up programme in patients with heart failure after hospital discharge, compared with usual care. Methods A multicentre, prospective, longitudinal, quasi-experimental study was conducted. Adult patients (≥18 years) with heart failure (HFrEF or NYHA III–IV), at least two previous hospital admissions and an identified primary caregiver were included. The intervention group received structured follow-up led by specialised cardiac nurses, including comprehensive clinical assessment, therapeutic education, treatment optimisation, early detection of decompensation and direct telephone access. The control group received usual follow-up by cardiology and primary care. The follow-up period was 12 months. Clinical variables, self-care behaviours, quality of life and healthcare costs were analysed. Results Preliminary analysis (June–October 2025) included 49 patients, with a mean age of 70.7 years, predominance of men (79.6%), a mean left ventricular ejection fraction of 31.2% and a high level of polypharmacy (mean 8.4 drugs per patient). Most patients were classified as NYHA functional class II–III. Early findings suggest improvements in clinical stability, treatment adherence and self-care, together with a reduction in potentially avoidable hospitalisations and a more efficient use of healthcare resources. Conclusions These preliminary results support the role of structured nurse-led follow-up as an effective and potentially efficient strategy for the comprehensive management of complex patients with heart failure.