Addressing Care Gaps in Chronic Disease Management: A Systematic Review of Nursing Interventions

Background/Objectives: Chronic diseases are a major contributor to the global burden of disease and are often associated with care gaps that adversely affect health outcomes and healthcare quality. Nurses play a central role in delivering interventions to address these gaps. This systematic review aimed to identify which nursing interventions address care gaps in chronic disease management and to assess the outcomes of their implementation among adults with chronic diseases. Methods: A systematic review was conducted in accordance with PRISMA guidelines. Five electronic databases were searched for studies. Studies involving adults with chronic diseases that evaluated nursing interventions targeting care gaps were eligible for inclusion. Methodological quality was assessed using JBI critical appraisal tools appropriate for the study design, and studies were not excluded based on quality assessment. Data from primary studies and systematic reviews were synthesized narratively and separately to avoid double counting of evidence. Overlap between included systematic reviews and primary studies was assessed and documented. Results: Twenty reports were included and synthesized separately: 17 reports of 16 primary studies (randomized and cluster-randomized controlled trials, quasi-experimental studies, and one cohort study) and three systematic reviews with meta-analysis. In the primary studies, the most frequently targeted care gap was continuity of care, followed by unmet needs, fragmented care, and health literacy or information gaps. The most common interventions were nurse-led case management, telehealth follow-up, and self-management support. Reported improvements, mostly in outcomes related to rather than direct measures of the targeted gaps, included care coordination, self-management behaviors, treatment adherence, quality of life, patient satisfaction, and selected clinical outcomes. Of the 17 primary-study reports, eight showed a statistically significant between-group benefit on the primary outcome, and four showed mixed effects; the remainder showed non-significant, within-group-only, or uncontrolled changes or did not test effectiveness. The three systematic reviews of transitional care and nurse-managed protocols reported reductions in readmissions and mortality and modest improvements in clinical risk factors. Conclusions: Nurse-led interventions are frequently designed to target care gaps in chronic disease management and have been associated with improvements in selected patient, service, and clinical outcomes. However, few studies measured the targeted gaps directly, so evidence that these gaps actually narrowed remains limited. Case management, telehealth follow-up, and self-management support were the most frequently evaluated approaches and warrant rigorous evaluation using direct measures of care gaps.