Multidisciplinary nurse-led transitional care and 30-day readmission in patients with heart failure: a retrospective cohort study

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.