Nurse-led intervention to improve quality of life and reduce rehospitalization in heart failure patients: A scoping review

Q: What is the clinical evidence from this study?

Study design: Systematic Review. Population: Heart failure (n=573). Intervention: Nurse-led interventions (structured education, transitional care, collaborative health management, and post-discharge follow-up) vs. Standard or usual routine care. Primary outcome: Quality of life and rehospitalization rates.

Q: What does this research mean for the field?

Nurse-led interventions improve quality of life and reduce hospital readmissions in patients with heart failure. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Tobi Pitora; Rahmawati Dian Nurani; Dewin Safitri; Devi Harmita; Arthanti Latifah

doi:10.31962/inj.v4i1.14

July 23, 2026Indonesian Nursing JournalOpen Access

Nurse-led intervention to improve quality of life and reduce rehospitalization in heart failure patients: A scoping review

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Key result

Nurse-led interventions improve quality of life and reduce rehospitalizations in heart failure vs. usual care.

n=573

Why the study?

Heart failure imposes a substantial healthcare burden through high hospitalization rates, and this scoping review aimed to evaluate the effectiveness of nurse-led interventions in improving quality of life and reducing readmissions.

Does nurse-led intervention improve quality of life and reduce rehospitalization rates in patients with heart failure?

Key Points

To evaluate the effectiveness of nurse-led interventions in improving quality of life and reducing readmission rates in patients diagnosed with heart failure.
Conducted a scoping review following the PRISMA-ScR framework across PubMed, ScienceDirect, EBSCO, and Scopus databases between July 30, 2025, and August 28, 2025.
Assessed eligible primary studies using the Cochrane Risk of Bias Scale (ROB 2.0), selecting five randomized controlled trials for synthesis.
Nurse-led interventions consistently improved quality of life across the included studies through structured education on symptom monitoring, lifestyle modifications, and medication adherence.
Hospital readmission outcomes varied by intervention intensity, including reductions such as 0% versus 34% readmissions in one trial and fewer cardiovascular hospitalizations in another (17 vs. 35; HR 2.115, 95% CI 1.228–3.643, p = 0.009).
Transitional care programs initiated within the immediate post-discharge period demonstrated the highest potential for reducing subsequent rehospitalizations.

Study Design

Type

Systematic Review (n=573)

Structured PICO

Does nurse-led intervention improve quality of life and reduce rehospitalization rates in patients with heart failure?

P

Population

573 patients with heart failure (and atrial fibrillation in one trial) across 5 randomized controlled trials evaluating nurse-led interventions for quality of life and hospital readmissions, followed for 30 days to 12 months.

I

Intervention

Nurse-led interventions (including the Chronic Care Model and Collaborative Health Management Model, structured nursing education on disease management, medication adherence, lifestyle changes, and symptom monitoring, post-discharge transitional care programs during the first 14 to 30 days post-discharge, and pre-discharge/follow-up care).

C

Comparator

Standard routine care or usual care (e.g., standard care without additional detailed education, or printed and verbal heart failure discharge education delivered by the primary hospital RN).

O

Outcome

Quality of life (QoL) and hospital readmission / rehospitalization rates (evaluated at varying timeframes such as 30 days, 6 months, or 12 months post-discharge).

This scoping review of 5 RCTs demonstrates that structured nurse-led interventions consistently improve quality of life and can reduce hospital readmissions in heart failure patients, particularly when delivered as intensive transitional care post-discharge.

Limitations

No meta-analysis was conducted to quantify pooled effects or statistically assess heterogeneity.
Potential publication bias as positive results are more likely to be published.
High heterogeneity of interventions, populations, quality of life instruments, and rehospitalization definitions across included studies.
Variable evaluation timeframes for readmissions (ranging from 30 days to 12 months), limiting uniform conclusions on long-term sustainability.
Scarcity of cost-effectiveness analyses in the included studies.
Most included studies were conducted in high-income countries, limiting generalizability to low- and middle-income settings.
No meta-analysis was conducted, preventing quantification of pooled effects or statistical assessment of heterogeneity
Potential publication bias
Heterogeneity of interventions, populations, QoL instruments, and rehospitalization definitions across studies
Few studies evaluated results beyond 12 months, creating uncertainty about long-term sustainability
Scarcity of cost-effectiveness analyses
Most included studies were conducted in high-income countries, limiting generalizability to low- and middle-income countries
Variations in the evaluation timeframe for readmissions (e.g., 30 days, 90 days, or 12 months)

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Implication

Supports integration of nurse-led interventions into HF care; confirms consistent RCT benefits for transitional models.

Abstract

Introduction: Heart failure (HF) remains a major global health problem, characterized by high morbidity and mortality rates. HF imposes a substantial burden on healthcare systems due to high rates of hospitalizations and the need for intensive medical care. Nurse-led interventions have been increasingly recognized for their potential to improve patient outcomes across various healthcare settings Objectives: This article aims to evaluate the effectiveness of a nurse-led intervention to improve the quality of life and reduce readmission rates in patients with heart failure. Methods: This study used the PRISMA-ScR (Preferred Reporting Elements for Systematic Reviews and Meta-Analyses) framework. Searches for primary studies in any language were conducted in electronic databases such as PubMed, ScienceDirect, EBSCO, and Scopus. The search began on July 30, 2025, and was updated on August 28, 2025. Articles were assessed using the Cochrane Risk of Bias Scale (ROB 2.0). Results: Five articles were included in this scoping review. Nurses provide tailored education that promotes medication adherence, lifestyle modification, and symptom monitoring, which together enhance self-care behavior and patient empowerment. Nurse-led interventions appear most effective at enhancing QoL, while their impact on rehospitalization depends on the intervention’s timing, duration, and intensity. Nurse-led interventions should be integrated into routine HF management, particularly during transitional care following hospital discharge, when patients are most vulnerable to readmission Conclusion: Nurse-led interventions improve QoL and show potential to reduce rehospitalization among HF patients.

Discussion

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Cite This Study

Pitora et al. (2026) conducted a systematic review in Heart failure (n=573). Nurse-led interventions (structured education, transitional care, collaborative health management, and post-discharge follow-up) vs. Standard or usual routine care was evaluated on Quality of life and rehospitalization rates. Nurse-led interventions across 5 RCTs consistently improved quality of life and reduced rehospitalizations (e.g., 0% vs. 34% in HFrEF) in heart failure patients compared to usual care.

synapsesocial.com/papers/6aeccb54818025a9f7709293 https://doi.org/10.31962/inj.v4i1.14

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Nurse-led intervention to improve quality of life and reduce rehospitalization in heart failure patients: A scoping review

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Nurse-led intervention to improve quality of life and reduce rehospitalization in heart failure patients: A scoping review

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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