BRIDGING THE GAP: NURSE PRACTITIONER-LED OUTPATIENT
INTERVENTIONS TO BREAK THE CYCLE OF HEART FAILURE READMISSIONS

by

Gal Ziv
P.C.P., Justice Institute of British Columbia, 2017
B.Sc.N., British Columbia Institute of Technology, 2021

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENT FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING - FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
April 2025
© Gal Ziv, 2025

ii
Abstract
Aim: To explore whether Nurse Practitioner-led outpatient interventions targeting heart failure
patients can reduce hospital readmissions or emergency department visits, thereby improving
healthcare efficiency and demands on hospitals.
Background: Heart failure is a leading cause of hospital readmissions, contributing significantly
to healthcare system strain. Despite advancements in HF care, readmission rates remain high,
posing substantial clinical and financial burdens. Nurse Practitioners, with their expertise in
chronic disease management and holistic care, are well-positioned to address these challenges
through proactive, personalized post-discharge care.
Method: An integrative review synthesizing most recent evidence on Nurse Practitioner-led
outpatient care models for heart failure patients, focusing on their impact on readmissions and
emergency department visits.
Results: Evidence suggests that Nurse Practitioner-led interventions improve post-discharge
continuity of care, reducing preventable readmissions and emergency department visits. These
models effectively target key factors contributing to readmissions, including medication
adherence, dietary management, patient education, and timely patient follow-ups. Although no
ethical concerns were identified, additional rigorous research across diverse populations and
settings is necessary to solidify the evidence base and guide widespread implementation.
Conclusion: Nurse Practitioner-led care presents a viable and scalable strategy to improve
outcomes in heart failure management and alleviate healthcare system pressures. Further
research and policy support are crucial to expand and standardize these programs.

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Table of Contents
Abstract

ii

Table of Contents

iii

List of Tables

v

List of Figures

vi

Acknowledgements

vii

Chapter One: Introduction

1

Chapter Two: Background

2

Purpose
Chapter Three: Research Methods

6
7

Design

7

Key Terms

7

Database Selection

8

Search Strategy

8

CINAHL Database

9

Ovid MEDLINE Database

10

Google Scholar Database

11

Systematic Review Article Search

12

Inclusion and Exclusion Criteria

12

Disclosure of Search Strategy Limitations

14

Critical Analysis

14

Data Extraction

15

Chapter Four: Findings

16

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Chapter Five: Discussion

28

Recommendations

33

Limitations

33

Declaration of Conflicting Interests

34

Chapter Six: Conclusion

35

References

36

Appendix A 3 CINAHL Search Strategy

43

Appendix B 3 Ovid Medline Search Strategy

44

Appendix C 3 Search Strategy Summary

45

Appendix D 3 Articles Retracted within the Inclusion/Exclusion Guidelines

47

Appendix E 3 Critical Appraisals

48

Appendix F 3 Data Extraction

58

v
List of Tables
Table 1: Study Credibility Rating Scale

15

vi
List of Figures
Figure 1: PRISMA Diagram

13

vii
Acknowledgement
For years, I have witnessed the relentless cycle of heart failure readmissions firsthand in
the chaotic environment of the emergency department. Each return visit is not just a statistic; it is
a story of struggle, with patients caught in a revolving door of hospital care. This is not just a
burden on the system; it's a human cost that resonates deeply with me as an emergency nurse and
former paramedic. This integrative review is born from that experience, a desire to find a better
way to support individuals and alleviate the strain on our already overwhelmed emergency
services. The support stems to not only improve the lives of those suffering from heart failure,
but also that of my fellow colleagues who are struggling to finish the day in the emergency
department. I would like to thank my coworkers for supporting me throughout my Nurse
Practitioner education program, and to my professor Dr. Catharine Schiller for her inspiring
mentorship and invaluable knowledge she imparted throughout the making of this project. As
Hippocrates, the father of medicine, said, "Wherever the art of medicine is loved, there is also a
love of humanity= (Aron, 2020). This review is dedicated to the patients on their journey to
healing, and to the pursuit of a healthcare system that truly embodies that love.

1
Chapter One: Introduction
Healthcare systems are under mounting pressure, with hospitals and emergency
departments (EDs) struggling to manage high patient volumes while ensuring quality care. Rapid
discharge has become essential to free up hospital resources, but for many patients, this signals
the beginning of a highly challenging recovery period. The potential for post-discharge
complications, lack of timely follow-up, and limited access to primary care have contributed to
preventable readmissions, placing further strain on an already overwhelmed system (Barber et
al., 2022). This escalating cycle of readmissions is particularly concerning in the context of
chronic diseases, where effective post-discharge management is paramount (Finlayson et al.,
2018).
Heart failure (HF) is a major contributor to hospital readmissions, given its high
prevalence rates and associated comorbidity (Virani et al., 2017). Despite advancements in HF
care, readmission rates remain high, and the financial burden related to treatment continues to
grow (Virani et al., 2017). Addressing HF through targeted, cost-effective interventions is crucial
to improving outcomes and easing the strain on healthcare resources.
Nurse Practitioners (NPs) have emerged as key players in chronic disease management,
offering a cost-effective and holistic approach to patient care. Their ability to provide
personalized, continuous post-discharge care positions them uniquely to address the key factors
driving HF readmissions. This integrative review explores whether NP-led outpatient
interventions can reduce readmissions and improve healthcare efficiency by bridging critical
gaps in HF management. By synthesizing current evidence, this review aims to highlight
strategies for implementing scalable NP-led care models that could enhance patient outcomes,
reduce hospital utilization, and offer a sustainable solution to Canada’s growing healthcare crisis.

2
Chapter Two: Background
In today's overburdened healthcare systems, the pressure to expedite patient discharges
has become an unavoidable reality. EDs in many countries are facing a national crisis, with both
overcrowding and staff shortages creating significant barriers to timely patient care, increasing
staff frustration and burnout, and ultimately putting patient safety at risk (Yarmohammadian et
al., 2017). With hospitals stretched thin and resources limited, healthcare professionals are often
forced to focus on immediate treatment and efficient patient turnover (Yong, 2021). Yet for
many patients, discharge is not the end, but rather, the beginning of a high-stake journey fraught
with fears and challenges (Rising et al., 2016).
Nationally, 77% of patients treated in EDs are discharged following evaluation and
treatment, resulting in a <treat-and-release= approach (Iyeke et al., 2023, p. 2). Unfortunately,
once discharged from the hospital, many patients are left to navigate the recovery process alone,
without the support and resources available during hospitalization. This discontinuity of care is
often due to the difficulty patients face in accessing primary care and follow-up services in a
timely fashion (Field et al., 2015).
Canada is grappling with an escalating crisis in primary care and specialist service
accessibility (Flood et al., 2023). Primary care clinics, vital for post-discharge continuity, are
themselves under strain from limited resources and surging demand. As of 2023, one in six
Canadians lack a regular family healthcare provider, and fewer than half can secure a same-day
or next-day appointment (Flood et al., 2023). This shortage of timely access fuels significant
downstream effects, including delayed diagnoses, restricted specialist referrals, and heavy
reliance on already overcrowded EDs (Flood et al., 2023).

3
Between 2021 and 2022, more than 14 million Canadians visited EDs (Rader & Ritchie,
2023), with a substantial share of these visits stemming from conditions that could have been
managed in a primary care setting, had access been available (Flood et al., 2023). In 2020 alone,
39% of Canadians seeking emergency care noted that their conditions could have been addressed
by a primary care provider, if they had had the ability to secure a timely appointment (Flood et
al., 2023). The <treat-and-release= model practiced by most EDs (Iyeke et al., 2023, p. 2)
ultimately sets patients up for treatment failure in a system that lacks continuity and timely
resources.
Moreover, the post-discharge period presents an elevated risk of complications,
medication errors, and poor adherence to care plans; these are factors that often result in
avoidable readmissions, skyrocketing healthcare costs, and an overall decline in quality of life
(Barber et al., 2022). The transition from hospital to home therefore represents a critical window
in which effective follow-up care, prompt interventions, and coordinated support can make the
difference between a successful recovery and relapse and deterioration (Finlayson et al., 2018).
A retrospective cohort study conducted by Moe et al. (2022) aimed to identify which
specific subgroup of patients who visited EDs in Canada disproportionally contributed to the
highest healthcare spending and increasing acuity needs. This study identified that older adults
with multiple chronic comorbidities contributed disproportionally to all other ED visits. Smith et
al. (2016) demonstrated that, for these high readmission risk groups, up to 50% of discharged
patients presented back to the hospital within 30 days of discharge. Their study identified that
timely follow-up services profoundly and positively reduce readmission rates, and this finding is
consistent with a significant body of literature. Another study conducted by Field et al. (2014)
expanded on this research and found that post-discharge visits in high-risk individuals have far

4
better outcomes if they are incorporated into comprehensive transitional care programs rather
than early primary care physician visits.
The disproportionate burden placed on healthcare resources by high-risk, high-need
subgroups necessitates a shift towards targeted interventions. Chronic diseases accounts for
substantial healthcare costs in Canada, with nearly 73% of seniors age 65 and older living with at
least one chronic condition (Public Health Agency of Canada, 2020). The financial and clinical
burden associated with chronic disease makes this population a critical target for interventions.
Research by Moe et al. (2022) in Ontario and Alberta underscores this, revealing that older
adults with chronic diseases are significant contributors to ED strain due to their increasing highacuity needs.
To address this issue, policymakers must design and implement tailored, patient-specific
care strategies aimed at these high-need groups. This recommendation reinforces the established
principle that patients with chronic diseases achieve superior outcomes through consistent,
integrated care, as opposed to fragmented, episodic interventions in emergency settings or
routine primary care visits (Field et al., 2015; Rader & Ritchie, 2023). Their complex healthcare
needs not only necessitates rigorous monitoring but also proactive, patient-centered, multifaceted interventions that are often not achieved, or achievable, in ED environments and primary
care centers. Ironically, the need for such interventions is particularly prevalent in patients who
present to EDs for care, which only serves to worsen the problem.
The complexities of HF make it a particularly difficult chronic disease to manage,
resulting in high treatment failure rates and a considerable strain on healthcare resources. HF is
the leading cause of cardiovascular morbidity, mortality, and healthcare utilization in Canada
(Virani et al., 2017) and is a leading cause of hospital readmissions in the United States

5
(Breathett et al., 2018). It is defined as a clinical syndrome, characterized by a constellation of
signs and symptoms (leg swelling, pulmonary congestion, dyspnea, orthopnea), and caused by a
structural and/or functional cardiac muscle dysfunction that results in reduced cardiac output
(Kurmani & Squire, 2017).
In 2017, over 600,000 Canadians were affected by HF (Virani et al., 2017). At least 20%
of discharged HF patients return to EDs after 30 days (Virani et al., 2017), and 30% die within
one year of discharge (Charteris & Pounds, 2020). Globally, mortality rate nears 50% within 5
years of diagnosis (Mangini et al., 2013). From an economic perspective, $2.8 billion Canadian
dollars are spent on HF and its associated sequelae per year (Virani et al., 2017), and these
hospital costs are only projected to rise in the future (Tran et al., 2016). An article published by
the Canadian Journal of Cardiology provided an urgent call to action for all Canadian
stakeholders to redesign policy initiatives which <must be championed to affect meaningful
change= for an optimal and cost-effective future (Virani et al., 2017, p.1). These alarming
forecasts underscore the urgent need for new and innovative care models that can prevent
hospitalizations resulting from HF and improve patient outcomes.
NPs have emerged as a cost-effective solution to address global physician shortages
(Fichadiya et al., 2021; Hansen-Turton et al., 2010). Their scope of practice spans autonomous
and collaborative roles across diverse settings, including hospitals, outpatient clinics, and
specialized care (Grant et al., 2017). Initially developed to mitigate anticipated medical
professional shortages, NPs now function as either autonomous primary care providers or as
integral members of multidisciplinary teams, enhancing overall care delivery (Grant et al., 2017).
Beyond their broad clinical expertise, NPs excel in chronic disease management, prevention, and
health maintenance (Craswell et al., 2018). Their unique value lies in the integration of advanced

6
medical practice with holistic care, encompassing patient education, counseling, and advocacy;
these are skills cultivated throughout their nursing careers (King-Dailey et al., 2022).
With respect to HF care in particular, these core NP competencies directly address key
factors that contribute to hospital readmissions, such as medication and dietary non-adherence,
inadequate patient education, and delayed follow-up (Charteris & Pounds, 2020). Research
consistently demonstrates the effectiveness and proficiency of NPs in managing these critical
areas, positioning them well to improve HF outcomes. Despite growing recognition of NP
capabilities, much of the remaining skepticism surrounding their role compared to physicians
stems from earlier research (Donelan et al., 2013). Currently, there is a notable lack of recent
evidence assessing whether the NP scope of practice is equivalent and/or well-suited for the
comprehensive management of complex HF patients.
Purpose
The purpose of this integrative review is to systematically analyze the potential for NPled outpatient interventions to mitigate HF readmissions and ED visits, and to evaluate the
viability of expanding programs as a strategy to improve healthcare efficiency. For outpatient
interventions to be effective in managing HF, they must take into account the nature of this
disease, which is both chronic and complex, and they must acknowledge that hospital discharge
represents a fragile transition point in patient care. This review posits that NP-led models, which
emphasize post-discharge continuity of care, may provide a structured framework to disrupt the
cycle of recurrent hospitalizations. By synthesizing existing research on this topic, this
integrative review will generate evidence to inform the development and implementation of
scalable, patient-centered interventions aimed at addressing the needs of HF patients in Canada.

7
Chapter Three: Research Methods
Design
This integrative review is focused on the following question: are NP-led outpatient
interventions effective at reducing hospital readmission rates or ED visits for HF patients? To
systematically explore this question, the Population, Intervention, Outcome (PIO) framework
was adopted. Widely recognized in healthcare research, the PIO framework facilitates the
identification and evaluation of evidence by narrowing the focus to a specific population,
targeted intervention, and measurable outcomes (Bramer et al., 2018). This structured approach
ensures a comprehensive and methodical review, guiding the selection of studies that are most
relevant to answering the research question (Bramer et al., 2018).
Key Terms
For the purposes of this review, the terms NPs, outpatient, HF, and readmission and ED
visits are defined as follows. NPs refer to any advanced care nurses who are licensed to assess,
diagnose, treat, and manage patient care independently, without physician supervision. HF is
used as an umbrella term that encompasses all forms of HF, including systolic and diastolic
dysfunction, decompensated HF, congestive HF, and both acute and chronic presentations.
Readmission and ED visits refer to any return to the hospital4either through inpatient admission
or ED presentation4following a previous hospital encounter, regardless of whether the patient
was admitted or discharged. Outpatient refers to any NP-led intervention that takes place outside
of the hospital setting, such as in primary care clinics, home visits, telephone consultations,
remote monitoring, or other community-based services.

8
Database Selection
A systematic literature search was conducted in November 2024 to identify primary
research studies that evaluated the impact of NP-led primary care clinics on readmission rates
among HF patients. This integrative review employed a comprehensive search strategy across
three key databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid
MEDLINE, and Google Scholar. Electronic database searches were supplemented by a review of
the reference list of each included study to ensure that all relevant literature was captured. To
optimize search efficacy, an experienced Knowledge Synthesis Librarian from the University of
Northern British Columbia provided expert consultation in the development of subject headings
and surrogate terms.
CINAHL was selected for its comprehensive coverage of nursing and allied health
literature (Subirana et al., 2005). Ovid MEDLINE, the premier database for biomedical
literature, was chosen to capture relevant medical research pertaining to cardiac readmissions
and related clinical outcomes (Subirana et al., 2005). Google Scholar was included to broaden
the search and capture grey literature or reports not indexed in traditional databases, thereby
enhancing the comprehensiveness of the review. These databases, in addition to Google Scholar,
were deemed most appropriate for their scope and relevance to the research question, ensuring a
robust and thorough analysis of the existing literature.
Search Strategy
As a result of various lexes and interpretations of the concepts <Nurse Practitioner=,
<readmission=, and <cardiac patients=, multiple search terms were used in each database to fully
capture their respective notions. A description of the search strategy and concepts used for each
database is described below.

9
CINAHL Database
A comprehensive literature search was conducted using the CINAHL Complete database
via the EBSCOhost interface, employing advanced search techniques through a combination of
CINAHL subject headings and subheadings. CINAHL subject headings are standardized,
hierarchical terms from a controlled vocabulary that are used to index and organize articles on a
specific topic (Clark College, n.d.). They help to ensure that articles related to a concept are
grouped together, regardless of variations in the terminology that may be used by different
authors (Clark College, n.d.). Subheadings are qualifiers applied to subject headings to focus on
a particular aspect of the topic (Clark College, n.d.). By combining subject headings with
relevant subheadings, searches can be refined to retrieve more targeted results on specific
dimensions of a broader topic.
This integrative review employed a structured search strategy to explore the intersection
of three core concepts: HF, NPs, and Hospital Readmissions. For the concept of HF, the
CINAHL subject heading "Heart Diseases" was initially selected to maintain a broad search
scope. The "explode" function was utilized to incorporate all related terms, including "Heart
Diseases," "Arrhythmia," "Cardiovascular Abnormalities," "Heart Failure," "Heart Hypertrophy,"
"Myocardial Injury," "Myocardial Ischemia," "Ventricular Dysfunction," and "Heart Defects,
Congenital," resulting in 265,630 records. To further enhance comprehensiveness, equivalent
subheadings, such as "Cardiac," "Heart," "Cardio," and "Heart Injury," were manually added,
expanding the search to 697,491 records. A separate search was conducted using "Heart Failure"
as a subject heading to evaluate suggested terms; CINAHL recommended retaining this term,
which was subsequently added as a subheading to ensure both broad and relevant coverage.

10
To explore the concept <Nurse Practitioner=, the CINAHL subject heading "Nurse
Practitioners" was selected, and the "explode" function was applied to capture all related
subheadings, yielding 26,362 articles. Additional keyword searches utilizing "Advanced
Providers," "Advanced Practice Nurs," and "Advanced Nurs" were performed, resulting in
24,482 articles. These terms were then combined to create a broader search set, producing a total
of 46,102 records. Given that NPs are considered advanced providers and advanced practice
nurses, these subheadings were included to ensure a comprehensive search.
For the concept of readmissions, the CINAHL subject headings "Readmission" and
"Patient Admission" were used, initially retrieving 11,956 articles. To expand the search,
additional subheadings, including "Rehospitalization," "Return to Hospital," "Return to
Emergency," "Hospital Revisit," and "Emergency Revisit," were incorporated, resulting in
42,537 records.
As a final step in the CINAHL database search, the three concept sets were combined
using the Boolean operator "AND" to identify articles addressing the convergence of all three
concepts. This final combined search yielded 133 articles. A visual representation of this search
strategy is provided in Appendix A.
Ovid MEDLINE Database
Within the Ovid MEDLINE platform, a comparable search strategy was implemented.
For the concept of HF, the MeSH (Medical Subject Headings) term "Heart Diseases" was
selected. Upon selection, Ovid MEDLINE recommended the inclusion of the broader term
"Cardiovascular Diseases" and the term "Heart Diseases," both of which were further exploded
to capture all related terms. Additionally, the MeSH term "Heart Failure" was utilized, and
related narrower terms, including "Edema, Cardiac," "Heart Failure, Diastolic," and "Heart

11
Failure, Systolic," were incorporated. To further broaden the search, supplementary keywords
such as "Cardiac," "Heart," "Congestive Heart Failure," "CHF," "HF," and "Heart Injury" were
applied. These searches were combined using the Boolean operator "OR," yielding 1,061,725
records.
For the concept of NPs, the MeSH term "Nurse Practitioners" was selected. Furthermore,
the subheading "Family Nurse Practitioner" was included. To ensure comprehensive coverage,
the keyword "Advanced Practitioners" was incorporated, and all terms were combined using the
Boolean Operator "OR," producing 19,434 articles.
For the concept of readmission, the MeSH term "Patient Readmission" was selected and
exploded to include the narrower terms "Hospitalization," "Patient Readmission," and "Patient
Admission." Supplementary key terms, encompassing "Return to Hospital," "Return to
Emergency," "Hospital Revisit," and "Emergency Revisit," were applied. These terms were
combined using the Boolean operator "OR," resulting in 314,015 articles.
As a final step, the three concept sets were combined using the Boolean Operator "AND,"
yielding 47 articles. A visual representation of this search strategy is provided in Appendix B.
Google Scholar
Consistent with recommendations for supplementing traditional database searches, a
targeted search was conducted in Google Scholar without a formal protocol, given its
unstructured nature for comprehensive literature reviews (Haddaway et al., 2015). This final scan
aimed to capture recent publications potentially not indexed in traditional databases (Haddaway
et al., 2015). Following advice of the Knowledge Synthesis Librarian, the first 4 pages of results
for the search terms "Nurse practitioner readmission cardiac" were reviewed. This process

12
retrieved two additional articles that had not been captured within the CINAHL or Ovid
MEDLINE databases.
As a final step, the reference lists of all of the selected studies were briefly scanned to
identify any additional relevant articles cited by the authors.
Systematic Review Article Search
To enhance the search strategy and ensure comprehensive coverage, a systematic review
by Fichadiya et al. (2021) was retrieved from the CINAHL database and its reference list was
examined. This systematic review had been selected for its high relevance to the topic and its
recent publication date. Reviewing the reference list of this systematic review uncovered three
further articles that were relevant to the research question but had not been located through the
database and Google Scholar searches.
Inclusion and Exclusion Criteria
The parameters of this review were established prior to beginning any of the searches
described previously. The initial searches, undertaken using a date restriction of publication
within the past 10 years, revealed only a limited number of relevant primary research articles. To
ensure an adequate sample size for a robust synthesis, this criterion was expanded to include
studies published within the past 20 years.
Only primary research studies were considered, with the exception of one systematic
review. Any included study needed to: (1) involve NPs as the care providers, (2) focus on HF
patients as the patient population of interest, and (3) use hospital readmission rates or ED visits
as an outcome. Only studies in the English language were included. The review's scope was
further defined by limiting the included studies to those investigating NP care in outpatient
settings, specifically excluding interventions conducted solely within a hospital environment.

13
Additionally, only studies involving HF patients discharged from hospitals, irrespective of their
acuity levels, gender, or racial group, were included. Studies that focused on physicians or other
advanced practice providers, rather than NPs, were excluded. Figure 1 shows a PRISMA Flow
Diagram to visually represent the above search strategies and application of inclusion/exclusion
criteria. The complete list and details of selected studies are presented in Appendix D.
Figure 1
PRISMA Flow Diagram

14
Disclosure of Search Strategy Limitations
To ensure methodological transparency, the limitations inherent in the search strategy are
being disclosed. It is possible that restricting the search to English-language publications and to
studies published within a 20-year timeframe may have prevented the inclusion of potentially
relevant research. Second, the reliance on two specific databases, primarily CINAHL and Ovid
MEDLINE, may have resulted in the omission of studies that are indexed in other repositories.
The supplementary Google Scholar search, conducted without a pre-defined protocol, could
introduce the potential for selection bias. Lastly, the narrow timeline in which this integrative
review needed to be completed may have limited the scope of the literature review and resulted
in the exclusion of additional pertinent articles.
Critical Analysis
Ten articles, selected according to predefined inclusion and exclusion criteria, underwent
a rigorous critical appraisal process. This appraisal was conducted using the Critical Appraisal
Skills Programme (CASP) checklist guidelines. The CASP checklists are evidence-based tools
designed to help users effectively make sense of critical appraisal by assessing the
methodological quality, validity, rigor, and potential biases of various study designs (Buccheri &
Sharifi, 2017). This process was also conducted within the framework of established reporting
guidelines, ensuring that no essential information was omitted during the appraisal (Buccheri &
Sharifi, 2017).
Following the critical appraisal, each article was assigned a subjective credibility rating
by the author of this integrative review. This rating, ranging from Level I to Level V, represented
the overall credibility and strength of the evidence presented in each study. Level I indicated the
weakest evidence, characterized by significant methodological limitations; Level V represented

15
the strongest evidence, demonstrating robust methodology and a high degree of relevancy. A
description of each Level is presented in Table 1. Appendix E contains a table with the detailed
critical appraisal of each study.
Table 1
Study Credibility Rating Scale
Level

Description

Credibility

Level I

Weakest study; least credible evidence

Minimal reliability

Level II

Slightly stronger than Level I

Limited reliability

Level III

Moderate strength and credibility

Moderate reliability

Level IV

Strong evidence; high credibility

Significant reliability

Level V

Strongest study; most credible evidence

Maximum reliability

Data Extraction
To achieve a rigorous and comprehensive synthesis of evidence, a data extraction table
was meticulously constructed, as detailed in Appendix F. This table served as a structured
repository, designed to collate and organize pivotal information from the ten selected studies.
Recognizing the inherent variability across research methodologies and reporting styles, the
rationale behind this approach was to standardize the presentation of key study attributes that are
most applicable to the research question (Büchter et al., 2020). This methodology facilitated a
nuanced comparison and analysis of results across the studies, which was essential for
identifying overarching trends, clarifying inconsistencies, and establishing a robust foundation
for addressing the research question.

16
Chapter Four: Findings
Lowery et al. (2012) conducted a retrospective quasi-experimental study to evaluate the
effectiveness of an NP-led outpatient disease management clinic, compared to usual physicianled primary care for patients with HF. The study included 969 veterans across six Veterans
Affairs medical centers in the Midwestern United States, with participants followed over a twoyear period. The intervention protocol adhered to the guidelines of the American College of
Cardiology Foundation and included individualized face-to-face patient education, medication
adjustments as clinically indicated, structured follow-up telephone calls, and support for lifestyle
modifications.
The results demonstrated statistically significant reductions in all-cause mortality at both
one and two years post-intervention, although the observed reduction in hospital readmissions
was attenuated by the second year. Despite its quasi-experimental design, the study demonstrated
strong methodological rigor and was one of the first to identify the diminishing long-term impact
of NP-led interventions on HF readmission rates beyond the initial year. This finding challenges
the adequacy of the 30-day readmission rates as the sole metric of intervention success and
emphasizes the need for long-term outcome evaluation.
External validity was strengthened by the recruitment of a large sample (n = 969) from
multiple outpatient sites, thereby enhancing the generalizability of findings. However, the study's
non-randomized design and the exclusive inclusion of an all-male veteran population may
introduce selection bias and limit applicability to more diverse groups. Notably, the inclusion of
participants with fewer comorbidities4specifically those with a life expectancy greater than six
months4may have minimized confounding variables and strengthened internal validity. The
presence of a relatively healthy cohort likely contributed to the strength of the observed

17
outcomes, suggesting that the intervention’s effectiveness may be more pronounced in patients
with less complex health profiles. Nonetheless, further research is needed to determine whether
these results can be replicated in more clinically diverse populations.
When comparing the findings from Lowery et al. (2012) with those of Blum and Gottlieb
(2014), several key similarities and distinctions emerge regarding the short and long-term
effectiveness of NP-led interventions in HF management. Although both studies provide
evidence supporting NP-led care in reducing readmission rates, they also consistently
demonstrate a decline in effectiveness over time, emphasizing the need for sustained follow-up
strategies.
Blum and Gottlieb (2014) conducted an RCT involving 204 HF patients across multiple
hospital discharge sites in the United States. The intervention consisted of a comprehensive NPled outpatient telemonitoring program, which included remote monitoring devices to track
weight, blood pressure, heart rate, as well as individualized patient education and guidelinebased treatment protocols. Abnormal data readings triggered early clinical evaluations by the NP,
who assessed whether treatment escalation was required. Although the intervention design
shared several components with that of Lowery et al. (2012), including education and follow-up,
the Blum and Gottlieb (2014) study employed a more robust research design (RCT) but involved
a smaller sample size.
Importantly, Blum and Gottlieb (2014) did not report detailed information about
participants’ comorbidities like in the Lowery et al. (2012) study, though they excluded
individuals with conditions likely to confound results, such as active substance use, cancer,
obesity, and dementia. This approach, while potentially reducing variability, may limit the
study’s applicability to real-world, complex HF populations. Additionally, the follow-up period

18
was extended to a mean of 802 ± 430 days (median of 823 days), and concerningly the authors
did not disclose the rationale for such variability in this timeline, raising concerns about the
consistency of its design.
Nonetheless, the study reported statistically significant reductions in 30-day readmission
rates that waned after the first year, corroborating the findings on short-term efficacy of NP-led
outpatient interventions seen in the Lowery et al. (2012) study. This pattern is particularly
important, as both studies were the longest in duration out of the ten studies reviewed, and hence,
reveal a shared challenge: the waning impact of these interventions over time.
A notable limitation of the Blum and Gottlieb (2014) study was that all interventions
were delivered by a single NP. The authors noted that this provider offered care that surpassed
typical practice standards, yet no specific examples were provided to define what constituted
such <exemplary= care. This lack of detail makes replication difficult and raises concerns about
generalizability. It is plausible that the observed positive outcomes were influenced by the
exceptional skill set of the individual NP rather than the intervention model itself, thereby
limiting its applicability across broader NP practice settings.
Similar to the study design of Lowery et al. (2012), Rhiantong et al. (2019) conducted a
quasi-experimental study that evaluated the impact of an NP-led continuing care program on 71
patients with HF following myocardial infarction who had been discharged from a cardiac care
unit at a University Hospital in Thailand. Through a Designed Continuing Care Program, the
study’s interventions were similar to those observed in the aforementioned studies,
encompassing timely follow-ups within 14 days of discharge, body weight changes, meticulous
care coordination, patient education, medication reconciliation, thorough patient assessments,
problem identification, and prompt interventions.

19
The study resulted in statistically significant reductions in healthcare costs, shorter
hospital stays, improved functional status, enhanced quality of life, and greater patient
satisfaction, however, they did not lead to statistically significant reductions in three-month
readmission rates and ED visits. This finding aligns with the pattern of diminishing intervention
efficacy previously observed in Lowery et al. (2012) and Blum and Gottlieb (2014).
It is important to note, that the overall reliability of the study is limited by the
characteristics of its unique patient population4who were recruited following myocardial
infarction4with HF as a secondary comorbidity rather than a primary diagnosis. This cohort
differs significantly from those in previously discussed studies, as patients recovering from
myocardial infarction often present with more complex clinical profiles and higher acuity
needs4such as increased risk for arrhythmias, hemodynamic instability, and multi-organ
involvement. As a result, their patterns of hospital readmission may have been influenced by
factors beyond HF alone, potentially obscuring the true effect of NP-led intervention on
readmission rates. Nonetheless, shorter duration of effect (less than three months) further
underscores the importance of identifying strategies to sustain long-term benefits, particularly
when compared to the one-year efficacy reported in earlier studies.
Similar to the Blum and Gottlieb (2014) study, Breathett et al. (2018) also employed an
RCT design, representing another high standard in critical appraisal, and examined the
effectiveness of NP-led interventions in reducing 30-day readmission rates among HF patients.
Breathett et al. (2018) conducted a single-center, investigator-blinded RCT with 206 participants,
evaluating the impact of one-on-one outpatient NP education combined with an enhanced tabletbased intervention. The tablet-based intervention included a designed application program which
provided patients with extra education around HF, nutrition planning, medication adherence, and

20
life-style changes. As seen in the Blum and Gottlieb (2014) study, any arisen issues were flagged
to medical staff, and early interventions and escalation of care was conducted to prevent medical
deterioration. Despite this strong methodological approach, the study's limited sample size, and a
funding constraint, led to an underpowered primary analysis.
Due to the primary analysis funding constraints, a secondary analysis was conducted
which focused solely on the tablet-based intervention, excluding the one-on-one outpatient NP
interventions. The lack of face-to-face NP interactions revealed a statistically significant increase
in readmission rates. While the study did not yield robust evidence in support of the tablet-based
intervention, it underscored the significance of face-to-face outpatient NP interventions in
reducing 30-day readmission rates. This finding is particularly significant as it not only supports
the role of NP-led education in reducing HF readmission rates, but also demonstrates that its
absence may contribute to increased readmissions4highlighting a strong, potentially causal
relationship between NP-led education and improved patient outcomes.
In contrast to the previously discussed studies, Breathett et al. (2018) focused exclusively
on 30-day readmission rates and did not evaluate the long-term effects of NP-led interventions.
Additionally, the single-center design4similar to that of Blum and Gottlieb (2014)4limits the
generalizability of the findings to more diverse populations. Despite ongoing calls in the
literature for multi-site studies to strengthen external validity, this gap remains unaddressed,
highlighting the continued need for broader evaluation of NP-led models across varied clinical
contexts.
Smith et al. (2016) employed a distinct patient recruitment methodology, achieving
objectivity despite targeting an HF group with multiple and complex comorbidities. Utilizing the
LACE tool, a validated risk stratification instrument, Smith et al. (2016) conducted a case-

21
control study that objectively identified patients at elevated risk for readmission. The LACE tool
assigned participants a score based on: (1) length of the original hospital stay, (2) acuity of their
last admission, (3) comorbidity index, and (4) prior ED utilization. A score of 036 indicated
<low-risk,= 7310 <intermediate risk,= and 11315 <high-risk= for readmission. Their study
involved 532 patients discharged from a community hospital in Colorado with a LACE score
between 11 and 15, representing a patient population with a 21.48% overall readmission risk.
The study assessed the efficacy of a single NP-led home visit, conducted within 24372
hours post-discharge, in reducing 30-day hospital readmission rates and ED visits. Interventions
focused on clinical assessment, medication adherence, patient education, and necessary medical
adjustments. Notably, the study demonstrated a 48.2% relative reduction in 30-day readmissions
and a 53.9% relative reduction in ED visits, exceeding the impact observed in the other studies.
This drastic improvement may have stemmed from the earlier timing of follow-up, as patients
were seen sooner post-discharge than in studies that utilized delayed intervention periods. These
findings stand to contradict the notion that a healthier participant cohort, as seen in the Lowery et
al. (2012) study, resulted in lower readmission rates.
Although the study’s follow-up period was limited to 30 days, as also seen within the
Breathett et al. (2018) study, it intentionally targeted a high-risk population with multiple
comorbidities, as reflected by elevated LACE scores. The strong outcomes achieved within this
context underscore the potential of timely NP-led interventions. Nonetheless, as a quasiexperimental study, it shared the limitations of non-randomized design, which may have
introduced selection bias. Additionally, the LACE score-based selection criteria may have
excluded certain HF patients who could have benefited from the intervention, potentially
influencing the generalizability of findings.

22
Moore (2016), in collaboration with a Medicare-certified home health agency, developed
and piloted an NP-led, home-based HF clinical pathway program aimed at improving postdischarge care, reducing 30-day readmission rates, and achieving better cost savings. This
program is defined by its highly integrative approach, implemented and led by an NP working in
conjunction with a multidisciplinary team including physical therapists, registered nurses,
dieticians, pharmacists, occupational therapists, social workers, and home health aides. This
integrative approach to care provision surpasses the integrative interventions observed in other
studies, which primarily focused on individual interventions or smaller interdisciplinary teams.
Similar to the early follow-ups seen within the Smith et al. (2016) study, patients were
also assessed and seen by an NP earlier, within seven days of initiating home health services, and
received a comprehensive intervention over a four-month period. The intervention included
routine monitoring of vital signs and weight changes, patient education, medication
reconciliation, care escalation protocols, and the use of various telemonitoring technologies4
similar to the interventions implemented in the Rhiantong et al. (2019) study. The pathway
demonstrated a substantial reduction in ED visits and a significant decrease in 30-day
readmission rates, from 27.8% to 9%, with only two patients experiencing readmissions. This
represents one of the most pronounced reductions in readmission among the studies reviewed
and supports Smith et al.’s (2016) findings that early NP-led intervention produces lower
readmission rates. While these results align with existing evidence supporting the effectiveness
of NP-led interventions, the magnitude of improvement observed in this study may be partially
attributed to the involvement of a multidisciplinary care team, which likely enhanced care
coordination, patient monitoring, and education. HF patients may particularly benefit from this
approach, as HF decompensation is often influenced by factors beyond medical management

23
alone4including dietary adherence, fluid restriction, physical activity, and medication
compliance (Charteris & Pounds, 2020).
However, Moore (2016) utilized a convenience sampling method and a non-randomized
design, without the inclusion of a control group. The use of convenience sampling is particularly
concerning, as the study did not report participant characteristics, raising the possibility that the
positive outcomes observed may have been influenced by the inclusion of individuals with fewer
comorbidities or a higher likelihood of success, rather than the intervention itself. The study's
sample size of 22 was small, with no reported power analysis to justify this limited sample.
Siodlak et al. (2020) conducted a pilot study, mirroring the design of Moore (2016), to
evaluate a collaborative model involving Clinical Pharmacist Specialists (CPS) and NPs in a HF
Access Clinic. While both studies employed a multidisciplinary approach, Siodlak et al. (2020)
demonstrated a less integrated model compared to Moore (2016). The intervention described in
Siodlak et al. (2020) emphasized a flexible diuretic regimen, timely medication adjustments, and
patient education, leading to the greatest reduction in 30-day readmission rates among the studies
reviewed. Readmissions decreased to 8%, a significant improvement compared to the
institution’s historical rate of 15.8%. Notably, no ED visits or mortality were reported during the
follow-up period. This pronounced reduction in readmissions aligns with the positive trends
observed in Moore (2016) and demonstrating the efficacy of interdisciplinary interventions.
Notably, the study's emphasis on interprofessional collaboration, particularly the CPS
involvement, leading to medication discrepancy identification in 58% of visits and optimization
in 54% of patients, highlights a unique aspect compared to other studies under review.
However, the study’s methodological limitations were similar to that of Moore (2016),
who also relied on descriptive statistics, thereby limiting the strength of its evidence. A small

24
sample size and short follow-up period further raise concerns about generalizability, a limitation
shared with the other single-center studies. While the pilot study by Siodlak et al. (2020) may not
possess the methodological rigor of Moore (2016), its significant reduction in readmissions
reinforces the positive trends observed in other studies, suggesting the potential benefit of
collaborative models in HF management.
Charteris and Pounds (2020) employed a quality improvement study using Plan-DoStudy-Act cycles to evaluate an NP led multidisciplinary clinic model for veterans with HF. The
study was developed by a Cardiology NP, who established a dedicated HF clinic in collaboration
with dietitians and pharmacists, focusing on patient education and goal-setting. Charteris and
Pounds (2020) posited that these interventions are critical, as medication nonadherence and poor
dietary practices are leading contributors to HF decompensation and subsequent hospital
readmissions. The intervention, despite incorporating elements similar to all the other studies,
like timely follow-up appointments and patient education, achieved only a 0.2% reduction in 30day readmissions. These results, although trended positive, contrasts with the substantial
reductions seen in all of the other aforementioned studies. This minimal impact, coupled with a
small sample size (n=43), high attrition (50%), and substantial inconsistent implementation of
engagement tools, raises concerns about the effectiveness and generalizability of their model.
The study's limitations, including the lack of a control group and non-randomized design.
Despite these methodological shortcomings, the study contributes to the body of evidence on NP
led multidisciplinary approaches, suggesting a need for further research with more rigorous
designs.
Ballard-Hernandez et al. (2010), being the oldest study that utilized a multidisciplinary
approach, aimed at reducing 30-day all-cause readmission rates for HF patients. In this study,

25
high-readmission risk hospitalized HF patients were identified using questionnaires, who later
connected with an NP as an outpatient who conducted follow-up phone calls, monitoring, and
referrals as needed. This study, while demonstrating a reduction in readmission rates from 25.9%
to 17.6%, shared the same critical limitation of the other non-randomized studies: the absence of
a control group and randomization. A significant limitation to this study is the heterogeneous
nature of the interventions, encompassing both inpatient and outpatient settings, representing a
critical flaw that significantly impairs the relevance of the study's conclusions to this integrative
review. Credibility is further compromised by the study's failure to provide any statistical details
for its Performance Improvement Project. Despite this deficiency, the study’s results stand to
support NPs leading a multidisciplinary approach, as shown within the Moore (2016), Siodlak et
al. (2020), and Charteris and Pounds (2020) studies.
To broaden the scope of this analysis, a systematic review by Delgado-Passler and
McCaffrey (2006) compared the effectiveness of NP-led post-discharge management
interventions to those led by Registered Nurses (RNs) for HF patients. This review, unlike the
individual studies previously discussed, synthesized findings from predominantly RCT studies,
focusing on outcomes such as readmission rates, length of stay, mortality, and healthcare costs.
While individual study results varied, a general trend supported the superiority of APN led
interventions in reducing readmissions compared to RN led programs. This aligns with the
positive trends observed in the majority of the studies reviewed that advocated for NP led
interventions. One of the most significant findings identified in the systematic review is
presented in the analysis by Delgado-Passler and McCaffrey (2006) of a study conducted by
Benatar et al. (2003), who hypothesized that the method of outpatient care delivery may
influence outcomes in the HF population. Benatar et al. (2003) found that home visits by

26
specialist cardiac RNs were less effective in reducing hospital readmission rates compared to
NP-led outpatient telemonitoring (Delgado-Passler & McCaffrey, 2006). This finding is
particularly important, as it suggests that the effectiveness of face-to-face interventions, such as
those demonstrated in the study by Breathett et al. (2018), may not be attributed solely to the
delivery format, but rather to the distinct impact of the NP encounter itself.
The review identified inconsistencies in results, likely due to differences in intervention
scope, intensity, patient populations, and study designs. For instance, significant reductions in
readmissions and mortality were observed in studies like Naylor et al. (1999) and Dahl and
Penque (2000), while others, such as Debusk et al. (2004), showed no significant changes in
hospitalization rates. These variations highlight the challenge of generalizing findings across
diverse healthcare settings, a concern echoed in the variability of results seen in the individual
studies reviewed. Furthermore, despite employing a seemingly comprehensive search strategy,
the review did not fully address potential biases in study selection or assess the quality of the
included studies, thereby limiting its overall reliability. This lack of quality assessment contrasts
with the rigorous methodological appraisal applied to the individual studies in this analysis.
Despite these limitations, the systematic review offers valuable insights into the potential
benefits of NP-led interventions in managing HF. The variability in results underscores the need
for clearly defined population groups and standardized intervention protocols when interpreting
outcomes. This highlights the importance of future high-quality, long-term studies to confirm the
effectiveness of NP-led post-discharge management and improve generalizability, a
recommendation that reinforces the conclusions drawn from the individual study analyses.
Lastly, while Delgado-Passler and McCaffrey (2006) compared NP-led care to that
provided by RNs, comparisons to other clinic models4such as outpatient cardiology clinics4

27
remain limited in the literature. Much of the existing literature advocates for the utilization of
NPs in healthcare due to their cost-effectiveness (Perloff et al., 2016), but there is a scarcity of
research directly comparing NP-led interventions to those led by cardiologists. This gap in the
literature underscores the need for further investigation to delineate the specific contributions of
NPs in cardiology care. While such a comparison would likely reveal higher costs associated
with cardiologist-led care, the clinical outcomes and cost-effectiveness of NP led interventions
compared to specialist-led care remain to be fully elucidated.
In this context, Lowery et al. (2012) provided valuable insights by comparing NP
interventions to those delivered in physician-led primary care centers. The study's findings
demonstrated that NP led models yielded superior outcomes compared to physician-led primary
care centers, challenging the notion that physician-led care is inherently superior and supporting
the potential for NPs to provide high-quality, cost-effective care in cardiology.

28
Chapter Five: Discussion
This integrative review appraised the efficacy of NP-led outpatient interventions in
mitigating hospital readmissions among patients with HF. The literature included in this
integrative review revealed a reduction in both hospital readmission rates and reliance on ED
services when discharged HF patients received NP-led outpatient interventions. While a majority
of the studies exhibited statistically significant reductions in these two areas, the magnitude of
this effect varied considerably across investigations.
One reason for this variability in outcomes may relate to the diverse intervention
modalities employed within each study, as well as the different intensity and comprehensiveness
with which they were employed. While the specific interventions used in the studies resulted in
varied outcomes, the importance of structured patient education and sustained follow-up care in
effective HF management was consistent. In essence, NP-provided patient education, coupled
with regular follow-up by the NP, was associated with a significant reduction in hospital
readmissions for HF patients. This observation aligns with existing research emphasizing the
positive impact of patient education, self-care empowerment, and active patient engagement,
particularly among individuals with multiple comorbidities (Charteris & Pounds, 2020).
Furthermore, the findings suggest that, while adjunctive educational approaches, such as
telemonitoring or digital interventions, may be utilized, their efficacy is most optimized when
integrated with direct face-to-face NP engagement (approximately 60 minutes) rather than when
they are employed as standalone interventions.
Despite the promising outcomes reported, several challenges remain. The variability in
long-term effectiveness of NP-led interventions in reducing HF-related readmission rates and ED
visits suggests that, while these strategies are effective during the first year post-discharge,

29
sustaining their impact over longer periods is more difficult. Further research is needed to
identify effective intervention strategies that will make the positive impact last for a longer
amount of time. This is particularly crucial given the chronic and progressive nature of HF,
which demands continuous and adaptive care within a structured program. Therefore, future
efforts should prioritize the development of long-term intervention strategies that extend beyond
the initial 30-day to one-year post-discharge period, so that improvements in patient health and
the decreased risk of hospital readmissions become longer-lasting outcomes.
This integrative review also emphasized the significance of interdisciplinary
collaboration within NP-led care models. Interprofessional models of intervention delivery that
integrated pharmacists, dietitians, and other allied healthcare professionals into the care team
demonstrated greater reductions in HF readmission rates compared to those that offered NP
interventions only. This finding underscores the value of team-based care approaches in
managing complex conditions such as HF, reinforcing the imperative for healthcare systems to
implement integrated care models rather than using a system of fragmented care delivery. This
finding is particularly salient given that research consistently identifies medication nonadherence and dietary indiscretion as primary contributors to acute HF decompensations
(Charteris & Pounds, 2020). Addressing these multifactorial contributors requires coordinated
efforts from multiple disciplines, highlighting why isolated care models often fall short in
preventing readmissions.
A significant knowledge gap regarding HF exists within both the general population and
among HF patients themselves (Cowie et al., 2014). Survey data indicates that many individuals
who have experienced acute HF will still struggle to recognize the prodromal symptoms of
subsequent exacerbations (Cowie et al., 2014). This is particularly concerning given that several

30
modifiable factors, such as hypertension, respiratory infections, and medication non-adherence,
contribute to the exacerbation of HF (Fonarow et al., 2008) but can be effectively managed in
outpatient settings. These modifiable risk factors for HF decompensation underscore the
necessity of integrating other professions into the care team, such as dieticians and occupational
therapists, to augment the care provided by NPs and optimize patient outcomes.
Additionally, this review found that the timing of NP-led interventions played a critical
role in their effectiveness at reducing readmission rates and ED visits. Interventions initiated
within the first few days post-discharge were consistently associated with superior patient
outcomes, including greater reductions in both readmission rates and ED utilization. A
contributing factor may be the increasing pressure on hospitals to discharge patients rapidly in
order to free up inpatient and ED capacity (Iyeke et al., 2023). However, EDs have not yet
systematically integrated HF-specific risk stratification tools to assess discharge readiness, which
may result in patients being discharged before they are clinically stable or adequately prepared to
self-manage at home (Miró et al., 2020). Early NP involvement during this critical transition
period helps bridge these systemic gaps by offering timely reassessment, medication
optimization, and individualized education, thereby reducing the likelihood of deterioration and
unplanned readmissions.
The generalizability of study findings, or the extent to which the results of the included
studies can be applied to broader populations, remains a concern in the existing HF literature.
This limitation stems from the single-center design of most studies as well as other
methodological weaknesses and research flaws, such as the utilization of a non-randomized
research design, selection bias, lack of control groups, and variability of interventions. Therefore,
establishing standardized NP-specific protocols for widespread implementation across diverse

31
healthcare systems will continue to be challenging until further research can extend these
findings across diverse settings and populations.
The findings of this review also held implications for healthcare policymakers,
particularly in the context of resource allocation and strategic planning. The expansion of NP-led
transitional care programs offers a potentially cost-effective strategy to mitigate hospital
congestion and enhance HF patient outcomes, addressing a critical need in an aging
demographic. Hospital readmissions for HF impose substantial financial burdens on both
healthcare institutions and patients, diverting important resources away from preventative care
initiatives and long-term management strategies. Each HF-related hospitalization in Canada and
the U.S. incurs thousands of dollars per patient, with aggregate expenses exceeding billions
annually (Smith et al., 2016); this highlights the economic imperative for finding effective
interventions with long-term positive impact. However, future research endeavours should
prioritize multi-center studies with larger sample sizes to validate these findings across diverse
populations and to explore specific contextual factors that can influence program efficacy.
This review also revealed a particularly striking finding: NP-led HF interventions
demonstrated superior efficacy compared to care delivered by a physician-led primary care
center (Lowery et al., 2012). These finding challenges prevailing notions and biases regarding
the necessity of using physician care for HF interventions as compared to NPs (Htay &
Whitehead, 2021). This observation has several important sequelae: (1) the benefits for HF
patients if an integrative model, offering specialized and enhanced care beyond the scope of
traditional primary care centers, is used; and (2) a recognition that clinical skills of NPs, honed
through prior nursing experience, and including such skills as patient advocacy, continuous
monitoring, early recognition of critical signs, and health promotion (King-Dailey et al., 2022),

32
are unique to the role and vital in effective HF management. This finding is also consistent with
existing evidence demonstrating the value of the NP role and the tremendous benefits that NPs
bring to the care team in various clinical settings (Htay & Whitehead, 2021). Nevertheless, it is
important to note that further research is still warranted to quantify the differences in hospital
readmission rates between NP-led outpatient interventions and those provided by medical
practitioners.
The escalating burden of HF, a leading cause of hospital admissions for individuals aged
65 and above (Fonarow et al., 2008), presents a critical challenge to the Canadian healthcare
system. With readmission rates ranging from 20-50% within six months of discharge (DelgadoPassler & McCaffrey, 2006) and the elderly population projected to double in the next decade
(Charteris & Pounds, 2020), the strain on EDs is only expected to intensify. This healthcare crisis
will continue to converge with the existing primary care deficit in Canada, where a severe
shortage of physicians and protracted wait times impede timely access to essential healthcare
needs (Field et al., 2015). For patients with chronic conditions such as HF, this scarcity of
practitioners and healthcare services is particularly devastating, as continuous monitoring,
education, and coordinated care are paramount for preventing exacerbations and maintaining
quality of life. This integrative review illuminates a compelling solution: empowering NPs to
lead transitional care programs. NPs possess the advanced education and clinical expertise to
provide comprehensive care, including patient education, medication management, and
interdisciplinary coordination. By strategically utilizing NPs, Canada can simultaneously address
the rising tide of HF-related hospital visits and expand access to vital primary care services,
thereby alleviating the strain on overburdened EDs and fostering a more resilient healthcare
system. This approach would also align seamlessly with the core principles of the Canada Health

33
Act, ensuring a more equitable access to essential healthcare for all Canadians, irrespective of
geographic location or socioeconomic status (Martin et al., 2018).
Recommendations
This integrative review highlighted the potential of NPs to improve HF management and
address critical gaps in primary care access and ED over-utilization. Recommendations arising
out of this review include:
•

financially empowering and supporting NPs to lead transitional care programs that use
robust interprofessional collaboration,

•

establishing standardized, evidence-based multidisciplinary protocols for NP-led HF care,
particularly in seeing patients face-to-face within less than a week post-discharge, and

•

prioritizing research aimed at establishing the long-term efficacy and long-term outcomes
obtained through an NP-led approach to HF care.

By optimizing NP utilization, healthcare systems can enhance HF patient outcomes, reduce
hospital readmissions in this patient population, and improve their access to lifesaving care, all of
which are particularly important amidst the escalating human and financial burden of HF and the
ongoing primary care and ED crisis in Canada.
Limitations
This review does have limitations associated with the way in which it was conducted and
the characteristics of the studies that were included within it. Variability in intervention
components and outcome measures across studies hindered precise comparisons between them.
The inclusion of studies in the analysis that had methodological weaknesses may have impacted
the overall quality of the evidence. Notably, all the studies included in this review recommended
further research to validate their findings and to address remaining gaps in knowledge. The

34
search strategies that were selected and used for this review may not have retrieved all
potentially relevant publications on this topic. It is also possible that searching only two
databases (CINAHL and Ovid MEDLINE) may have restricted the results; had additional
databases, such as Academic Search Complete, PubMed, or Science Direct, been included in the
searches, this would have increased confidence that the search results were comprehensive.
Finally, the author of this review is a prospective NP; personal aspirations and professional
identity may have inadvertently influenced interpretation of the findings. This potential bias
should be acknowledged when considering the conclusions drawn.
Declaration of Conflicting Interests
The author received no financial support for the integrative review research, authorship,
and/or publication of this paper. The author’s enrollment in a NP program may introduce a bias
toward the positive outcomes of NP-led models of care. Additionally, the author’s experience as
an emergency nurse, having witnessed ED overcrowding and frequent readmissions, may
influence the perspective on the effectiveness of NP-led clinics in reducing hospital readmission
rates. Efforts have been made to maintain objectivity and provide a balanced analysis of the
literature.

35
Chapter Six: Conclusion
The findings of this integrative review underscore the urgent need for healthcare reform
in post-discharge HF management. NPs, with their expertise in chronic disease management,
continuous monitoring, early recognition of complications, and patient education, offer a
scalable, cost-effective, and highly impactful solution. Through NP-led transitional care
programs, hospitals can reduce preventable readmissions and decrease reliance on EDs, which
has been a consistent driver of healthcare strain. However, HF is only one aspect of a much
larger crisis: the overwhelming burden of chronic diseases. The fundamental principles of
transitional care4continuity, early follow-up, patient education, and interdisciplinary
collaboration4are universally applicable to conditions such as diabetes, chronic obstructive
pulmonary disease, kidney disease, and the complex healthcare needs of aging populations.
Without decisive action from policymakers, hospitals will continue to be inundated with
avoidable readmissions, escalating costs, and worsening patient outcomes. The evidence is clear:
NP-led transitional care presents a transformative opportunity to redefine chronic disease
management, enhance healthcare efficiency, and improve patient well-being. The time for
incremental change has passed4healthcare leaders must commit to expanding these models,
recognizing that the sustainability of our healthcare system hinges on proactive, patient-centered
interventions that address the root causes of chronic disease mismanagement.

36
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43
Appendix A
CINAHL Search Strategy

Note. Screenshot taken from the CINAHL Complete database via EBSCOhost.
EBSCOhost. (n.d.). CINAHL Complete. EBSCO. Retrieved November 24, 2024, from
https://www.ebsco.com/products/research-databases/cinahl-complete

44
Appendix B
Search Strategy Ovid MEDLINE

Note. Screenshot taken from the Ovid MEDLINE database.
Wolters Kluwer. (n.d.). Ovid MEDLINE. Ovid. Retrieved November 24, 2024, from
https://www.ovid.com/product-details.medline.html

45
Appendix C
Search Strategy Summary
Database
Source

Inclusion
Rationale

Search Strategy

Results

CINAHL
Complete

Thorough
indexing of
nursing and
allied health
literature

Concept 1: Heart failure

133
articles

Via
EBSCO
host

Step 1: CINAHL subject heading term: <Heart disease= exploded to
include related subheadings such as <Heart Diseases=, <Arrhythmia=,
<Heart Failure=, <Myocardial Injury=, etc.
Step 2: Additional subheadings <Cardiac*=, <Heart*=, <Cardio*=,
<Heart injur*=, <congestive heart failure=, CHF=, <HF=.
Step 3: Combined with OR to retrieve 697,491 results.
Concept 2: Nurse Practitioner
Step 4: CINAHL subject heading: <Nurse Practitioners= exploded to
include related subheadings: <primary care nurse practitioner=
Step 5: Additional subheadings: <Advanced Providers=, <Advanced
Practice Nurs*=, <Advanced Nurs*=, <NP=, <APN=.
Step 6: Combined with OR to retrieve 46,102 results.
Concept 3: Readmission
Step 7: CINAHL subject heading: <Readmission= and <Patient
Admission=
Step 8: Additional subheadings: <Rehospitalization=, <Return to
hospital=, <return to emergency=, <Hospital revisit=, <Emergency
revisit=, <emergency room visits=
Step 9: Combined with OR to retrieve 42,537 results.
Step 10: Final combination 3 all three concepts combined with AND
to retrieve 133 articles.

46

Ovid
MEDLINE

Extensive
biomedical
database
providing
robust source
of peerreviewed
clinical
research

Concept 1: Heart failure
Step 1: MeSH term: <Heart Diseases= exploded to include
recommended terms: <cardiovascular diseases=, <heart diseases=,
<Heart failure=, <edema, cardiac=, <heart failure, diastolic=, <heart
failure, systolic=.

47
articles

Step 2: Additional keywords: <cardiac*=, <heart*=, <congestive heart
failure=, <CHF=, <HF=, <Heart injur*=
Step 3: Combined with OR to retrieve 1,061,725 results
Concept 2: Nurse Practitioner
Step 4: MeSH term: <Nurse Practitioners= with qualifier term <family
Nurse practitioner=
Step 5: Additional keyword: <Advance Practitioners=
Step 6: Combined with OR to retrieve 19,434 results
Concept 3: Readmission
Step 7: MeSH term: <Patient Readmission= exploded to include
<Hospitalization= and <Patient Admission=
Step 8: Additional keywords: <Return to hospital=, <Hospital revisit=,
<Emergency revisit=, <return to emergency=.
Step 9: Combined with OR to retrieve 314,015 results
Step 10: Final combination 3 all three concepts combined with AND
to retrieve 47 articles

Google
Scholar

Used for a
broader scan,
capturing
recent
publications
not indexed in
traditional
databases

Step 1: keywords inserted into search bar: <Nurse Practitioner
readmission cardiac=

2
articles

Step 2: reviewed first 3-4 pages of search results
Step 3: identified additional relevant articles not indexed in databases
Step 4: articles which cited study were also reviewed.
Step 4: process guided by UNBC librarian recommendations

Systematic
Review by
Fichadiya et
al. (2021)

Relevance and
recent
publication
date

Step 1: systematic review found in CINHAL
Step 2: article read and included articles reviewed
Step 3: 3 articles selected due to high relevance to the topic
Step 4: ensured inclusion of studies not captured in database
searches.

3
articles

47
Appendix D
Articles Retracted within the Inclusion/Exclusion Guidelines
Platform

Number of Articles after
Inclusion/Exclusion
Criteria

CINAHL

4

Ovid
MEDLINE

2

Article Title and Author

1.

Nurse practitioners improving the transition from hospital to
home and reducing acute care readmission rates in heart
failure patients.
Author: Ballard-Hernandez et al. (2010)

2.

A nurse practitioner-led effort to reduce 30-day heart failure
readmissions.
Author: Charteris and Pounds (2020)

3.

Evaluation of the efficacy of a nurse practitioner-led homebased congestive heart failure clinical pathway.
Author: Moore (2016)

4.

Outcomes of an advanced practice nurse-led continuing care
program in people with heart failure.
Author: Rhiantong et al. (2019)

5.

Pilot randomized controlled trial to reduce readmission for
heart failure using novel tablet and nurse practitioner
education.
Author: Breathett et al. (2018)

6.

The influences of post discharge management by nurse
practitioners on hospital readmission for heart failure.
Author: Delgado-Passler and McCaffrey (2006)

Google
Scholar

1

7.

Integrated Nurse Practitioner and Pharmacist Post-discharge
Heart Failure Clinic: Impact on Patient Outcomes.
Author: Siodlak et al. (2020)

Systematic
Article

3

8.

The effect of a randomized trial of home telemonitoring on
medical costs, 30‐day readmissions, mortality and health‐
related quality of life in a cohort of community‐dwelling heart
failure patients.
Author: Blum and Gottlieb (2014)

9.

Evaluation of a nurse practitioner disease management model
for chronic heart failure: A multi‐site implementation study
Author: Lowery et al. (2012)

(Fichadiya
et al.,
2021)

10. A nurse practitioner‒led intervention to reduce hospital
readmissions.
Author: Smith et al. (2016)

48
Appendix E
Critical Appraisals
Ballard-Hernandez et al. (2010)

Purpose

The study assessed the efficacy of a NP-led intervention in reducing 30-day readmission rates
for HF patients.

Design
&
Intervention

performance improvement team intervention approach, utilizing a pre-post intervention
design. The intervention consisted of a NP-led multidisciplinary approach, which included the
creation of standardized order sets, provision of education, consultations, and follow-up
visits/phone calls

Validity

Limited detail on sample size or participant characteristics beyond HF diagnosis hindered
external validity assessment, yet the outcome, 30-day all-cause readmission rates, was clearly
defined, relevant, and measurable.

Methodological
Soundness

While a detailed description of interventions was provided, the analysis lacked mention of
controls for potential confounding variables. The pre-post intervention comparison design,
absent a control group and failing to address confounding variables, weakens the study's rigor,
and insufficient sampling details preclude generalizability.

Result/Outcome

30-day all-cause readmission rates decreased from 25.9% to 17.6%; statistical significance
and confidence intervals were not reported; no formal layout of results; no detailed analysis
on participant characteristics

Applicability

Despite methodological limitations that weakened overall credibility, the study demonstrated
promising outcomes for heart failure patients benefiting from individualized education,
counseling, and earlier, more frequent follow-ups. The pivotal role of NP participation in HF
patient care was suggested, but requires further credible research for conclusive
demonstration

Disclosed
Bias/Limitation

The study exhibited a lack of clearly defined inclusion/exclusion criteria for the study
population and lacked clarity regarding consistent implementation of the intervention across
different patients and settings within the hospital.

Credibility
Rating

Rate Level: II
limited reliability and credibility

49

Blum and Gottlieb (2014)

Purpose

Evaluate the impact of home telemonitoring on 30-day readmissions, hospitalizations, rates,
costs, mortality, and quality of life in HF patients. while not the primary focus, the study
involved NP-led care within the telemonitoring group.

Design
&
Intervention

Randomized Controlled Trial; outpatient telemonitoring using technology such as weight
scales, blood pressure monitoring, and other devices, remote assessments, medications, etc.;
included guideline-based treatment and intervention done by one NP; Patients followed until
death or until end of study, at 30-day readmission, 1 year, and 2 years.

Validity

Patients were randomized; no mention blinding; study matched patients based on
characteristics such as age, gender, comorbidities, disease severity, etc.; both groups received
consistent guideline-based therapy/interventions and monitoring by one NP; clear mention of
inclusion/exclusion criteria; mention of confounding variable control efforts; very clear
implementation of intervention; results reliable and analyzed using chi-square tests and t
tests; CI mentioned

Methodological
Soundness

Large number of participants (204) to detect meaningful data with good statistical power;
very clear primary outcome (30-day readmission); participants allowed to care outside of
study which could have influenced results

Result/Outcome

Statistically significant results in telemonitoring with NP involvement led to a reduction in
30-day readmission rates (33.7%) compared to usual care (45.3%), noticeably during the first
year; reduction in hospitalization and costs, although not statistically significant in long-term

Applicability

NP outpatient telemonitoring resulted in a moderate decrease in 30-day and 1-year
readmission rates, but did not have sustained effects after 1 year; since no reduction in
hospitalization, costs, or quality of life observed, study raised questions regarding the "30-day
readmission timeline" as a quality indicator and the use of telemonitoring in the management
of HF.

Disclosed
Bias/Limitation

Statistically significant results only observed in first year; study mentioned that findings may
not be generalized to all populations; adherence to telemonitoring; technical aspects of the
telemonitoring system 3 malfunctioning, may cause variation in results; no mention on
performance bias; no mention of dropout rates or how missing data was handled; participants
received exceptional care by one NP which can introduce performance bias and results which
could not be replicated

Credibility
Rating

Rate Level: IV
high credibility and reliable results

50

Breathett et al. (2018)

Purpose

Evaluated whether the addition of a novel tablet application to NP education was superior to
NP education alone in reducing 30-day readmission rates after heart failure hospitalization

Design
&
Intervention

Randomized-control trial; intervention involved education with tablet application in addition
to one-on-one NP education session; focused on HF overview, nutrition planning, medication
adherence, and life-style modifications

Validity

Detailed and consistent intervention; investigator-blinded study; randomizations; clear
exclusion and inclusion criteria; clear details on participants who were similar between
control and treatment groups; clear primary and secondary outcomes; results laid out clearly
with chi-analyses and t-testing; obtained institutional board approvals; clear sample size; no
mention of CI

Methodological
Soundness

Study did not mention if it controlled for potential confounding variable; study underpowered
and did not reach enough participants for a strong effect size; single-center location and
cannot form generalizability; study acknowledged for these factors; ethical considerations
taken

Result/Outcome

30-day all-cause readmission rates increased to 50% without NP education compared to
20.4% with NP education which was statistically significant. All-cause readmission rates at
30-days trended lower in patients with treatment compared to control but was not statistically
significant.

Applicability

Study showed promising results that patients with HF benefit from individualized one-on-one
education, counseling, and guidance; inconclusive as to which education methods are
superior; NP interventions are effective at reducing HF readmission rates, although more
research needed to form generalizability

Disclosed
Bias/Limitation

Single centered, underpowered and under-funded; cannot generalize results without further
research

Credibility
Rating

Rate Level: IV
high credibility and reliable results

51

Charteris and Pounds (2020)

Purpose

The study aimed to reduce 30-day all-cause readmissions in veterans with HF and to improve
patient engagement in care.

Design
&
Intervention

A quality improvement design was implemented using Plan-Do-Study-Act (PDSA) cycles.
The intervention consisted of a multidisciplinary clinic model incorporating follow-up
appointments, patient education, and engagement tools.

Validity

The study was not a RCT, limiting the ability to establish causality. The sample size was
small (n=43), and the population was narrow. Recruitment was limited by follow-up
difficulties.

Methodological
Soundness

The interventions were inconsistent and subjective. Engagement tools and measurements
changed throughout the study, leading to potentially untrustworthy results.

Result/Outcome

A minimal readmission reduction of 0.2% was observed. Patient engagement and satisfaction
improved. However, due to the very specific clinic model, the results may not be
generalizable to larger populations.

Applicability

NP-led interventions were found to improve self-care and reduce hospitalizations in veterans
with HF. However, the study's limitations suggest that further research is needed, requiring
cautious interpretation of the findings.

Disclosed
Bias/Limitation

The study had a small sample size, and 50% of the patients were uncontacted. The
implementation of the engagement tools was inconsistent, and the intervention period was
short (8 weeks).

Credibility
Rating

Rate: Level I
very weak and unreliable study, needs further research for stronger evidence

52

Delgado-Passler and McCaffrey (2006)

Purpose

Design

Evaluate how post-discharge management interventions done by NPs versus Registered
Nurses (RNs) impact hospital readmission rates for patients with HF.

RCTs and other controlled clinical studies, all focusing on post-discharge interventions for
HF patients.

Validity

Study selection criteria and inclusion criteria were clearly defined; however, exclusion
criteria were not specified. Measured outcomes included readmission rates, length of stay,
mortality, and costs. Various statistical analyses, including t-tests, ANOVA, chi-square,
regression analysis, and ANCOVA, were employed to assess outcomes across intervention
and control groups.

Methodological
Soundness

While individual studies exhibited outcome variability, the general trend supported the
effectiveness of NP-led interventions compared to RN-led interventions in reducing
readmission rates. Variable study limitations, including small sample sizes and short followup periods, hindered the generalizability of findings. Inconsistencies across studies,
potentially attributable to differences in intervention scope and intensity, variations in
population health conditions, follow-up periods, and study designs, were observed. Results
precision varied, yet consistent outcomes were also noted.

Result/Outcome

Riegel et al. (2002): Telephonic nurse case management resulted in a significant decrease in
rehospitalization rates and inpatient costs.
Debusk et al. (2004): Nurse care management did not yield a significant reduction in
hospitalization rates.
Dahl and Penque (2000): NP-led multidisciplinary programs significantly reduced mortality
and readmissions.
Benatar et al. (2003): tele-management by NPs was more effective than home nurse visits in
reducing HF readmissions.
Naylor et al. (1999): NP-led discharge planning and home visits demonstrated a significant
reduction in rehospitalizations.

Applicability

Offers valuable insights into the effectiveness of NP-led interventions in reducing
readmissions for HF patients and seems rigorous with comprehensive search strategy.
Intervention benefits are not uniformly effective across diverse patient populations or
healthcare settings, suggesting a need for further high-quality, long-term studies to validate
these findings

Disclosed
Bias/Limitation

Intervention benefits are not uniformly effective across diverse patient populations or
healthcare settings. Long-term studies required for validation; quality of studies variable;
potential selection bias not fully addressed; studies are older and may not be applicable

Credibility
Rating

Rate Level: II
limited strength and reliability

53

Rhiantong et al. (2019)

Purpose

The study aims to compare outcomes of individuals with HF receiving a Continuing Care
Program led by NPs and those receiving usual care

Design
&
Intervention

quasi-experimental study employed a pretest and post-test design with a comparison group.
Study outcomes included body weight changes, complications, functional status, quality of
life, ED visits, the time interval between discharge and first readmission, and readmission
rates. The intervention comprised timely follow-up appointments within 14 days postdischarge and Monday-Friday availability, care coordination, problem identification, patient
education and counseling, medication reconciliation, monitoring, and proactive interventions.
The study was conducted at a 2000-bed university hospital in Thailand. Clear data collection
methods.

Validity

Purposive sampling; participants were recruited from two urban clinics, resulting in a small
sample size of n=71, an effect size of 0.5 was observed. Ethical approval was obtained, and
informed consent was documented; clear inclusion/exclusion criteria; design was appropriate
and addressed a clear research question. Details of interventions clearly laid out and
consistent; Participant demographics were clearly outlined, representing a generalized patient
population. CI and p values stated.

Methodological
Soundness

Robust data collection was conducted using hospital records (EMRs), ensuring
standardization; however, cross-checking was not reported. The follow-up period focused on
the 30-day readmission rate. Statistical methods employed included chi-square for categorical
data. Results were clearly presented. Ethical considerations stated.

Result/Outcome

Body weight showed no changes at discharge/three months. ED visits and readmissions rate
were not statistically significant at three months post-discharge. Length of stay and costs of
care were significantly reduced in the intervention group. Satisfaction, quality of life, and
functional status significantly improved. P-values and CI reported.

Applicability

NP-led primary care reduced hospital readmissions for HF. Patients reported higher
satisfaction, improved health outcomes, and cost-effectiveness. The findings support the
expansion of NP roles in primary care for enhanced care continuity and reduced
hospitalizations. However, further research is needed to assess long-term effects and broader
applications.

Disclosed
Bias/Limitation

Study limitations were clearly delineated, including the intervention's conduct at a single
hospital, potentially limiting representation of other settings, and a small sample size with
high attrition. Recruiting patients with a wider range of HF severity would enhance result
generalizability, particularly given the small sample size, and would have bolstered the
study's power and significance.

Credibility
Rating

Rate Level: IV
high strength and reliability

54

Lowery et al. (2012)

Purpose

Reduce all-cause mortality, decrease hospital admissions & ED visits at 1 and 2 years, and
improve titration of HF medication.

Design
&
Intervention

Prospective, quasi-experimental study; outpatient NP-led HF clinic compared to usual care
(physician-led primary care)
Interventions included patient education/motivation, life-style changes, and identifying
patients high-risk of complications, follow-up phone calls, medication titration requirements
followed by guidelines from the American College of Cardiology Association

Validity

Intervention accurately measured; NP-led disease management was well-defined and
measured; comprehensive disease management, individualized care plans, medication
optimization, monitoring and follow-up, education and self-management support,
coordination of care; patient demographics clearly reported; outcomes measured using
standardized data collection methods from Veteran Affairs records, and mortality rates
adjusted for baseline differences using Cox proportional hazard regression models.

Methodological
Soundness

No randomization; study included all HF patients within the Veterans Health Administration
System; high participation rates, male only; study followed patient for 2 years, longest HF
management study (insight into sustained interventions); intervention had higher use of betablockers and Spironolactone usage, critical in HF management; p value and CI reported,
results clearly laid out; ethical consent obtained; details participant characteristics

Result/Outcome

Reduced all-cause mortality in NP-led models at one year and two years; statistically
significant results; HF-related hospital admissions were lower in the intervention group at 1
year, but diminished effects at 2 years.

Applicability

Strong evidence that NP-led outpatient management programs improve HF outcomes and
reduce readmission rates; bigger RCT studies with randomization needed to eliminate bias
and potential confounding factors; study sheds light into long-term effects of interventions.

Disclosed
Bias/Limitation

Limited generalizability due to unique patient population; selection bias 3 patients were
volunteers; non-randomization design; lack of resource utilization data from facilities outside
the Veterans health care system; although confounding factors were addressed, there's
possibility for other unmeasured group differences 3 primarily male population.

Credibility
Rating

Rate Level: IV
- strong evidence and highly credible

55

Moore (2016)

Purpose

The study aimed to evaluate the effectiveness of a NP-led, home-based HF Clinical Pathway
Program in reducing 30-day hospital readmissions for HF patients aged ≥ 65 years.

Design
&
Intervention

clinical pathway program; NP-led at home interdisciplinary approach to HF management;
included early NP assessments, telemonitoring, and interdisciplinary care.

Validity

The intervention was well-documented, however, variability in NP visits (e.g., some patients
were seen within 7 days while others were seen within 14 days) could lead to inconsistencies
in exposure to the pathway.

Methodological
Soundness

Convenience sampling was used, and the study was non-randomized and non-blinded. A lack
of a control group and a small sample size (n=22) were present. Not all confounding factors
were identified, and no confidence intervals or statistical tests were provided for key findings.

Result/Outcome

A significant reduction in readmission rates was observed (27.8% pre-Pathway vs. 9% postPathway). Two patients had readmissions (1 for CHF exacerbation, 1 for atrial fibrillation).
Early NP interventions and weekly monitoring were key in reducing readmissions. Fewer ED
visits were noted. The results are statistically significant but limited by the small sample size
(n=22).

Applicability

Statistically significant results may be promising evidence that a HF clinical pathway led by
NPs at home can significantly reduce 30-day readmission rates. However, larger and more
credible studies are needed to support broader implementation.

Disclosed
Bias/Limitation

The non-randomized design and small sample size limit the strength of evidence. Results are
context-specific to home health and may not generalize to broader populations. The study was
biased as blinding was not achieved, and there is potential for selection bias due to
convenience sampling.

Credibility
Rating

Rate level: III
Moderate strength and reliability

56

Siodlak et al. (2020)

Purpose

Evaluated 30-day HF readmission, ED visits, and all-cause mortality in post-discharge
patients who were seen at a pilot NP-led Heart Failure Access Clinic (HFAC).

Design
&
Intervention

Pilot study assessing a Clinical Pharmacy Specialist (CPS) and a NP-led Heart Failure Access
Clinic (HFAC); Integrated clinic focused on medication reconciliation, education, and dose
optimization

Validity

The pilot study design inherently restricts the generalizability of findings due to the absence
of a control group, lack of randomization procedures, and a limited sample size of 24
participants; disclosure of patient characteristics

Methodological
Soundness

The analysis utilized descriptive statistics, and a detailed description of intervention processes
was provided; however, a formal comparative analysis between the integrated clinic and
standard care was not conducted.

Result/Outcome

The 30-day readmission rate was 8%, significantly lower than the institution's historical rate
of 15.8%; no ED visits or mortality were observed; and the CPS identified medication
discrepancies in 58% of visits, resulting in optimized medications for 54% of patients.

Applicability

The integration model demonstrates strong potential, though further research utilizing larger
sample sizes is necessary to validate its effectiveness; furthermore, the interdisciplinary
approach also exhibits strong potential.

Disclosed
Bias/Limitation

The study employed a small, non-random sample, lacked a control group for comparison with
standard care outcomes, and utilized a short follow-up period of 3-4 months

Credibility
Rating

Rate Level: II
limited reliability

57

Smith et al. (2016)

Purpose

The study aimed to reduce 30-day readmission rates and acute care return rates (emergency
room and other admissions).

Design
&
Intervention

A case-control study was conducted at a 192-bed community hospital in Denver, USA. The
intervention consisted of home visits by NPs within 24-72 hours post-discharge for high-risk
HF patients. This single home visit included clinical assessment, medication
compliance/education/discrepancy review, medical adjustments, and follow-up laboratory
tests.

Validity

Methodological
Soundness

Result/Outcome

The Length of stay, Acuity, Comorbidity, and ED visits in 6 months (LACE) tool was utilized
to quantitatively identify patients at risk for hospital readmissions and to stratify all patients.
Participants included those with a LACE score of 11-15, with fewer participants in the control
group. The study employed a clear outcome measure and addressed a well-defined research
question.

P-values and CI were reported. Sampling was conducted based on LACE score, age, and
gender, maintaining consistency across participants. The study included 538 qualified
participants, with 144 in the control group, demonstrating a good sample size.

A reduction in 30-day readmission rates and acute care return rates was observed compared to
usual care. Results were clearly presented with detailed statistical outcomes. Specifically, a
42-53.9% reduction in readmission was achieved. The PACT intervention was clearly
documented and objective, with statistically significant outcomes and reliable findings.

Applicability

The authors convincingly argue that the PACT intervention, utilizing NP home visits within
24-72 hours of HF discharge, reduces 30-day readmission rates. The study emphasizes the
importance of targeted, high-intensity interventions tailored to high-risk patients.

Disclosed
Bias/Limitation

The single-hospital study design limits generalizability. Patients in the intervention group
were older, potentially underestimating the intervention's effect due to baseline high
readmission rates and other comorbidities. Potential confounders, such as demographic
differences, were acknowledged. The study focused solely on patients with a LACE score of
11-15, excluding other high-risk groups.

Credibility
Rating

Rate Level: V
strong study, most credible evidence

58
Appendix F
Data Extraction Table
Population

Ballard-Hernandez et al. (2010)
HF patients discharged of hospital

Setting

Hoang Hospital in California USA

Intervention

NP-led standardized order sets, education, consultations, follow-ups visits/phone calls, referrals,
monitoring; high-risk patients followed as an outpatient in Heart and Vascular Institute by NP

Comparator

None

Measured
Outcome
Key
Findings
Limitations

30-day all-cause readmission rates

Strength

Population

Readmission rates decreased from 25.9% to 17.6% post-intervention
No control group, unclear sample size/characteristics, no mention of confounding variables,
limited generalizability.
Although weak study, results consistent with larger RCTs, and can support NP-led interventions
on reducing 30-day readmission rates
Blum and Gottlieb (2014)
204 HF patients enrolled in Medicare with hospital admission within last year

Setting

the University of Maryland Medical Center, Baltimore Veterans Administration center, and
private cardiology practices in Baltimore/Washington DC, USA

Intervention

NP-led telemonitoring, remote assessments, medication management, weight, blood pressure
monitoring, guideline-based care

Comparator

Usual care

Measured
Outcome
Key
Findings
Limitations

30-day readmission rates and hospitalization rates

Strength

30-day readmission rates reduced from 45.3 to 33.7%; observed within 1 year only.
No blinding, technical issues with telemonitoring, unclear handling of missing data/dropouts,
performance bias; results not sustained after 1 year.
RCT with large sample size, multiple sites, diverse group of HF patients; consistent guidelines,
well-defined outcomes, strong statistical power; strong study supporting NP led interventions to
reduce readmissions and hospitalizations

59
Breathett et al. (2018)
Population

126 Patients admitted with primary diagnosis of HF

Setting

Quaternary academic center

Intervention

NP education in clinic alongside standardized tablet education

Comparator

Primary comparator: NP education alone
Secondary comparator: no NP education

Measured
Outcome
Key
Findings

30-day all-cause readmission rates
NP care with tablet education had lower 30-day readmission rates, not statistically significant;
significantly higher readmission rates without NP education

Limitations

Underpowered, single-center, limited external validity.

Strength

Lack of NP education results in significantly worse outcomes for HF patients and increased 30day readmission rates. Study strengthens the importance of NP education in improving patient
outcomes

Population

Charteris and Pounds (2020)
Veterans with HF diagnosis

Setting

Southern Arizona Veterans Administration Health Care System with 5,600 patients

Intervention

Multidisciplinary clinic model led by NPs conducting follow-up, education, engagement etc.

Comparator

None

Measured
Outcome
Key
Findings
Limitations

30-day all-cause readmissions

Strength

0.2% reduction in readmissions, not statistically significant
Small sample, narrow population, inconsistent interventions during study, short study, 50% of
patients uncontacted
Easy replication of intervention; hope for better outcomes if intervention sustained overtime and
larger sample size

60

Population

Delgado-Passler and McCaffrey (2006)
HF patients in various studies

Setting

Systematic review of RCTs and clinical studies

Intervention

NP-led post-discharge interventions of HF patients

Comparator

RN-led interventions

Measured
Outcome
Key
Findings
Limitations

Hospital readmission rates; varying timeframe

Strength

NP-led outpatient interventions reduced readmission rates vs. RN-led interventions
Variable study quality, inconsistent outcomes, no exclusion criteria for study selection, limited
generalizability, varying interventions and follow-up periods.
Although weak, most studies report that outpatient NP-interventions reduce readmissions. More
consistency needed between studies to support strength for specific interventions.

Population

Rhiantong et al. (2019)
HF patients, n = 71 recruited from CCU at the University Hospital in Thailand following acute
myocardial infarction and heart failure as a complication.

Setting

2000-bed university hospital in Thailand, outpatient departments

Intervention

NP-led continuing care program: timely follow-ups within 14 days, care coordination, education,
medications, monitoring, phone availabilities and care access

Comparator

Usual care

Measured
Outcome
Key
Findings
Limitations

30-day readmission rates, ED visits
No statistically significant differences in ED visits and readmission rates between groups

Strength

robust data collection, standardized and consistent interventions, credible study

Small sample size, single-site, lack of diversity in patient population, limited generalizability,
NPs had inpatient unit involvement during study 3 could have interfered with outpatient results.

Study hold strong support that directed programs for HF can significantly improve outcomes

61

Population

Lowery et al. (2012)
969 male veterans treated for HF with no other comorbidities with a life expectancy < 6 months

Setting

6 Veterans Affair primary care medical centers in Midwest USA and 1 affiliated outpatient clinic

Intervention

NP-led disease management, individualized care, medication optimization, education, selfmanagement support

Comparator

Usual care

Measured
Outcome
Key
Findings
Limitations

Hospital admissions and ED visits

Strength

37% decrease in admissions at 1 year of discharge
Non-randomized, male-only, selection bias, limited generalizability, potential unmeasured
confounders
Large and credible study; substantial reduction in admission rates; improved health outcomes;
multiple sites; intervention can be replicated to more diverse populations; importance of a
multidisciplinary team for HF

Population

Moore (2016)
22 HF patients 65 years of age or older

Setting

HF patients admitted to Medicare certified home health services in Northeastern USA

Intervention

HF Clinical Pathway Program led by NPs providing HF management at home; interdisciplinary
care with physical therapists/dieticians/social workers, early assessments, monitoring, regular
follow-ups

Comparator

Usual care

Measured
Outcome
Key
Findings

30-day readmission rates, ED visits

Limitations

Non-randomized, convenience sampling, small sample size, no control group.

Strength

Well-documented intervention with clear pathway; strong study; early NP involvement in a
multidisciplinary model shown to reduce readmissions and ED visits

Readmission rates reduced from 27.8% to 9% with fewer ED visits; statistically significant
results

62

Population

Siodlak et al. (2020)
Post-discharge acute decompensated HF patients with LVED < 50%

Setting

NP and Clinical Pharmacy Specialist-led HF Access Clinic

Intervention

Integrated care: medication reconciliation, education, dose optimization, monitoring

Comparator

Usual population

Measured
Outcome
Key
Findings
Limitations

30-day readmission rate and ED visits

Strength

Although weak in credibility, results consistent among similar studies and aids in supporting NP
led interventions

30-day readmission rate of 8% vs. historical rate of 15.8%; no ED visits
Weak study; pilot-design, small and non-randomized sample, no control group, short follow-up,
limited generalizability

Population

Smith et al. (2016)
High-risk HF patients with LACE score 11-15

Setting

192-bed community hospital, Denver USA

Intervention

NP-led home visit within 24-72 hours post-discharge: assess improvement, medications, labs,
trends

Comparator

Usual care

Measured
Outcome
Key
Findings
Limitations

30-day readmission and acute care return rates

Strength

Strong study; support for directed post-discharge intervention during vulnerable post-discharge
period results in profound reduction in readmissions.

42-53.9% reduction in readmissions; statistical significance
Single-site study, older intervention group, excluded other high-risk groups, potential
confounders