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Effectiveness of nurse-led transitional care interventions for adult patients discharged from acute care hospitals: a systematic review and meta-analysis

BMC Nursing volume 24, Article number: 379 (2025) Cite this article

Abstract

Background

With the guidance of healthcare policy and advances in medical technology, the average length of stay in hospitals continues to decrease. In this context, expectations for nurse-led interventions for patients discharged home are increasing. However, few systematic reviews of nurse-led transitional care have focused on patients discharged from acute care hospitals. This systematic review aimed to assess the effects of nurse-led transitional care interventions on readmission rates, unscheduled outpatient-visit rates, and quality of life (QOL) of adult patients discharged from acute care hospitals, compared with usual care.

Methods

Four electronic databases were searched for articles published through October 2023. Individual and cluster randomized controlled trials (RCTs) examining the effectiveness of nurse-led transitional care interventions were included. Independent reviewers performed study selection, data extraction, risk of bias assessment, and certainty of evidence using the GRADE approach.

Results

Sixteen RCTs were included. In a meta-analysis of RCTs with readmission rates as the outcome, readmission rates were significantly reduced in the intervention group when the data collection period exceeded 12 weeks (RR 0.67; 95% CI, 0.49–0.92; P = 0.01; I² = 66%; certainty: moderate). The rate of emergency room visits was also significantly reduced in the intervention group (RR 0.63; 95% CI, 0.49–0.81; P = 0.0003; I² = 0%; certainty: high). QOL measured with the SF-36 was significantly higher after 5 weeks (MD 1.27; 95% CI, 0.52–2.02; P = 0.0009, I² = 0%; certainty: low) and after 6 weeks (MD 2.46; 95% CI, 1.67–3.25; P = 0.00001; I² = 19%; certainty: low), both showing a possibility of improvement in the intervention group. However, the number of studies and samples included in the meta-analysis, particularly for readmission rates and QOL, were small, and the results should be interpreted with caution due to differences in subjects, institutions, and types of interventions.

Conclusion

Nurse-led transitional care interventions effectively reduced readmission and emergency department visit rates and improved QOL in adult patients discharged from acute care hospitals.

Peer Review reports

Background

The rising cost of healthcare has become a global issue, with Japan experiencing one of the highest healthcare costs relative to GDP [1]. To address this, Japan’s Fourth National Plan for Optimizing Healthcare Costs emphasized efficient use of medical resources, including hospital bed differentiation and outpatient care improvements [2]. The countries with the highest density of hospital beds worldwide include Korea and Japan. Japan has around 12.6 hospital beds per 1,000 population. On the other hand, the United States reported just 2.8 hospital beds per 1,000 population [3]. Furthermore, Japan also has a long average length of hospital stay, but this is decreasing owing to policy changes and advances in medical technology [4]. As a result, early discharge is increasingly promoted, leading to a higher number of patients discharged with significant medical needs. While early discharge has benefits, it also raises concerns about readmissions, as seen in the U.S. with the implementation of the Hospital Readmissions Reduction Program in 2012 [5,6,7]. With a shift from “hospital-based health care” to “community-based health care” care, preventing severe illness and disease recurrence in outpatient settings has become more important. Therefore, the role of nursing staff in providing health-care guidance and support to ensure continued home care and improve patients’ physical symptoms and quality of life (QOL) is critical [8]. In other countries, established transitional care programs and guidelines facilitate smooth transitions from hospital to home [9,10,11,12]. Although systematic reviews on transitional care have demonstrated effects on readmission rates and QOL [13,14,15,16,17], there is a lack of reviews focusing specifically on patients discharged from acute care hospitals.

Hence, this systematic review aims to evaluate the effects of nurse-led transitional care interventions on the outcomes of readmission rates, unscheduled outpatient visits, and QOL in adult patients discharged from acute care hospitals compared with usual care.

Methods

Electronic database searches

This systematic review followed the Cochrane Handbook for systematic reviews of interventions [18] and the PRISMA 2020 guidelines [19]. We searched using the term “nurse-led transitional care” in PubMed, EMBASE, Cochrane Central (CENTRAL), and CINAHL for articles published through October 2023. The search strategy was developed with the advice of the librarian. For consistency of interpretation and feasibility, we limited ourselves to English-language articles only. In addition, gray literature, including conference abstracts, was excluded from this review to ensure quality and stable access to the research. We excluded articles published from low-income countries because we believed that the different levels of health care would make comparisons and analysis difficult. The search ended on March 31, 2024. The protocol was registered in PROSPERO (CRD: 42024507120).

Study selection

We included individual and cluster RCTs that assessed nurse-led transitional care for adult patients discharged from acute care hospitals. Non-randomized trials and studies lacking detailed intervention descriptions were excluded. Acute care hospitals were medical institutions providing acute care, excluding inpatient facilities and nursing homes whose main purpose is recuperation and rehabilitation, and included general hospitals, university hospitals, tertiary or quaternary care institutions. In this review, acute care is defined as medical care provided for the purpose of curing or recovering from the onset of cardiac disease or stroke, or exacerbation of chronic diseases such as respiratory, gastrointestinal, and nephrology. Participants were adults discharged from acute care, excluding pediatrics, psychiatry, obstetrics, and rehabilitation. Selection was performed using Rayyan [20], and two reviewers (CS, EE) independently evaluated titles and abstracts, resolving disagreements through discussion.

Intervention

Nurse-led transitional care interventions for adults discharged home were reviewed. Coleman et al. defined transitional care as “a series of strategic interventions aimed at ensuring seamless coordination and continuity of healthcare services during patients’ transitions across various healthcare settings or different levels of care within the same setting” [21]. These interventions aimed to ensure coordination and continuity of care, including education on illness, self-care, follow-up by phone or in person, and collaboration with other professionals. Studies focusing solely on pre-discharge interventions, telemonitoring, or single-disease management were excluded. The control group received usual care, such as discharge teaching or placebo interventions.

Outcomes

The outcomes included readmission rates, unscheduled visits, and QOL, as defined by the authors using quantitative tools.

Data extraction and management

Data on study design, participants, interventions, outcomes, and results were extracted and cross-checked by two reviewers (CS, EE). Any discrepancies were resolved with a third reviewer. Transition care components were categorized using 18 elements from previous studies [13, 22].

Risk of bias assessment

Two reviewers (CS, EO) independently assessed the risk of bias using the RoB 1.0 tool in the Cochrane Handbook [23]. The risk was categorized as low, high, or unclear for random sequence generation, allocation concealment, blinding, incomplete data, selective reporting, and other biases. Disagreements were resolved through discussion.

Data synthesis and statistical analysis

For outcomes with cluster RCTs, we combined hazard ratios (HRs) from both cluster and individual RCTs using the generic inverse variance method with random-effects model. For the two cluster RCTs [34, 38], we used the adjusted HRs and their confidence intervals as reported in the original papers, which had already accounted for clustering effects. For individual RCTs, we converted the reported data to HRs using the methods described by Tierney et al. [24]. The standard errors were derived from the reported confidence intervals using the formula: SE = (ln (upper CI) - ln (lower CI))/3.92.

For outcomes without cluster RCTs, we combined relative risks (RRs) using the Mantel-Haenszel method. We applied random-effects model when heterogeneity was evident based on clinical diversity, methodological diversity, and statistical heterogeneity. Fixed-effects model was used when heterogeneity was minimal. For dichotomous outcomes, we extracted the number of events and total participants from each study. Heterogeneity was measured with the I² statistic, using risk ratios for binary data and mean differences with 95% confidence intervals for continuous data.

All effect estimates are reported with their 95% confidence intervals (CIs). All analyses were performed using Review Manager (RevMan) [Version 5.4, The Cochrane Collaboration, 2020].

Sensitivity analysis was performed for studies with high risk of bias or heterogeneity. Subgroup analysis was conducted for readmission rates, dividing patients into two groups according to intervention period (6 weeks or less vs. 7 weeks or more). In addition, subgroup analysis was conducted for the QOL subscale.

Certainty of evidence

The GRADE approach [25] was used to evaluate the certainty of evidence for readmission rates, emergency department visits, and QOL, categorized into high, medium, low, or very low levels.

Results

The database searches yielded 2647 articles. The screening of abstracts and titles identified 19 relevant articles. After excluding one conference abstract, one duplicate, one non-RCT article, and two articles focused entirely on medical management for a specific condition, 16 RCTs remained. The flow and number of studies included in this systematic review are described in the PRISMA flow diagram (Fig. 1).

Fig. 1
figure 1

Flow diagram of studies included in this systematic review

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Characteristics of the included studies

Table 1 provides an overview of the 16 RCTs included [26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41]. The study designs included 11 single-center RCTs [26, 27, 29, 30, 32,33,34, 36,37,38, 40], three multicenter RCTs [28, 31, 41], and two step-wedge cluster RCTs [35, 39]. Six RCTs were conducted in China, two each in Hong Kong, the United States, and Canada, and one each in France, Denmark, the Netherlands, and Turkey. In terms of subject admission sites, four were university hospitals, one was teaching hospital, one was tertiary care institution, seven were general hospitals, and one was regional hospital; the two step-wedge cluster RCTs included university hospitals and general hospitals or tertiary or quaternary care hospitals. The total number of subjects was 6005, ranging from 40 to 616 in the individual RCTs and from 705 to 2494 in 10 clusters in both step-wedge cluster RCTs.

Table 1 Characteristics of included trials
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The study characteristics with respect to the subject’s disease were as follows: Five RCTs included cardiac disease, three RCTs included stroke, two RCTs included other chronic diseases, two RCTs included multiple diseases and four RCTs did not have disease restriction. Because transitional care interventions in the included RCTs included a variety of components, they were categorized by intervention components with reference to the classification of previous studies [13, 22] (Table 2).

Table 2 Components of each study on transitional care interventions 1)
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The main intervention components included telephone follow-up (15 RCTs), patient education, self-management (11 RCTs each) discharge planning, and home visits (9 RCTs each). The duration of the implementation of the intervention varied, with all trials beginning before discharge, four RCTs after four weeks, two trials after ten days and six weeks, and others at different time periods (ranging from two days to 12 months).

Regarding the type of intervention, most interventions were performed by nurses only, while two RCTs reported interventions by a multidisciplinary team led by a nurse. The control group received usual care at discharge, nursing discharge instructions on medication and other issues, discharge planning, health counseling, prompting for medical visits, routine physical training programs, discretionary guidance from physicians and others, usual home nursing visits, telephone follow-up and other usual care, or placebo calls.

Risk of bias in included studies

The risk of bias was evaluated for the 16 RCTs included in this review (Fig. 2). For random sequence generation, the risk was considered low because computer- or table-based random number generation and random blocks were used, except for three RCTs where the method was not described.

Regarding allocation concealment, papers that did not provide specific descriptions of envelope management methods were considered unclear. Regarding the blinding for participants and personnel, all trials were single-blind or open-label. If the outcome was reported by the patient, RCTs with unclear impact of blinding for outcome assessors were considered unclear. RCTs that were incompletely blinded, but collected information on readmission and emergency department visit rates from medical records, were considered low risk. For incomplete outcome data, RCTs with less than 20% missing data or RCTs analyzed intention-to-treat were considered low risk. For selective reporting, studies for which protocols were available and all outcomes were reported were considered low risk; other studies were considered equivocal.

Fig. 2
figure 2

Risk of bias for each trial

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Effects of intervention

A meta-analysis of the effects of nurse-led transitional care interventions for patients discharged from acute care hospitals was conducted in RCTs using readmission rates, emergency department visit rates, and QOL as outcomes.

Readmission rates

A meta-analysis was conducted by pooling data from 13 RCTs with readmission rates as the outcome, using the occurrence of patients readmitted at least once during the data collection period as the binary variable, regardless of the number of readmissions. Three RCTs [28, 30, 35] were analyzed separately for multiple time periods, thus data were analyzed separately for studies with data collection periods of less than 12 weeks after discharge and for RCTs with data collection periods of 12 weeks or longer. Because we conducted a meta-analysis incorporating cluster randomized controlled trials (cRCTs) and individually randomized controlled trials (iRCTs), we employed the generalized inverse variance (GIV) method with HRs log-transformed (logHR) to appropriately account for both cRCTs and iRCTs. A random-effects model was applied due to the high statistical heterogeneity of 66%. As a result, the relative risk ratios for binary variable data on readmission rates were not significantly different for the seven RCTs that were less than 12 weeks after discharge. However, nine RCTs (3739 participants) in 12 weeks or more revealed that the readmission rates in the intervention group were significantly decreased by 33% (RR 0.67; 95% CI, 0.49–0.92; P = 0.01; I2 = 66%; certainty: moderate) compared with usual care (Fig. 3). The 13 RCT interventions included in the meta-analysis were characterized using telephone follow-up (12 trials) and patient education focused on self-management (9 trials).

Fig. 3
figure 3

Forest Plot of the effect of transitional care interventions on readmission rates with duration of data collection of twelve weeks and more

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Subgroup analysis by intervention period on readmission rates

To examine differences in effects according to the intervention period, a subgroup analysis was performed on 13 RCTs, dividing them into two groups: within six weeks after discharge and seven weeks or more. For the three RCTs [27, 29, 34] included within six weeks, data was collected over multiple periods. Therefore, the data from the first time point of these three RCTs were combined with the data from the other ten RCTs and meta-analyses carried out. Because the subgroup analysis included two cRCTs [35, 39], we employed the GIV method with logHR as in the meta-analysis on readmission rates. A random-effects model was applied due to statistical heterogeneity of 52%. No significant differences were found between the subgroups (I2 = 64.2%, P = 0.09), therefore, we focus on the results of merging the two subgroups. 　Regardless of the timing of the intervention, the readmission rate in the intervention group was significantly reduced compared to the readmission rate in the control group (RR 0.70; 95% CI, 0.52–0.92; P = 0.01; I2 = 52%; certainty: moderate) (Fig. 4).

Fig. 4
figure 4

Forest Plot of the effect of transitional care interventions on readmission rates

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Emergency department visit rate

A meta-analysis was conducted by pooling data from four RCTs (3464 participants) [26, 31, 35, 39] that described the occurrence of emergency department visits and unplanned outpatient visits during the study period as binary variables. The RCT did not specify whether the visit was unplanned [28] and the two RCTs that used nonbinary measures [29, 37] were excluded. Among these trials, one [35] provided data for two periods (30 days and 12 weeks post-discharge). Data 30 days after discharge were combined with the other three RCTs for meta-analysis, while data 12 weeks after discharge were combined with another RCT [26] that collected data for the same period for meta-analysis. Because the meta-analysis incorporated cRCTs and iRCTs, GIV method with logHR was employed, as was the readmission rate. Statistical heterogeneity was 0%, and a fixed-effects model was applied. The results showed a significantly reduced risk of emergency department visits in the intervention group compared to the control group (RR 0.63; 95% CI, 0.49–0.81; P = 0.0003; I2 = 0%; certainty: high) (Fig. 5). There was no significant difference between the two RCTs with data collected 12 weeks after discharge. Interventions in the four RCTs that focused on emergency department visit rates included telephone follow-ups, home visits, and streamlining.

Fig. 5
figure 5

Forest plot of the effect of transitional care interventions on emergency department visit rates

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Quality of life

In RCTs that used QOL as an outcome, various scales were used, including SF-36, EQ-5D, and several other measures. Among these, a meta-analysis was performed on five RCTs using SF-36. SF-36 is a scale that measures comprehensive health-related QOL and has been proven to have sufficient psychometric properties in terms of reliability, validity, and responsiveness. It consists of 36 items, eight scales, and two summary scales that aggregate the eight scales. Each subscale is scored in a range of 0 to 100, with higher scores indicating better health, after weighting certain response options [42]. Among the RCTs that used SF-36, some investigated eight subscales, while others examined the two components of physical and mental factors [30, 31], and one RCT [26] investigated three components: physical factors, mental factors, and general health. Therefore, a meta-analysis was performed by pooling data on physical and mental factors only for the three RCTs that included each of the two factors as outcomes. Additionally, subgroup analyses were performed for the three RCTs with eight subscales of the SF-36 as outcomes.

Physical and mental components of SF-36: The three RCTs (449 participants) that examined physical and psychological components collected data at two time points, thus meta-analyses were performed for each component up to four weeks and five to twelve weeks after discharge. A random effects model was used for the meta-analysis of the physical component five to twelve weeks after discharge owing to high heterogeneity (I2 = 77%, P = 0.01), while a fixed effect model was used for the remainder of the time-period. The results showed a significantly higher physical component on average up to four weeks after discharge in the intervention group (MD 0.85; 95% CI, 0.41–1.29; P = 0.0001; I2 = 0%; certainty: moderate). For the mental component, the intervention group had a significantly higher mean at both time points (up to four weeks: MD 0.72, 95% CI, 0.34–1.11; P = 0.0002, I2 = 0%; five to twelve weeks: MD 0.60, 95% CI, 0.15–1.04, P = 0.008, I2 = 37%; certainty: moderate).

Subgroup analysis of SF-36: Among the three RCTs that examined the eight subscales of the SF-36, two RCTs [30, 34] collected data at two time points. Therefore, subgroup analyzes were conducted separately for the two RCTs within five weeks after discharge (225 participants) and the three RCTs at six weeks or later (289 participants). In the two RCTs within five weeks post-discharge, I2 = 0% (P = 0.57), and thus a fixed-effects model was adopted. For the three RCTs at six weeks or later, I2 = 92% (P < 0.00001), necessitating the adoption of a random effects model and the execution of a sensitivity analysis. Specifically, a subgroup analysis was performed again for the three trials at six weeks or later, excluding one RCT [40], which showed a significant difference in the mean of each scale compared with the other two trials (225 participants). As a result, A subgroup analysis of the SF-36 with data collection within 5 weeks of discharge showed a significant score improvement of 1.27 points in the intervention group. (MD 1.27; 95% CI, 0.52–2.02; P = 0.0009; I2 = 0%; certainty: low) (Fig. 6). In the sensitivity analysis for trials up to six weeks post-discharge, I2 = 19% (P = 0.23), led to the adoption of a fixed effects model. The subgroup analysis of SF-36 at six weeks or later also showed that the mean in the intervention group was significantly higher (MD 2.46; 95% CI, 1.67–3.25; P = 0.00001; I2 = 19%; certainty: low) (Fig. 7). However, because the Test for subgroup differences is I2 = 59.2% (P = 0.02), focusing on the results for each subgroup, we found a significant score improvement of more than 2 points in all seven groups except “social functioning” (Fig. 7). The two RCTs included in the analysis of the effects of nurse-led transitional care interventions on QOL featured telephone follow-ups, medication intervention and home visits as part of the intervention.

Subgroup (Duration of intervention: within six weeks versus seven to twelve weeks versus thirteen weeks and more) Duration of data collection: less than twelve weeks.

Fig. 6
figure 6

Forest plot of the effect of transitional care interventions on quality of life

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Subgroup analysis of SF-36 subscale: duration of data collection up to five weeks.

Fig. 7
figure 7

Forest plot of the effect of transitional care interventions on quality of life

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Subgroup analysis of SF-36 subscale: sensitivity analysis, duration of data collection: six weeks and more.

The certainty of evidence

The results of the GRADE evaluation of the effects of the nurse-led transition support intervention on readmission rates, emergency department visit rates, and QOL are presented in the GRADE summary table (Table 3). For readmission rates, heterogeneity was 66% (P = 0.003) for meta-analyses with a data collection period of at least 12 weeks after discharge and was therefore rated moderate. The subgroup analysis by intervention duration was rated − 2 low due to heterogeneity of 52% (0.01) and small sample size in the group with an intervention duration of more than 7 weeks. The rate of emergency department visits was rated as high. For QOL (SF-36), the outcomes for each component were generally rated as moderate. The reason for the downgrade was that the risk of bias was unclear for more than half of the items. The outcomes with eight to 12 weeks of follow-up for the physical component were rated very low because the 95% CI did not include an effect, and the heterogeneity was 77% (P = 0.01). For the outcomes of the SF-36 subgroup analysis with eight subscales, the results were rated low for up to five weeks of follow-up and for more than six weeks of follow-up and its sensitivity analysis. The reasons for the downgrade (-2) were that the risk of bias was unclear for more than half of the items and the small sample size.

Table 3 Transitional care intervention compared to usual care for readmission, emergency department visit, and quality of life
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Discussion

The purpose of this review was to evaluate the effects of nurse-led transitional care interventions on the outcomes (i.e., readmission rates, unscheduled outpatient visits, and QOL) of adult patients discharged from an acute care hospital. The results indicated that nurse-led transitional care interventions reduced the readmission and emergency department visit rates and improved QOL after discharge.

Readmission rates

Nurse-led transitional care interventions were found to have the potential to reduce readmissions by 330 per 1,000 patients when the data collection period was at least 12 weeks after discharge. Most of the integrated RCTs were characterized by the inclusion of telephone follow-up and the intervention that focused on self-care management. These interventions were intended to promote patient empowerment, suggesting the potential for long-term effects. A meta-analysis of adult surgical patients [17] similarly observed a decrease in readmission rates following a nurse-led discharge services intervention. A systematic review of inpatients with chronic illness and rehabilitation needs [15] also found that nurse-led early discharge planning programs reduced readmission rates compared with usual care. Given the results of these two reviews [15, 17], nurse-led transitional care interventions may be effective in reducing readmission rates in a wide range of subjects. More validation of the effectiveness of population-based patient interventions is needed. Our review found a significant effect on readmission reduction in a meta-analysis of trials with follow-up periods longer than 12 weeks after discharge, indicating that nurse-led transitional care interventions are effective in reducing readmission rates over longer periods. The RCT interventions integrated into the meta-analysis were unique in that seven of the eight RCTs included telephone follow-up and six RCTs included patient education focused on self-care management. Including these interventions may increase their effectiveness in reducing readmission rates. However, the limited number of articles included in the analysis differed in terms of target population, type of health care organization, type and duration of intervention, and study design, and were highly statistically heterogeneous. In determining the effectiveness of nurse-led transitional care interventions, research and reviews are needed to narrow the focus of the subjects and to identify the components and duration of effective interventions.

Emergency department visit rates

Emergency department visits were potentially reduced by 370 per 1,000 patients in the nurse-led transitional care intervention group. A review of nurse-led discharge services for adult surgical patients [17] also demonstrated effectiveness in reducing emergency department visit rates. The two RCTs included in the meta-analysis of this review included telephone follow-up and home visits. It is possible that these nurse-led interventions were effective. However, Regarding the impact of interventions on emergency department visit rates, the number of RCTs that could be pooled for analysis was small, and the subject populations and interventions differed. No studies were able to include the rate of unscheduled outpatient visits in the meta-analysis as a binary variable. Further empirical research on the effectiveness of nurse-led transitional care interventions is needed to narrow the target population and intervention methods, and to use emergency department visit rates and unscheduled outpatient visit rates as outcomes.

Quality of life

A meta-analysis of the effects of transitional care interventions for adult patients discharged from acute care hospitals on the two components (physical and mental) of SF-36 found an effect on the mental component regardless of the follow-up period. The subgroup analysis of the eight SF-36 subscales showed significant improvement in scores during the follow-up period up to 5 weeks after discharge, and significant improvement in all subscales except “social functioning” during the follow-up period of 6 weeks or longer. Nurse-led transitional care interventions are effective in mental health and can have short- and long-term effects on overall QOL. Conversely, no significant difference was observed in “social functioning” at any time point, suggesting challenges in improving social functioning with nurse-led intervention, possibly due to the nature of the questions comprising social functioning, which focus on “decrease in socializing” and “decrease in time spent socializing”. A previous review of adult surgical patients [17] found that the intervention group had a higher mean than the control group in a subgroup analysis of the eight scales of SF-36. The results of this review on the effects of nurse-led transitional care interventions on QOL, although with different subjects, support the findings of this review and suggest that nurse-led transitional care interventions for patients discharged from the hospital may have positive outcomes on patient QOL. However, the number of studies and sample sizes in this analysis were small, and the circumstances of the populations covered were different. Sensitivity analysis was necessary because of the high heterogeneity in RCTs with follow-up periods longer than 6 weeks. A trial [40], which was excluded from the analysis owing to sensitivity analysis, differed in that it included surgical patients scheduled for surgery, while all other RCTs included medical conditions, and did not use telephone follow-up, which all other trials included as a component of the intervention, which may have increased heterogeneity. Few studies have used QOL as an outcome of transitional care interventions, and the wide variety of measures makes it difficult to integrate the effects. QOL is an important indicator for patients transitioning from acute care to home care, and further validation of effectiveness using a common outcome is needed.

Limitations

Only 16 RCTs were included in this review. The number of RCTs included in the meta- and subgroup analyses was small, and subject populations, institution types, interventions, and timing varied, as did outcome types and data collection periods; in particular, heterogeneity was high for readmission rate outcomes, and the number of studies in subgroup analyses of QOL (SF-36) subscales and sample sizes were small. In addition, the review was limited to English-language articles only and excluded studies from low-income countries, which should be interpreted in consideration of their impact on the generalizability of the results.

Conclusions

Nurse-led transitional care interventions were potentially effective in reducing readmission and emergency department visit rates and improving QOL in adult patients discharged from acute care hospitals. Long-term effects can be expected for readmission rates, and short- and long-term effects can be expected for quality of life. However, the number of RCTs included in the meta-analysis and subgroup analyses in this review was small. The sample size was also small for QOL outcomes. These limitations require careful interpretation of the trials from this review. A unique feature of the RCTs included in the meta-analysis was that all but one RCT for readmission rates and all RCT interventions for emergency department visit rates and QOL included telephone follow-up, which may have contributed to making the interventions more effective. On this point as well, further evidence on practices that include these elements and their application to clinical practice, implementation studies to evaluate practices, and randomized controlled trials are needed to determine the effectiveness of the interventions and specific elements.

Data availability

A portion of this systematic review was presented at the 44th Annual Meeting of the Japanese Society of Nursing Science on December 7, 2024, and an abstract was published in the journal. The Japanese abstract of the presentations made at the 44th Annual Meeting of the Japanese Society of Nursing Science can be found on the Society’s website (https://confit.atlas.jp/guide/event/jans44/subject/P1-1-24/entries).

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Acknowledgements

We would like to thank Ms. Sato, our librarian, for her invaluable advice and support in developing the search strategy for this systematic review, and Professors Barroga and Porter for their guidance in writing the English article.

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Authors and Affiliations

  1. Nursing Department, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, Japan

    Chizuko Sakashita

  2. Graduate School of Nursing Doctoral Program, St. Luke’s International University, Tokyo, Japan

    Chizuko Sakashita & Emi Endo

  3. Nursing Department, Yokohama City University Medical Center, Yokohama, Japan

    Emi Endo

  4. Graduate School of Nursing, St. Luke’s International University, Tokyo, Japan

    Erika Ota & Hiromi Oku

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Contributions

The conception and planning were performed by C.S., E.O., and H.O.; the selection and extraction of data by C.S. and E.E.; and the analysis by C.S., E.O., and H.O. The first draft of the manuscript, figures and tables were written by C.S., and all authors commented on previous versions of the manuscript. All authors (C.S., E.E., E.O., and H.O.) read and approved the final manuscript.

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Sakashita, C., Endo, E., Ota, E. et al. Effectiveness of nurse-led transitional care interventions for adult patients discharged from acute care hospitals: a systematic review and meta-analysis. BMC Nurs 24, 379 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03040-w

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BMC Nursing

ISSN: 1472-6955

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