The Impact Of Nurse-Led Transitional Care Models On Preventing Hospital Readmission In Older Adults Following Major Surgery: A Systematic Review & Meta-Analysis

Abstract

Background: The world is witnessing an increase in its aging population, hence a surge in major surgeries carried out on this population. The transition process from hospital to home is a critical period within which this population is highly exposed to complications. There is, therefore, a need to find a remedy for this challenge, and this is where the nurse-led transitional care (TC) comes in. There is inconsistent information regarding its effectiveness, however, among this particular population. The main objective of this systematic review is to undertake a systematic review and meta-analysis of existing information regarding the effectiveness of nurse-led transitional care in improving hospital readmission rates, ED visits, and QoL among older adults after major surgery. Methods: We conducted a systematic search of the relevant literature within the following databases: PubMed, CINAHL, Scopus, and the Cochrane Library, to find RCT designs published between January 2020 and December 2025. The studies had to examine the effectiveness of nurse-led TC interventions in patients aged 65 years and over with recent discharge from home following major surgery, without any exclusion criteria in comparison to control subjects receiving the usual care. The present study used the following outcomes: % RRR of all-cause hospital readmission within 30 and 90 days following the index admission as the primary outcomes, while secondary outcomes included ED visits, QoL, and the patients' functional status. Results: Based on a study using meta-analyses of the RCTs conducted among ten studies involving 7,854 older patients who were subjected to the aforementioned interventions by the nurse-led care teams, the efficacy of the aforementioned interventions has been established in the fact that the lower rates of hospital readmissions within the first 30 days of the aforementioned surgeries have been evident (Risk Ratio [RR] 0.72; 95% CI, 0.61 to 0.85; P < 0.001; I² 45%). Similarly, the aforementioned result has been sustained within the next 90-day period (RR 0.79; 95% CI, 0.68 to 0.92; P = 0.003; I² 52%). Efficacy of the aforementioned interventions has also been established in the fact that the visits to the ED were also fewer (RR 0.69; 95% CI, 0.58 to 0.82; P < 0.001; I² 38%). The QoL of the patients who were subjected to the aforementioned interventions was not compromised, especially when assessed within the context of the aforementioned domain of physical functioning. Conclusion: Interventions focusing on methods such as nurse-led transitional care methods, including components such as patient education and telephone calls, have been proved to be effective in reducing readmissions and ED use among the patient population who are older and underwent major surgeries. Additionally, these methods have a positive impact on the improvement of the quality of life of the patient as well. There is a need to consider implementing these methods for the betterment of healthcare outcomes.