1

Integrative Review of the Literature

Morgan Horn

Bon Secours Memorial College of Nursing

NUR 4242 Nursing Research

Dr. Christine Turner

April 23, 2022

“I pledge…..Morgan Horn”
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Abstract

Purpose: The purpose of this integrative review is to examine if a scheduled follow-up appointment

within one week of discharge compared to a routine office visit within 30 days of discharge affects

hospital readmission rates for heart failure patients. Background: Heart failure is one of the most

common causes of hospitalizations in the United States. Once discharged from the hospital, heart failure

patients are at a higher risk for readmission within 30 days. By improving the transition of care from

hospital to home through early follow-up appointments, reduction in hospital readmissions may occur.

Design and Search Method: The research design is an integrative review based on three research

articles selected from PubMed and Ovid using the eLibrary database. The three articles reviewed are

quantitative research designs. Results and Findings: Scheduled telephone follow-up appointments

within one week of discharge for heart failure patients can help promote positive patient outcomes and

lower the risk of emergency room visits, readmission and death. Limitations: All articles in this review

are quantitative studies. Two with randomized control trials and the third as nonrandomized. The

nonrandomized study has small sample size. Implications for Practice: The results of this review indicate

a need for specialized heart failure transitional care teams and pathways to be initiated to promote

early follow-up care for patients after discharge. Heart failure patients need tailored, individualized

education on self-care management of symptoms to prevent emergency room visits, further clinic

appointments and hospital readmissions. Recommendations for Future Research: Future research

should focus on how heart failure education can be promoted throughout the hospital stay, as well as at

discharge. Research needs to be performed to help identify the barriers that heart failure patients have

that prevent them from proper follow-up care. Larger sample sizes would also be beneficial in future

studies.
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Integrative Review of the Literature

The purpose of this integrative review is to examine if implementing scheduled telephone

follow-up appointments within one week of discharge for heart failure patients will help decrease

hospital readmission rates. Heart failure patients suffer from many emotional and physical symptoms of

the disease including depression, fatigue, shortness of breath, edema and difficult with sleeping. These

symptoms can negatively affect how they perform their daily activities and when not treated properly,

their health and well-being become poor. Stress caused from their functional limitations can increase

their chances of needing immediate medical care and being readmitted to the hospital. Transitional

care, including telephone follow-up within one week of discharge, is key to continuity of care and

prevention of these patients from returning to the hospital.

Education throughout the patient’s admissions as well as at the time of discharge is considered

the best step in promoting self-care behavior and supporting these patients. Follow-up after discharge

can be difficult for some patients due to long travel distances, required time for each visit and lack of

resources or money so remote tele-monitoring is essential in attempting to provide the recommended

support needed for heart failure patients (Negarandeh et al., 2019). The aim of this integrative review is

to discuss and analyze the research studies related to the PICOT question: In heart failure patients (P),

how does scheduled telephone follow-up appointments within one week of discharge (I) compared to a

routine office visit after discharge (C) affect hospital readmission rates (O) within 30 days of discharge

(T)?
Design and Search Methods

The research design is an integrative review. The search for research articles was conducted

utilizing the computer-based search engines Ovid and PubMed, specifically the eLibrary database
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system. The search terms included, ‘heart failure’, ‘readmission rates’, ‘follow-up’, ‘telephone’, and

‘discharge.’ The search yielded 13 articles from PubMed and 16 from Ovid, indicating a limited amount

of literature on the specific topic. To maintain a current approach to the issue, the search was limited to

peer-reviewed quantitative and qualitative nursing research journal articles, written between 2015-2021

and published in English.

The articles had to pertain to the researcher’s PICOT question, “In heart failure patients(P), how

does scheduled telephone follow-up appointments within one week of discharge (I) compared to a

routine office visit after discharge (C) affect hospital readmission rated (O) within 30 days of discharge

(T)?” The articles were then selected based on the following inclusion criteria: heart failure patients,

readmission rate reduction and telephone follow-up appointments within one week of discharge. The

research articles were screened based on inclusion criteria and PICOT question significance. Articles that

did not match with the criteria were not used in this review. The screening produced three quantitative

heart failure readmission articles.

Findings and Results

The findings and results of the three reviewed studies indicate a positive effect of

implementing follow-up appointments, specifically via telephone, within one week of discharge from the

hospital for heart failure patients (Negarandeh et al., 2019). A synopsis of the complied research articles

is presented in Appendix 1. The researcher framed the review according to the following categories:

telephone follow-up appointments and variables related to self-care management of heart failure

symptoms.

Telephone follow-up appointments

There was a consensus among the three studies that early follow-up appointments after

discharge helps improve heart failure education to patients and improves self-care abilities (Dev et al.,
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2021; Lee et al., 2020; Negarandeh et al., 2019; ). Specifically, two of the articles focused on telephone

follow-up appointments within 7 days of discharge assisting in the decrease in the need for physical

clinical visits and emergency room visits. Early transitional care from hospital to home and including

patients in their own care has shown to be efficient in helping healthcare systems succeed and promote

positive patient outcomes.

Lee et al. (2020) aimed to explore heart failure patient outcomes after discharge by analyzing

data collected from two different follow-up appointment strategies. One group was assigned a follow-up

appointment guided by an in-person primary care provider while the other group was assigned an initial

follow-up through a structured telephone appointment with a specialized heart failure nurse and

trained pharmacist. This study took place in Northern California, involving over 16 hospitals, over a 14-

month period. Patients 21 years of age and older with a primary diagnosis of heart failure were

identified for participation in the study. After exclusion criteria was met, 2091 eligible patients were

randomly assigned to one of the two follow-up guided appointments. The patients receiving the

telephone follow-up care were called by a cardiac nurse and given education on medications, self-care

management of the disease and how to monitor vital signs. They also had access to heart failure

physicians for support. The in-person clinic appointment patients did not received education on heart

failure protocols.

Data-analysis was performed using statistical analytic software and baseline variables and

characteristics were compared using standardized differences. A log-rank test was used to compare the

outcomes of each strategy, as well as a Cox proportional hazards regression analysis. Results indicated

no statistically significant difference in decreased heart failure readmissions between telephone follow-

up appointments versus in-person follow-up within seven days of discharge. The telephone follow-up

did prove to help with early health management after discharge for these patients, as well as decrease
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the need for further clinical visits.

Negarandeh et al. (2019) used a quantitative design study aimed to explore follow-up telephone

monitoring after discharge for heart failure patients that focused on self-care and continued patient

engagement to improve their overall health. This study took place in Dezful, Iran in 2016 where the

study population in included heart failure patients hospitalized at the cardiac intensive care units of the

Grand Hospital. Consecutive sampling was used to enroll participants in the study and they were

assigned to either a control group or intervention group using a randomized method. Eighty participants

were involved in this study. Questionnaires were used to gather data including a demographic form, a

self-care behavior form and a reporting form for the number of readmissions during the follow-up

period. Those participants assigned to the intervention group had follow-up telephone monitoring up to

2 months after discharge where educational needs were met based on the questionnaires. Up to two

weekly calls were also made to help in reinforcing self-care behavior to manage heart failure symptoms.

The control group did not have telephone follow-up care and were discharged according to the usual

discharge care routine.

Data-analysis was performed using the chi-square and Fisher’s exact tests to compare

demographics and readmission rates between the control group and intervention group. An

independent t-test, frequency tables and an analysis of covariance were used. The Kolmogorv-Smimov

test was used to score the self-care behaviors of the participants. Results did show a significant

difference after one month in the intervention group compared to the control group in improving self-

care behaviors related to heart failure symptoms (Negarandeh et al., 2019). The intervention group was

unable to show a significant difference in regard to a decrease in hospital readmissions though.

Variables related to self-care management of heart failure patients

The three studies provided data to support early follow-up appointments after discharge as a
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means to prevent readmissions through education on proper self-care management of heart failure

symptoms (Dev et al., 2021; Lee et al., 2020; Negarandeh et al., 2019;. These articles highlighted the

importance of how specialized heart failure teams can improve patient outcomes both in the hospital

and after discharge. Proper care of heart failure patients through teaching self-care in the transitional

stage from hospital to home can be beneficial in the reduction of hospital readmissions.

The purpose of the pre- and postintervention quantitative analysis study by Dev et al. (2021)

was to determine the effectiveness of early follow-up care after heart failure hospitalization through

specified heart failure education. This study took place in the United States over a 32-month period.

Two hundred and eighty-two hospitalized patients who were found to be classified with heart failure as

a primary diagnosis during that time period were studied. Variables that were considered for the sample

size included demographics, BUN and creatinine levels, gender, vital signs, length of hospital stay and

left ventricular ejection fraction (Dev at el., 2021). Participants were divided among a control group and

an intervention group. Within the intervention group, a transitional care pathway was developed for

each patient within 7 to 14 days after discharge. Specialized cardiology care was given while in the

hospital until discharge, a blood pressure cuff and scale were provided and heart failure contact

information was given to help in improving self-care. There was a nurse who was available during

daytime hours to help triage concerns, answer questions about medications and set up future

appointments. The control group did not have a cardiology follow-up and were seen by the inpatient

hospitalist team.

Data-analysis was performed using a Cox proportional hazards model to assess the effect of the

postintervention period with the pre-intervention period. The RE-AIM framework used adoption,

effectiveness, implementation and maintenance to help describe the impact the intervention had on the

study (De at el., 2021). The study identified the effectiveness of earlier cardiology follow-up visits after
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hospitalization and how it helps in produces outcomes that include lower risk of visiting the emergency

room, readmission and death.

Negarandeh et al. (2019) also highlighted the importance of self-care management of heart

failure patients during their study when they used the questionnaires as a way to collect data about the

participants. The questionnaires helped the researchers identify educational needs of the participants so

they could be followed up during the study. These participants were also followed after discharge

through tele-monitoring to provide recommendations and education for performing proper self-care

behaviors ( Negarendeh at el., 20219).

Discussion and Implications for Practice

The research articles used for this integrative review offer an understanding of the benefits of

implementing scheduled telephone follow-up appointments within 7 days of discharge for heart failure

patients. The three research studies highlight important findings relating to the effect of proper

transitional care from hospital to home for patients and the importance of self-care education to

promote proper management of heart failure symptoms (Negarandeh et al., 2019; De et al., 2021; Lee et

al., 2020). Each study aids in the need for follow-up appointments as a necessity in ensuring patients are

receiving the education and attention they need to manage symptoms and improve their quality of life.

Differences between the studies include the type of research designs. One study was a

pragmatic randomized trial comparing two strategies of intervention, one was a pretest-posttest design

study and the other was a retrospective, nonrandomized single-center study with pre- and

postintervention analysis. Each study differs in sample sizing and how participants were chosen, as well

as how data was collected. All the studies looked at the impact that early follow-up telephone

appointments had on patient outcomes.

The implication of these findings suggests that the use of scheduled follow-up appointments via
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telephone within 7 days of discharge helps improve the patient’s symptom management of the disease.

Involving patients in their own self-care from hospital to home has shown evidence of less need for

clinic visits or emergency room visits (Dev et al., 2021). However, the studies have not shown any

statistical significance in reducing readmission rates within one month of discharge. Future research

should further explore longer periods of follow-up monitoring for these patients, as well as researching

ways to develop tailored, educated instructions for patients based on their disease knowledge.

Limitations

The articles that were utilized in this integrative review provide some evidence of the need of

further research due to limitations in each study. Negarandeh et al. (2019) focused on a small sample

size with a short follow-up period to analyze data results. It is also important to consider in this study

the lack of heart failure knowledge the patient’s exhibited when answering the questionnaires for the

intervention group. Dev et al.(2021) analyzed a nonrandomized study, in which some predictors may

not have been accounted for in each group. This study was also limited more to men as participants

considering it was at a veteran’s hospital setting. Lee et al. (2020) used a pragmatic clinical trial that led

some providers involved in the study to be cautious in supporting a randomization of patients who

would receive the telephone-guided follow up strategy.

Value to Practice

In conclusion, the research obtained in this integrative review examined the implementation of

scheduled telephone follow-up appointments within 7 days of discharge from the hospital for heart

failure patients. The research findings suggest the benefits of early transitional care from hospital to

home within 7 days of discharge, as well as the importance of proper education on self-care and

management of heart failure symptoms. Various analyses were performed to collect data from three
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studies that focused on heart failure patients at time of discharge. The studies involved interventions

and strategies related to telephone follow-up care within 7 days of discharge (Negarandeh et al., 2019;

De et a., 2021; Lee et al., 2020). The results indicate that early follow-up care can help heart failure

patients with promotion of self-care management, as well as reduce the chances of needed clinic

appointments and emergency room visits. In relation to the researcher’s PICOT question, “In heart

failure patients, how does scheduled telephone appointments within 1 week of discharge compared to a

routine office visit after discharge affect hospital readmission rates within 30 days of discharge?”, the

findings concluded that this intervention could help improve the importance of early health

management after discharge that helps reduce the chance of further follow-up visits. Efficiency in

outpatient care is very important in helping healthcare systems succeed and bring positive outcomes to

our heart failure patients.

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References

Dev, S., Fawcett, J., Ahma, S., Wu, W. & Schwenke, D. (2021). Implementation of early

follow-up care after heart failure hospitalization. The American Journal of

Managed Care. 27(2). https://doi.org/10.37765/ajmc.2021.88588

Lee, K., Thomas, R., Tan, T., Leong, T., Steimle, A. & Go, A. (2020). The heart failure readmission

intervention by variable early follow-up (THRIVE) study. Circulation: Cardiovascular Quality and

Outcomes, 13(10). https://doi.org/10.1161/CIRCOUTCOMES.120.006553

Negarandeh, R. Zolfaghari, M. Bashi, N. & Kiarsi, M. (2019). Evaluating the effect of monitoring through

telephone (tele-monitoring) on self-care behaviors and readmission of patients with heart

failure after discharge. Applied Clinical Informatics, 20(2), 261-268.

https://doi.org.10.1055/s-0039-1685167
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Appendix 1: Summary of Literature Tables
APA Citation of article
Background/Problem
Statement
Research Design (i.e.
qualitative, quantitative)
Specific Design (i.e.
Phenomenology,
Experimental)
Philosophical
Underpinnings (for
qualitative designs only)
Sample (size, type,
sampling method)
Geographical location
Setting of the Study
Dev, S., Fawcett, J., Ahma, S., Wu, W. &
Schwenke, D. (2021). Implementation of
early follow-up care after heart failure
hospitalization. The American Journal of
Managed Care. 27(2).
https://doi.org/10.37765/ajmc.2021.88588
Heart failure patients are often readmitted to
the hospital within 30 days of discharge,
causing huge burdens on the patients,
hospital staff and spending costs. Early
follow-up with patients after discharge has
been a goal for helping reduce hospital
readmissions and leading patients to a
better transition of care from hospital to
home.
Quantitative; retrospective single-center
study; pre- and postintervention analysis;
nonrandomized; RE-AIM framework
Patients found within a classified primary
diagnosis of heart failure who were
hospitalized between specified times were
studied. The diagnosis of the disease was
coded by hospital coding staff. Variables
that were considered for the sample size
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Type of Data Collected
(Major Variables Studied-
independent, dependent
and their definitions), if
appropriate
Method of Data
Collection/Measurement
Tools (i.e. BP cuff, Visual
analog scale, Beck
Depression Index)
Data Analysis (ex.
Statistical tests used (linear
regression, paired t-tests,
etc.) or Content/Thematic
analysis.
NOT software [i.e. NUD*st
or SPSS or SAS])
Themes generated/
statistical significance
Findings (describes major
included demographics, hemoglobin, BUN,
creatinine, gender, vital signs, length of
hospital stay, LVEF. Patients were excluded
if they were going to hospice care, had
already enrolled in a follow-up study or left
against advice from their doctor. 282
patients were studied, 21 excluded.
The hospital doctors identified heart failure
patients, placed a consult to heart failure
clinic team and transitional care pathway for
the patient was developed. Follow-up within
7 to 14 days; resources like telehealth
monitoring and home nurse services were
made available
For the intervention period, data collection
was done when heart failure patients were
identified; cardiology nurse provided blood
pressure cuff and scale, as well as heart
failure instructions and education related to
self-care and medication management. A
heart failure clinic appointment was made,
and a nurse was made available throughout
the day the answer questions. With control
group, only hospital team saw patient and
no recommended cardiology follow-up was
suggested.
A Cox proportional hazards model was used
to assess the effect of the postintervention
period with the preintervention period. The
RE-AIM framework used effectiveness,
adoption, implementation and maintenance
to describe the impact the intervention had
on the study.
Initial theme compared to preintervention
and postintervention group, effectiveness
was not significantly shown. Adjustments
made to some clinical predictors (BP, BNP,
hemoglobin, LVEF) did end up showing a
significant reduction in the incidence of
negative clinical outcomes.
This article identified the effectiveness of
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findings in the article) structured and earlier cardiology follow-up

visits posthospitalization. Positive patient
outcomes occur when follow-up is within 7
days. These outcomes include lower risk of
visiting the emergency department,
readmissions and death.
Value to Practice based This article has shown the importance of
on PICOT Question specialized heart failure teams and how they
(describe how findings can improve patient outcomes both in the
relate to the PICOT hospital and after discharge. It is suggested
question) that hospitals begin to adopt heart failure
champions to help promote proper care of
heart failure patients during hospitalization
and in the outside world.

The study in this article reviewed in person

scheduled follow-up appointments within 7
days of discharge but not specifically on
telephone or telehealth appointments. It
does not go into detail about telephone
contact other than a nurse is available via
phone to answer questions. The PICOT
questions is somewhat answered because
the study’s time period is relevant and
shows evidence of reducing hospital
readmissions, as well as ER visits and
death.
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Et al, APA Citation Lee, K., Thomas, R., Tan, T., Leong, T.,
of article Steimle, A. & Go, A. (2020). The heart

failure readmission intervention by variable

early follow-up (THRIVE) study.

Circulation: Cardiovascular Quality and

Outcomes, 13(10).

https://doi.org/10.1161/CIRCOUTCOMES.120.0065
53
Background/Problem
Statement Follow-up visits are important for heart failure
patients discharged from the hospital. In-
person follow-up appointments have been
associated with lower occurrences of
readmissions within 30 days. It has been
difficult for in-person visits due to the pandemic,
so a scheduled telephone follow-up call has
been considered to help maintain proper follow-
up care after hospitalization.
Research Design (i.e. Quantitative; pragmatic randomized trial
qualitative, quantitative) comparing two strategies of intervention
Specific Design (i.e.
Phenomenology,
Experimental)
Philosophical
Underpinnings (for
qualitative designs only)

Sample (size, type,

sampling method) Patients older than 21, hospitalized in 16
Geographical different hospitals between certain time frame:
location Setting of Northern California with large healthcare
the Study delivery system. Patients were identified as
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heart failure through classification system and

diagnosis code for hospital. SAS software-
based algorithm was used to assign patients a
certain strategy randomly. 2019 patients were
eligible for the study

Type of Data Collected Data collected included heart failure patients

(Major Variables being discharged; one group followed strategy
Studied- independent, of initial follow-up guided by in-person clinic
dependent and their appointment with a primary care provider while
definitions), if
the second group followed strategy of initial
appropriate
follow-up group by a structured telephone
appointment with nurse/pharmacist trained in
heart failure care
Method of Data Patients receiving telephone follow-up were
Collection/Measureme called by nurse and given education on
nt Tools (i.e. BP cuff, medications, self-care management of the
Visual analog scale, disease, when to weigh each morning and how
Beck Depression Index)
to monitor vital signs. The patients also had
access to heart failure physicians for support
and would schedule more appointments if
deemed necessary. The in-person clinic
appointment patients were not educated on
heart failure care protocols. Follow-up
appointments were considered completed if
done within 7 days of discharge and
readmission within 30 days of discharge was
assessed for each group of patients.
Data Analysis (ex. Statistical analytics software was used, and
Statistical tests used baseline variables and characteristics were
(linear regression, paired compared using standardized differences. A
t-tests, etc.) or log-rank test was used to compare the
Content/Thematic
outcomes of each group. The Cox proportional
analysis.
NOT software [i.e.
hazards regression analysis was used to
NUD*st or SPSS or assess different variables as well. Subgroup
SAS]) analyses were also done between age, gender
and LVEF to determine the readmission rates.

Themes generated/ No significant difference was found for

statistical decreased heart failure readmissions in 30
significance days compared to telephone follow-up and in-
person follow-up within 7 days of discharge.
Findings (describes Telephone follow-up within 7 days help improve
major findings in the the importance of early health management
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article) after discharge and also decreased the need

for physician clinical visits within the first 7 days
of discharge. Efficiency in care, especially
outpatient, seems to be very important in
helping healthcare systems succeed and it also
brings positive outcomes to patients.
Value to Practice The evidence found in this article supports the
based on PICOT PICOT question of how follow-up appointments
Question (describe how within 7 days of discharge can help reduce the
findings relate to the chances of further follow-up visits and
PICOT question) readmissions. Telephone follow-up is
mentioned to be specifically effective in
promoting early intervention in the transitional
period from hospital to home.

APA Citation of article Negarandeh, R. Zolfaghari, M. Bashi, N. &

Kiarsi, M. (2019). Evaluating the effect of

monitoring through telephone (tele-

monitoring) on self-care behaviors and

readmission of patients with heart failure after

discharge. Applied Clinical

Background/Problem
Statement
Research Design (i.e.
qualitative, quantitative)
Specific Design (i.e.
Phenomenology,
Informatics,20(2), 261-268.
https://doi.org.10.1055/s-0039-1685167
Heart failure is a very prevalent disease that
affects millions of people around the world.
For heart failure patients, self-care
management of their symptoms is key in
caring for their condition. All too often
patients don’t adhere to the suggested self-
care management actions causing
readmission to hospital after discharge.
Education and tele-monitoring are important
in continuing to engage patients in their own
care and help improve their health. There
are many forms of telehealth medicine that
can help healthcare providers provide
efficient care.
Quantitative; randomized clinical trial with
pretest-posttest design.
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Experimental)
Philosophical
Underpinnings (for
qualitative designs only)
Sample (size, type,
sampling method)
Geographical location
Setting of the Study
Type of Data Collected
(Major Variables Studied-
independent, dependent
and their definitions), if
appropriate
Method of Data
Collection/Measurement
Tools (i.e. BP cuff, Visual
analog scale, Beck
Depression Index)
Data Analysis (ex.
Statistical tests used (linear
regression, paired t-tests,
etc.) or Content/Thematic
analysis.
NOT software [i.e. NUD*st
or SPSS or SAS])
Themes generated/
statistical significance
The sampling method used was consecutive
sampling in which the cardiac ICU was in
contact with the researcher and identified
eligible heart failure patients. Inclusion
criteria was used; these were hospitalized
heart failure patients in the cardiac ICU of a
hospital in Dezful
Randomized block method with a fixed-size
four-piece block was used to identify control
groups and intervention groups; 80
participants
Intervention group had follow-up telephone
monitoring for 2 months after discharge
where educational needs were met based
on the questionnaires provided prior to
intervention; two weekly calls were made to
help with reinforcing self-care behavior
management of symptoms
Control group did not have telephone follow-
up and were discharge according to the
usual care routine
Data tools included three questionaries; a
demographic form, a self-care behavior form
and a reporting form for the number of
readmissions during the follow-up period.
The chi-square and Fisher’s exact tests
were used to compare demographics and
readmission rates between the control and
intervention groups. The Kolmogorv-
Smirnov test was used to score the self-care
behaviors. An independent t-test, frequency
tables, and analysis of covariance were also
used.
There was a significant difference after one
month in the intervention group compared to
the control group in improving self-care
behaviors. The intervention group was not
able to show a statistically significant
difference in regard to a decreased in the
rate of readmissions though.
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Findings (describes major This study highlighted the importance of

findings in the article) tele-monitoring and how it can improve heart
failure education to patients and allow them
to care for themselves more appropriately. It
can be specifically vital in remote areas of
the world where there is limited access to
health care needs.
Value to Practice based Heart failure patients require long-term
on PICOT Question support and reassurance, especially after
(describe how findings hospitalization. This tele-monitoring can help
relate to the PICOT benefit these patients and maintain a
question) continued level of care after discharge.
Pursuing health management for patients
after discharge is important for nurses and
other healthcare personnel to consider.
This study found evidence that there is a
positive relationship between early
telephone follow-up and better patient self-
care of symptoms which related to the
PICOT question. It did not however identify
that it caused a decrease in the number of
hospital readmissions after discharge.