JMIR Publications

ABSTRACT

Background:

Conventional heart failure (HF) management is challenged by high loss to follow-up, fragmented care, and insufficient multidisciplinary collaboration (MDT), contributing to a 30% readmission rate during the vulnerable post-discharge period. While the integration of remote monitoring and telehealth signals a paradigm shift towards proactive intervention, the effectiveness of a nurse-led, mHealth-based multidisciplinary model in this critical phase requires further validation.

Objective:

This randomized controlled trial evaluated a nurse-led, app-based multidisciplinary telemanagement program for improving self-care, symptoms, and clinical outcomes in vulnerable-phase HF patients.

Methods:

A single-blind, randomized controlled trial was conducted. 100 heart failure patients (left ventricular ejection fraction ≤50%) from a tertiary hospital in Beijing were randomly assigned to either an intervention group (n=50) or a control group (n=50). The intervention group received a 3-month, nurse-led, multidisciplinary telemanagement program via a cardiovascular health management APP. This program included structured education, personalized care plans (medication, self-monitoring, follow-up), automated reminders, and proactive monitoring. A core component was the nurse-coordinated multidisciplinary case discussion (involving doctors, pharmacists, and nurses) triggered by abnormal patient data. The control group received routine heart failure outpatient follow-up. The Self-Care of Heart Failure Index (SCHFI), the Memorial Symptom Assessment Scale-Heart Failure (MSAS-HF), B-type natriuretic peptide (BNP) levels, and NYHA functional class were assessed at baseline and 3 months.

Results:

After the 3-month intervention, the intervention group demonstrated significantly greater improvements compared to the control group in the SCHFI total score and its three subscales (self-care maintenance, management, and confidence), the MSAS-HF total score and its subscales (physical, psychological, and heart failure-specific symptoms), and BNP levels (t=2.302 to 3.953, -2.204 to -2.841, Z=-3.354, P < 0.05). Moreover, a significantly higher proportion of patients in the intervention group achieved NYHA class I (84.0% vs. 66.0%; χ²=4.320, P < 0.05).

Conclusions:

This nurse-led, mHealth-facilitated multidisciplinary telemanagement program led to significant improvements in self-care, symptom burden, NYHA functional class, and BNP among patients with heart failure during the vulnerable post-discharge period. By demonstrating these benefits, the model effectively overcomes critical limitations inherent in traditional post-discharge management approaches.