Peripheral arterial disease (PAD) affects between 3% and 10% of the global population. Transitional care programmes (TCPs) aim to ensure continuity between hospital-based acute care and primary healthcare. Nurses play a pivotal role in supporting this transition. TCPs may reduce hospital readmissions, emergency department (ED) attendances and improve patients’ quality of life (QoL). This scoping review examines whether nurse-led TCP improves the management of patients undergoing lower limb vascular surgery, including the effectiveness of remote (telehealth) delivery.
Methods:
This review followed the Joanna Briggs Institute (JBI) methodology. Eligible studies included adults hospitalised with peripheral vascular disease who had undergone major surgery. A comprehensive search of PubMed, CINAHL, Web of Science, Scopus, JBI Evidence Synthesis and grey literature via Google Scholar was conducted for studies published between 1 January 2000 and 30 June 2024.
Results:
Of 888 papers screened, 6 met the inclusion criteria. Nurse-led TCPs were associated with reduced hospital readmissions and improved patient reported QoL. No significant differences were observed in unplanned surgery, major amputation, or mortality.
Conclusion:
TCPs are associated with improved patient QoL outcomes and reduces hospital readmissions when incorporating education, telenursing, and a multiprofessional approach - led by a transition nurse.
AicherBOHanlonERosenbergerS, et al. (2019) Reduced length of stay and 30-day readmission rate on an inpatient vascular surgery service. Journal of Vascular Nursing37: 78–85. DOI: 10.1016/j.jvn.2018.11.004.
BadgerSASoongCVO’DonnellME, et al. (2007) Benefits of a supervised exercise program after lower limb bypass surgery. Vascular and Endovascular Surgery41: 27–32. DOI: 10.1177/1538574406296209.
4.
BerthelsenCMøllerNBunkenborgG (2024) Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review. Journal of Clinical Nursing33: 481–496. DOI: 10.1111/jocn.16913.
5.
BrushettSCaldwellHATCameronES, et al. (2022) Strategies and indicators to address health equity in health service and delivery systems: A scoping review protocol. Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports20: 249–259. DOI: 10.11124/JBIES-21-00001.
6.
BurmeisterRAJarockiCHolmesCM, et al. (2021) Postoperative healing in the diabetic foot is impacted by discharge destination. International Wound Journal18: 657–663. DOI: 10.1111/iwj.13567.
7.
CaggianelliGSferrazzaSPampoorickalK, et al. (2023) Effectiveness of transitional care interventions in patients with serious illness and their caregivers: A systematic review protocol. JBI Evidence Synthesis21: 762–768. DOI: 10.11124/JBIES-22-00119.
8.
ColemanEABoultC (2003) American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society51: 556–557. DOI: 10.1046/j.1532-5415.2003.51186.x.
9.
CriquiMHMatsushitaKAboyansV, et al. (2021) Lower extremity peripheral artery disease: Contemporary epidemiology, management gaps, and future directions: A scientific statement from the American Heart Association. Circulation144: e171–e191. DOI: 10.1161/CIR.0000000000001005.
10.
DağATulekZSeyahiE. (2025) The impact of nurse-led disease management education on outcomes of patients with ankylosing spondylitis: a randomised controlled trial. Journal of Research in Nursing. 0(0). doi:10.1177/17449871251328936
11.
DavisCBenderMSmithT, et al. (2015). Feasibility and acute care utilization outcomes of a post-acute transitional telemonitoring program for underserved chronic disease patients. Telemedicine Journal and e-health21: 705–713. DOI: 10.1089/tmj.2014.0181.
12.
DuaALeeCJ (2016) Epidemiology of peripheral arterial disease and critical limb ischemia. Techniques in Vascular and Interventional Radiology19: 91–95. DOI: 10.1053/j.tvir.2016.04.001.
13.
FarahBQRitti-DiasRMMontgomeryPS, et al. (2016) Sedentary behavior is associated with impaired biomarkers in claudicants. Journal of Vascular Surgery63: 657–663. DOI: 10.1016/j.jvs.2015.09.018.
14.
FereydooniAGoreckaJDardikA (2020) Using the epidemiology of critical limb ischemia to estimate the number of patients amenable to endovascular therapy. Vascular Medicine25: 78–87. DOI: 10.1177/1358863X19878271.
15.
FinlaysonKChangAMCourtneyMD, et al. (2018) Transitional care interventions reduce unplanned hospital readmissions in high-risk older adults. BMC Health Services Research18: 956.
16.
FirnhaberJMPowellCS (2019) Lower Extremity peripheral artery disease: Diagnosis and treatment. American Family Physician99: 362–369.
17.
Gerhard-HermanMDGornikHLBarrettC, et al. (2017) 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation135: e726–e779. DOI: 10.1161/CIR.0000000000000471.
18.
GuidonMMcGeeH (2013) One-year effect of a supervised exercise programme on functional capacity and quality of life in peripheral arterial disease. Disability and Rehabilitation, 35(5), 397–404.
19.
GraingerA (2023) Commentary: Discharge transitional care programme for older adults after hip fracture surgery: a quasi-experimental study. Journal of Research in Nursing28(8): 594–595. doi:10.1177/17449871231206613
20.
GrammatopoulosTHunterJWSMunnZ, et al. (2023) Reporting quality and risk of bias in JBI systematic reviews evaluating the effectiveness of interventions: A methodological review protocol. Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports21: 584–591. DOI: 10.11124/JBIES-22-00317.
21.
InglisSCClarkRADierckxR, et al. (2015) Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database of Systematic Reviews10: CD007228.
22.
JakubsevičienėEVasiliauskasDVeličkaL, et al. (2014) Effectiveness of a new exercise program after lower limb arterial blood flow surgery in patients with peripheral arterial disease: A randomized clinical trial. International Journal of Environmental Research and Public Health11: 7961–7976. DOI: 10.3390/ijerph110807961.
KlevsgårdRRisbergBOThomsenMB, et al. (2001) A 1-year follow-up quality of life study after hemodynamically successful or unsuccessful surgical revascularization of lower limb ischemia. Journal of Vascular Surgery33: 114–122. DOI: 10.1067/mva.2001.109769.
25.
KoYHwangJMBaekSH (2023). Discharge transitional care programme for older adults after hip fracture surgery: a quasi-experimental study. Journal of Research in Nursing. 28(8): 582–593. doi:10.1177/17449871231204499
26.
LaydenJMichaelsJBerminghamS, et al.; Guideline Development Group. (2012) Diagnosis and management of lower limb peripheral arterial disease: Summary of NICE guidance. British Medical Journal345: e4947. DOI: 10.1136/bmj.e4947.
27.
LiuJChenTWangS, et al. (2019) The effect of transitional care on the prevention of diabetic foot ulcers in patients at elevated risk for diabetic foot. International Journal of Diabetes in Developing Countries39: 659–666. DOI: 10.1007/s13410-019-00736-z.
28.
MedinaDZil-E-AliADaoudD, et al. (2022) Implementation of transitional care planning is associated with reduced readmission rates in patients undergoing lower extremity bypass surgery for peripheral arterial disease. Annals of Vascular Surgery84: 28–39. DOI: 10.1016/j.avsg.2022.02.018.
29.
NaylorMDAikenLHKurtzmanET, et al. (2011) The care span: The importance of transitional care in achieving health reform. Health Affairs, 30: 746–754.
30.
NordanstigJBehrendtCABradburyAW (2023) Peripheral arterial disease (PAD) – A challenging manifestation of atherosclerosis. Preventive Medicine171: 107489. DOI: 10.1016/j.ypmed.2023.107489
31.
OlinicDMSpinuMOlinicM, et al. (2018) Epidemiology of peripheral artery disease in Europe: VAS Educational Paper. Journal of the International Union of Angiology37: 327–334. DOI: 10.23736/S0392-9590.18.03996-2.
32.
ParryCMahoneyEChalmersSA, et al. (2008) Assessing the quality of transitional care: Further applications of the care transitions measure. Medical Care46: 317–322. DOI: 10.1097/MLR.0b013e3181589bdc.
33.
PetersMDJGodfreyCMcInerneyP, et al. (2024) Scoping reviews. JBI Manual for Evidence Synthesis. Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports. DOI: 10.46658/JBIMES-24-09.
34.
RajabiSMomeniMRanjbaranM, et al. (2025). Effect of telenursing empowerment programme on self-efficacy and health status of patients with chronic obstructive pulmonary disease: randomised controlled trial. Journal of Research in Nursing. 0(0). doi:10.1177/17449871241308826
35.
Rezapour-NasrabadR (2018) Transitional care model: Managing the experience of hospital at home. Electronic Journal of General Medicine15: em73. DOI: 10.29333/ejgm/93445.
36.
SchullerKALinSHGammLD, et al. (2015) Discharge phone calls: A technique to improve patient care during the transition from hospital to home. Journal for Health Care Quality37: 163–172. DOI: 10.1111/jhq.12051.
37.
SecemskyEASchermerhornMCarrollBJ, et al. (2018) Readmissions after revascularization procedures for peripheral arterial disease: A nationwide cohort study. Annals of Internal Medicine168: 93–99. DOI: 10.7326/M17-1058.
38.
SohYYZhangHTohJJY, et al. (2023) The effectiveness of tele-transitions of care interventions in high-risk older adults: A systematic review and meta-analysis. International Journal of Nursing Studies139: 104428. DOI: 10.1016/j.ijnurstu.2022.104428.
39.
StormMSiemsenIMLaugalandK, et al. (2014) Quality in transitional care of the elderly: Key challenges and relevant improvement measures. International Journal of Integrated Care14: e013. DOI: 10.5334/ijic.1194.
40.
TriccoACLillieEZarinW, et al. (2018) PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine169: 467–473. DOI: 10.7326/M18-0850
41.
YadavSKalalNSharmaSK, et al. (2023). The development and randomised feasibility trial of a Nurse-led lifestyle modification follow-up programme among post-myocardial infarction patients. Journal of Research in Nursing28(3): 230–246. doi:10.1177/17449871231163983
42.
ZouDWangLLiJ, et al. (2022) The benefits of transitional care in older patients with chronic diseases: A systematic review and meta-analysis. Aging Clinical and Experimental Research34: 741–750. https://doi.org/10.1007/s40520-021-01973-1
