Nurse-led Transitional Care and Postdischarge Outcomes in Stroke Survivors: A Systematic Review and Meta-analysis

Nurse-led transitional care may improve continuity of care after stroke, but its effects on postdischarge outcomes remain uncertain. This systematic review and meta-analysis evaluated its effects on readmission, functional outcomes, quality of life, and caregiver burden in stroke survivors.

PubMed, Embase, the Cochrane Library, CINAHL, and Web of Science were searched from January 2015 to November 19, 2025. English-language randomized controlled trials of nurse-led transitional care in adult stroke survivors were included. Random-effects meta-analyses were performed. Risk of bias was appraised using the Cochrane risk-of-bias tool, and evidence certainty was rated using GRADE.

Sixteen trials involving 7487 participants were included. Nurse-led transitional care was associated with a lower risk of readmission than usual care (RR, 0.43; 95% CI: 0.26-0.73; I²=0%); however, this finding should be interpreted cautiously because the readmission analysis included only 4 trials involving 455 participants. It was also associated with improved functional outcomes (SMD, 0.58; 95% CI: 0.20-0.96; I²=93%) and quality of life (SMD, 1.09; 95% CI: 0.40-1.78; I²=90%). Caregiver burden did not differ significantly between groups (MD, -0.68; 95% CI: -2.22 to 0.86; I²=81%). Evidence certainty was low for readmission, functional outcomes, and quality of life and very low for caregiver burden.

Nurse-led transitional care may be associated with a lower risk of readmission and improved functional outcomes and quality of life after stroke. However, risk of bias, imprecision, and substantial heterogeneity limit confidence in these findings. Rigorous trials using standardized outcomes are needed. Neuroscience nurses may promote continuity through structured discharge preparation, early follow-up, and home-based support.