NURS FPX 8004 Assessment 3 Annotated Bibliography

Student name
Capella University
NURS-FPX8004
Professor Name
Submission Date

Annotated Bibliography

The practice environment is a large specialty hospital in the Southeastern region of the United States that provides state-of-the-art cardiopulmonary care to an ethnically diverse population of adults. Inferences Pulmonary hypertension (PH) a condition which is usually missed as it is being handled for other co-existing pathologies with non-specific early presentation, is a major concern across the organization with delayed diagnosis and referred at varying times. The target audience will be adults with or at risk of pulmonary hypertension who may experience barriers to receiving timely specialty care and treatment according to the guideline. Patients/patient families, physicians, nurses, advanced practice clinicians, case managers, and administrators are the stakeholders who will be directly affected by care delays. The project introduces a standard referral and monitoring procedure to reduce disparity, achieve greater guideline adherence, and work to maximize the outcomes. The initiative supports the mission of providing timely, equitable and patient-centered care in the hospital by preventing disease progression and burden on healthcare and by resolving diagnostic delays and reinforcing coordination.

The PICOT

In adult patients, aged 40 to 80 years with pulmonary hypertension (P), how does implementing an early recognition and streamlined referral pathway to PH specialists (I), compared with the current standard referral process (C), affect time to diagnosis (O) within 12 weeks (T)?

Problem Statement

One of the factors behind significant delays in the identification and referral of pulmonary hypertension patients to the practice site is limited access to timely care. The delays lead to diagnosis in late-stage disease and worse outcomes. It will help the organization to attain national standards and improve patient health outcomes by dedicating a quality improvement project to reduce the time needed to present symptoms and then to specialty referral by at least 25% over a six-month period.

Thesis Statement

The quality improvement initiative aims to minimize the length of diagnosis and access to care related to pulmonary hypertension through increased education of providers, refinements in referral methods, and interprofessional collaboration. Through this, the project will help to reduce the number of people who are waiting to be diagnosed, improve access to specialist services and promote patient-centered outcomes in the lives of people with pulmonary hypertension.

Literature Search Process

A literature review on the evidence that is available was conducted to identify interventions that can improve access to specialty care and timely diagnosis among patients having pulmonary hypertension. PublMed, CINAHL, and Scopus were searched using Boolean operators AND, OR, and NOT to refine the results and cross keywords like pulmonary hypertension, access to care, referral, early diagnosis, quality improvement, equity, and outpatient specialty care. The study was limited to English-written publications since 2020, with 158 results obtained initially. Upon achieving the elimination of redundancy and filtering through the abstracts using predetermined inclusion criteria, 45 full-text articles were then evaluated in more detail. The searches were filtered out when they lacked outcome data, were not in full text or had no abstract and were investigating hospital-based care not pertinent to specialty referral. Finally, a total of 14 high-quality sources such as randomised controlled trials, cohort studies, implementation evaluations, systematic reviews and studies from secondary outcomes were selected. The articles provided the most and the best relevant evidence to inform a quality improvement project that would lead to a reduction in diagnostic delays and permit the establishment of standard access to pulmonary hypertension services.

Annotated Bibliography

Bernardo, R. J., & Perez, V. A. de J. (2023). Health care disparities in pulmonary arterial hypertension. Clinics in Chest Medicine, 44(3), 543–554. https://doi.org/10.1016/j.ccm.2023.03.010

 The researchers of the study have explored health inequalities in pulmonary arterial hypertension in a narrative review. The objective was to identify how race, ethnicity, and socioeconomic status as social determinants of health affected disparities in diagnosis, treatment, and outcome. The structure of the review synthesised the literature available, with a focus on enrolment of the trials, as well as, registry representation, and systemic problems with specialty care. Findings revealed that racial and ethnic minorities remained under-represented in PAH studies and limited the external validity of available evidence, and further supported the disproportionality of treatment access. The paper contributed to the evidence base with a focus on the importance of community-based intervention, training for clinicians, and more participation in research by diverse populations. It was not a quality improvement project but a review paper.

Didden, E., Lee, E., Wyckmans, J., Quinn, D. A., & Perchenet. (2023). Time to diagnosis of pulmonary hypertension and diagnostic burden: A retrospective analysis of nationwide US healthcare data. Pulmonary Circulation, 13(1), e12188.

The primary purpose of the present retrospective research study was to determine diagnostic delays and utilization of healthcare resources in patients of pulmonary arterial hypertension. The information was obtained using the Optum insurance claims and electronic health records in the adults initially diagnosed with chronic unexplained dyspnea who ultimately were diagnosed with PAH. The median time to diagnosis was 2.26 years, in which the patients underwent multiple echocardiograms, visits to specialists and hospital admissions. Approximately one-third were delayed more than ten months prior to echocardiography. Both delayed time to diagnosis and high healthcare use were outcomes. The study that was contributed to the literature by indicating the need to develop better referral systems and earlier diagnosis systems to overcome diagnostic inefficiency.

Fonseca, O. C., & Jamie. (2022). Where’s the easy button? The many barriers to care for patients with pulmonary arterial hypertension. Journal of the American Heart Association. Cardiovascular and Cerebrovascular Disease, 11(22), e027967. https://doi.org/10.1161/jaha.122.027967

 The objective of the research was to examine barriers to prompt and equal access to the treatment of pulmonary arterial hypertension. The article was written in the form of commentary rather than empirical evidence with a focus on systemic and administrative obstacles in the American healthcare system. The most significant barriers identified were capped insurance practices, specialty pharmacy hold-ups, and drug acquisition inefficiencies all of which contributed toward catalyzing delays in initiating treatment and care disruptions. No primary data were present and the analysis focused on the real-life implications of the structural barriers. The article contributed to the literature by framing issues of access as systemic disparities and highlighting the importance of health policy and quality improvement initiatives to close disparities in the treatment of PAH.

Gillmeyer, K. R., Rinne, S. T., Rucci, J. M., Klings, E. S., & Wiener, R. S. (2025). Factors associated with referral to expert providers among patients with pulmonary hypertension. Annals of the American Thoracic Society, 22(6), 838–845. https://doi.org/10.1513/annalsats.202408-901oc

The authors of the retrospective research study reviewed patient-level factors that predict referral to pulmonary hypertension experts using the Massachusetts all-payer claims database (201517). Of 12,505 new diagnosis patients, 5.6% had been referred to experts, and the percentage was somewhat higher among individuals at risk of pulmonary arterial hypertension. Multivariate analysis revealed that Medicaid enrollments, mental illness and more distant specialty centers were associated with significantly lower odds of referral. The study added to the literature by measuring access differences in specialist care and proposing geographic, socioeconomic, and mental health barriers, thereby identifying what can be done to improve the quality of the referral process.

Gillmeyer, K. R., Shusterman, S., Rinne, S. T., Elwy, A. R., & Wiener, R. S. (2025). Gaps in access to pulmonary hypertension care and opportunities for improvement: A multi-site qualitative study. BioMed Central Pulmonary Medicine, 25(1), 355. https://doi.org/10.1186/s12890-025-03817-4

The multisite qualitative research study estimated delay-inducing barriers to timely PH care. The authors conducted interviews with patients and health care providers in three American expert PH centers. Findings revealed a barrier of entrenched access along the continuum of care, including symptom onset through persistent care, low PH awareness by non-specialist clinicians, symptom denial, geographic and socioeconomic barriers, inappropriate referral processes, and insurance. Treatments suggested by the participants included telementoring of community clinicians, provider networks, facilitated diagnostic routes, and increased medication availability. The study contributed to the literature by gaining lived experience reports of barriers to access and context-relevant actionable recommendations to inform quality improvement interventions to enhance equity and timeliness in PH care delivery.

Maarman, G. J. (2022). Pulmonary hypertension in developing countries: Limiting factors in time to diagnosis, specialised medications and contextualised recommendations. African Journal of Thoracic and Critical Care Medicine, 28(1), 28–32. https://doi.org/10.7196/ajtccm.2022.v28i1.176

The authors of the review paper explored the limitations to PH care in the developing world and particularly in sub-Saharan Africa. Barriers recorded in literature synthesis include poor screening practices, frequent misdiagnosis, delays in diagnosis, lack of awareness among clinicians and patients, unnecessary high treatment costs and inadequate availability of specialized treatment. Recommendations were made involving development of locally relevant screening strategies, more clinician training, development of rural breathlessness clinics and advocacy partnerships with social science, non-profit agencies and funding bodies. The review also highlighted the future of new therapies and genetic biomarker discovery. The results contributed to the literature as they described context-specific measures directed to overcoming systemic pathways in resource-limited health systems.

Naing, P., Kangaharan, N., Scalia, G. M., Strange, G., & Playford, D. (2022). Pulmonary hypertension in remote and disadvantaged population: Overcoming unique challenges for improved outcomes. Internal Medicine Journal, 53(1), 12–20. https://doi.org/10.1111/imj.15860

The review article was focused on issues of PH diagnosis in remote and socioeconomically disadvantaged geographic locations. The method involved an epidemiological narrative synthesis of data, pathways of diagnosis, and case studies with emphasis on unique regional impediments. The major obstacles were the lack of diagnostic units, the lack of knowledge about the presentations of PH, and the lack of facilities. The authors proposed a simplified diagnostic algorithm relying on clinical assessment, echocardiography, and escalation principles to overcome the obstacles. The approach has been put in context using two clinical scenarios. The study contributed to the literature by offering a practical diagnostic algorithm applicable to resource-limited settings, which aids efforts for improving both early detection and management of PH in the under-represented southern region.

Small, M., Perchenet, L., Bennett, A., & Linder, J. (2024). The diagnostic journey of pulmonary arterial hypertension patients: Results from a multinational real-world survey. Therapeutic Advances in Respiratory Disease, 18. https://doi.org/10.1177/17534666231218886

The cross-sectional study evaluated the process of diagnosing pulmonary arterial hypertension using a multinational point-in-time survey in five European countries, Japan and the United States. The authors retrieved patient record forms through physician and patient anonymous self-reporting. The findings revealed that the median time of diagnostic delay is 17.0 months, which is 13.8 months as per the physician estimates. Nearly 72% of patients initially encountered primary care, 41% were misdiagnosed and most of those patients visited more than a single clinician before being diagnosed. The research contributed to the literature by providing evidence of a systemic delay in the diagnosis process and the importance of increasing the connections between referrals and screening.

Conclusion

Late detection of pulmonary hypertension poses significant problems to patients and healthcare institutions. BACKGROUND: Provider-patient interactions and health literacy issues can contribute to disparities in outcomes by influencing several aspects of care, and evidence-based mechanisms for managing clinical encounters can reduce disparities by standardizing care and improving adherence to guidelines. The proposed quality improvement initiative in the practice setting focuses on provider training, effective referral process, and collaboration between professions. The initiative can lead to more effective patient outcomes, ensure that care aligns with national standards, and create a sustainable model aimed at equitable pulmonary hypertension management, reducing barriers on the patient, provider, and system levels.