Literature Review
Student name
Capella University
NURS-FPX8004
Professor Name
Submission Date
Literature Review
Pulmonary hypertension (PH) remains a significant issue at the specialty hospital in the Southeastern United States where patients usually manifest with late-stage disease due to late diagnosis and referral. The issue, which is not limited to the practice location but remains in the entire United States (DuBrock et al., 2023). The problem resulted in creating the following population, intervention, comparison, outcome, and timeframe (PICOT) question: In adult patients aged 40 to 80 years with pulmonary hypertension (P), how an early recognition and simplified referral pathway to PH specialists (I) compared to the current standard referral process (C) affect time to diagnosis (O) within 12 weeks (T)? A literature search was conducted in PubMed, CINAHL, and Scopus using the keywords pulmonary hypertension, referral, access to care, diagnostic delay, and quality improvement, with Boolean operators AND/OR/NOT, and limited to English language articles published in 202025. The search returned high-quality studies and reviews that informed the creation of an equity-based, standardized protocol to refer to. The results of the research studies warranted the introduction of a quality improvement initiative incorporating provider education, effective referral, and interprofessional collaboration to reduce diagnostic delays, increase access to specialty care, and improve patient-centered outcomes in patients with pulmonary hypertension.
Thematic Synthesis of Literature
Theme 1: Strategies to Improve Access to Pulmonary Rehabilitation
Patients with pulmonary hypertension and chronic obstructive pulmonary disease (COPD) have an ongoing problem with access to pulmonary rehabilitation (PR). Among the most common barriers presented in the literature are absence of provider interaction, logistical barriers, and variability in referents, with the solutions proposed varying in degree and scope. Kotejoshyer et al. (2023) demonstrated that multicomponent interventions such as education of the clinician, bedside counseling, and transportation support proved effective to improve attendance at PR after COPD hospitalization. However, Bailey and DuBrock (2024) found that PH patient underutilization was mediated primarily through clinician-patient consultation, suggesting that interventions mediated through communication (versus structural facilitation) probably will be more effective in the population. Narasimhan et al. (2025) took this same perspective further by showing that those COPD patients with comorbidities who were referred to two different physicians through individualised referral pathways and training saw improved access, with implications for the value of personalisation. McCormack et al. (2021) led the pack by focusing on technological solutions, in which PR programs implemented at home under supervision through telehealth addressed geographic inequalities. Overall, the included studies highlight that while structural supports and individualised pathways help reduce access barriers in COPD populations, PH patients may benefit more from having direct contact with a practitioner and more recent models of delivery, emphasising the need for flexible disease-specific solutions.
Theme 2: Barriers to Access to Pulmonary Hypertension Care
Although impressive progress in the treatment of pulmonary hypertension has been made, obstacles to equal access remains. Fonseca and Jamie (2022) identified barriers in the structure and administration, such as restrictive insurance coverage and pharmacy hold-ups of specially targeted therapy, as interfering with the start and continuation of treatment. Continuing on the systems-level conversation, Rochester (2024) further described patient, socioeconomic, and geographic barriers to pulmonary rehabilitation, including symptom load, low motivation, program inaccessibility, and transportation barriers, which all contribute to the underutilization of pulmonary rehabilitation. Nevertheless, Gillmeyer et al. (2025) concentrated on how referral differences disproportionately affected Medicaid patients, the mentally ill, and patients living in distant areas of specialist facilities thereby demonstrating the intersection of social determinants and access to specialist care. The papers indicate that the administrative inefficiencies that hinder treatment provision are not the sole cause of inequities in referral and rehabilitation, as patient-level factors and geographic disparities exacerbate inequities. Taken together, the results suggest that collaboration is required to develop solutions that combine provider education, improved referral procedures and policy changes that will help to facilitate timely and equitable PH care delivery to all populations.
Theme 3: Delayed Diagnosis of Pulmonary Hypertension Leads to Adverse Outcomes
Late PH diagnosis has been shown over and over again to worsen the clinical and economic outcomes. Inefficiency of diagnostic workup was noted by Didden et al. (2023) where the median length of time without diagnosis of pulmonary arterial hypertension was 2.26 years following symptom onset, and patients underwent numerous diagnostic tests, multiple referrals, and hospitalizations. Nonetheless, DuBrock et al. (2023) also noted cost and resource implications of later detection and reported that longer diagnostic delays were associated with higher rates of hospital and intensive care unit (ICU) admissions, readmissions, and outpatient visits, and added up to an estimated additional monthly costs of between $3,986 and 5,366 in the first year after diagnosis. Kubota et al. (2023) corroborated the results presenting evidence that patients diagnosed over 12 months used acute-care and accrued significantly higher healthcare costs than patients diagnosed earlier. The results all explain the effects of inefficiency in terms of clinical risk and financial cost. Collectively, the researches reinforce the idea that effective prevention of the detrimental effects of diagnostic delays in pulmonary hypertension lies in early detection and referral, as well as evaluation in line with the guidelines.
Recommendations for Future Research and Practice
Future studies should aim at developing standardized evidence-based screening methods to enable earlier pulmonary hypertension diagnosis in different clinical settings. Research highlighted the need for multicenter studies on referral pathways, algorithms for symptom trackers and biomarker-driven diagnosis as potential strategies to reduce delay to diagnosis (Gunatilleke et al., 2022). In addition to innovation in clinical approaches, cost-effectiveness studies of early intervention approaches are important for guiding the allocation of resources, and qualitative research on patient and provider experiences can uncover cultural, socioeconomic, and structural barriers that affect access to care. The literature suggests that quantitative and qualitative approaches will be needed to develop powerful, fair diagnostic systems.
For training, the use of clinical decision support in electronic health records, developing provider education programs, and using standardized criteria for referrals can help make the practice of diagnosing more equitable and uniform. Evidence also highlighted the need for the use of cooperative networks between community providers and PH specialty centers in order to simplify the process of referrals and improve evidence-based compliance of guidelines (Obi et al., 2024). In line with these systemic changes, patient-centered interventions such as education, advocacy, and shared decision-making will play an important role in sustaining practice change. Together, these recommendations suggest a multi-pronged approach where research changes policy, and practice innovations contribute to earlier and more equitable access and improved outcomes for patients.
Conclusion
The literature refers to three mutually dependent problems in the treatment of pulmonary hypertension, namely delayed diagnosis, the presence of barriers to equal access to specialty care, and the need to take steps to improve access to pulmonary rehabilitation. Diagnostic delays make outcomes worse, with patients being misdiagnosed or referred too late due to a nonspecific presentation and inconsistent disease processes. The restriction of access to timely diagnosis and treatment extends through barriers, such as limited awareness, socioeconomic disparities, and limitations of the health system. At the same time, interventions such as standardized referral practices, provider education, telehealth implementation, and patient-centered care interventions show potential in increasing access to pulmonary rehabilitation. Together, this evidence underscores the urgency to reconcile practice with evidence-based standards by improving quality, equitably allocating resources, and developing novel care models to improve survival and quality of life in individuals with pulmonary hypertension.
References for Nurs-fpx 8004 Assessment 4
Bailey, M., & DuBrock, H. M. (2024). Pulmonary hypertension patient perspectives toward pulmonary rehabilitation. Pulmonary Circulation, 14(1), e12338. https://doi.org/10.1002/pul2.12338
Didden, E., Lee, E., Wyckmans, J., & Quinn, D. A. (2023). Time to diagnosis of pulmonary hypertension and diagnostic burden: A retrospective analysis of nationwide US healthcare data. Pulmonary Circulation, 13(1), e12188. https://doi.org/10.1002/pul2.12188
DuBrock, H. M., Germack, H. D., Loiselle, M. G., Linder, J., Manceur, A. M., Cloutier, M., Lefebvre, P., & Frantz, R. P. (2023). Economic burden of delayed diagnosis in patients with pulmonary arterial hypertension (PAH). PharmacoEconomics – Open, 8(1), 133–146. https://doi.org/10.1007/s41669-023-00453-8
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). https://doi.org/10.1161/jaha.122.027967
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). https://doi.org/10.1513/annalsats.202408-901oc
Gunatilleke, N. J., Fleuriot, J., & Anand, A. (2022). A literature review on the analysis of symptom-based clinical pathways: Time for a different approach? PLOS Digital Health, 1(5), e0000042. https://doi.org/10.1371/journal.pdig.0000042
