The Effectiveness of Personalized Nursing on Quality of Life in Cardiovascular Disease Patients: A Systematic Review and Meta-analysis

Aims This study aimed to examine the potential effectiveness of personalized nursing interventions on improving the heart-related quality of life of patients with CVDs versus an usual care. Design A systematic review and meta-analysis. Data Sources. The study researched the article between January 2011 and December 2021 from four electronic databases: PubMed, Embase, Cochrane library, and Web of Science. Review Methods. Randomized controlled trials (RCTs) related to personalized nursing in CVDs population were included. The main variables were analyzed by standardized mean differences with 95% confidence intervals and heterogeneity was used by the I2 test and P value. Results Of 734 studies, fourteen articles were eligible for this study. Personalized nursing significantly improved the quality of life [SMD = 0.39, 95% CI (0.29, 0.49)] with obvious heterogeneity (P = 0.000, I2 = 66.1%) which needs to be further subgroup analyzed. The nurse-led intervention was considered the main-related effect to influence the heterogeneity with value of 0.39 (I2 = 66.1%, P = 0.000; Group 1: I2 = 48.4%, P = 0.071, and Group 2: I2 = 0.0%,. In addition, related results of athletic ability and mental health and follow-up and education in the intervention had higher level of quality of life compared to the control group [SMD = 0.27, 95% CI (0.10, 0.44); SMD = 0.21, 95% CI (0.04, 0.37); SMD = 0.39, 95% CI (0.29, 0.49) and SMD = 0.28, 95% CI (0.11, 0.44)]. Conclusion Effectiveness studies of personalized care focus on more relevant outcomes have higher health outcomes, whereas evidence of the effectiveness of personalized nursing approach is still limited. Therefore, more and more high-quality RCT are needed.


Introduction
Cardiovascular diseases (CVDs) is the main reason for mortality with more than 17 million deaths each year (World Health Organization, 2019-40) and responsible for one-third of the deaths worldwide. In particular, 80% of CVD-related deaths were recorded and increasing in low-and middleincome countries [1]. In China, CVDs have become the most prevalent disease in aged over 65 years people with sufering health condition [2]. CVDs are a type of chronic illness which typically lead to a decline in physical capacities and emotional conditions, the patient becomes lonely and socially isolated which are the complex and long-time progressive nature of CVDs. Tey may cause high rehospitalization and fnancial burden cost of medical care and eventually negatively infuence a patient's health-related quality of life (HRQOL) [3].
Health-related quality of life covers multidimensional domains that are linked to the physical, emotional, psychological, and social functions which has the important role in the prevention of chronic disease relapse like cardiology sequel [4]. Quality of life has been identifed as one of the main indicators of measurement of cardiovascular health outcome [5]. In general, cardiovascular diseases patients had low level of HRQOL, and patients with unhealthy lifestyle, being lack of confdence in treatment and prognosis and being failure to actively and strictly follow the doctor's advice to take medicine and rehabilitation training have been indicated to tend to be lower HRQOL [6].
For CVDs, some patients may ignore its continuous treatment throughout life and compliance behavior mainly by motor disturbances and emotional caring following their discharge from a healthcare institution, therefore, in order to improve the health status and treatment outcome related to quality of life, it is necessary to apply nursing theories integrated care interventions in patients after-treatment [7,8]. Te carers' roles in the supportive process are taken when the patients are ready to learn and do more something, but he/she cannot do it without help and guidance. Previous studies have been informed that skillful and personal nursing like provision of medical and psychological guidance to the patients is critical to improving their quality of life [9]. With continuous nursing, especially personalized care, as an extension of high-quality medial caring to the recovering, it mainly included providing education, counseling, emotional support, or help with accessing services by using information packages, limiting sodium intake, improve physical activity, fruit and vegetable consumption, and weight loss [9].
It should be noted that intense care by nurses for CVDs has contributed immensely in the complete success after hospital treatment [3]. As we know, treatment of CVDs play a key role in improving clinical outcomes, early physician follow-ups may reduce the risk of 30-day readmission for those with cardiovascular diseases [10]. However, due to the fact that heart failure is a chronic disease, the role of nurses had an meaningful efect on identifcation of problems and support of patients, dealing with the diagnosis, guiding their behavioral and lifestyle modifcations for achieving more efective management, recurring, and even how to deal with death in the process of after-treatment [11,12]. At present, the role of nurses has often been underestimated and left unnoticed through research in chronic after hospital treatment. Although a number of randomized controlled studies have confrmed that personalized care can reduce the negative emotion and promoting the recovery of physical function and in patients with post-CVDs and play a positive role in improving the quality of life. Few studies were to explore the details of nursing programs, contents, and results and its lack of reliable evidence-based measurements which limits the promotion of this program. Terefore, this study examined the potential efectiveness of personal care interventions in improving the HRQOL of patients with CVDs versus a usual care.

Protocol and Registration.
Te study was reported following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020). We registered the study on PROSPERO under the registration number (CRD42022354872).

Search Strategy.
Te electronic network databases were researched in PubMed, EMBASE, Web of Science, and the Cochrane Library. Te retrieval teams were mainly based on a combination of MeSH subject words and relatedfree words.
Te search terms regarding the participant included ("Cardiovascular diseases" OR "Cardiovascular Disease" OR "Disease, Cardiovascular" OR "Diseases, Cardiovascular"). With "Nursing" OR "Nursings" OR "Caring" OR "Empathy" OR "Compassion" as the intervention searched terms. Te type of study was limited "randomized controlled trial (RCT) OR placebo" in English. Te measurement of outcome used for "Quality of life OR Health-Related Quality Of Life" in English and so on. Reference lists of studies and relevant systematic reviews were manually screened to identify further eligible research. Te retrieval type or blinding were not limited, and the research time was conducted from January 1 st , 2011 to December 31 st , 2021. Te detailed full electronic search strategy of Embase is shown in supplementary fle. (Available here).

Inclusion criteria.
(1) Studies on patients with related cardiovascular and cerebrovascular diseases who were diagnosed by coronary heart disease, hypertension, heart failure and so on. Tere were no age or gender limits; (2) the intervention group was treated with personalized care, while the control group was treated with usual care; (3) the primary outcome was health-related quality of life as measured by reliable and validated instruments, with athletic ability and mental health as secondary outcomes (details of the indicators were shown in "Outcome indicators").

Exclusion Criteria.
(1) Non-RCTs; (2) systematic reviews, meta-analysis, case reports, meeting abstracts, animals tests, and related commentaries; (3) inconsistent, incomplete, or ambiguous baseline data on disease and other associated characteristics of the participants; (4) Lack of original data, only partial abstracts or data provided, no full text, or no response to contacting the author.

Intervention and Control
Measurements. Te intervention group was treated with personalized care, such as education, follow-up, rehabilitation exercise and so on. Meanwhile, the control group received only usual care

Outcome Measurement Indicators
(1) Primary Outcomes. Te retrieved studies contained primary and secondary indicators, with quality of life being the primary outcome measured in reliable and valid scales. Te quality of life was measured at the time of baseline and the end of intervention, based on reliable and valid scales that have been used around the world including the following scoring tools: the 36-Item Short Form Health Survey (SF-36), SF-12, and WHOQOL-BREF.
SF-36 is a set of generic, coherent, and easily administered QOL measure. Its measures rely on patient selfreporting and are widely utilized for routine monitoring and assessment of care outcomes in adult patients. It comprises 36 questions which cover eight domains of health: physical activities, social activities, usual role activities, bodily pain, general mental health (psychological distress and well-being), usual role activities, vitality (energy and fatigue), and general health perceptions. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. Te lower score means that the more disability.
WHOQOL-BREF, World Health Organization Quality of Life project 26-item instrument. Te lower score means that the more disability.
(2) Secondary Outcomes. Te secondary outcome measures with caring-related outcome included QOL-related outcomes like athletic ability, mental health, and the intervention methods like follow-up and education.

Data Extraction and Screening.
After the selected studies were extracted and imported into Note Express for electronic and manual duplicate checks, [13] two researchers independently examined abstracts, screened, read, and excluded the irrelevant papers. Publications with inappropriate study type designs, incomplete results data, and full-text were removed. A full-text screening and data extraction were performed according to the above eligible inclusion and exaction criteria comprising participants, interventions, controls, outcomes, and study design framework (PICOS). Also, their diferences will be resolved with the help of a third reviewer until a consistent conclusion and consensus were reached. Te detailed information was extracted from the fnal eligible articles and recorded in a Microsoft Excel: Tose sheets included details of the authors, year of publication, study design, characteristics of participants, intervention, control group, and outcomes (Table 1).

Data
Analysis. Extracted data were analyzed by the Stata 16.0 software to perform meta-analysis. We used the chisquare test and the I 2 statistic and P value to evaluate heterogeneity among the studies. If the outcome indicator is a continuous variable, we used the standardized mean diference (SMD) or mean diference (MD) and 95% confdence interval (CI) to analyze the studies. Te MD and SMD were used as a summary statistic if all trails collected the same outcome indicator by the same scale. According to the results of quantitative analysis, we considered P < 0.05 and I 2 < 50% to be statistically signifcant that meant good agreement and the fxed efect model was chosen.
To test the stability of the meta-analysis results of each index, we used the one-by-one elimination method to analyze the sensitivity of the main outcome indicators. To test the stability results of each index, a sensitivity analysis was conducted to investigate the potential source of heterogeneity and determine whether the fnal conclusion of the research is for a specifc method or research design features used. We will further explore the efect of diferent detailed care approaches and related outcome indicators and other factors. Tey are analyzed based on the apparent homogeneity of results that can be qualitatively measured. Stata 16.0 software was used for sensitivity analysis, subgroup analysis, and sensitivity analysis and charts were drawn.

Publication Bias.
Funnel chart is used to evaluate whether there is publication bias and Begg's test is used for the evaluation of potential publication bias. Figure 1 presents the PRISMA 2020 fow diagram of this study. A total of 734 related articles that met the search criteria were collected from four English databases (PubMed: n � 24, Web of Science: n � 316, Embase: n � 154, Cochrane: n � 240). Te retrieved articles were recorded in Note Express and 128 duplicated papers have been excluded by automatically screening. In addition, inappropriate studies like reviews, meta-analysis, and animal mechanism experiments (n � 156) were removed after reading the titles and abstracts. Furthermore, articles that did not meet the study inclusion standard, including 379 studies with inconsistent content, 36 studies with unreasonable design, and 21 inconsistent outcome indicators, they were eliminated after reading the full text. Finally, 14 documents were included in the quantitative meta-analysis.

Study Characteristics.
Te included studies had a total of 1562 patients (intervention group: n = 844 and control group: n = 718) covering the period from 2011 to 2021. Te researched subjects were patients who were diagnosed with related cardiovascular disease, and there was no signifcant diference between groups for these outcomes. Te age of patients varied from 18 to 85 years. Te duration of intervention ranged from ten weeks to one year. Quality of life was categorized as a primary outcome measurement in all trials. Te intervention group received the personalized care while the control group received the usual care or routine care. Te included studies were conducted in the all of world, and all of the outcomes of quality of life were scored using Evidence-Based Complementary and Alternative Medicine  Table 1 shows the characteristics of the included study.

Summary of the Quality and Bias Risk of the Trials.
According to Cochrane collaboration risk of bias tools, most of the trails had relatively low risk of bias. All of the included studies had similar group characteristics at baseline. It was found that only 13 studies reported random sequence generation details, 5 included studies blind of their patients, investigators, or the assessors. Te additional sources of bias in all trails were low due to inclusion criteria. Details of risk of bias are summarized in Figures 2 and 3.

Outcome Measures
3.4.1. Efect of the Quality of Life. "Quality of life" was measured by standard and generic scales around the world, and was the primary outcome measure for all the included articles. We evaluated the diferences in the efect of outcome between the intervention group (personalized care) and control care (usual care). 14 studies involving 1562 patients (844 patients in the intervention group and 718 patients in the control group) showed that, compared to the control group, the meta-analyses indicated that personalized care improved the level of quality of life [SMD � 0.39, 95% CI (0.29, 0.49)], and there was obvious heterogeneity (P � 0.000 , I 2 � 66.1%); thus, the random efects model was used to analyze the data (Figure 4). Te causes of the observed heterogeneity were further investigated by using the subgroup and sensitive analyses. To examine the origin of heterogeneity, we explored that detailed intervention can be used to distinguish subgroups of patients with cardiovascular and cerebrovascular diseases had diferent quality of life.

Subgroup Analysis for Quality of Life.
In this metaanalysis, the nurse-led intervention was considered as the main related efect to infuence the heterogeneity, and the two subgroups (Group 1: being nurse-led intervention; Group 2: without nurse-led intervention) indicated that they were extremely heterogeneous. Tere was no heterogeneity within each subgroup as shown by an efective value of 0.39 (I 2 � 66.1%, P � 0.000; Group 1: I 2 � 48.4%, P � 0.071, and Group 2: I 2 � 0.0%, P � 0.571), suggesting that nurse-led intervention as a treatment may infuence the heterogeneity and improve the QOL among cardiovascular disease patients. Te results of the subgroup analysis could be carried out and found in Figure 5.  (Figure 7).   (Figure 9).

Funnel Plot. Te comparison-corrected funnel plot
shows that most of the dots are symmetrically distributed on both sides of the X = 0 vertical line, suggesting that publication bias and small sample efects are less likely. (see Figure 10 4

. Discussion
Te occurrence of CVDs might bring physical or emotional disorders and further worsening or even being die. Caring or nursing ofers in basic skills of physical activities and Evidence-Based Complementary and Alternative Medicine reduced negative emotional function which plays a positive role in the posthospital treatment and rehabilitation to improve the quality of life in CVDs patients [14]. Te study aims to system review standardized and high-quality papers to explore the detailed approaches and outcomes of continuous personalized nursing intervention for improving the quality of life among CVDs patients. For secondary results, our results show that the intervention group has higher quality of life with focusing on athletic ability and mental health compared to the control group, in addition, the intervention group by application continuous education and follow-up care is higher in quality of life than in the control group with usual care which it has been confrmed in previous study. Identifcation of studies via other methods   Evidence-Based Complementary and Alternative Medicine

Identifcation of studies via databases and registers
Our main result showed that personalized caring had a signifcant improvement in quality of life compared to usual caring, which were consistent with previous studies [15]. Te personalized caring is usually considered as an efective on the psychological adaptation and reduction of manipulative behaviors in patients with CVD [15].
Personalized nursing with nurse-patient communication could reduce disease burden, and negative emotions to rebuild their confdence may help improve clinical outcomes which may monitor and improve quality of life [15,16]. In our subgroup analysis, we found that diferent detailed treatment approaches of nurse-led intervention infuenced    Evidence-Based Complementary and Alternative Medicine the heterogeneity of measurement QOL in our study. Previous studies showed that all the CVDs-related nursing intervention approaches and related outcomes had a greater or lesser impact on the QOL [14]. Nurse practitioner roles could assist patients improve social functioning, role functioning emotional, and mental health with achieving these health system goals for CVDs patients [17]. For the comparison between QOL and outcomes, it might be a matter of patients unintentionally believing that they had the best possible care when seeing a laded nurse instead of usual caring, regardless of clinical outcome, and the fact that the proportion of patient over time was higher in the usual care group compared with the nurse-led care group in previous studies. Currently some potential sources of bias and unreported outcomes may infuence the heterogeneity and subgroup analysis for improving QOL is inconsistent and limited.
Our results also showed that the patients in the intervention group had low level of emotional and physical function. Nowadays, there is sufcient evidence to support the urgent implementation of nurse interventions aimed at encouraging physical activity for enhancing limb function and muscle strength to carry out the activities of daily life which could somehow infuence the QOL (quality of life) [9]. In the whole process, the nurses will discuss to the patients with their profles and assess their activity level according to the actual situation in order to raise awareness of selfmonitoring, self-monitor, and self-efcacy for improving the patient's level of physical activity [19]. Regarding the emotion dimension, patients in the nursing stage are more aware of the condition and what will happen once relapsing after a period of treatment [20]. For these reasons, they may follow nurses' suggestions by enhancing confdence and optimistic emotion to improve prognosis [20]. As we know, emotional management was important for CVDs, with a vital role for the nurse specialist in terms of counseling and reassurance by focusing on patient activating patients to perform self-management, recovering from depression, may positively infuence to change their actions more autonomously [15]. All the above research further supports the results of this current analysis.   According to the fndings of our study, personalized nursing related the detailed approach of educational management and follow-ups can be efective in improving the quality of life of CVDs patients. For CVDs patients, the medical focus changes from "cure" to "care" which includes providing education support to families who usually provided detailed information and practical skills by using patient-directed goal setting and introducing the experience of role models that facilitated the participants' confdence in improving the health situation [21]. Obviously, this kind of care might be diferent from the "usual care." For example, in one study, the efect of intervention on HRQoL was high assessed by long-timefollow-up [22]. For durable personalized caring, nurses could connect communication by spending long time to build trusting which are more suitable than other families or professionals as educators for chronic illness patients [23,24].

Strength and Limitation
In this meta-analysis, we performed a detailed classifcation and analysis of the intervention group which will enhance reproducibility of the intervention. Meanwhile, this work included the inclusion of only RCTs, two authors assessed  Evidence-Based Complementary and Alternative Medicine study quality ratings, adverse events were analyzed using the Cochrane and Grade, and subgroup analyses were performed to identify potential associations between intervention nursing methods and quality of life. While this systematic review still has some limitations, frstly, due to many diferent specifc established standardized intervention caring regimens and contain a small size of participants identifed will increase the uncertainty of generalizability of these studies. In addition, most studies had follow-up care of no more than 1 year with being lacked the long-termfollow-up data, therefore, we did not perform the meta-analysis to assess the long-term efect  of the improvement of quality of life for CVD patients. Finally, the QoL is a kind of subjective data, which are infuenced by many factors such as the situation of understanding or communication and prone to be biased.

Conclusion
Nurse-led disease management program appears to be effective in improving the quality of life for patients with CVDs. Our study reviewed new and valuable insight from patients and nursers on the post-treatment of those CVDs primary care providers. Tis meta-analysis showed that patients with personalized caring who attended this program revealed higher levels of quality of life, physical activity, and emotional activity compared with the usual caring. However, the promising results should be cautiously interpreted and generalized. Large-scale, prospective, randomized controlled trials are still needed to verify the preliminary fndings of the current study.

Abbreviations
CVDs: Cardiovascular diseases QOL: Quality of life HRQOL: Health-related quality of life OSF: Open science framework SF-36: Te 36-item short form health survey WHOQOL-BREF: World Health Organization quality of life project 26-item instrument PICOS: Participants, interventions, controls, outcomes, and study design framework RCTs: Randomized controlled trials non-RCTs: Nonrandomized controlled trials SMD: Standardized mean diference MD: Mean diference CI: Confdence interval.

Data Availability
All the data supporting this meta-analysis are from previously reported studies and datasets, which have been cited. Te processed data are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that they have no conficts of interest.

Supplementary Materials
Te detailed full electronic search strategy of Embase was shown in supplementary fle. A full-text screening and data extraction were performed according to the principle of "Participants, Interventions, Controls, Outcomes and Study design" (PICOS). Te 1 st and 2 nd step was to search "patients disease" with MeSH and its free words. Te 3 rh step was to combine them both; Te 4 th and 5 th was to search "intervention methods" with MeSH and its free words and 6 th was to combine the step of 4 th and 5 th ; Te 7 th and 8 th used outcome of our research as search strategy with MeSH and its free words, and the 9 th was to combine them; Te 10 th was to search articles with type of "Random Controlled Trails." At last, we integrated all above search strategies at the Evidence-Based Complementary and Alternative Medicine 11