Key result
RCT protocol evaluates whether a tailored transition program reduces 30-day rehospitalizations versus usual care.
Why the study?
Hospital rehospitalizations within 30 days are a burden for patients and healthcare systems, and improving care during hospital discharge could reduce avoidable rehospitalizations.
Does individualized and coordinated discharge management reduce the 30-day rehospitalization rate in adult patients hospitalized in an acute internal medicine department with a high risk of rehospitalization?
RCT
open-label
randomized
No
Does individualized and coordinated discharge management reduce the 30-day rehospitalization rate in adult patients hospitalized in an acute internal medicine department with a high risk of rehospitalization?
This trial protocol outlines a pragmatic, randomized, open-label study to evaluate whether a tailored, multimodal discharge transition program reduces 30-day rehospitalizations in high-risk internal medicine patients.
Clinicians should not change discharge practices for high-risk patients yet; this pragmatic RCT leaves open efficacy of tailored transition on 30-day rehospitalization.
Background Hospital rehospitalizations within 30 days represent a burden for patients and the healthcare system. Improving the care during the hospital discharge period could decrease the risk of avoidable rehospitalizations.Aim To describe the methods of our trial aiming to define the efficacy of a tailored transition program in patients with high risk for rehospitalization compared to the usual discharge procedure with the endpoint of 30 day rehospitalization rate.Methods Pragmatic, randomized, open-label, single-center superiority trial with a follow-up of 30 days. Included are adult patients hospitalized in an acute internal medicine department who are planned to be discharged home with a high estimated risk (20% or more) of 30-day rehospitalization. Patients in the intervention group will receive individualized and coordinated discharge management by an interdisciplinary team, compared to usual care in the control group. The multimodal intervention includes individualized pre-discharge, bridging, and post-discharge intervention components.Ethics And Dissemination Before enrolling the first patient, the trial was prospectively registered at the ISRCTN registry (registration date April 4th 2023) under the number ISRCTN11162162 and was approved by the ethical committee (Ethikkommission Nordwest- und Zentralschweiz (EKNZ), ID 2022-01040).Conclusion This trial aims to assess the efficacy of a well-defined multicomponent discharge intervention to reduce unplanned rehospitalization rates in high-risk patients.
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Brennecke et al. (2026) conducted an RCT in High risk for rehospitalization. Tailored transition program (individualized and coordinated discharge management) vs. Usual care was evaluated on 30-day rehospitalization rate. This protocol describes a randomized trial evaluating whether a tailored transition program reduces 30-day rehospitalization rates compared to usual care in patients with ≥20% baseline risk.
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