September 28, 2026JMIR Research ProtocolsOpen Access

A Transition of Care Service to Reduce Hospital Readmissions for High-Risk Cardiology Patients (RECARD): Protocol for a Pre-Post Interventional Trial

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Acute myocardial infarction (AMI) or cardiothoracic surgery (CS) (n=4422). Intervention: Pharmacist-led interdisciplinary transition of care (TOC) service vs. Usual care. Primary outcome: Medication-related 30-day hospital readmission.

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Key result

Pharmacist-led care transition service evaluated for reducing 30-day medication-related readmissions in high-risk cardiology patients.

n=4,422

Why the study?

Does a pharmacist-led interdisciplinary transition of care service reduce medication-related 30-day hospital readmissions in high-risk cardiology patients post-AMI or cardiothoracic surgery?

Population

Adults discharged following an index diagnosis of acute myocardial infarction or cardiothoracic surgery…

Comparison

Pharmacist-led interdisciplinary transition of… vs Retrospective usual care cohort and concurrent…

Design

Cohort

Follow-up

30 days (up to 90 days for secondary outcomes)

Authors

NFNazanin FalconerThe University of Queensland SWShelley A. WilkinsonThe University of Queensland CSCentaine L. SnoswellThe University of Queensland

Discussion

Member takes

Implication

This protocol outlines a pre-post trial to evaluate whether a pharmacist-led transition of care service reduces medication-related 30-day hospital readmissions in high-risk patients following acute myocardial infarction or cardiothoracic surgery.

Key Points

To evaluate the impact of a pharmacist-led interdisciplinary transition of care service on reducing medication-related 30-day hospital readmissions among high-risk cardiology patients following acute myocardial infarction or cardiothoracic surgery.
Study design: Multicenter pre-post interventional trial (RECARD) conducted across 3 Australian tertiary hospitals (Princess Alexandra Hospital, Townsville University Hospital, Royal Brisbane and Women's Hospital).
Phase 1 developed a risk prediction model to identify acute myocardial infarction and cardiothoracic surgery patients at high risk of 30-day medication-related readmissions.
Phase 2 compares a 12-month retrospective usual care cohort with a prospective cohort receiving individualized transition of care bundles (including home visits), analyzed using multivariable logistic regression and the RE-AIM framework.
Intervention enrollment commenced on December 10, 2025, and as of May 27, 2026, a total of 343 patients have been recruited across the 3 study sites (159 at Princess Alexandra Hospital, 131 at Townsville University Hospital, and 53 at Royal Brisbane and Women's Hospital).
No preliminary comparative analysis has been undertaken as recruitment is ongoing through November 2026, with primary endpoint analysis planned for January to March 2027.
Medication-related readmissions within 30 days are adjudicated via ICD-10-AM 'Y' codes, dual senior pharmacist review, and an expert multidisciplinary panel utilizing causality tools such as the Naranjo algorithm.

Study Design

Type

Cohort (n=4,422)

Multicenter

Yes

Structured PICO

Does a pharmacist-led interdisciplinary transition of care service reduce medication-related 30-day hospital readmissions in high-risk cardiology patients post-AMI or cardiothoracic surgery?

Population

Planned pre-post cohort study of 4,422 adults recovering from acute myocardial infarction or cardiothoracic surgery to evaluate a pharmacist-led transition of care service on 30-day medication-related readmissions.

Intervention

Pharmacist-led interdisciplinary transition of care (TOC) service, including inpatient medication review, discharge medication record, and postdischarge follow-up (within 14-30 days via preferred platform or home visit), targeted at patients identified as high-risk for medication-related readmission.

Comparator

Retrospective usual care cohort (pre-intervention period) and concurrent usual care for non-high-risk patients in the post-intervention period.

Outcome

Medication-related 30-day hospital readmission.hard clinical

Limitations

Potential failure to achieve the intended recruitment target in the postintervention phase
Temporal changes in patient characteristics and clinical practice may confound the results
Retrospective-prospective nature of the design involves comparing different patient cohorts across separate time periods, meaning that the groups are not strictly comparable

Cite This Study

Falconer et al. (2026) conducted a cohort in Acute myocardial infarction (AMI) or cardiothoracic surgery (CS) (n=4,422). Pharmacist-led interdisciplinary transition of care (TOC) service vs. Usual care was evaluated on Medication-related 30-day hospital readmission. A pharmacist-led interdisciplinary transition of care service is being evaluated for its impact on 30-day medication-related hospital readmissions in high-risk cardiology patients.

synapsesocial.com/papers/6ab9b5167822ec8fc3d8f726 https://doi.org/10.2196/94841

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A Transition of Care Service to Reduce Hospital Readmissions for High-Risk Cardiology Patients (RECARD): Protocol for a Pre-Post Interventional Trial

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Limitations

Cite This Study

A Transition of Care Service to Reduce Hospital Readmissions for High-Risk Cardiology Patients (RECARD): Protocol for a Pre-Post Interventional Trial

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Limitations

Cite This Study

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