A Transition of Care Service to Reduce Hospital Readmissions for High-Risk Cardiology Patients (RECARD): Protocol for...

Transition of care (TOC) is a high-risk period for medication errors as patients move between multiple health care professionals, settings, and changing medication regimens. Ineffective communication systems further increase the likelihood of medication harm and hospital readmission. A TOC service with tailored, patient-specific support may help reduce these risks. Cardiovascular medicines significantly contribute to medication harm, and patients recovering from acute myocardial infarction (AMI) or cardiothoracic surgery (CS) are vulnerable due to complex regimens and frequent medication changes. Pharmacists, as medication experts embedded within cardiology teams, are well positioned to support these high-risk patients, facilitate safer transitions from hospital to home, and provide coordinated postdischarge follow-up.

This study aims to evaluate the impact of a pharmacist-led interdisciplinary TOC service on reducing medication harm for cardiology patients post-AMI or CS.

The study will be conducted in two phases: phase 1-intervention development will combine scoping review findings with stakeholder input to design an evidence-based, cocreated, culturally relevant intervention, underpinned by implementation science. A risk prediction model will be developed and validated to identify AMI/CS patients at high risk of medication-related unplanned readmission within 30 days. Phase 2: the RECARD (Reduce Hospital Readmissions for High-Risk Cardiology Patients) trial will use a pre-post design across 3 Australian tertiary hospitals (2 metropolitan and 1 regional) to compare a retrospective usual care patient cohort (referred to as "pre") with a different prospective patient cohort (referred to as "post") that includes both usual care and intervention AMI/CS patients receiving the TOC service. Only high-risk poststudy patients will receive the intervention TOC service, consisting of an individualized bundle of TOC activities to optimize medication management, while the remaining poststudy patients will receive usual care. A unique feature of the service is its capacity for hospital clinicians to conduct postdischarge home visits for patients needing additional support. The primary outcome for this study is medication-related 30-day hospital readmission. The analysis will consist of multivariable logistic regression. An economic analysis will be conducted to evaluate the costs associated with the intervention and medication-related readmissions. A comprehensive process evaluation will be conducted using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to enable learnings from the trial to inform sustainable improvements in this field. A patient survey will be administered at the end of the trial to assess patient experience and elicit patient preferences using a discrete choice experiment.

The predata are currently being collected for patients discharged from the 3 hospital sites during the 12-month prestudy period. The postdata intervention began on December 10, 2025. As of May 27, 2026, a total of 343 patients have been recruited at the 3 study sites.

The findings of this study will inform future implementation of a sustainable cardiac TOC model within the Australian health care setting.