2026 Southeastern Residency Conference

Background
Patients discharged after coronary artery bypass graft (CABG) or aortic valve replacement (AVR) surgery are at high risk for hospital readmissions, medication discrepancies, and adverse drug events during care transitions. Readmission rates following cardiac surgery range from 11-25%, carrying significant clinical and economic consequences with an estimated annual national cost exceeding $250 million for CABG alone.1-3 The transition from hospital to home represents a particularly vulnerable period, as approximately 50% of patients experience medication errors or unintentional discrepancies following discharge. While pharmacist-led medication reconciliation has been shown to reduce medication discrepancies and hospital readmissions in general populations, limited data exist evaluating the clinical impact of these interventions specifically in the cardiac surgery population.

Objective
To evaluate the impact of a pharmacist-led medication reconciliation intervention on clinical outcomes in patients following cardiac surgery, and to identify opportunities to standardize and improve discharge workflows.

Methods
A retrospective chart review was completed to evaluate patients' post discharge with scheduled Transition of Care Management (TCM) appointments between June 2024 to June 2025. Patients were included if they were at least 18 years of age, discharged from AdventHealth Celebration following CABG or valve replacement surgery, and had a scheduled TCM visit. Patients were excluded if they had no scheduled TCM appointment at discharge or death occurred prior to visit. Upon discharge, patients who are referred to TCM are contacted by an ambulatory care pharmacist within the AdventHealth Celebration Clinical Pharmacy Services Teams. At this time, pharmacists perform a medication reconciliation and correct any discrepancies found prior to TCM visit. The primary outcome of the study was 30-day all cause readmission rate. Secondary outcomes included TCM show rate, pharmacist interventions, and medication discrepancies identified.

Results
The study included 297 patients who underwent cardiac surgery. Of these, 212 patients (71%) received pharmacist intervention prior to their transitional care management (TCM) visit, while 85 patients (29%) did not receive intervention. Patients who received pharmacist intervention had a 30-day readmission rate of 18% versus 22% in those who did not receive intervention. TCM visit attendance was 94% in the intervention group versus 92% in the comparison group. The most prevalent medication discrepancy identified during pharmacist contact was commission errors, followed by frequency errors and dosing errors.
Among patients who underwent CABG, the 30-day readmission rate was 20% in those who received pharmacist intervention versus 22% in those who did not. The average time to readmission was 10 days in the intervention group versus 3 days in the comparison group. TCM visit attendance was 94% for the intervention group versus 93% in the comparison group.
Among patients undergoing aortic valve replacement (AVR), the 30-day readmission rate was 11% in those who received pharmacist intervention versus 25% in those who did not. The average time to readmission was 3 days in the intervention group versus 2 days in the comparison group. TCM visit attendance was 93% in the intervention group versus 75% in the no-intervention group.

Conclusion
The delayed time to readmission in the intervention group (particularly CABG) may indicate that pharmacist involvement helps patients manage early post-discharge issues that would otherwise result in rapid readmission. The later readmissions might represent disease progression or complications less amenable to medication management and education.

References
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3. Readmissions Following Isolated Coronary Artery Bypass Graft Surgery in the United States (From the Nationwide Readmissions Database 2010 to 2014). The American Journal of Cardiology. 2019. Khoury H, Sanaiha Y, Rudasill SE, et al.
4. Jošt M, Kerec Kos M, Kos M, Knez L. Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial. Front Pharmacol. 2024;15:1377781. Published 2024 Mar 28. doi:10.3389/fphar.2024.1377781
5. Incidence, Cost, and Risk Factors for Readmission After Coronary Artery Bypass Grafting. The Annals of Thoracic Surgery. 2019. Shah RM, Zhang Q, Chatterjee S, et al.
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