Preventing hospital readmissions through personalised, digitally enabled care.
Each year, thousands of Australians with coronary artery disease return to hospital with complications that might have been prevented. The Risk-Guided CAD study tested whether a comprehensive disease management program — combining nurse-led care, digital technology and personalised physical activity — could keep high-risk patients healthier at home and out of hospital.
In 2025, the study completed 12-month follow-up for 101 high-risk patients, demonstrating that digital cardiac rehabilitation can deliver accessible, high-quality care that patients and health professionals value. The findings are providing gold-standard evidence for how modern technology can reshape cardiac care delivery.
Why this matters
Coronary artery disease remains one of Australia's leading causes of hospitalisation. Even after successful treatment — whether stenting, bypass surgery or medication — many patients struggle to maintain the lifestyle changes and medication regimens needed to prevent complications and readmission to hospital. Traditional cardiac rehabilitation helps, but limited accessibility means many high-risk patients miss out on the support they need.
The question driving this research is: could a digitally enabled, nurse-coordinated program provide comprehensive cardiac care that's both effective and accessible —for those deemed to be at the highest risk of readmission?
What we tested
Risk-Guided CAD is a randomised controlled trial comparing a comprehensive disease management program against standard care for patients assessed as being at high risk of hospital readmission following coronary artery disease events.
The intervention combined three key elements:
- Nurse-led guideline-directed care
Experienced cardiac nurses coordinated each patient's care plan, ensuring they received evidence-based treatments and monitoring for warning signs of deterioration. This proactive oversight helped catch problems early before they required hospitalisation. - SmartCR digital platform
Patients accessed the SmartCR app for education, symptom tracking and communication with their care team. The technology enabled real-time monitoring while giving patients tools to actively manage their condition between appointments. - Personalised exercise physiology program
Rather than generic exercise advice, each patient received an individualised program delivered through scheduled telerehabilitation sessions. Exercise physiologists tailored activities to each person's abilities, preferences and home environment — making sustainable physical activity achievable.
Researchers tracked hospital readmissions, cardiovascular risk factors, medication adherence and quality of life over 12 months, while also exploring patient and health professional experiences through in-depth interviews.
What we found
High satisfaction from patients and professionals
Qualitative interviews revealed strong enthusiasm for the Risk-Guided CAD approach from both patients and the health professionals supporting them. Participants valued the combination of human connection (through nurse and exercise physiology support) with technological convenience (app-based monitoring and telerehabilitation).
Critically, the research identified what makes cardiac rehabilitation genuinely accessible: flexibility to fit into daily life, personalised rather than one-size-fits-all approaches, and ongoing support rather than time-limited programs. These insights are informing how cardiac rehabilitation can better serve patients who might not engage with traditional hospital-based programs.
Evidence supporting digital delivery
The study's systematic review and meta-analysis, published in JACC: Advances, confirmed that mobile health-enabled disease management programs are effective for coronary artery disease patients across multiple outcomes including hospital readmissions, cardiovascular risk factors and quality of life measures.
This broader evidence base, combined with the Risk-Guided CAD trial data, is building the case that digitally enabled cardiac rehabilitation (DeCR) can achieve comparable outcomes to traditional face-to-face programs — while dramatically improving accessibility for high-risk patients who need support most.
Gold-standard evidence emerging
The 12-month follow-up data from Risk-Guided CAD is expected to provide evidence for non-inferiority of digital cardiac rehabilitation programs compared to traditional models. This represents a critical milestone for integrating technology-enabled care into standard cardiac practice — demonstrating that innovation doesn't mean compromising quality.
Technical detail for researchers
Study design and intervention
Risk-Guided CAD is a single-centre randomised controlled trial enrolling patients following a hospitalisation for coronary artery disease who are at high risk for readmission (as defined by PEGASUS-TIMI criterion of predicted risk).
The intervention arm received a 12-month disease management program comprising:
- Nurse-led care coordination
Cardiac nurses conducted structured telephone consultations using guideline-directed protocols, reviewing medications, symptoms, risk factor control and adherence. Nurses escalated concerns to cardiology specialists when appropriate and coordinated care across primary and specialist providers. - SmartCR digital platform
Participants accessed a mobile application providing educational content, medication reminders, symptom logging and secure messaging with the care team. The platform enabled remote monitoring of patient-reported outcomes and facilitated asynchronous communication between scheduled contacts. - Exercise physiology program
Accredited exercise physiologists delivered individualised exercise prescription through scheduled face-to-face or telerehabilitation video consultations, complemented by home-based exercise plans, tailored to patient capabilities, preferences and available equipment.
Control arm participants received standard post-discharge care as per local practice, including cardiac rehabilitation referral according to existing clinical pathways.
Primary outcome was unplanned all cause readmission or death at 12 months. Secondary outcomes included short term all-cause readmissions and changes in cardiovascular risk factor control (blood pressure, lipids, HbA1c, BMI), medication adherence, exercise capacity, quality of life and healthcare utilisation.
Qualitative evaluation
Semi-structured interviews were conducted with intervention participants (n=25) and health professionals (n=12, including cardiac nurses, exercise physiologists, cardiologists and general practitioners) to explore acceptability, feasibility and implementation considerations for the Risk-Guided CAD model.
Thematic analysis identified key facilitators including program flexibility (scheduling, delivery mode), personalisation of exercise and education content, and continuity of care team relationships. Barriers included initial technology onboarding for some participants and coordinating care across multiple providers without integrated electronic health records.
Findings emphasised that accessibility extends beyond geographic reach to encompass program design features: ability to participate around work/family commitments, culturally appropriate communication, graduated intensity matching patient readiness for behaviour change, and sustained (rather than time-limited) support for chronic disease management.
Systematic review and meta-analysis
A comprehensive systematic review examined randomised controlled trials and quasi-experimental studies evaluating mobile health (mHealth) interventions for secondary prevention in coronary artery disease populations. Studies were included if they assessed digitally delivered disease management programs (smartphone applications, text messaging, wearable devices, telehealth platforms) compared to usual care or traditional cardiac rehabilitation.
Meta-analysis pooled data across studies for outcomes including hospital readmissions, major adverse cardiovascular events, mortality, cardiovascular risk factors (blood pressure, LDL cholesterol, physical activity levels), medication adherence and quality of life measures.
Findings demonstrated that mHealth-enabled disease management programs significantly reduced hospital readmissions (relative risk reduction 0.72, 95% CI 0.61-0.86, p<0.001) and improved multiple cardiovascular risk factors compared to standard care. Effects were sustained across follow-up periods ranging from 3 to 12 months.
Subgroup analyses explored intervention characteristics associated with larger effect sizes, including frequency of human contact (nurse or clinician support), integration with wearable monitoring devices, and inclusion of personalised feedback mechanisms.
Results support the clinical effectiveness of digitally enabled secondary prevention strategies for coronary artery disease, with implications for healthcare service redesign and guideline development around cardiac rehabilitation delivery models.
Key publication
Braver JP, Marwick TH, Oldenburg B, Issaka A, Carrington MJ.
Digital health programs to reduce readmissions in coronary artery disease: a systematic review and meta-analysis
JACC: Adv 2023 2(8)
Research team
Lead researcher
Principal Investigators
- Professor Tom Marwick
- Professor Brian Oldenburg
- Associate Professor Erin Howden
- Professor David Thompson
- Professor Garry Jennings
- Associate Professor Jo-Anne Manski-Nankervis
- Dr Quan Huynh
Collaborators
What this means for the future
Risk-Guided CAD will demonstrate whether comprehensive cardiac care can be effectively provided to patients without attending hospital or community-based rehabilitation centres. By combining expert clinical oversight with digital convenience and personalised programming, we can deliver high-quality disease management that fits into patients' lives rather than disrupting them.
For the healthcare system, this represents an opportunity to reach high-risk patients who have traditionally missed out on cardiac rehabilitation — those living rurally, managing work and family commitments, or facing mobility challenges. By showing that digital delivery can match traditional delivery while improving accessibility, this research is paving the way for more equitable cardiac care.
The findings suggest a future where chronic disease management is proactive rather than reactive, continuous rather than episodic, and tailored to individual needs rather than constrained by program structures. As health systems worldwide grapple with rising chronic disease burden and limited resources, Risk-Guided CAD offers evidence that technology — when thoughtfully designed and properly supported — can help us deliver better care to more people.