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Pharmacist-led management improved risk factor control in stroke
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Active case management by pharmacists provided better risk factor control at 6 months among patients with ischemic stroke than nurse-led case management, in a recent prospective, randomized controlled, open-label trial.
Researchers evaluated 279 adults with recent minor ischemic stroke or transient ischemic attack with systolic BP or lipid values above target levels. All patients were older than 18 years (mean, 67.6 years) and had presented for care at one of three stroke prevention clinics in Edmonton, Alberta, Canada. Patients were randomly assigned at a 1:1 ratio to a case management group led by a pharmacist (intervention group) or a nurse-led case management group (active control) between 2009 and 2012.
All patients underwent monthly visits for 6 months. In the active control group, a study nurse provided lifestyle advice regarding exercise, maintaining a low-sodium diet, smoking cessation and medication adherence; checked the participant’s BP and LDL cholesterol levels; and faxed relevant measurements and medication information to the patient’s physician. In the intervention group, the pharmacists performed the same tasks as the nurses, and also began or titrated antihypertensive and/or lipid-lowering medications as needed, according to Canadian guidelines.
The primary outcome was the percentage of participants who achieved target BP and lipid control at 6 months (systolic BP ≤140 mm Hg and fasting LDL cholesterol ≤2 mmol/L). Secondary outcomes included mortality, self-reported adherence, BMI and smoking status.
None of the patients in either group met target goals at baseline evaluation. At 6 months, significant improvements were observed in both groups: In the intervention group, 43.4% of participants met both systolic BP and LDL cholesterol goals vs. 30.9% of patients in the active control group (12.5% absolute difference; P = .03). Multivariable analysis indicated a significantly increased likelihood of attaining these goals in the intervention group vs. the active control group (adjusted OR=2.31; 95% CI, 1.29-4.2). The two groups did not differ according to evaluated secondary outcomes.
Sensitivity analysis in which the systolic BP target was 130 mm Hg among patients with diabetes did not alter results, with 42% of patients meeting both goals in the intervention group vs. 30.9% in the control group (P=.04). Per-protocol analysis of 220 patients who attended one or more study visits and did not withdraw early also yielded similar results (52.7% in the intervention group at 6 months vs. 35.5% in the control group; P<.001).
The researchers wrote that both groups experienced significant improvements to key risk factors for stroke, but “even greater improvements were seen among patients whose care was managed by a pharmacist case manager, who was empowered to initiate and titrate medications to attain guideline-recommended targets.”
“We believe that both approaches hold great promise, not only for patients with stroke or transient ischemic attack but also for all patients with, or at high risk of, vascular disease, and our study provides much-needed information on their comparative effectiveness,” they wrote.
Disclosure: See the full study for a list of relevant financial disclosures.
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