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April 23, 2014
Pharmacists Help Stroke Patients Reduce CV Disease Risks
Edmonton, Alberta—Management by pharmacists helped stroke patients achieve a 12.5% greater improvement in blood pressure and low-density lipoprotein (LDL) compared to a control group, according to a new study. The study, published recently in the Canadian Medical Association Journal, points out that many patients receive suboptimal care after a stroke or transient ischemic attack, even though such an event puts them at high risk of adverse cardiovascular events. Based on past research indicating that designated case managers helped patients reduce their risks, researchers sought to determine if pharmacists could effectively fill that role. In Canada, pharmacists can prescribe drugs for minor self-diagnosed or self-limiting ailments; monitor and authorize refills of existing prescriptions; modify and adapt a prescription to alter dose, formulation, regimen, or duration; complete missing information on the prescription; and provide emergency supplies of a prescribed medication to a patient, according to a recent report from the American Pharmacists Association. Pharmacists also are allowed to provide a therapeutic alternative; prescribe independently or in collaboration with a physician when a diagnosis is provided; and provide comprehensive medication therapy management. Alberta, where this study was done, was the first province to authorize pharmacist prescribing, with all licensed pharmacists getting basic prescribing authority after attending an orientation. Pharmacists who meet additional requirements, including 1 year of full-time experience in direct patient care, can earn additional prescribing authority. The trial divided the 279 adult participants in Edmonton, Alberta—mostly men 65 or older—between a group receiving care from a pharmacist or a control group where a nurse managed care. All of the patients had monthly visits to the care manager over 6 months. While both nurses and pharmacists counselled participants on diet, smoking, exercise, and other lifestyle factors; checked blood pressure and LDL levels, and provided summaries to patients’ physicians after each visit, pharmacists also prescribed medications based on the current Canadian guidelines and adjusted doses to achieve the best result for each patient. None of the participants originally had blood pressure or cholesterol levels that met targets recommended in the Canadian Stroke Guidelines, but, by 6 months into the study, both groups had significant improvements. The control group managed by nurses showed a 30% improvement; the group with pharmacist case managers, however, had much greater control of risk factors, improving 43%. “Calling our control arm ‘usual care’ would be a misnomer, and patients in the active control group (nurse-led group) showed a 30% absolute improvement in risk factor control over a six-month period,” writes lead author Finlay McAlister, MD, of the University of Alberta and coauthors. “The 43% absolute improvement at six months seen in our pharmacist case manager group was achieved despite the fact that over three-quarters of patients were already taking an antihypertensive or lipid-lowering medication at baseline.” Antihypertensives were being used by 78.1% of the study participants, and 84.6% of them were on statins. Reductions in blood pressure were similar in both groups, but the pharmacist-led group had greater improvements in LDL cholesterol targets, 51%, compared with 34% in the nurse-led group. The researchers point out that the pharmacist case managers actively adjusted medication to achieve desired results and suggest this contributed to the beneficial effect. Minimal benefit has been documented in past studies where case managers lacked prescribing authority, according to the report, which concludes, “Compared with nurse-led case management (risk factor evaluation, counselling and feedback to primary care providers), active case management by pharmacists substantially improved risk factor control at 6 months among patients who had experienced a stroke.” The authors suggest 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.”
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