Pharmacists more effective case managers of stroke patients than nurses

Pharmacist-led care with prescribing authority substantially improved risk factors at 6 months among stroke survivors versus nurse case managers who monitored patients and provided feedback to their primary care physicians, according to a report published in the Canadian Medical Association’s journal, CMAJ.

Following stroke, patients are at high risk for cardiovascular events, and vascular risk factors-systolic blood pressure and lipid levels-need to be optimally managed, which typically is not the case.

Finlay A. McAlister, MD, MSc, of the University of Alberta, Edmonton, and colleagues conducted a 6-month, prospective, randomized, controlled trial of adults who had experienced a recent minor stroke or transient ischemic attack, to determine if pharmacists as case managers could improve these risk factors.

In the past, the researchers had shown that nurse case managers could help improve hypertension control with monthly evaluations, so this study compared active prescribing by pharmacist case managers versus nurse managers screening and referring to primary care physicians.

Of 279 eligible study participants, 143 were assigned to the pharmacist-led group and received monthly care, including lifestyle advice, blood pressure and lipid level monitoring, and initial and titrated antihypertensive and/or lipid-lowering agents as needed. In the nurse-led group, 136 were assigned and received the same level of care, except the monitoring results and medication lists were sent to the primary care physicians for medication adjustments.

Both groups of patients had similar characteristics. About 60% were 65 years and older, 58% were men, almost 16% had diabetes, and more than 50% had a transient ischemic attack prior to the study. None of the study participants met the target recommendations for systolic blood pressure and low-density lipoprotein (LDL) cholesterol levels at baseline.

The optimal blood pressure goal was defined as systolic blood pressure ≤ 140 mm Hg and the optimal lipid goal was fasting LDL cholesterol ≤ 2.0 mmol/L, which were based on the Canadian guidelines.

There were 31 patients in the pharmacist-led group and nine in the nurse-led group who were excluded from the analysis, due to early withdrawal and other reasons.

At the end of the 6-month study, 43.3% of the patients in the pharmacist-led group reached both systolic blood pressure and LDL cholesterol goals, compared to 30.9% of patients in the nurse-led group.

“The benefits of case management by pharmacists were largely driven by the higher proportion of patients who met their LDL cholesterol targets (pharmacist-led group: 51.1%; nurse-led group: 33.8%, p=0.003),” the researchers noted.

“Systolic blood pressure and lipid level targets were attained by 52.7% of patients in the pharmacist case manager group compared with 35.5% of patients in the control group at 6 months (p<0.001),” they said.

The researchers concluded that both pharmacist and nurse case managers are effective for patients at high risk or with vascular disease.  “Our study provides much-needed information on their comparative effectiveness,” they said.