Pharmacists as Care Providers for Stroke Patients: A Systematic Review

Developing Disability Advocates Through Deliberate Interprofessional Conversations Regarding Quality of Life After Stroke

OBJECTIVE

Stroke can result in significant mental and physical impairment. Training health care professionals on effective strategies for mitigating stroke-related quality-of-life issues is crucial in facilitating comprehensive stroke management. This study aimed to evaluate the impact of an interprofessional education (IPE) experience on students' attitudes regarding poststroke disability.

METHODS

In this pre-post interventional study, pharmacy and medical students received an electronic patient chart and a store-and-forward video depicting physical and cognitive impairment in a patient with stroke. Students were instructed to discuss the acute management and postdischarge needs of the patient from an advocacy perspective. After the IPE experience, students completed the Student Perceptions of Interprofessional Clinical Education-Revised, version 2 and an unvalidated disability attitudes survey. The surveys were analyzed using a paired t test. In addition, students reflected on the prompt, "What are some things you had NOT considered prior to this IPE?"

RESULTS

A total of 708 students completed the surveys. After IPE, there was a significant improvement in all domains of the Student Perceptions of Interprofessional Clinical Education-Revised, version 2. On the disability survey, there was significant improvement on all statements, including "rate your comfort with…": "discussing the expected disabilities associated with new-onset stroke" and "discussing strategies for improving the quality of life of a patient who has long-term disabilities." On the self-reflections, 31.7% (n = 211) had not considered the need for poststroke care services before this IPE.

CONCLUSION

This IPE experience was instrumental in improving student perspectives regarding poststroke disability.

Defining rural spaces within pharmacy practice research: Current practice and implications

The literature suggests that community pharmacies are a critical buffer to poor health for rural spaces, which are disproportionately impacted by a lack of facilities, providers, and resources. Yet, the actual impact is hard to measure because location is not often considered in assessments of community pharmacy practice. We explored the definitions applied to rural spaces in community pharmacy practice-based research studies that explicitly discuss rural pharmacy practice in 2 U.S. based pharmacy practice research publications. Across both journals, we identified 10 articles that used 8 different definitions of "rural" including both a variety of federal designations and idiosyncratic definitions developed just for that research. A consensus definition in rural community pharmacy practice research could make comparison across studies possible, help to build the evidence base for rurally focused interventions, and ultimately improve patient outcomes in this setting.

Evaluation of Physicians' Compliance With Secondary Prevention Among Ischemic Stroke Patients: A Retrospective Study

BACKGROUND

Stroke is a leading cause of disability and death worldwide. Globally, stroke affects 13.7 million individuals every year. Several studies have shown an increase in the rehospitalization rate among stroke patients caused by non-adherence to secondary prevention as recommended by the American Heart Association/American Stroke Association (AHA/ASA) guideline. The aim of this study was to evaluate physicians' compliance with secondary prevention of stroke upon patients' discharge.

METHODS

A retrospective chart review study was conducted at King Fahad Medical City. The primary outcome of this study was the number of patients discharged with the recommended medications for the secondary prevention of ischemic stroke (IS). The data were collected from the patient's medical record files and analyzed using the Statistical Package for the Social Sciences (SPSS).

RESULTS

Of the 675 patients who were screened for eligibility, 507 were included and 168 were excluded. The mean age of the patients was 59.5 (± 15.6) years. Of the 507 patients, 181 (35.7%) had a history of previous stroke. Overall, 376 (74%) stroke patients were discharged with appropriate secondary prevention recommendation per AHA/ASA guideline.

CONCLUSIONS

This study stresses the importance of compliance with the AHA/ASA guideline for secondary stroke prevention and highlights the role of pharmacists in the stroke unit in which it is necessary to ensure that all stroke patients are discharged with the recommended medications to reduce recurrent stroke.

Clinical pharmacist's contribution to treatment adherence and quality of life in patients with stroke

PRIMARY OBJECTIVE

The optimal treatment adherence rate among patients with stroke is low. This study aims to determine the effect of clinical pharmacists' intervention on treatment adherence and quality of life (QOL) in patients with first-ever stroke.

RESEARCH DESIGN

This open, controlled, prospective and interventional study was conducted sequentially at two different university hospitals for 3 months. Patients in the intervention group (IG) were provided with clinical pharmacist-led education whereas the control group (CG) only received routine care.

METHODS AND PROCEDURES

Treatment adherence and QOL were assessed on discharge day, and in months 1 and 3 after discharge. Morisky Green Levine Adherence Scale and Stroke Specific Quality of Life Scale were employed to evaluate treatment adherence and QOL, respectively.

MAIN OUTCOMES AND RESULTS

Changes in treatment adherence score were higher between discharge day, 1^st and 3^rd months after discharge in IG than CG (p < 0.001). Regarding 'energy' and 'work/productivity' domains, patients' scores in IG were higher than those from CG at months 1 and 3 after discharge (p < 0.05).

CONCLUSION

Clinical pharmacist-led education improves treatment adherence in patients with first-ever stroke. The clinical pharmacist might be integrated into the multidisciplinary team to improve QOL and treatment adherence.

The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis

Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.

Retrospective cohort study on risk factors for developing ischemic stroke

Background

There is a paucity of studies describing the risk factors for developing ischemic stroke in our region.

Objective

The objective of the current study was to delineate the potential risk factors for the development of ischemic stroke.

Methods

We have conducted a retrospective cohort hospitalbased study that has enrolled 231 subjects. The subjects have had presented to the emergency department in a tertiary hospital in the United Arab Emirates. Subjects were diagnosed with ischemic stroke within 24 hours of presentation.

Outcome measure

The main outcome measure was the development of ischemic stroke during an indexed hospital visit.

Results

The mean age was 47.5 ±3.2 with a higher preponderance of males over females (60.9%) and 48.1% were ≥ 65 years. The final logistic regression model for the development of ischemic stroke contains seven variables. In descending order, the seven predictive risk factors for the development of ischemic stroke were: hypertension (OR 6.1, CI 2.4-9.5; P = 0.029), coronary artery disease (OR 4.2, 3.7-9.1; P = 0.038), low physical activity (OR 4.2, CI 2.1-9.1; P = 0.035), history of previous stroke (OR 4.1, 1.4-3.4; P = 0.033), atrial fibrillation (OR 3.2, CI 2.6-8.2; P = 0.017), family history of stroke (OR 3.1, 1.3-6.9; P = 0.042) and diabetes mellitus (OR 2.7, CI 1.25-6.1; P = 0.035). The specificity of the model was 58.1%; the sensitivity was 86.1%, and the overall accuracy was 75.7%.

Conclusion

It is prudent to control modifiable risk factors for the development of strokes such as hypertension, diabetes, atrial fibrillation, coronary artery disease, and low physical activity.

TASC (Telehealth After Stroke Care): a study protocol for a randomized controlled feasibility trial of telehealth-enabled multidisciplinary stroke care in an underserved urban setting

Background

Hypertension is the most important modifiable risk factor for recurrent stroke, and blood pressure (BP) reduction is associated with decreased risk of stroke recurrence. However, hypertension remains poorly controlled in many stroke survivors. Black and Hispanic patients have a higher prevalence of uncontrolled BP and higher rates of stroke. Limited access to care contributes to challenges in post-stroke care. Telehealth After Stroke Care (TASC) is a telehealth intervention that integrates remote BP monitoring (RBPM) including nursing telephone support, tailored BP infographics and telehealth video visits with a multidisciplinary team approach including pharmacy to improve post-stroke care and reduce stroke disparities.

Methods

In this pilot trial, 50 acute stroke patients with hypertension will be screened for inclusion prior to hospital discharge and randomized to usual care or TASC. Usual care patients will be seen by a primary care nurse practitioner at 1–2 weeks and a stroke neurologist at 1 and 3 months. In addition to these usual care visits, TASC intervention patients will see a pharmacist at 4 and 8 weeks and will be enrolled in RBPM consisting of home BP monitoring with interval calls by a centralized team of telehealth nurses. As part of RBPM, TASC patients will be provided with a home BP monitoring device and electronic tablet that wirelessly transmits home BP data to the electronic health record. They will also receive tailored BP infographics that help explain their BP readings. The primary outcome will be feasibility including recruitment, adherence to at least one video visit and retention rates. The clinical outcome for consideration in a subsequent trial will be within-patient change in BP from baseline to 3 months after discharge. Secondary outcomes will be medication adherence self-efficacy and satisfaction with post-stroke telehealth, both measured at 3 months. Additional patient reported outcomes will include depression, cognitive function, and socioeconomic determinants. Multidisciplinary team competency and fidelity measures will also be assessed.

Conclusions

Integrated team-based interventions may improve BP control and reduce racial/ethnic disparities in post-stroke care. TASC is a post-acute stroke care model that is novel in providing RBPM with tailored infographics, and a multidisciplinary team approach including pharmacy. Our pilot will determine if such an approach is feasible and effective in enhancing post-stroke BP control and promoting self-efficacy.

Trial registration

ClinicalTrials.gov NCT04640519

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01025-z.

Integrating neurology and pharmacy through telemedicine: A novel care model

Teleneurology had been best studied in acute stroke care, but the Coronavirus (COVID)-19 pandemic has highlighted applicability in outpatient practice. Telepharmacy is a convenient method for pharmacists to provide medication management to enhance care. Studies in the outpatient space suggest non-inferiority of teleneurology to increase access to specialized care for patients in rural locations. The role of telemedicine based interdisciplinary collaborations in a metropolitan and under-resourced setting has not been explored. We describe our approach to a teleneurology-telepharmacy collaboration at an urban academic medical center. Since its implementation pre-COVID, the program has expanded and transformed to serve the community further.

Impact of an emergency medicine pharmacist on door to needle alteplase time and patient outcomes in acute ischemic stroke

PURPOSE

Time is a critical metric in the emergency department (ED) for acute ischemic stroke and thrombolytic therapy. National guidelines have emphasized tracking time from stroke onset to treatment and decreasing door to needle (DTN) time [1, 2]. Multidisciplinary teamwork is encouraged but, there is limited evidence demonstrating the value of the pharmacist on the stroke response team. The goal of this study is to compare DTN times in the ED with or without a pharmacist at bedside and examine the impact on subsequent patient outcomes.

METHODS

This was a single-center retrospective cohort study. Investigators identified patients who presented to the ED between August 2016 - May 2020 with signs of ischemic stroke and subsequently received intravenous alteplase. Patients were excluded if they refused alteplase or received alteplase off-campus before being transferred. Pharmacist documentation of clinical interventions was used to identify participation on the stroke response team. The primary outcome was median DTN time. Secondary outcomes included severity of deficits measured by the National Institutes of Health Stroke Scale (NIHSS), hospital length of stay (LOS), 90-day Modified Rankin Scale (mRS), incidence of intracranial hemorrhage (ICH), and inpatient all-cause mortality.

RESULTS

Of the 164 patients included, 31 had an emergency medicine pharmacist at bedside (EMP group) and 133 did not (No EMP group). The median DTN time was significantly shorter at 35 min EMP [interquartile range (IQR) 29-44] vs 42 min No EMP [IQR 34-55]; p = 0.003. The number of cases achieving a DTN time of 30 min or less was significantly higher when a pharmacist was involved (35.5% vs.16.5%; p = 0.018) as well as the number of patients receiving alteplase within 45 min (80.7% vs. 57.1%; p = 0.015). NIHSS scores at discharge were lower in the EMP group (2 [IQR 0-5] vs. 4 [IQR 0-8.25]; p = 0.049). In patients with magnetic resonance imaging (MRI) confirmed stroke, a difference was not observed in the secondary outcomes.

CONCLUSION

Patients with an emergency medicine pharmacist as part of their stroke response team had significantly lower DTN times. A higher proportion of these cases met benchmark DTN times less than 45 min and 30 min. An emergency medicine pharmacist on a stroke response team has the potential to improve patient care.

Healthcare Costs Associated with Complications in Patients with Type 2 Diabetes among 1.85 Million Adults in Beijing, China

We aimed to provide reliable regression estimates of expenditures associated with various complications in type 2 diabetics in China. In total, 1,859,039 type 2 diabetes patients with complications were obtained from the Beijing Medical Claim Data for Employees database from 2008 to 2016. We estimated costs for complications using a generalized estimating equation model adjusted for age, sex, and the incidence of various complications. The average total cost for diabetic patients with complications was 17.12 thousand RMB. Prescribed drugs accounted for 63.4% of costs. We observed a significant increase in costs in the first year after the onset of complications. Compared with costs before the incidence of complications, the additional costs per person in the first year and >1 year after the event would be 10,631.16 RMB and 1150.71 RMB for cardiovascular disease, 1017.62 RMB and 653.82 RMB for cerebrovascular disease, and 301.14 RMB and 624.00 RMB for kidney disease, respectively. The estimated coefficients for outpatient visits were relatively lower than those of inpatient visits. Complications in diabetics exert a significant impact on total healthcare costs in the first year of their onset and in subsequent years. Our estimates may assist policymakers in quantifying the economic burden of diabetes complications.

The best person (or machine) for the job: Rethinking task shifting in healthcare

Globally, health systems are faced with the difficult challenge of how to get the best results with the often limited number of health workers available to them. Exacerbating this challenge is the task of meeting ever-changing needs of service users and managing unprecedented technological advances. The process of matching skills to changing needs and opportunities is termed task shifting. It involves questioning health service goals, what health workers do, asking if it can be done in a better way, and implementing change. Task shifting in healthcare is often conceptualised as a process of transferring responsibility for 'simple' tasks from high-skilled but scarce health workers to those with less expertise and lower pay, and predominantly viewed as a means to reduce costs and promote efficiency. Here we present a position paper based on the work and expertise of the European Commission Expert Panel on Effective ways of Investing in Health. It contends that this is over simplistic, and aims to provide a new task shifting framework, informed by relevant evidence, and a series of recommendations. While far from comprehensive, there is a growing body of evidence that certain tasks traditionally undertaken by one type of health worker can be undertaken by others (or machines), in some cases to a higher standard, thus challenging the persistence of rigid professional boundaries. Task shifting has the potential to contribute to health systems strengthening when accompanied by adequate planning, resources, education, training and transparency.

Health care providers' perceptions of factors that influence the provision of acute stroke care in urban and rural settings: A qualitative study

Objectives

Individuals living in rural areas have comparatively less access to acute stroke care than their urban counterparts. Understanding the local barriers and facilitators to the use of current best practice for acute stroke may inform efforts to reduce this disparity.

Methods

A qualitative study featuring semi-structured interviews and focus groups was conducted in the Australian state of Tasmania. Clinical staff from a range of disciplines involved in acute stroke care were recruited from three of the state's four major public hospitals (one urban and two rural). A semi-structured interview guide based on the findings of an earlier quantitative study was used to elicit discussion about the barriers and facilitators associated with providing acute stroke care. An inductive process of thematic analysis was then used to identify themes and subthemes across the data set.

Results

Two focus groups and five individual interviews were conducted. Four major themes were identified from analysis of the data: systemic issues, clinician factors, additional support and patient-related factors. Acute stroke care within the study's urban hospital was structured and comprehensive, aided by the hospital's acute stroke unit and specialist nursing support. In contrast, care provided in the study's rural hospitals was somewhat less comprehensive, and often constrained by an absence of infrastructure or poor access to existing resources.

Conclusion

The identified factors help to characterise acute stroke care within urban and rural hospitals and will assist quality improvement efforts in Tasmania's hospitals.

Impact of a Pharmacist-Driven Poststroke Transitions of Care Clinic on 30 and 90-Day Hospital Readmission Rates

BACKGROUND

Stroke impacts nearly 800,000 people annually and the risk of recurrent stroke and hospital readmission is increased early following the initial event. Due to the increase in morbidity and mortality associated with secondary events, a pharmacist-driven poststroke transitions of care clinic was created at Methodist University Hospital to provide risk factor modification in an effort to decrease risk of recurrence and hospital readmissions.

METHODS

A retrospective matched-cohort study was conducted between 9/1/2017 and 2/28/2019. Adult patients with a primary diagnosis of stroke, discharged to home, and attended a poststroke transitions of care clinic visit were included. Patients were matched on the basis of age ±3 years, race, gender, and type of stroke to those who did not receive pharmacist intervention during the same time period. The primary endpoint was 30-day hospital readmissions. Secondary endpoints included 90-day readmissions, 30 and 90-day emergency department visits, and recurrent stroke rates. Type and quantity of pharmacist interventions was also assessed.

RESULTS

One hundred and eighty-eight patients were included in the analysis. Baseline differences existed between the groups in the following: history of transient ischemic attack, stroke severity score, and insurance status. No significant difference was found in 30-day readmissions. There was a significant difference found in 90-day readmissions (5.3% versus 21.3%, P = .001). There were no significant differences in emergency department utilization at 30 or 90 days or stroke recurrence rates. Pharmacists made a mean of 3.5 interventions made during each visit.

CONCLUSIONS

Although the primary goal to reduce 30-day readmission was not met, a pharmacist-driven poststroke transitions of care clinic significantly decreased 90-day hospital readmission rates.

The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods

BACKGROUND

Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles.

METHODS

This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability.

DISCUSSION

PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02769338 [May 11, 2016].

Medication-Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

People with decompensated cirrhosis are often prescribed a complex regimen of therapeutic and prophylactic medications. In other chronic diseases, polypharmacy increases the risk of medication misadventure and medication-related problems (MRPs), with associated increased morbidity, mortality, and health care costs. This study examined MRPs in a cohort of ambulatory patients with a history of decompensated cirrhosis who were enrolled in a randomized controlled trial of a pharmacist-led, patient-oriented medication education intervention and assessed the association between MRPs and patient outcomes. A total of 375 MRPs were identified among 57 intervention patients (median, 6.0; interquartile range, 3.5-8.0 per patient; maximum 17). Nonadherence (31.5%) and indication issues (29.1%) were the most prevalent MRP types. The risk of potential harm associated with MRPs was low in 18.9% of instances, medium in 33.1%, and high in 48.0%, as categorized by a clinician panel using a risk matrix tool. Patients had a greater incidence rate of high-risk MRPs if they had a higher Child-Pugh score (incidence rate ratio [IRR], 1.31; 95% confidence interval [CI], 1.09-1.56); greater comorbidity burden (IRR, 1.15; 95% CI, 1.02-1.29); and were taking more medications (IRR, 1.12; 95% CI, 1.04-1.22). A total of 221 MRPs (58.9%) were resolved following pharmacist intervention. A greater proportion of high-risk MRPs were resolved compared to those of low and medium risk (68.9% versus 49.7%; P < 0.001). During the 12-month follow-up period, intervention patients had a lower incidence rate of unplanned admissions compared to usual care (IRR, 0.52; 95% CI, 0.30-0.92). Conclusion: High-risk MRPs are prevalent among adults with decompensated cirrhosis. Pharmacist intervention facilitated identification and resolution of high-risk MRPs and was associated with reduced incidence rate of unplanned hospital admissions in this group.

Cardiovascular disease as a leading cause of death: how are pharmacists getting involved?

Cardiovascular diseases (CVDs) are a leading cause of death globally. This article explores the evidence surrounding community pharmacist interventions to reduce cardiovascular events and related mortality and to improve the management of CVD risk factors. We summarize a range of systematic reviews and leading randomized controlled trials and provide critical appraisal. Major observations are that very few trials directly measure clinical outcomes, potentially owing to a range of challenges in this regard. By contrast, there is an extensive, high-quality evidence to suggest that improvements can be achieved for key CVD risk factors such as hypertension, dyslipidemia, tobacco use, and elevated hemoglobin A1c. The heterogeneity of interventions tested and considerable variation of the context under which implementation occurred suggest that caution is warranted in the interpretation of meta-analyses. It is highly important to generate evidence for pharmacist interventions in developing countries where a majority of the global CVD burden will be experienced in the near future. A growing capacity for clinical registry trials and data linkage might allow future research to collect clinical outcomes data more often.