Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial

The effect of clinical pharmacist-led pharmaceutical care services on medication adherence, clinical outcomes and quality of life in patients with stroke: a randomised controlled trial

BACKGROUND

Stroke is a major cause of morbidity and mortality worldwide. Pharmaceutical care services play a significant role in managing the risk factors associated with stroke.

AIM

This study aimed to examine the effects of a one-year pharmaceutical care programme on medication adherence, quality of life and clinical outcomes of patients with stroke.

METHOD

This study was conducted as a randomised controlled trial at the neurology clinic of a university hospital in Türkiye. Patients were randomly assigned to either an intervention group or usual care group (IG vs UCG). A simple randomization method using computer-based random numbers was used to assign participants in a 1:1 ratio. The IG received pharmaceutical care including medication reconciliation, medication review and patient education in addition to routine health services. The medication adherence, quality of life and clinical parameters of the patients were evaluated at the beginning and the end of the 12th month.

RESULTS

This study included 193 patients (89 and 104 patients in the IG and the UCG, respectively; mean age: 60.1 years), of whom 67.4% were male. At the one-year follow-up evaluation, the percentage of adherent patients (86.5% vs 47.1%, p < 0.001) and the total Stroke-Specific Quality of Life score (184.9 vs 166.0, p < 0.001) were higher in the IG than in the UCG. The stroke recurrence rate at the one-year follow-up (2.2% vs 10.6%, p = 0.044) was lower in the IG than in the UCG.

CONCLUSION

Pharmaceutical care services improved the medication adherence, quality of life and clinical outcomes of patients with stroke.

THE CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06129318; Study Registration Date: 13 November 2023.

Stroke Risk Reduction in Atrial Fibrillation Through Pharmacist Prescribing: A Randomized Clinical Trial

Importance

Major gaps in the delivery of appropriate oral anticoagulation therapy (OAC) exist, leaving a large proportion of persons with atrial fibrillation (AF) unnecessarily at risk for stroke and its sequalae.

Objective

To investigate whether pharmacist-led OAC prescription can increase the delivery of stroke risk reduction therapy in individuals with AF.

Design, Setting, and Participants

This prospective, open-label, patient-level randomized clinical trial of early vs delayed pharmacist intervention from January 1, 2019, to December 31, 2022, was performed in 27 community pharmacies in Alberta, Canada. Pharmacists identified patients 65 years or older with 1 additional stroke risk factor and known, untreated AF (OAC nonprescription or OAC suboptimal dosing) or performed screening using a 30-second single-lead electrocardiogram to detect previously unrecognized AF. Patients with undertreated or newly diagnosed AF eligible for OAC therapy were considered to have actionable AF. Data were analyzed from April 3 to November 30, 2023.

Interventions

In the early intervention group, pharmacists prescribed OAC using guideline-based algorithms with follow-up visits at 1 and 3 months. In the delayed intervention group, which served as the usual care control, the primary care physician (PCP) was sent a notification of actionable AF along with a medication list (both enhancement over usual care). After 3 months, patients without OAC optimization in the control group underwent delayed pharmacist intervention.

Main Outcomes and Measures

The primary outcome was the difference in the rate of guideline-concordant OAC use in the 2 groups at 3-month follow-up ascertained by a research pharmacist blinded to treatment allocation.

Results

Eighty patients were enrolled with actionable AF (9 [11.3%] newly diagnosed in 235 individuals screened). The mean (SD) age was 79.7 (7.4) years, and 45 patients (56.3%) were female. The median CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack) score was 2 (IQR, 2-3). Seventy patients completed follow-up. Guideline-concordant OAC use at 3 months occurred in 36 of 39 patients (92.3%) in the early intervention group vs 23 of 41 (56.1%) in the control group (P < .001), with an absolute increase of 34% and number needed to treat of 3. Of the 23 patients who received appropriate OAC prescription in the control group, the PCP called the pharmacist for prescribing advice in 6 patients.

Conclusions and Relevance

This randomized clinical trial found that pharmacist OAC prescription is a potentially high-yield opportunity to effectively close gaps in the delivery of stroke risk reduction therapy for AF. Scalability and sustainability of pharmacist OAC prescription will require larger trials demonstrating effectiveness and safety.

Trial Registration

ClinicalTrials.gov Identifier: NCT03126214.

Accreditation of stroke programs at the MENA + region; between aspiration and reality

INTRODUCTION

Despite global progress in stroke care, challenges persist, especially in Low- and Middle-Income countries (LMIC). The Middle East and North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO) Stroke Program Accreditation Initiative aims to improve stroke care regionally.

MATERIAL & METHOD

A 2022 survey assessed stroke unit readiness in the Middle East and North Africa (MENA) + region, revealing significant regional disparities in stroke care between high-income and low-income countries. Additionally, it demonstrated interest in the accreditation procedure and suggested that regional stroke program accreditation will improve stroke care for the involved centers.

CONCLUSION

An accreditation program that is specifically tailored to the regional needs in the MENA + countries might be the solution. In this brief review, we will discuss potential challenges faced by such a program and we will put forward a well-defined 5-step accreditation process, beginning with a letter of intent, through processing the request and appointment of reviewers, the actual audit, the certification decisions, and culminating in granting a MIENA-SINO tier-specific certificate with recertification every 5 years.

Improving Patient-Reported Outcomes in Stroke Care using Remote Blood Pressure Monitoring and Telehealth

BACKGROUND

Inequities in health care access leads to suboptimal medication adherence and blood pressure (BP) control. Informatics-based approaches may deliver equitable care and enhance self-management. Patient-reported outcomes (PROs) complement clinical measures to assess the impact of illness on patients' well-being in poststroke care.

OBJECTIVES

The aim of this study was to determine the feasibility of incorporating PROs into Telehealth After Stroke Care (TASC) and to explore the effect of this team-based remote BP monitoring program on psychological distress and quality of life in an underserved urban setting.

METHODS

Patients discharged home from a Comprehensive Stroke Center were randomized to TASC or usual care for 3 months. They were provided with a BP monitor and a tablet that wirelessly transmitted data to a cloud-based platform, which were integrated with the electronic health record. Participants who did not complete the tablet surveys were contacted via telephone or e-mail. We collected the Patient-Reported Outcomes Measurement Information System Managing Medications and Treatment (PROMIS-MMT), Patient Activation Measure (PAM), Neuro-QOL (Quality of Life in Neurological Disorders) Cognitive Function, Neuro-QOL Depression, and Patient Health Questionnaire-9 (PHQ-9). T-tests and linear regression were used to evaluate the differences in PRO change between the arms.

RESULTS

Of the 50 participants, two-thirds were Hispanic or non-Hispanic Black individuals. Mechanisms of PRO submission for the arms included tablet (62 vs. 47%), phone (24 vs. 37%), tablet with phone coaching (10 vs. 16%), and e-mail (4 vs. 0%). PHQ-9 depressive scores were nominally lower in TASC at 3 months compared with usual care (2.7 ± 3.6 vs. 4.0 ± 4.1; p = 0.06). No significant differences were observed in PROMIS-MMT, PAM, or Neuro-QoL measures.

CONCLUSION

Findings suggest the feasibility of collecting PROs through an interactive web-based platform. The team-based remote BP monitoring demonstrated a favorable impact on patients' well-being. Patients equipped with appropriate resources can engage in poststroke self-care to mitigate inequities in health outcomes.

Effects of a Computerized Prescriber Order Entry System on Pharmacist Prescribing

Background

In Alberta, pharmacists are eligible to obtain additional prescribing authority (APA). At the University of Alberta Hospital, a transition was made from a paper-based prescriber order entry system to a computerized prescriber order entry (CPOE) system.

Objectives

The primary objective was to quantify any change in pharmacist prescribing after CPOE implementation. The secondary objective was to compare the paper-based and CPOE systems in terms of drug schedule, order type, medication class, and the pharmacist's area of clinical practice.

Methods

A retrospective comparative review of pharmacist orders was completed using 2-week periods of data from each of the paper-based order entry system and the CPOE system, spaced 1 year apart (in January 2019 and January 2020).

Results

Pharmacists prescribed a mean of 3.76 (95% confidence interval 1.97-5.96) more orders per day within the CPOE system than in the paper-based system (p < 0.001). Schedule I medications accounted for a higher proportion of pharmacists' prescriptions in the CPOE system than in the paper-based system (77.7% versus 70.5%, p < 0.001). In terms of order type, discontinuation orders accounted for a much higher proportion of pharmacists' orders in the CPOE system than in the paper-based order entry system (58.0% versus 19.8%, p < 0.001).

Conclusions

This study showed that a CPOE system resulted in more use of APA by pharmacists, with schedule I medications accounting for a higher proportion of pharmacists' prescriptions. With the CPOE system, pharmacists used their prescribing privileges to discontinue a higher proportion of orders than was the case with the paper-based system. Therefore, the CPOE system is a potential facilitator of pharmacist prescribing.

Updates in mechanical thrombectomy

Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.

Stroke services in the Middle East and adjacent region: A survey of 34 hospital-based stroke services

Background

Acute stroke care is complex and requires multidisciplinary networking. There are insufficient data on stroke care in the Middle East and adjacent regions in Asia and Africa.

Objective

Evaluate the state of readiness of stroke programs in the Middle East North Africa and surrounding regions (MENA+) to treat acute stroke.

Method

Online questionnaire survey on the evaluation of stroke care across hospitals of MENA+ region between April 2021 and January 2022.

Results

The survey was completed by 34/50 (68%) hospitals. The median population serviced by participating hospitals was 2 million. The median admission of patients with stroke/year was 600 (250–1,100). The median length of stay at the stroke units was 5 days. 34/34 (100%) of these hospitals have 24/7 CT head available. 17/34 (50%) have emergency guidelines for prehospital acute stroke care. Mechanical thrombectomy with/without IVT was available in 24/34 (70.6%). 51% was the median (IQR; 15–75%) of patients treated with IVT within 60 min from arrival. Thirty-five minutes were the median time to reverse warfarin-associated ICH.

Conclusion

This is the first large study on the availability of resources for the management of acute stroke in the MENA+ region. We noted the disparity in stroke care between high-income and low-income countries. Concerted efforts are required to improve stroke care in low-income countries. Accreditation of stroke programs in the region will be helpful.

Telemonitoring and protocolized case management for hypertensive community dwelling older adults (TECHNOMED): a randomized controlled trial

BACKGROUND

Home blood pressure (BP) telemonitoring combined with case management leads to BP reductions in individuals with hypertension. However, its benefits are less clear in older (age ≥ 65 years) adults.

METHODS

Twelve-month, open-label, randomized trial of community-dwelling older adults comparing the combination of home BP telemonitoring (HBPM) and pharmacist-led case management, vs. enhanced usual care with HBPM alone. The primary outcome was the proportion achieving systolic BP targets on 24-h ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regressions were used for analyses, adjusted for baseline BP.

RESULTS

Enrollment was stopped early due to coronavirus disease 2019. Participants randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age 79.5 years. The adjusted odds ratio for ABPM BP target achievement was 1.48 (95% confidence interval 0.87-2.52, P = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (P-value 0.26 for systolic BP and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (P-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group participants had hypotension (systolic BP < 110) more frequently (21% vs. 5%, P = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or emergency department visits.

CONCLUSIONS

Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It did not result in major adverse consequences.

Effectiveness of Community Pharmacy Diabetes and Hypertension Care Program: An Unexplored Opportunity for Community Pharmacists in Pakistan

Background: The effective management of patients diagnosed with both Diabetes as well as Hypertension is linked with administration of efficacious pharmacological therapy as well as improvement in adherence through counseling and other strategies. Being a part of primary healthcare team, community pharmacists can effectively provide patient care for chronic disease management. The objective of the study was to evaluate the impact of pharmacist counseling on blood pressure and blood glucose control among patients having both hypertension and diabetes attending community pharmacies in Pakistan. Method: A randomized, controlled, single-blind, pre-post-intervention study design was used. The respondents included patients diagnosed with diabetes mellitus (Type I or II) and hypertension visiting community pharmacies to purchase their regular medicine. A simple random sampling technique using the lottery method was used to select community pharmacies in groups A (intervention, n = 4) and group B (control, n = 4). The total number of patients was 40 in each group, while estimating a dropout rate of 25%. The patients in the intervention group received special counseling. Blood pressure and blood glucose were checked after every 15 days for 6 months. Prevalidated tools such as the hypertension knowledge level scale, the diabetes knowledge questionnaire 24, and a brief medication questionnaire was used. Data were coded and analyzed using SPSS 21. Wilcoxon test (p < 0.05) was used to compare pre-post intervention knowledge regarding the disease, while the Mann-Whitney test (p < 0.05) was used to find differences in medication adherence among control and intervention groups. Results: A significant improvement in mean knowledge scores of patients with diabetes (16.02 ±2.93 vs. 19.97 ±2.66) and hypertension (15.60 ±3.33 vs. 18.35 ±2.31) in the intervention group receiving counseling for 6 months than control group (p < 0.05) was noted. Furthermore, the fasting blood glucose levels (8.25 ±1.45) and systolic BP (130.10 ±6.89) were significantly controlled after 6 months in the intervention group. Conclusion: The current study results concluded that community pharmacists' counselling has a positive impact on blood glucose and blood pressure management among patients suffering with both diabetes and hypertension.

Multiprofessional intervention to improve adherence to medication in stroke patients: a study protocol for a randomised controlled trial (ADMED AVC study)

INTRODUCTION

Adherence to secondary preventive medications is often suboptimal in patients with stroke, exposing them to an increased risk of recurrent cerebral and/or cardiovascular events. Effective actions in the long term to improve adherence to medication are needed. The study will evaluate the efficacy of a collaborative multiprofessional patient-centred intervention conducted by a pharmacist on adherence to secondary preventive medication in stroke survivors.

METHODS AND ANALYSIS

This is a multicentre cluster-randomised controlled trial. Two groups of 91 patients (intervention vs standard care) will be recruited. The clinical pharmacist intervention targeting secondary preventive medication will consist of three parts over 1 year: (1) an individual semi-structured interview at hospital discharge; (2) follow-up telephone interviews at 3, 6 and 9 months after discharge; and (3) a final individual semi-structured interview 1 year after discharge. Information on patient follow-up will be shared with the general practitioner and the community pharmacist by sending a report of each interview. The primary outcome is adherence to medication during the 12 months after hospital discharge, assessed using a composite endpoint: the medication possession ratio associated with a self-administered questionnaire.

ETHICS AND DISSEMINATION

The local ethics committee, the national committee for use of personal data in medical research and the national data protection agency approved the study. The sponsor has no role in study design; collection, analysis and interpretation of data; or report writing.

DISCUSSION

This pharmacist-led educational programme has the potential to significantly improve adherence to medication in stroke survivors which could lead to a decrease in recurrent cerebral and/or cardiovascular events.

TRIAL REGISTRATION NUMBER

NCT02611440.

Co-design and evaluation of a patient-centred transition programme for stroke patients, combining case management and access to an internet information platform: study protocol for a randomized controlled trial - NAVISTROKE

BACKGROUND

Stroke affects many aspects of life in stroke survivors and their family, and returning home after hospital discharge is a key step for the patient and his or her relatives. Patients and caregivers report a significant need for advice and information during this transition period. Our hypothesis is that, through a comprehensive, individualised and flexible support for patients and their caregivers, a patient-centred post-stroke hospital/home transition programme, combining an Internet information platform and telephone follow-up by a case manager, could improve patients' level of participation and quality of life.

METHODS

An open parallel-group randomized trial will be conducted in two centres in France. We will recruit 170 adult patients who have had a first confirmed stroke, and were directly discharged home from the stroke unit with a modified Rankin score ≤3. Intervention content will be defined using a user-centred approach involving patients, caregivers, health-care professionals and social workers. Patients randomized to the intervention group will receive telephonic support by a trained case manager and access to an interactive Internet information platform during the 12 months following their return home. Patients randomized to the control group will receive usual care. The primary outcome is patient participation, measured by the "participation" dimension score of the Stroke Impact Scale 6 months after discharge. Secondary outcomes will include, for patients, quality of life, activation, care consumption, as well as physical, mental and social outcomes; and for caregivers, quality of life and burden. Patients will be contacted within one week after discharge, at 6 and 12 months for the outcomes collection. A process evaluation alongside the study is planned.

DISCUSSION

Our patient-centred programme will empower patients and their carers, through individualised and progressive follow-up, to find their way around the range of available healthcare and social services, to better understand them and to use them more effectively. The action of a centralised case manager by telephone and the online platform will make it possible to disseminate this intervention to a large number of patients, over a wide area and even in cases of geographical isolation.

TRIAL REGISTRATION

ClinicalTrials NCT03956160 , Posted: May-2019 and Update: September-2021.

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.

Related factors based on non-targeted metabolomics methods in minor ischaemic stroke

OBJECTIVE

This study aimed to identify potential biomarkers associated with the occurrence of minor ischaemic stroke.

METHODS

Four hundred patients hospitalized with minor ischaemic stroke were enrolled in the department of neurological internal medicine in Taiyuan Central Hospital, and 210 healthy subjects examined at the Taiyuan Central Hospital Medical Center during the same period were selected. We collected information on the general demographic characteristics and fasting blood samples of the subjects. We then used untargeted metabolomic assay to measure blood glucose, blood lipids, homocysteine, and high-sensitivity C-reactive protein.

RESULTS

There were statistically significant differences between the mild ischemic stroke group and the healthy control group in smoking, hypertension, and physical activity (P< 0.05). Compared with the healthy group, the minor ischaemic stroke group showed increased lactate, pyruvate, trimetlylamine oxide levels, and lactic acid, pyruvic acid, and trimethylamine N-oxidation (TMAO) levels were statistically significant (P< 0.001). In the minor ischaemic stroke risk model, hypertension, physical activity, smoking, and elevated TMAO levels influenced the occurrence of minor stroke.

CONCLUSION

Increased levels of lactic acid, pyruvate, and TMAO may be related to the pathophysiological changes in the minor ischaemic stroke population. High blood pressure, a lack of physical activity, smoking, and increased TMAO level were the influencing factors for the occurrence of minor ischaemic stroke. The serum metabolite TMAO may be associated with MS occurrence.

Longer term patient management following stroke: A systematic review

BACKGROUND

Tremendous progress in acute stroke therapy has improved short-term outcome but part of this achievement may be lost in the long run. Concepts for a better long-term management of stroke survivors are needed to address their unmet needs and to reduce the burden of post-stroke complications, residual deficits, and recurrent vascular events.

AIMS

This review summarizes current knowledge on post-hospital care and the scientific evidence supporting individual programs.

SUMMARY OF REVIEW

A systematic search of electronic databases according to PRISMA guidelines identified 10,374 articles, 77 of which met the inclusion criteria. One large randomised controlled trial on a multifaceted care program delivered by the multidisciplinary stroke team reduced recurrent vascular events and improved quality of life and functional outcome one year after the event, while a number of studies offer solutions for individual components of post-hospital disease management like patient education, counselling, and self-management or the management of post-stroke complications and residual deficits. A majority of studies, however, was small in size and limited by a short follow-up. Most initiatives with a narrow focus on risk factor control failed to lower the risk of recurrent events. The caregivers' central role in post-stroke patient management is broadly neglected in research.

CONCLUSIONS

Over the past years, first knowledge on how to best organize post-hospital care of stroke patients has emerged. Comprehensive and pragmatic programs operated by the multidisciplinary stroke team hold promise to reduce the long-term health burden of stroke. There is a clear need for further high-quality studies with both clinical endpoints and patient-reported outcomes to establish sustainable solutions in different settings and regions to improve life after stroke, a key priority of the Stroke Action Plan for Europe 2018-2030.

Nurse-based secondary preventive follow-up by telephone reduced recurrence of cardiovascular events: a randomised controlled trial

Enhanced follow-up is needed to improve the results of secondary preventive care in patients with established cardiovascular disease. We examined the effect of long-term, nurse-based, secondary preventive follow-up by telephone on the recurrence of cardiovascular events. Open, randomised, controlled trial with two parallel groups. Between 1 January 2010 and 31 December 2014, consecutive patients (n = 1890) admitted to hospital due to stroke, transient ischaemic attack (TIA), or acute coronary syndrome (ACS) were included. Participants were randomised (1:1) to nurse-based telephone follow-up (intervention, n = 944) or usual care (control, n = 946) and followed until 31 December 2017. The primary endpoint was a composite of stroke, myocardial infarction, cardiac revascularisation, and cardiovascular death. The individual components of the primary endpoint, TIA, and all-cause mortality were analysed as secondary endpoints. The assessment of outcome events was blinded to study group assignment. After a mean follow-up of 4.5 years, 22.7% (n = 214) of patients in the intervention group and 27.1% (n = 256) in the control group reached the primary composite endpoint (HR 0.81, 95% CI 0.68-0.97; ARR 4.4%, 95% CI 0.5-8.3). Secondary endpoints did not differ significantly between groups. Nurse-based secondary preventive follow-up by telephone reduced the recurrence of cardiovascular events during long-term follow-up.

Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

A Primary Care Agenda for Brain Health: A Scientific Statement From the American Heart Association

A healthy brain is critical for living a longer and fuller life. The projected aging of the population, however, raises new challenges in maintaining quality of life. As we age, there is increasing compromise of neuronal activity that affects functions such as cognition, also making the brain vulnerable to disease. Once pathology-induced decline begins, few therapeutic options are available. Prevention is therefore paramount, and primary care can play a critical role. The purpose of this American Heart Association scientific statement is to provide an up-to-date summary for primary care providers in the assessment and modification of risk factors at the individual level that maintain brain health and prevent cognitive impairment. Building on the 2017 American Heart Association/American Stroke Association presidential advisory on defining brain health that included "Life's Simple 7," we describe here modifiable risk factors for cognitive decline, including depression, hypertension, physical inactivity, diabetes, obesity, hyperlipidemia, poor diet, smoking, social isolation, excessive alcohol use, sleep disorders, and hearing loss. These risk factors include behaviors, conditions, and lifestyles that can emerge before adulthood and can be routinely identified and managed by primary care clinicians.

A De Novo Pharmacist-Family Physician Collaboration Model in a Family Medicine Clinic in Alberta, Canada

Collaborative practice in health-care has proven to be an effective and efficient method for the management of chronic diseases. This study describes a de novo collaborative practice between a pharmacist and a family physician. The primary objective of the study is to describe the collaboration model between a pharmacist and family physician. The secondary objective is to describe the pharmacist workload. A list of patients who had at least one interaction with the pharmacist was generated and printed from the electronic medical record. There were 389 patients on the patient panel. The pharmacist had at least one encounter with 159 patients. There were 83 females. The most common medical condition seen by the pharmacist was hypertension. A total of 583 patient consultations were made by the pharmacist and 219 of those were independent visits. The pharmacist wrote 1361 prescriptions. The expanded scope of practice for pharmacists in Alberta includes additional prescribing authority. The pharmacists’ education and clinical experience gained trust from the family physician. These, coupled with the family physician’s previous positive experience working with pharmacists made the collaboration achievable.

Pharmaceutical care program for ischemic stroke patients: a randomized controlled trial

Background Effective secondary prevention is essential for reducing stroke recurrence. Objective This parallel randomized-controlled study aimed to evaluate the impact of a pharmaceutical care program on risk factor control (blood pressure, blood glucose, lipid profile, and medication adherence) and hospital readmissions in post-stroke care. Setting The First Hospital of Hebei Medical University, China. Method Ischemic stroke patients were enrolled in the study. Upon hospital discharge, patients were randomly allocated either to a control group (CG, no pharmaceutical care) or to an intervention group (IG, monthly pharmaceutical care follow-up for 6 months). The interventions aimed to increase medication adherence and improve risk factor control through education and counseling. Medication adherence and surrogate laboratory markers of risk factors were assessed and compared between the two groups. Main outcome measures Blood pressure, blood glucose, lipid profile, and medication adherence. Results A total of 184 patients with ischemic strokes were randomly assigned, and 84 patients in IG and 82 in CG were analyzed. There were no significant differences (P > 0.05) in both groups concerning demographic and clinical characteristics. Compared to CG, at the 6-month follow-up, medication adherence rates significantly increased regarding antihypertensive drugs (92.86% versus 78.57%, P = 0.031), anti-diabetic drugs (91.67% versus 69.7%, P = 0.02), and lipid-lowering drugs (77.38% versus 60.98%, P = 0.022) in IG. Compared to CG, more patients in IG attained the goal surrogate risk factor control markers of hemoglobin A1c (87.88% vs. 52.78%, P = 0.038) and low-density lipoprotein-C (66.67% vs. 48.78%, P = 0.02). Significantly fewer patients were re-admitted to the hospital in IG than CG (7.14% vs. 18.3%, P = 0.03). Conclusion Pharmaceutical care programs can improve risk factor control for the secondary prevention of stroke recurrence in ischemic stroke patients.

Implementation strategies to improve statin utilization in individuals with hypercholesterolemia: a systematic review and meta-analysis

BACKGROUND

Numerous implementation strategies to improve utilization of statins in patients with hypercholesterolemia have been utilized, with varying degrees of success. The aim of this systematic review is to determine the state of evidence of implementation strategies on the uptake of statins.

METHODS AND RESULTS

This systematic review identified and categorized implementation strategies, according to the Expert Recommendations for Implementing Change (ERIC) compilation, used in studies to improve statin use. We searched Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from inception to October 2018. All included studies were reported in English and had at least one strategy to promote statin uptake that could be categorized using the ERIC compilation. Data extraction was completed independently, in duplicate, and disagreements were resolved by consensus. We extracted LDL-C (concentration and target achievement), statin prescribing, and statin adherence (percentage and target achievement). A total of 258 strategies were used across 86 trials. The median number of strategies used was 3 (SD 2.2, range 1-13). Implementation strategy descriptions often did not include key defining characteristics: temporality was reported in 59%, dose in 52%, affected outcome in 9%, and justification in 6%. Thirty-one trials reported at least 1 of the 3 outcomes of interest: significantly reduced LDL-C (standardized mean difference [SMD] - 0.17, 95% CI - 0.27 to - 0.07, p = 0.0006; odds ratio [OR] 1.33, 95% CI 1.13 to 1.58, p = 0.0008), increased rates of statin prescribing (OR 2.21, 95% CI 1.60 to 3.06, p < 0.0001), and improved statin adherence (SMD 0.13, 95% CI 0.06 to 0.19; p = 0.0002; OR 1.30, 95% CI 1.04 to 1.63, p = 0.023). The number of implementation strategies used per study positively influenced the efficacy outcomes.

CONCLUSION

Although studies demonstrated improved statin prescribing, statin adherence, and reduced LDL-C, no single strategy or group of strategies consistently improved outcomes.

TRIAL REGISTRATION

PROSPERO CRD42018114952 .

Pharmacy and medical students' competence and confidence with prescribing: A cross-sectional study

INTRODUCTION

Previous research has shown that prescribing competence is weakly correlated with prescribing confidence. This questions whether undergraduate programs adequately prepare students and junior practitioners for safe and rational prescribing. The goal of this project was to investigate whether there are differences in prescribing competence and confidence between fourth year pharmacy and medical students at the University of Alberta.

METHODS

A cross-sectional design measured prescribing competence using five case scenarios and prescribing confidence with a survey. All fourth-year pharmacy and medical students at the University of Alberta were eligible to participate. Answers to the cases were graded based on therapeutic appropriateness and inclusion of all legal requirements. The confidence survey assessed self-rated confidence of both assessment and prescribing skills. Chi-square tests were used to compare frequencies of prescribing errors and self-rated confidence. The Spearman correlation coefficient was used to explore the correlation between prescribing competence and confidence for both cohorts independently.

RESULTS

Thirty-one pharmacy students and 16 medical students (response rate 24% and 10%, respectively) completed the assessment between December 2018 and March 2019. Pharmacy students had significantly more appropriate prescriptions and fewer inappropriate prescriptions than medical students. Both rated themselves as confident or very confident with prescribing, however neither group consistently included all the legal requirements of a prescription. There were no significant correlations between competence and confidence.

CONCLUSIONS

There are differences in prescribing competence and confidence between pharmacy and medical students. This assessment identified deficits in prescribing skills that could be targeted by future educational initiatives.

A New Case Manager for Diabetic Patients: A Pilot Observational Study of the Role of Community Pharmacists and Pharmacy Services in the Case Management of Diabetic Patients

The adherence of type 2 diabetes mellitus (DM2) patients with an individual care plan (ICP) is often not satisfactory, nor does it allow for a significant improvement in outcome, because of poor accessibility to services, poor integration of pathway articulations, poor reconciliation with the patient’s life, or the lack of a constant reference person. The purpose of this study was to evaluate the contribution of community pharmacists and pharmacy services in improving adherence with periodic controls in DM2. The study was conducted at a rural pharmacy. A sample of 40 patients was calculated with respect to a historical cohort and subsequently enrolled. Clinical and personal data were collected in an electronic case report form. Pharmacists acting as a case manager followed patients carrying out their ICP developed by an attending physician. Some of the activities foreseen by the ICP, such as electrocardiogram, fundus examination, and self-analysis of blood and urine, were carried out directly in the pharmacy by the pharmacist through the use of telemedicine services and point of care units. Activities that could not be performed in the pharmacy were booked by the pharmacist at the accredited units. Examination results were electronically reported by the pharmacist to the attending physician. The primary endpoint was the variation in patient adherence with the ICP compared to a historical cohort. Secondary endpoints were variation in waiting time for the examinations, mean percentage change in glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels and blood pressure, impact on healthcare-related costs, and perceived quality of care. Adherence to the ICP significantly increased. Waiting times were reduced and clinical outcomes improved with conceivable effects on costs. Patients appreciated the easier access to services. Community pharmacists and pharmacy services represent ideal actors and context that, integrated in the care network, can really favor ICP adherence and obtain daily morbidity reduction and cost savings through proper disease control and an early diagnosis of complications.

Pharmacist Prescribing in Pediatric and Neonatal Acute Care: An Observational Study

OBJECTIVE

The intent of this project was to objectively describe the frequency of pharmacist prescribing in acute care pediatrics and neonatology and to determine the medications most often prescribed by pharmacists practicing in a jurisdiction that permits pharmacists' prescribing.

METHODS

This was a subgroup analysis of a retrospective observational study using prescribing data from an electronic medical record system used in 5 acute care hospitals (1 pediatric, 4 primarily adult but with pediatric and neonatal units) within Calgary, Alberta, Canada.

RESULTS

Considering orders for pediatric or neonatal patients only, there was a mean (SD) of 126 (226) prescriptions per pharmacist per year, with a wide range (1–1101 per year). Considering only the 9 clinical pharmacist full-time equivalents (FTEs) assigned to pediatrics and/or neonatology (i.e., not including dispensary pharmacist FTE), this represents 572 prescriptions per clinical pharmacist FTE per year (726 in pediatrics and 380 in neonatology). The most common medication classes on pediatric units included anti-infective agents, central nervous system agents, and gastrointestinal agents. In NICUs, blood formation, coagulation and thrombosis agents (mainly iron), electrolytes, caloric and water balance agents (primarily sodium supplements), and vitamins were also commonly prescribed by pharmacists.

CONCLUSIONS

As the scope of pharmacy practice expands to include prescribing, health team leadership can use these data to support incorporation of this role into practice. Prescribing pharmacists can ensure appropriate use of many medications used in acutely ill infants and children, potentially improving efficiency and quality of care.

Blood pressure after follow-up in a stroke prevention clinic

OBJECTIVES

In Denmark, 25% of hospital admissions with stroke are recurrent strokes. With thrombolytic treatment, more patients survive with only minor disability. This promising development should be followed up by intensive secondary prevention. Hypertension is the most important target. We aimed at testing the hypotheses that early follow-up in a preventive clinic would result in (a) a higher proportion of patients with blood pressure at target and (b) time to stroke recurrence, myocardial infarction, and death would be longer in the intervention group compared to controls.

MATERIALS AND METHODS

Eligible patients admitted to the stroke unit of Herlev Hospital were randomized shortly before discharge to intervention or control group. Of 78 included participants, data from 73 were available for follow-up 9 months after inclusion. Patients in the intervention group were seen in the clinic within 1 week. In case of hypertension, treatment was initiated or supplied with a new drug. We used individual targets for blood pressure according to diagnosis of stroke and patients' comorbidity. Patients in the intervention group had a median of five visits to the preventive clinic.

RESULTS

In the intervention group, blood pressure was treated to target in 25 patients (69%) versus 14 (38%) in the control group (p = .007). Median time to first event was 44 months (4-49) in the intervention group and 19 months (4-37) in controls (p = .316).

CONCLUSIONS

Treatment of hypertension to individual targets after stroke is feasible. It may postpone recurrent stroke and death in stroke survivors.

A support programme for secondary prevention in patients with transient ischaemic attack and minor stroke (INSPiRE-TMS): an open-label, randomised controlled trial

BACKGROUND

Patients with recent stroke or transient ischaemic attack are at high risk for a further vascular event, possibly leading to permanent disability or death. Although evidence-based treatments for secondary prevention are available, many patients do not achieve recommended behavioural modifications and pharmaceutical prevention targets in the long-term. We aimed to investigate whether a support programme for enhanced secondary prevention can reduce the frequency of recurrent vascular events.

METHODS

INSPiRE-TMS was an open-label, multicentre, international randomised controlled trial done at seven German hospitals with acute stroke units and a Danish stroke centre. Patients with non-disabling stroke or transient ischaemic attack within 2 weeks from study enrolment and at least one modifiable risk factor (ie, arterial hypertension, diabetes, atrial fibrillation, or smoking) were included. Computerised randomisation was used to allocate patients (1:1) either to the support programme in addition to conventional care or to conventional care alone. The support programme used feedback and motivational interviewing strategies with eight outpatient visits over 2 years aiming to improve adherence to secondary prevention targets. The primary outcome was the composite of major vascular events consisting of stroke, acute coronary syndrome, and vascular death, assessed in the intention-to-treat population (all patients who underwent randomisation, did not withdraw study participation, and had at least one follow-up). Outcomes were assessed at annual follow-ups using time-to-first-event analysis. All-cause death was monitored as a safety outcome. This trial is registered with ClinicalTrials.gov, NCT01586702.

FINDINGS

From Aug 22, 2011, to Oct 30, 2017, we enrolled 2098 patients. Of those, 1048 (50·0%) were randomly assigned to the support programme group and 1050 (50·0%) patients were assigned to the conventional care group. 1030 (98·3%) patients in the support group and 1042 (99·2%) patients in the conventional care group were included in the intention-to-treat analysis. The mean age of analysed participants was 67·4 years and 700 (34%) were women. After a mean follow-up of 3·6 years, the primary outcome of major vascular events had occurred in 163 (15·8%) of 1030 patients of the support programme group and in 175 (16·8%) of 1042 patients of the conventional care group (hazard ratio [HR] 0·92, 95% CI 0·75-1·14). Total major vascular event numbers were 209 for the support programme group and 225 for the conventional care group (incidence rate ratio 0·93, 95% CI 0·77-1·12; p=0·46) and all-cause death occurred in 73 (7·1%) patients in the support programme group and 85 (8·2%) patients in the conventional care group (HR 0·85, 0·62-1·17). More patients in the support programme group achieved secondary prevention targets (eg, in 1-year-follow-up 52% vs 42% [p<0·0001] for blood pressure, 62% vs 54% [p=0·0010] for LDL, 33% vs 19% [p<0·0001] for physical activity, and 51% vs 34% [p=0·0010] for smoking cessation).

INTERPRETATION

Provision of an intensified secondary prevention programme in patients with non-disabling stroke or transient ischaemic attack was associated with improved achievement of secondary prevention targets but did not lead to a significantly lower rate of major vascular events. Further research is needed to investigate the effects of support programmes in selected patients who do not achieve secondary prevention targets soon after discharge.

FUNDING

German Federal Ministry of Education and Research, Pfizer, and German Stroke Foundation.

CAPABLE: Calgary zone usage of Additional Prescribing Authorization By pharmacists in an inpatient setting: review of the prescribing Landscape and Environment

BACKGROUND

In Alberta, Canada, pharmacists have been granted the ability to prescribe most medications independently after completing an additional authorization process. While there are data to support the use of pharmacists' prescribing in the community setting, little is known about its use in the inpatient hospital setting.

OBJECTIVES

To describe the prescribing patterns of pharmacists in an inpatient setting including the percentage of pharmacists using their prescribing authority, the care areas where prescribing occurred, and the frequency of prescribing. Secondary objectives included describing the medications prescribed, and to determine if pharmacists are documenting their prescribing interventions.

METHODS

A descriptive, retrospective, cross-sectional study of medications ordered by pharmacists through the electronic order entry system in Calgary, Alberta, Canada. Prescriptions were examined in the context of how often each pharmacist prescribed, the medications prescribed, and an audit of documentation practices was performed using patient charts.

RESULTS

A total of 64,293 orders from 172 pharmacists were included in the analysis, of which 51% (n = 32,681) were discontinuation orders. It was found that 90% of pharmacists used their prescribing authority, ordering a median of 11.3 prescriptions monthly (interquartile range 4.3-32.8). Clinical areas with the most overall prescribing included critical care (854.8), oncology and palliative care (463.0), and surgery (409.3) prescriptions per pharmacist Full-Time Equivalent per year.

CONCLUSIONS

This study demonstrates a broad range of prescribing from pharmacists within acute care practice and a wide variety of medication prescribed. Future areas for research include barriers and enablers to pharmacist prescribing and examination of where prescribing pharmacists have the greatest value.

Antihypertensive drug use and blood pressure control among stroke survivors in the United States: NHANES 2003-2014

Understanding the patterns of antihypertensive drug use and blood pressure (BP) control among stroke survivors in the "real-world" setting is important to identify gaps in treatment and control, if any. The objective of our study was to assess trends and patterns in antihypertensive drug use and BP control among stroke survivors in the United States. We performed a retrospective cross-sectional analysis of the 2003-2014 National Health and Nutrition Examination Survey (NHANES). Stroke and hypertension diagnoses were self-reported. Information regarding the use of antihypertensive drugs was collected during an in-person interview. Measurement of BP was performed by trained medical professionals in mobile examination centers. A total 1244 adult stroke survivors (equating to 6 232 215 stroke survivors nationwide) were identified, of which 956 had hypertension. Antihypertensive drug use increased from 2003 (79.5%) to 2014 (92.2%; P for trend < 0.001). The prevalence of drug use was lower (52%) among survivors aged 20-39 years compared with older age groups. Use of ≥2 antihypertensive drugs was prevalent (63.8%), but diuretics alone or in combination with angiotensin-converting enzyme inhibitors were underutilized (22.4%). More than one-third of the survivors were not at BP goal (ie, BP < 140/90 mm Hg). Males were more likely to attain BP goal than female stroke survivors (odds ratio [OR] = 2.02; 95% CI: 1.34-3.05). Our findings suggest that despite improvements in antihypertensive drug use in the recent years, BP is not adequately controlled in a significant proportion of stroke survivors. Further research focusing on understanding the reasons for unmet BP goal in stroke survivors is needed.

ICARUSS: An effective model for risk factor management in stroke survivors

Background and purpose

After an initial stroke, the risk of recurrent stroke is high. Models that implement best-practice recommendations for risk factor management in stroke survivors to prevent stroke recurrence remain elusive. We examined a model which focuses on vascular risk factor management to prevent stroke recurrence in survivors returning to their primary care physicians. This model is coordinated from the stroke unit, integrates specialist stroke services with primary care physicians, and directly involves patients and carers in risk factor management. It is underpinned by the shared care principle in which there is joint participation of specialists as well as primary care physicians in a planned, integrated delivery of care with ongoing involvement of patients and carers, a structure which encourages implementation of best-practice recommendations as well as transferability and sustainability. We hypothesized that an integrated, multimodal intervention based on a shared-care model which supports joint participation of stroke specialists and primary care physicians would improve the implementation of best-practice recommendations for risk factor management in stroke survivors returning to the community.

Methods

We undertook a double-blind randomized controlled trial, testing the model in three Australian cities using stroke survivors admitted to stroke units and discharged from hospital to return to their primary care physicians. The model was a shared care, multifaceted integrated program which included bidirectional feedback between general practitioner and specialist unit, education, and engagement of patient and carer in self-management with ongoing input from a multidisciplinary team. The primary endpoint was improvement or abolition of risk factors such as raised blood pressure, diabetes, hyperlipidemia, the modification of adverse life-style factors such as lack of exercise, smoking and alcohol abuse and adherence to preventive medication at one year. Intermediate measurement points were scheduled at three monthly intervals. Analysis was by intention to treat, evaluated by covariance or a linear model adjusting for confounding factors or variance of base-line risk factors. The study was registered as ACTRN = 1261100026498.

Results

The study population was as follows: intervention ( n = 112), control ( n = 137). At baseline, there was no statistical difference between the groups for any variable. At the 12-month evaluation, there was a significant decrease in systolic blood pressure from baseline in the intervention group of 5.2 mmHg ( p < 0.01). This change was not observed in the control group ( p = 0.29). Moreover, at 12 months the mean systolic blood pressure in the intervention group was 129.4 mmHg (SD 14.7), a result which was not obtained in controls. Fasting total cholesterol as well as triglycerides was reduced significantly in the intervention group (both p < 0.01) but this was not the case in the control group ( p = 0.11 and p = 0.27, respectively). At 12 months, there was no change in BMI in the intervention group but there was a significant increase in BMI ( p = 0.02) in the control group. At 12 months in the intervention group, the mean distance walked with ease compared to the baseline measurements was increased by a mean distance of 600 m while in the control group the distance walked with ease was reduced compared to that measured at baseline. At 12 months, the Barthel index in the intervention group demonstrated improved function ( p = 0.01), but no change was observed in controls. At 12 months in the intervention group, there was a significant decrease in number of standard alcoholic drinks consumed per week compared to the baseline ( p = 0.04). This was not observed in the control group ( p = 0.34).

Conclusion

In stroke survivors, the ICARUSS (Integrated Care for the Reduction of Secondary Stroke) model is superior to usual care with respect to best-practice recommendations for traditional risk factors as well as behavioral and functional outcomes.

Identifying treatment related problems and associated factors among hospitalized post-stroke patients through medication management review: A multi-center study

Background

Stroke is a major cause of disability and one of the leading causes of death among the elderly. Treatment related problems can lead to undesirable consequences. The Medication Management Review (MMR) service is aimed at identifying, resolving and preventing TRPs, subsiding the undesirable outcomes associated with TRPs.

Objectives

To explore the types, frequencies and severity of TRPs amongst post-stroke patients recruited through hospitals via conducting the MMR service by clinical pharmacists in Jordan. Associations between patient factors and the identified TRPs were explored.

Methods

This cross-sectional descriptive study was conducted over three months in 2017 in different geographical areas throughout Jordan. Randomly recruited patients were interviewed at the hospitals to collect their demographic data and clinical characteristics. Types/frequencies/severity of TRPs for each stroke patient were identified by a clinical pharmacist. Associations between the identified TRPs and patient's factors were explored through multiple regression analysis.Key findings:Out of 198 stroke patients (mean age: 56.6 ± 14.2) who completed the study, 110 (55.6%) were males. Many of the patients (82 (41.6%)) were smokers and 61 (69.2%) had hypertension and/or diabetes. The mean number of TRPs per patient was 2.5 ± 1.1. The most common TRP categories involved efficacy issues (198 (40.6%)), inappropriate drug adherence (136 (27.9%)) and inappropriate patient knowledge (114 (23.4%)). More than 70.0% (342/487) of the identified TRPs were of major severity. Higher number of TRPs was found to be associated with being a male, having a lower educational level, being a current smoker, having a higher number of drugs and a poorer quality of life.

Conclusion

Lack of drug efficacy, inappropriate drug adherence and patient knowledge were the major TRPs identified via delivering the MMR service to post-stroke patients. The identified TRPs highlights the importance of the MMR service, and supports planning future strategies aimed at decreasing the incidence of strokes.

Long-term, telephone-based follow-up after stroke and TIA improves risk factors: 36-month results from the randomized controlled NAILED stroke risk factor trial

Background

Strategies are needed to improve adherence to the blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level recommendations after stroke and transient ischemic attack (TIA). We investigated whether nurse-led, telephone-based follow-up that included medication titration was more efficient than usual care in improving BP and LDL-C levels 36 months after discharge following stroke or TIA.

Methods

All patients admitted for stroke or TIA at Östersund hospital that could participate in the telephone-based follow-up were considered eligible. Participants were randomized to either nurse-led, telephone-based follow-up (intervention) or usual care (control). BP and LDL-C were measured one month after discharge and yearly thereafter. Intervention group patients who did not meet the target values received additional follow-up, including lifestyle counselling and medication titration, to reach their treatment goals (BP < 140/90 mmHg, LDL-C < 2.5 mmol/L). The primary outcome was the systolic BP level 36 months after discharge.

Results

Out of 871 randomized patients, 660 completed the 36-month follow-up. The mean systolic and diastolic BP values in the intervention group were 128.1 mmHg (95% CI 125.8–130.5) and 75.3 mmHg (95% CI 73.8–76.9), respectively. This was 6.1 mmHg (95% CI 3.6–8.6, p < 0.001) and 3.4 mmHg (95% CI 1.8–5.1, p < 0.001) lower than in the control group. The mean LDL-C level was 2.2 mmol/L in the intervention group, which was 0.3 mmol/L (95% CI 0.2–0.5, p < 0.001) lower than in controls. A larger proportion of the intervention group reached the treatment goal for BP (systolic: 79.4% vs. 55.3%, p < 0.001; diastolic: 90.3% vs. 77.9%, p < 0.001) as well as for LDL-C (69.3% vs. 48.9%, p < 0.001).

Conclusions

Compared with usual care, a nurse-led telephone-based intervention that included medication titration after stroke or TIA improved BP and LDL-C levels and increased the proportion of patients that reached the treatment target 36 months after discharge.

Trial registration

ISRCTN Registry ISRCTN23868518 (retrospectively registered, June 19, 2012).

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1158-5) contains supplementary material, which is available to authorized users.

Pharmacist services for non-hospitalised patients

BACKGROUND

This review focuses on non-dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory-care settings, to non-hospitalised patients, and is an update of a previously-published Cochrane Review.

OBJECTIVES

To examine the effect of pharmacists' non-dispensing services on non-hospitalised patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases and two trial registers in March 2015, together with reference checking and contact with study authors to identify additional studies. We included non-English language publications. We ran top-up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'.

SELECTION CRITERIA

Randomised trials of pharmacist services compared with the delivery of usual care or equivalent/similar services with the same objective delivered by other health professionals.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures of Cochrane and the Effective Practice and Organisation of Care Group. Two review authors independently checked studies for inclusion, extracted data and assessed risks of bias. We evaluated the overall certainty of evidence using GRADE.

MAIN RESULTS

We included 116 trials comprising 111 trials (39,729 participants) comparing pharmacist interventions with usual care and five trials (2122 participants) comparing pharmacist services with services from other healthcare professionals. Of the 116 trials, 76 were included in meta-analyses. The 40 remaining trials were not included in the meta-analyses because they each reported unique outcome measures which could not be combined. Most trials targeted chronic conditions and were conducted in a range of settings, mostly community pharmacies and hospital outpatient clinics, and were mainly but not exclusively conducted in high-income countries. Most trials had a low risk of reporting bias and about 25%-30% were at high risk of bias for performance, detection, and attrition. Selection bias was unclear for about half of the included studies.Compared with usual care, we are uncertain whether pharmacist services reduce the percentage of patients outside the glycated haemoglobin target range (5 trials, N = 558, odds ratio (OR) 0.29, 95% confidence interval (CI) 0.04 to 2.22; very low-certainty evidence). Pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range (18 trials, N = 4107, OR 0.40, 95% CI 0.29 to 0.55; low-certainty evidence) and probably lead to little or no difference in hospital attendance or admissions (14 trials, N = 3631, OR 0.85, 95% CI 0.65 to 1.11; moderate-certainty evidence). Pharmacist services may make little or no difference to adverse drug effects (3 trials, N = 590, OR 1.65, 95% CI 0.84 to 3.24) and may slightly improve physical functioning (7 trials, N = 1329, mean difference (MD) 5.84, 95% CI 1.21 to 10.48; low-certainty evidence). Pharmacist services may make little or no difference to mortality (9 trials, N = 1980, OR 0.79, 95% CI 0.56 to 1.12, low-certaintly evidence).Of the five studies that compared services delivered by pharmacists with other health professionals, no studies evaluated the impact of the intervention on the percentage of patients outside blood pressure or glycated haemoglobin target range, hospital attendance and admission, adverse drug effects, or physical functioning.

AUTHORS' CONCLUSIONS

The results demonstrate that pharmacist services have varying effects on patient outcomes compared with usual care. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. The results need to be interpreted cautiously because there was major heterogeneity in study populations, types of interventions delivered and reported outcomes.There was considerable heterogeneity within many of the meta-analyses, as well as considerable variation in the risks of bias.

Survey of pharmacist prescribing practices in Alberta

PURPOSE

Results of a survey to characterize pharmacist prescribing in the Canadian province of Alberta are reported.

METHODS

A cross-sectional survey of a random sample of pharmacists registered with the Alberta College of Pharmacists was conducted. The survey was developed in four stages, with evidence of reliability and construct validity compiled. Analysis of variance and chi-square testing were used to compare prescribing behaviors.

RESULTS

Three hundred fifty of 692 invited pharmacists (51%) completed the survey, with 76.9% and 11.1% indicating that they practiced in community and hospital settings, respectively, and 12.0% practicing in a consultant role (i.e., on a primary care team or in a long-term care setting). Overall, 93.4% of the pharmacists had prescribed. The most common practices were renewing prescriptions for continuity of therapy (92.3%), altering doses (74.3%), and substituting a medication due to a shortage (80.6%). Twenty-three pharmacists (6.6%) indicated that they did not prescribe because they were on an interprofessional team, had a consulting role, or preferred to fax physicians to request orders. Pharmacists with additional prescribing authorization (6.3% of the total survey population) were more likely to prescribe to adjust ongoing medications (63.6%) than to initiate a new medication (18.2%).

CONCLUSION

A survey showed that Alberta pharmacists prescribed in a manner that mirrored their practice environment. Compared with other groups, hospital and consultant pharmacists were more likely to adapt prescriptions, and community pharmacists were more likely to renew medications. Pharmacists in rural areas were prescribing most frequently.

Interventions for improving modifiable risk factor control in the secondary prevention of stroke

BACKGROUND

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximise the adoption of evidence-based strategies for secondary stroke prevention. Smoking-related interventions were examined in a separate review so were not considered in this review. This is an update of our 2014 review.

OBJECTIVES

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2017), CENTRAL (the Cochrane Library 2017, issue 3), MEDLINE (1950 to April 2017), Embase (1981 to April 2017) and 10 additional databases including clinical trials registers. We located further studies by searching reference lists of articles and contacting authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

DATA COLLECTION AND ANALYSIS

Four review authors selected studies for inclusion and independently extracted data. The quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach (GRADEpro GDT).Three review authors assessed the risk of bias for the included studies. We sought missing data from trialists.The results are presented in 'Summary of findings' tables.

MAIN RESULTS

The updated review included 16 new studies involving 25,819 participants, resulting in a total of 42 studies including 33,840 participants. We used the Cochrane risk of bias tool and assessed three studies at high risk of bias; the remainder were considered to have a low risk of bias. We included 26 studies that predominantly evaluated organisational interventions and 16 that evaluated educational and behavioural interventions for participants. We pooled results where appropriate, although some clinical and methodological heterogeneity was present.Educational and behavioural interventions showed no clear differences on any of the review outcomes, which include mean systolic and diastolic blood pressure, mean body mass index, achievement of HbA1c target, lipid profile, mean HbA1c level, medication adherence, or recurrent cardiovascular events. There was moderate-quality evidence that organisational interventions resulted in improved blood pressure control, in particular an improvement in achieving target blood pressure (odds ratio (OR) 1.44, 95% confidence interval (CI) 1.09 to1.90; 13 studies; 23,631 participants). However, there were no significant changes in mean systolic blood pressure (mean difference (MD), -1.58 mmHg 95% CI -4.66 to 1.51; 16 studies; 17,490 participants) and mean diastolic blood pressure (MD -0.91 mmHg 95% CI -2.75 to 0.93; 14 studies; 17,178 participants). There were no significant changes in the remaining review outcomes.

AUTHORS' CONCLUSIONS

We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Interventions, including patient education alone, did not lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.

Pharmacists’ Impact on Secondary Stroke Prevention

Background:

Patients admitted to our institution with a cerebrovascular accident (stroke) or transient ischemic attack (TIA) are referred to the pharmacist-run stroke prevention clinic (SPC) for medication and risk factor management.

Objective:

The objective was to determine if patients receiving care from the SPC have better outcomes than patients who received usual care.

Methods:

This was a retrospective chart review of patients referred to the SPC. At the time of stroke/TIA, before initial visit, and after last SPC visit, risk factor data was collected. Hospital readmissions were reviewed for secondary stroke/TIA, myocardial infarction (MI), and new or incidental peripheral artery disease (PAD). For patients that did not attend SPC visits, data was used as a control.

Results:

Patients referred to the SPC from October 2012 to December 2014 were reviewed. 455 records were reviewed. The primary composite end point of readmission for stroke/TIA, myocardial infarction, and new or incidental PAD was statistically significantly lower in the SPC group than the control group ( P = .013). All surrogate markers, including blood pressure, Low Density Lipoprotein, Hemoglobin A1c, and smoking status, improved in the SPC group.

Conclusion:

Pharmacists can play a role in reducing risk factors for secondary stroke/TIA and prevent future hospital admissions.

Evaluating the potential for pharmacists to prescribe oral anticoagulants for atrial fibrillation

Background

Oral anticoagulant therapy (OAC) to prevent atrial fibrillation (AF)-related strokes remains poorly used. Alternate strategies, such as community pharmacist prescribing of OAC, should be explored.

Methods

Approximately 400 pharmacists, half with additional prescribing authority (APA), randomly selected from the Alberta College of Pharmacists, were invited to participate in an online survey over a 6-week period. The survey consisted of demographics, case scenarios assessing appropriateness of OAC (based on the 2014 Canadian Cardiovascular Society AF guidelines) and perceived barriers to prescribing. Regression analysis was performed to determine predictors of knowledge.

Results

A total of 35% (139/397) of pharmacists responded to the survey, and 57% of these had APA. Depending on the case scenario, 55% to 92% of pharmacists correctly identified patients eligible for stroke prevention therapy, but only about a half selected the appropriate antithrombotic agent; there was no difference in the knowledge according to APA status. In multivariable analysis, predictors significantly associated with guideline-concordant prescribing were having the pharmacist interact as part of an interprofessional team (p = 0.04) and direct OAC (DOAC) self-efficacy (confidence in ability to extend, adapt, initiate or alter prescriptions; p = 0.02). Barriers to prescribing OAC for APA pharmacists included a lack of AF and DOAC knowledge and preference for consulting the physician first, but these same pharmacists also identified difficulty in contacting the physician as a major barrier.

Interpretation and Conclusion

Community pharmacists can identify patients who would benefit from stroke prevention therapy in AF. However, physician collaboration and further training on AF and guidelines for prescribing OAC are needed.

Pharmacists as Care Providers for Stroke Patients: A Systematic Review

BACKGROUND

Pharmacists have become an integral member of the multidisciplinary team providing clinical patient care in various healthcare settings. Although evidence supporting their role in the care of patients with other disease states is well-established, minimal literature has been published evaluating pharmacist interventions in stroke patients. The purpose of this systematic review is to summarize the evidence evaluating the impact of pharmacist interventions on stroke patient outcomes.

METHODS

Study abstracts and full-text articles evaluating the impact of a pharmacist intervention on outcomes in patients with an acute stroke/transient ischemic attack (TIA) or a history of an acute stroke/TIA were identified and a qualitative analysis performed.

RESULTS

A total of 20 abstracts and full-text studies were included. The included studies provided evidence supporting pharmacist interventions in multiple settings, including emergency departments, inpatient, outpatient, and community pharmacy settings. In a significant proportion of the studies, pharmacist care was collaborative with other healthcare professionals. Some of the pharmacist interventions included participation in a stroke response team, assessment for thrombolytic use, medication reconciliation, participation in patient rounds, identification and resolution of drug therapy problems, risk-factor reduction, and patient education. Pharmacist involvement was associated with increased use of evidence-based therapies, medication adherence, risk-factor target achievement, and maintenance of health-related quality of life.

CONCLUSIONS

Available evidence suggests that a variety of pharmacist interventions can have a positive impact on stroke patient outcomes. Pharmacists should be considered an integral member of the stroke patient care team.

[Organized Post-Stroke Care through Case Management on the Basis of a Standardized Treatment Pathway : Results of a Single-Centre Pilot Study]

BACKGROUND

Post-stroke care programs based on a standardized treatment pathway supported by case management may prevent secondary stroke and minimize risk factors.

OBJECTIVES

We aimed to determine the feasibility of a standardized treatment pathway and its impact on risk factor control, life-style changes and adherence to secondary prevention medication.

METHODS

We conducted a prospective pilot study in consecutive stroke patients. The 12-month post-stroke care program included regular perosnal and phone contact with a certified case manager. Target values for vascular risk factors following current recommendations of stroke guidelines were monitored and treated if necessary. In the case of deviations from the treatment pathway the case manager intervened. Patients were screened for recurrent stroke at the end of the program after 12 months.

RESULTS

We enrolled 101 patients: 57.4 % were male, the median age was 72 (IQR, 62-80) years, median baseline NIHSS score was 2(IQR, 1-5), 79.2 % had an ischemic stroke, 3 % a hemorrhagic stroke, and 17.8 % a transient ischemic attack (TIA). Eighty-six (85.1 %) patients completed the program, 12 (11.9 %) withdrew from the program and 3 died of malignant diseases. In total, 628 personal (6.2/patient) and 2,683 phone contacts (26.6/patient) were conducted by the case manager. Three hundred-seventy-nine specific interventions were necessary mostly because of missing medication, non-compliance, and social needs. After 12 months, target goals for blood pressure, body mass index, nicotine use, and cholesterol were more frequently (p < 0.05) achieved than at baseline. No recurrent stroke occurred during the program.

CONCLUSIONS

Our pilot data demonstrate that case management-based post-stroke care is feasible and may contribute to effective secondary prevention of stroke.

A pilot study to assess the practicality, acceptability and feasibility of a randomised controlled trial to evaluate the impact of a pharmacist complex intervention on patients with stroke in their own homes

OBJECTIVE

To test the practicality, acceptability and feasibility of recruitment, data collection, blood pressure (BP) monitoring and pharmaceutical care processes, in order to inform the design of a definitive randomised controlled trial of a pharmacist complex intervention on patients with stroke in their own homes.

METHODS

Patients with new stroke from acute, rehabilitation wards and a neurovascular clinic (NVC) were randomised to usual care or to an intervention group who received a home visit at 1, 3 and 6 months from a clinical pharmacist. Pharmaceutical care comprised medication review, medicines and lifestyle advice, pharmaceutical care issue (PCI) resolution and supply of individualised patient information. A pharmaceutical care plan was sent to the General Practitioner and Community Pharmacy. BP and lipids were measured for both groups at baseline and at 6 months. Questionnaires covering satisfaction, quality of life and medicine adherence were administered at 6 months.

RESULTS

Of the 430 potentially eligible patients, 30 inpatients and 10 NVC outpatients were recruited. Only 33/364 NVC outpatients (9.1%) had new stroke. 35 patients completed the study (intervention=18, usual care=17). Questionnaire completion rates were 91.4% and 84.4%, respectively. BP and lipid measurement processes were unreliable. From 104 identified PCIs, 19/23 recommendations (83%) made to general practitioners were accepted.

CONCLUSION

Modifications to recruitment is required to include patients with transient ischaemic attack. Questionnaire response rates met criteria but completion rates did not, which merits further analysis. Lipid measurements are not necessary as an outcome measure. A reliable BP-monitoring process is required.

A Systematic Review of Randomized Controlled Trials of Medication Adherence Interventions in Adult Stroke Survivors

BACKGROUND

Stroke survivors are at an increased risk for recurrent stroke. Despite recommendations to avoid recurrence from the American Heart Association/American Stroke Association, medication adherence (MA) in persons with chronic conditions such as stroke is only 50%.

PURPOSE

The aim of this study was to synthesize randomized controlled trial intervention studies designed to increase MA in adult stroke survivors.

SEARCH METHODS

The Cumulative Index of Nursing and Allied Health Literature, PsycINFO, PubMed, and Excerpta Medica database from January 1, 2009, to December 31, 2015, were searched.

STUDY SELECTION

This study reviewed randomized controlled trials evaluating MA interventions in stroke survivors.

DATA EXTRACTION

Two reviewers independently assessed all full-text articles, and those not meeting the inclusion criteria by both researchers were excluded.

RESULTS

This review included 18 studies involving 10 292 participants. Overall, the strength of the included studies was strong. Statistically significant results were reported in 5 of the 18 (28%) studies. Of these, 3 used cognitive/behavioral interventions to increase MA, whereas 2 studies used an educational-based intervention.

CONCLUSIONS

Despite some isolated success, most MA interventions in stroke survivors do not show statistically significant improvement. Future MA research must address the lack of consistent use of objective measurement tools and focus on the long-term benefits of MA interventions.

Pharmacist independent prescribing in secondary care: opportunities and challenges

In recent years a number of countries have extended prescribing rights to pharmacists in a variety of formats. The latter includes independent prescribing, which is a developing area of practice for pharmacists in secondary care. Potential opportunities presented by wide scale implementation of pharmacist prescribing in secondary care include improved prescribing safety, more efficient pharmacist medication reviews, increased scope of practice with greater pharmacist integration into acute patient care pathways and enhanced professional or job satisfaction. However, notable challenges remain and these need to be acknowledged and addressed if a pharmacist prescribing is to develop sufficiently within developing healthcare systems. These barriers can be broadly categorised as lack of support (financial and time resources), medical staff acceptance and the pharmacy profession itself (adoption, implementation strategy, research resources, second pharmacist clinical check). Larger multicentre studies that investigate the contribution of hospital-based pharmacist prescribers to medicines optimisation and patient-related outcomes are still needed. Furthermore, a strategic approach from the pharmacy profession and leadership is required to ensure that pharmacist prescribers are fully integrated into future healthcare service and workforce strategies.

Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care

BACKGROUND

A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines.

OBJECTIVES

To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care).

SEARCH METHODS

We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed.

MAIN RESULTS

We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed.

AUTHORS' CONCLUSIONS

The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.

Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial

Background

Diabetes and hypertension are devastating, deadly, and costly conditions that are very common in seniors. Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications. However, blood pressure (BP) must be lowered carefully because seniors are also susceptible to low BP and attendant harms. Achieving “optimal BP control” (ie, avoiding both undertreatment and overtreatment) is the ultimate therapeutic goal in such patients. Regular BP monitoring is required to achieve this goal. BP monitoring at home is cheap, convenient, widely used, and guideline endorsed. However, major barriers prevent proper use. These may be overcome through use of BP telemonitoring—the secure teletransmission of BP readings to a health portal, where BP data are summarized for provider and patient use, with or without protocolized case management.

Objective

To examine the incremental effectiveness, safety, cost-effectiveness, usability, and acceptability of home BP telemonitoring, used with or without protocolized case management, compared with “enhanced usual care” in community-dwelling seniors with diabetes and hypertension.

Methods

A 300-patient, 3-arm, pragmatic randomized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors’ residences in greater Edmonton. Consenting patients will be randomized to usual care, home BP telemonitoring alone, or home BP telemonitoring plus protocolized pharmacist case management. Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data. In both telemonitored arms, providers will receive telemonitored BP data summaries. In the case management arm, pharmacist case managers will be responsible for reviewing teletransmitted data and initiating guideline-concordant and protocolized changes in BP management.

Results

Outcomes will be ascertained at 6 and 12 months. Within-study-arm change scores will be calculated and compared between study arms. These include: (1) clinical outcomes: proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range (110-129 mmHg in patients 65-79 years and 110-139 mmHg in those ≥80 years: primary outcome); additional ambulatory and home BP outcomes; A1c and lipid profile; medications, cognition, health care use, cardiovascular events, and mortality. (2) Safety outcomes: number of serious episodes of hypotension, syncope, falls, and electrolyte disturbances (requiring third party assistance or medical attention). (3) Humanistic outcomes: quality of life, satisfaction, and medication adherence. (4) Economic outcomes: incremental costs, incremental cost-utility, and cost per mmHg change in BP of telemonitoring ± case management compared with usual care (health payor and societal perspectives). (5) Intervention usability and acceptability to patients and providers.

Conclusion

The potential benefits of telemonitoring remain largely unstudied and unproven in seniors. This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes. Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada.

Trial Registration

Clinicaltrials.gov NCT02721667; https://clinicaltrials.gov/ct2/show/NCT02721667 (Archived by Webcite at http://www.webcitation.org/6i8tB20Mc)

The stroke east Saxony pilot project for organized post-stroke care: a case-control study

BACKGROUND

Low adherence to secondary prevention guidelines in stroke survivors may increase the risk for recurrent stroke and adversely impact quality of life. We aimed to determine the feasibility of a self-developed standardized post-stroke pathway and its impact on secondary stroke prevention and long-term outcome in patients with acute stroke.

METHODS

Consecutive patients with acute stroke were prospectively included in a standardized post-stroke pathway accomplished through a single certified CM (case manager), which comprised educational discussions and quarterly checkups for vascular risk factors and adherence to antithrombotic/anticoagulant medication in addition to usual care. At 12 months, we compared achieved target goals for secondary prevention, functional outcome, stroke recurrence, and vascular death with age- and gender-matched controls that received only usual care after stroke.

RESULTS

We included 45 cases and 45 controls. The following target goals were more frequently achieved in CM-patients than in controls: blood pressure (100% vs. 46.2%, P < 0.001), cholesterol (100% vs. 74.4%, P < 0.001), and body mass index (67.4% vs. 46.2%, P = 0.052). The CM-intervention emerged as an independent predictor of favorable functional outcome (mRS ≤ 2) at 12 months after adjusting for stroke severity and systemic thrombolysis (OR: 4.27; 95%CI:1.2-15.21; P = 0.025). Quality of life was rated significantly higher in CM-patients than in controls (P = 0.049). As opposed to controls, none of the cases experienced a recurrent stroke (0% vs. 13.3%; P = 0.026) or suffered from vascular death (0% vs. 6.7%; P = 0.242).

CONCLUSIONS

Our pilot data suggest that organized post-stroke care enhances achievement of secondary prevention goals. Its possible effect on stroke recurrence, long-term disability, and quality of life is currently investigated in a prospective cohort study.