Integration of a Pharmacist into a Stroke Prevention Clinic Team
Stroke is the fourth leading cause of death in Canada, accounting for 14 000 deaths annually. Between 40 000 and 50 000 strokes occur every year, 75% of which result in some type of impairment or disability. Stroke survivors have a 20% risk of another stroke within 2 years of the initial event, and 33% of all strokes are thought to be repeat episodes. The use of antiplatelet agents and the management of risk factors, such as smoking, diabetes, atrial fibrillation, physical inactivity, excessive alcohol intake, hypertension, and dyslipidemias, are key to preventing recurrent stroke.
Although numerous studies have demonstrated that patient outcomes improve when pharmacists are involved in cardiovascular risk reduction and anticoagulation management, few publications have outlined pharmacists’ involvement in secondary stroke prevention. The purposes of this paper are to describe the rationale for pharmacist involvement in a stroke prevention clinic, to outline the role of the pharmacist in the clinic, and to retrospectively evaluate the pharmacist’s workload, to determine the number and nature of the patient care interventions performed.
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RATIONALE FOR PHARMACIST INVOLVEMENT
The participation of pharmacists in patient care may improve quality of life and medication adherence, while decreasing prescribing errors, morbidity, and mortality. Studies have also demonstrated consistent benefits of pharmacist involvement in the management of hypertension and dyslipidemia, 2 of the major modifiable risk factors targeted in stroke prevention. In one study, comanagement of hypertension by pharmacists and physicians (whereby the pharmacist was responsible for patient education and for recommending drug therapy changes to the physicians) resulted in significant reductions in blood pressure and increases in the number of patients who reached their blood pressure targets relative to physician management alone (60% versus 43%, p = 0.02). In another study, which was conducted in a multidisciplinary primary care unit, pharmacists provided patient education and made drug therapy recommendations to physicians, which resulted in significant decreases in blood pressure levels and led to more patients achieving target blood pressure readings relative to patients who received no pharmacist care (61% versus 41%, p = 0.017). In a smaller study, significantly more of the patients who were randomly assigned to attend monthly meetings with a clinical pharmacist (who changed medications and doses and provided hypertension education) experienced blood pressure control than patients with physician management alone (81% versus 30%, p < 0.0001). Similar results have also been obtained in community pharmacy settings.
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Several retrospective studies have highlighted the benefits of pharmacist involvement in cholesterol management.12-14 Cording and others found that 77% of patients achieved their low-density lipoprotein (LDL) goal after participation in a pharmacist-managed lipid clinic, compared to 44% at baseline. Till and others16 found that serum concentrations of LDL declined by an average of 18.5% when patients were followed in a pharmacist-managed lipid clinic; the mean reduction observed in the control group was 6.5%.
Prospective studies have also demonstrated the benefit of pharmacist interventions in cholesterol management. The Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) was a randomized controlled trial of 675 patients at high risk for cardiovascular events, who received either an intervention by a community pharmacist or usual care. Patients in the intervention arm received point-of-care cholesterol testing and standardized education about their cardiovascular risk factors. The pharmacist then made recommendations to the patient’s family physician. The primary composite endpoint of a complete fasting cholesterol panel (ordered by the patient’s physician), a new prescription for a cholesterol-lowering medication, or a change in dose of cholesterol-lowering medication was reached for 57% of patients in the intervention group and 31% in the usual-care group (p < 0.001). viagra soft
SCRIP-plus was a before—after study of the effect of a community pharmacist management program on serum cholesterol concentrations among patients considered to be at high risk for cardiovascular events. A 13% reduction in LDL levels was observed at 6 months (p < 0.0001), and 27% of the participants achieved their target LDL levels (95% confidence interval 23% to 32%).
Overall, the evidence for pharmacist involvement in cholesterol and blood pressure management is substantial. Therefore, the impact that a pharmacist could have on modifiable risk factors for stroke in a stroke prevention clinic would be significant. This impact might translate into a reduction in rates of recurrent stroke.
