Pharmacists prescribing for stroke patients shows benefits, researchers say

Stroke survivors gained better control over risk factors like cholesterol levels when a pharmacist actively adjusted their medications compared with similar patients who received counselling and management from nurses, Alberta researchers have found.

Alberta was the first province to grant pharmacists basic prescribing power. Some experienced pharmacists can earn more prescribing authority. In Mondays issue of the Canadian Medical Association Journal, researchers took advantage of that difference to evaluate how people whove had a stroke or "mini stroke" (transient ischemic attack) fare in terms of blood pressure and cholesterol levels when theyre randomly assigned to receive care from a pharmacist or a nurse as a control.

Both nurses and pharmacists:

• Counselled participants in Edmonton on diet, smoking, exercise and other lifestyle factors.
• Checked blood pressure and LDL (Low-density lipoprotein or "bad" cholesterol) levels.
• Gave summaries to the patients physician after each visit.

Pharmacists also prescribed medications based on the current Canadian guidelines and adjusted doses to achieve the best result for each patient. The patients were nearly 68 years of age on average and three quarters were already taking an antihypertensive or lipid-lowering medication when the study began.

"Compared with nurse-led case management (risk factor evaluation, counselling and feedback to primary care providers), active case management by pharmacists substantially improved risk factor control at six months among patients who had experienced a stroke," Dr. Finlay McAlister, of the internal medicine division at the University of Alberta and his co-authors concluded.

The pharmacist case managers were prescribing medications according to a standard treatment algorithm. They worked in concert with the patient's primary-care physician and the study physicians, rather than independently, McAlister said in an email.

Patients in both groups improved. Its the magnitude of the benefits that was higher with pharmacists, such as 12.5 per cent difference in meeting both systolic blood pressure (the top number, which represents the pressure when your heart contracts and pushes blood out) and LDL targets.

Pharmacists' ideal role

"We believe that both approaches hold great promise, not only for patients with stroke or transient ischemic attack but also for all patients with, or at high risk of, vascular disease, and our study provides much-needed information on their comparative effectiveness," the authors concluded.

• Slightly elevated blood pressure tied to strokes
• High blood pressure explained

The researchers only had six months of measurements for 225 patients too small and too short to tell whether the improvements pay off in fewer repeat strokes, heart attacks or deaths. Since the trial was not blinded, subjective measures like satisfaction with care could have been biased, the authors acknowledged.

The findings come as health care providers in other Canadian provinces, the U.S, U.K. and New Zealand are all moving towards having pharmacists independently or collaboratively prescribing, Dr. Cara Tannenbaum of the University of Montreal said in a 2013 study published in the same journal.

"I think that increasing life expectancy, the number of chronic conditions that patients have and the fact that people are becoming more concerned about drug side-effects and drug interactions has led to a greater acceptance by both the medical professions and the nursing professions of pharmacists playing an active role in medication management for our patients," Tannenbaum said in an interview.

"I think we're only at 20 per cent along that road," of having pharmacists perform their ideal role, Tannenbaum said.

Tannenbaum's own research focuses on improving pharmaceutical care in geriatric patients. To that end, she thinks people should know their systolic blood pressure and LDL and be able to communicate it to their different health-care professionals, who in turn can help reduce risks.

"The challenge is communicating between the different professionals," Tannenbaum said. "So if a pharmacist changes a medication dose, then how will they let the physician know in a timely manner?"

Michael Law, a pharmaceutical policy researcher at University of British Columbia, has reviewed pharmacy prescribing efforts in Canada.

In 2009, Law looked at pharmacists renewing prescriptions for chronic conditions such as hypertension and high cholesterol in B.C. He said it was hoped that if people went to a pharmacist instead of a physician for renewals then it would save doctors' time.

But Law found the renewal policy wasn't used that often. Law said he suspects that's likely because patients didn't know the service was available.

The study was funded by the Heart and Stroke Foundation of Alberta, the Alberta Foundation for Medical Research and Knowledge Translation Canada.