CMAJ. 2014 May 13;186(8):577-84. doi: 10.1503/cmaj.140053. Epub 2014 Apr 14.
Optimization of systolic blood pressure and lipid levels are essential for secondary prevention after ischemic stroke, but there are substantial gaps in care, which could be addressed by nurse- or pharmacist-led care. We compared 2 types of case management (active prescribing by pharmacists or nurse-led screening and feedback to primary care physicians) in addition to usual care.
We performed a prospective randomized controlled trial involving adults with recent minor ischemic stroke or transient ischemic attack whose systolic blood pressure or lipid levels were above guideline targets. Participants in both groups had a monthly visit for 6 months with either a nurse or pharmacist. Nurses measured cardiovascular risk factors, counselled patients and faxed results to primary care physicians (active control). Pharmacists did all of the above as well as prescribed according to treatment algorithms (intervention).
Most of the 279 study participants (mean age 67.6 yr, mean systolic blood pressure 134 mm Hg, mean low-density lipoprotein [LDL] cholesterol 3.23 mmol/L) were already receiving treatment at baseline (antihypertensives: 78.1%; statins: 84.6%), but none met guideline targets (systolic blood pressure ≤ 140 mm Hg, fasting LDL cholesterol ≤ 2.0 mmol/L). Substantial improvements were observed in both groups after 6 months: 43.4% of participants in the pharmacist case manager group met both systolic blood pressure and LDL guideline targets compared with 30.9% in the nurse-led group (12.5% absolute difference; number needed to treat = 8, p = 0.03).
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 6 months among patients who had experienced a stroke.
ClinicalTrials.gov, no. NCT00931788.
优化收缩压和血脂水平对于缺血性卒中后的二级预防至关重要，但护理中存在大量空白，这可以通过护士或药剂师主导的护理来解决。我们比较了两种类型的病例管理（药剂师主动处方或护士主导的筛查和反馈给初级保健医生），并与常规护理进行了比较。
我们进行了一项前瞻性随机对照试验，涉及近期发生轻微缺血性卒中和短暂性脑缺血发作的成年人，其收缩压或血脂水平高于指南目标。两组参与者每月接受一次为期 6 个月的访问，由护士或药剂师进行。护士测量心血管危险因素，对患者进行咨询，并将结果传真给初级保健医生（主动对照组）。药剂师除了上述所有工作外，还根据治疗算法开处方（干预组）。
在 279 名研究参与者中，大多数参与者（平均年龄 67.6 岁，平均收缩压 134mmHg，平均低密度脂蛋白[LDL]胆固醇 3.23mmol/L）在基线时已经接受治疗（抗高血压药物：78.1%；他汀类药物：84.6%），但均未达到指南目标（收缩压≤140mmHg，空腹 LDL 胆固醇≤2.0mmol/L）。两组在 6 个月后均有明显改善：与护士主导的病例管理组相比，药剂师主导的病例管理组中有 43.4%的参与者同时达到收缩压和 LDL 指南目标，而护士主导的病例管理组中只有 30.9%（12.5%的绝对差异；需要治疗的人数为 8，p=0.03）。
与护士主导的病例管理（危险因素评估、咨询和反馈给初级保健提供者）相比，药剂师主导的主动病例管理在 6 个月时显著改善了卒中患者的危险因素控制。
ClinicalTrials.gov，编号 NCT00931788。
