McAlister Finlay A, Grover Steven, Padwal Raj S, Youngson Erik, Fradette Miriam, Thompson Ann, Buck Brian, Dean Naeem, Tsuyuki Ross T, Shuaib Ashfaq, Majumdar Sumit R
Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada; Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada; The Epidemiology Coordinating and Research Centre, University of Alberta, Edmonton, Alberta, Canada.
McGill Cardiovascular Health Improvement Program, Division of General Internal Medicine, McGill University, Montreal, Canada.
Am Heart J. 2014 Dec;168(6):924-30. doi: 10.1016/j.ahj.2014.08.001. Epub 2014 Aug 7.
Survivors of ischemic stroke/transient ischemic attack (TIA) are at high risk for other vascular events. We evaluated the impact of 2 types of case management (hard touch with pharmacist or soft touch with nurse) added to usual care on global vascular risk.
This is a prespecified secondary analysis of a 6-month trial conducted in outpatients with recent stroke/TIA who received usual care and were randomized to additional monthly visits with either nurse case managers (who counseled patients, monitored risk factors, and communicated results to primary care physicians) or pharmacist case managers (who were also able to independently prescribe according to treatment algorithms). The Framingham Risk Score [FRS]) and the Cardiovascular Disease Life Expectancy Model (CDLEM) were used to estimate 10-year risk of any vascular event at baseline, 6 months (trial conclusion), and 12 months (6 months after last trial visit).
Mean age of the 275 evaluable patients was 67.6 years. Both study arms were well balanced at baseline and exhibited reductions in absolute global vascular risk estimates at 6 months: median 4.8% (Interquartile range (IQR) 0.3%-11.3%) for the pharmacist arm versus 5.1% (IQR 1.9%-12.5%) for the nurse arm on the FRS (P = .44 between arms) and median 10.0% (0.1%-31.6%) versus 12.5% (2.1%-30.5%) on the CDLEM (P = .37). These reductions persisted at 12 months: median 6.4% (1.2%-11.6%) versus 5.5% (2.0%-12.0%) for the FRS (P = .83) and median 8.4% (0.1%-28.3%) versus 13.1% (1.6%-31.6%) on the CDLEM (P = .20).
Case management by nonphysician providers is associated with improved global vascular risk in patients with recent stroke/TIA. Reductions achieved during the active phase of the trial persisted after trial conclusion.
缺血性中风/短暂性脑缺血发作（TIA）幸存者发生其他血管事件的风险很高。我们评估了在常规治疗基础上增加两种类型的病例管理（药剂师的强硬干预或护士的温和干预）对总体血管风险的影响。
这是一项对为期6个月的试验进行的预先设定的二次分析，该试验纳入近期中风/TIA门诊患者，这些患者接受常规治疗，并被随机分配每月额外就诊，就诊对象为护士病例管理员（为患者提供咨询、监测危险因素并将结果告知初级保健医生）或药剂师病例管理员（他们也能够根据治疗算法独立开处方）。采用弗雷明汉风险评分（FRS）和心血管疾病预期寿命模型（CDLEM）来估计基线、6个月（试验结束时）和12个月（最后一次试验就诊后6个月）时发生任何血管事件的10年风险。
275例可评估患者的平均年龄为67.6岁。两个研究组在基线时情况良好，在6个月时总体血管风险估计的绝对值均有所降低：在FRS上，药剂师组中位数为4.8%（四分位间距[IQR]0.3%-11.3%），护士组为5.1%（IQR 1.9%-12.5%）（两组间P = 0.44）；在CDLEM上，中位数分别为10.0%（0.1%-31.6%）和12.5%（2.1%-30.5%）（P = 0.37）。这些降低在12个月时仍然存在：在FRS上，中位数分别为6.4%（1.2%-11.6%）和5.5%（2.0%-12.0%）（P = 0.83）；在CDLEM上，中位数分别为8.4%（0.1%-28.3%）和13.1%（1.6%-31.6%）（P = 0.20）。
非医生提供者进行的病例管理与近期中风/TIA患者总体血管风险的改善相关。在试验活跃期实现的风险降低在试验结束后仍然持续。
