Researchers explore new standard of continuity of care for stroke patients

A new study from the Faculty of Medicine & Dentistry is looking at nurse- and pharmacist-led interventions to improve the standard of care for patients who have suffered minor stroke or transient ischemic attack, also known as "mini stoke."

"What we were finding was that six months or 12 months after their stroke, a lot of patients still had uncontrolled blood pressure and uncontrolled cholesterol," said Finlay McAlister (MD '90), lead author of the study. "[This factor] puts the patients at an increased risk of recurrent events, including strokes, heart attacks, amputation from peripheral vascular disease and death."

In order to improve the outcomes of these patients, McAlister and his group studied 279 individuals who had recovered well or fully after a stroke or mini stroke and were included in either nurse- or pharmacist-led interventions to improve blood pressure and cholesterol levels. Following an initial assessment at one of the three stroke prevention clinics in Edmonton, each patient had one appointment each month for six months with a nurse or pharmacist. Compared to statistics under the current standard of care, nurse-led care saw a 30 per cent improvement in blood pressure and cholesterol levels, while pharmacist-led care saw a 43 per cent improvement.

McAlister, a professor in the Division of Internal Medicine, says that each appointment consisted of the nurse or pharmacist measuring the patient's blood pressure and cholesterol levels, sending the results to the patient's primary care physician, as well as administering lifestyle advice on healthy eating, exercise, taking prescribed medications and quitting smoking.

In the nurse-led intervention, the nurses recommended to patients with blood pressure or cholesterol levels still above Canadian guideline-recommended levels that they should schedule an appointment with their primary care physician.

The pharmacists, however, had the ability to prescribe blood pressure or cholesterol lowering medication in accordance with treatment algorithms based on current Canadian guidelines for those patients whose blood pressure or cholesterol levels were still above target.

"The treatment algorithm [the pharmacists used] is based on the steps that are recommended in the Canadian guidelines [for controlling blood pressure and cholesterol]," McAlister said. "It doesn't name a specific drug; it just says start with this class, add a drug from this second class if still uncontrolled, and then add a drug from a third class if needed for achieving targets levels. The pharmacist had the option to choose the best drug within the class based on patient side effect profile, whether the patient had drug coverage, etcetera.

"Most of the blood pressures and cholesterols were dealt with and controlled fairly well by the pharmacist prescribing the medications," McAlister noted.

McAlister hopes the intervention will be rolled out in rural and smaller communities throughout Alberta, particularly those without a stroke prevention clinic.