Integrating clinical pharmacists in care management for secondary stroke prevention clinical trials: a scoping review

Introduction: Clinical pharmacist (CP) integration within interprofessional healthcare team models may effectively provide secondary stroke prevention care and address healthcare disparities.

Methods: This scoping review includes randomized controlled trials (RCTs) that evaluated the effect of interventions inclusive of team-based care by CPs on patient-oriented and health outcomes after stroke or transient ischemic attack (TIA). Search databases included MEDLINE/PubMed, EMBASE, and CINAHL, and ClinicalTrials.gov and the International Standard Randomised Controlled Trial Number (ISRCTN) trial registries. We describe the level of interaction between interprofessional team members, use of telehealth services, population diversity, and intervention effects on study outcomes.

Results: Of 132 RCTs, 14 met inclusion criteria and incorporated CPs in the intervention. These studies were conducted globally and included outcome measures such as medication adherence, morbidity and mortality, and vascular risk factor goal attainment. Twelve trials included multidisciplinary models, while two included interdisciplinary models, and none incorporated transdisciplinary models. Telehealth was leveraged in 8 of 14 trials. One study reported on healthcare disparities associated with poor risk factor control. Positive intervention effects were notable for goal attainment (4 of 10 trials).

Discussion: Published RCTs examining CP impact within secondary stroke prevention teams with limited data suggests that interventions inclusive of CPs delivering medication education, reconciliation, and titration may improve vascular risk factor control, medication adherence, and patient-oriented outcomes. We highlight the need for future secondary stroke prevention clinical trials to provide more insight into CP integration, promote diversity in study populations and clinician roles, and incorporate telehealth to enhance healthcare access.

Introduction

Each year in the U.S., about 795,000 strokes occur, including 185,000 recurrent events (1). Most are preventable, with 90.5% of the global stroke burden linked to modifiable risk factors like hypertension, diabetes, and dyslipidemia (2). Recent guidelines support tailored risk factor management and multidisciplinary, team-based care to enhance secondary stroke prevention (3).

Racial and ethnic minorities face a disproportionate burden of vascular risk factors and higher stroke recurrence rates due to healthcare inequities. These populations often encounter barriers to care such as access to medications, language challenges, mistrust of healthcare, low health literacy, and systemic racism (4–6). Team-based care may address these disparities through coordinated, patient-centered services (7, 8).

Traditionally, neurologists have led post-stroke care, but an aging population (9) and neurologist shortages (10, 11) highlight the need for interprofessional co-management. Within collaborative team-based models, team dynamics differ by disciplinary interaction (Figure 1). “Multidisciplinary” team works in parallel, while “interdisciplinary” signifies integrated services and “transdisciplinary” describes roles sharing across disciplines (12).

Figure 1

Figure 1. Types of team-based models. Disciplinary defined as independent pharmacist services without collaboration; multidisciplinary defined as multiple disciplines working in coordinated, yet separated services; interdisciplinary defined as multiple disciplines working together to provide care simultaneously; transdisciplinary defined as disciplines working together with less defined healthcare roles and services that transcend these traditional discipline roles (12).

Clinical pharmacists (CPs) are highly accessible medication experts who can support complex medication education and management at transitions of care (13–15). Within ambulatory post-stroke care, CPs can titrate medications, monitor adherence, and order labs to optimize risk factors. While all pharmacists hold advanced degrees (e.g., PharmD) and licensure, CPs can provide more advanced ambulatory care services, often administered through in-person or telehealth visits. Further, under Collaborative Practice agreements (CPAs), they can independently prescribe and manage medication therapy (16).

There is limited research that explores CP integration into secondary stroke prevention, particularly regarding health equity and telehealth (17). This review evaluates RCTs involving CP-inclusive care teams within secondary stroke prevention and examines the diversity of studied populations (18). Findings may inform future models to improve adherence, prevent recurrence, and reduce disparities in post-stroke care.

Methods

We conducted a structured scoping review to summarize the range and characteristics of research evaluating interventions inclusive of CPs to improve secondary prevention outcomes in patients with stroke and transient ischemic attack (TIA). We chose a scoping review for this purpose instead of a systematic review to capture trial designs, interventions, and outcomes of all posted studies to guide future research and practice priorities. Our scoping review followed reporting guidelines of Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) (Figure 2; Supplementary material) (19).

Figure 2

Figure 2. PRISMA diagram (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) including searches of databases, registers and other sources. *Databases included Ovid MEDLINE/PubMed, EMBASE, and CINAHL. Trial registers included ClinicalTrials.gov and International Standard Randomized Controlled Trial Number (ISRCTN). This included all studies submitted to the trial registers and/or published from database inception until 12 March 2024. **Reasons for record exclusion include studies that examined primary stroke prevention, did not include outpatient visits in the intervention, or did not examine stroke-specific outcomes. ***Outcome analysis not specific to stroke included any composite cardiovascular outcomes that included conditions outside of stroke (e.g., Sudden cardiac arrest).

Search strategy

We searched Ovid MEDLINE/PubMed, EMBASE, CINAHL, ClinicalTrials.gov, and ISRCTN using the query: “((stroke OR transient ischemic attack) AND (pharmacist OR pharmacists)),” filtered for randomized controlled trials (RCTs). Searches included from the trial registries and/or published from database inception until 12 March 2024. Additional studies were identified by manually searching bibliographies from included articles.

Selection of studies

We included RCTs enrolling adults (≥18 years) with stroke or TIA that tested secondary prevention interventions involving CPs in ambulatory settings. Studies were excluded if they focused on primary prevention, did not specify stroke-related outcomes, lacked ambulatory care components, or were non-randomized, observational, or non-English. Economic and process evaluations were excluded from the systematic search but are referenced in the discussion. An additional RCT abstract was identified from a recent systematic that focused on pharmacist roles in both primary and secondary prevention through 2021 but excluded ongoing trials (17, 20).

Three authors (J.T., H.L., I.A.N.) independently screened titles, abstracts, and full texts, reaching consensus at each stage. Data extraction was performed by one author (J.T.) using a standardized form and reviewed by two others (H.L., I.A.N.) for accuracy. These included information about the study site, study methods, patient population, interdisciplinary model, mode of delivery for patient visits, CP interventions, CP scope of practice (prescribing authority. no prescribing authority), interventional phase of care (assessed as time since stroke event), outcome measures, and study results. Study authors also extracted information on the timing and duration of intervention of any qualifying stroke event.

Consistent with a scoping review, evaluation of the methodological quality for each study was not conducted with the intention to include all available evidence. A narrative account was gathered by intervention type and outcomes with a focus on pharmacist engagement in team-based care models.

Results

Results of the search

Of 132 unique randomized controlled trials identified, 14 RCTs met inclusion criteria for this review – 13 through search strategies and one through manual selection (17, 20). Eight studies were excluded with outcomes analyses not specific to stroke, such as composite cardiovascular health outcomes that included, for example, cardiac arrest in addition to stroke.

Included studies

Of the 14 RCTs included, five are published with results (8, 21–24), four have been posted but are still pending results (25–28), one study has only been published as an abstract (20), and four studies are posted in trial databases, but still in progress (29–32). We included a secondary analysis of one of these original studies within our review, but did not consider this as a separate RCT for inclusion (23, 33).

All 14 studies included at least one site considered as an urban setting, while three studies (25, 30, 32) included sites in suburban settings (34). While numerous studies reported demographic data, only one study targeted these disparities (8). This study identified patient factors among their study population that are associated with poor blood pressure (BP) control, such as Black and Hispanic race/ethnicity, lower socioeconomic status, and low health literacy (8, 35, 36). Race and ethnicity reporting from all RCTs is reported in Table 1. A visual summary of all results is depicted in Figure 3.

Table 1

Table 1. Secondary stroke prevention RCTs demographics report.

Figure 3

Figure 3. Graphic representation of randomized clinical trials engaging clinical pharmacist interventions and outcome measures for secondary stroke prevention.

Intervention timing and duration

Most (11 of 14) study designs incorporated a 6-month (6 of 14 studies) (20–24, 31) or 12-month (5 of 14 studies) (25, 27, 29, 30, 32) intervention period. Clinical pharmacist interventions occurred within three months of a stroke event in two studies (8, 25), within six months post-stroke in four studies (22, 24, 28, 31), and within 12 months post-stroke in two studies (27, 30). Conversely, one study only looked at patients who had sustained a chronic stroke event at least 12 months prior to any intervention (21). Three studies (23, 29, 32) included interventions for patients less than or greater than 12 months post-stroke and two studies (20, 26) did not specify duration.

Clinical pharmacist roles

Of the 13 studies that described the CP roles, the most common CP contribution included medication education/counseling (13 of 13 studies), adherence assessment and education/counseling (12 of 13 studies) (8, 20–30), lifestyle education/counseling (10 of 13 studies) (8, 21–24, 26, 27, 29–31), and identification of medication-related adverse effects (10 of 13 studies) (8, 21, 22, 24–28, 30, 31). The least common were lab assessment (4 of 13 studies) (23, 26, 28, 31) and medication titration (5 of 13 studies) (23, 26, 28, 31, 32). Four of these studies (23, 26, 31, 32) confirmed that CPs had expanded practice scope, allowing them to independently make these medication titration decisions for patients. One other study that included medication titration as an intervention did not specify this (28). Clinical pharmacist intervention details are summarized in Table 2.

Table 2

Table 2. Clinical pharmacist interventions in secondary stroke prevention trials.

Types of team-based models

Most studies included multidisciplinary or interdisciplinary components, while no studies had transdisciplinary components. In two studies, CPs saw patients independently, without close coordination with any other healthcare professionals (22, 23). Twelve studies instead included a multidisciplinary model, allowing CPs to work with other disciplines in coordinated, but separate services (8, 20, 21, 24–32). Two of these 12 studies also utilized interdisciplinary pharmacist care, in which CPs worked together with other healthcare professionals to provide care during the same visit (28, 31). In both cases, the control group was designated as the multidisciplinary component, while the interventional group was the interdisciplinary component.

Mode of delivery

Modes of care delivery varied across studies, and each study often included multiple types of delivery in their methods. These forms of care delivery included telephone visits (7 of 14 studies) (20, 22, 24, 25, 28, 30, 31), in-person ambulatory visits (6 of 14 studies) (21–24, 27, 30), in-person visits at discharge (6 of 14 studies) (22, 24, 25, 27, 28, 30), and video visits (4 of 14 studies) (8, 24, 28, 31). The mode of delivery could not be assessed based on available information for two of the included ongoing studies (29, 32).

Intensity of intervention visits

For six out of 14 included studies, ambulatory CP follow-up visits were scheduled more frequently at the start of study periods (i.e., weekly or bi-weekly), followed by less frequent visits (i.e., monthly or quarterly) (22, 25, 28–31). In some cases, patients were only seen once monthly (4 of 14 studies) (8, 21, 23, 24) or once every three months (2 of 14 studies) (20, 27) from the start of the study period. Two of the studies that have not reported results also did not report the frequency of CP visits (29, 32). “Usual Care” differed significantly across studies, and follow-up schema that was specifically noted in the studies are listed in Table 3.

Table 3

Table 3. Clinical pharmacists integration in secondary stroke prevention: detail of trials, measures and results.

Outcome measures

Study outcome measures were categorized by the study authors into patient-oriented outcomes, feasibility of service implementation, and clinical efficacy outcomes. Of the seven trials that reported results, six had less than 10% of study participants withdraw prior to the final follow-up visit (8, 20–24). One of these did not publish results and did not have outcomes data for greater than 30% of participants in both groups (28). An overview of the methodologies and outcomes are reported in Table 3.

Outcome results from completed trials

Complete outcome results were available in the five of the included trials (8, 21–24), as well as the one included abstract (20). Another included RCT reported some results within the clinical trial database, but these were not statistically analyzed and interpretations could not be made due to a high patient drop-out rate (28).

Of the four studies with medication adherence results, two studies showed approximately 15 to 30% greater improvement in medication adherence rates within the CP-inclusive intervention group compared with the non-CP control group as measured by medication fill-data (20) or adherence questionnaire (24). Only one of the six trials with available results assessed other patient-oriented outcomes, such as patient satisfaction, and QOL measures, both of which improved in the intervention (CP) group (37). This study also assessed feasibility, and demonstrated that both patient adherence to study visits and patient retention were significantly higher in the multidisciplinary intervention group (91% vs. 75 and 84% vs. 64%, respectively) (8).

One study reported a composite clinical endpoint of death, myocardial infarction (MI), or hemorrhagic or ischemic stroke, which showed no significant difference between groups (22). Similarly, one study that only assessed patient mortality as an endpoint saw no appreciable difference between groups (23). One study that only assessed re-admissions as a clinical endpoint, however, showed that a lower percentage of patients within the intervention group had a re-admission within a 6-month period than the control group (7.1% vs. 18.3%, respectively) (24). Lastly, a secondary analysis of one of the studies that assessed models of future vascular event risk and life expectancy showed a non-significant difference between groups (33).

Among the five studies that reported results for patients meeting combined goals of vascular risk factor control including BP, glycemic, or lipid-lowering goals, all studies showed at least one area of significant benefit within the intervention group, without any worsened outcomes for any of these goals (8, 20, 21, 23, 24).

Of those studies that specifically assessed BP control, the percentage of patients with controlled BP by the end of the study ranged from 16% (20) to 22% (21) higher in the intervention group than the control group. Within the one study that focused on addressing healthcare racial/ethnic disparities, attainment of BP goals was specifically reported for Black and Hispanic patients, both of which had higher goal attainment in the intervention group than the control group (100% vs. 29 and 62% vs. 17%, respectively) (8, 35, 36). Another study did not demonstrate a significant difference between race/ethnicity groups, but did determine that the CP-inclusive intervention group goal attainment was nominally higher (89.3% vs. 76.8%) than the non-CP control group (24). One study looked at the combined attainment of BP and lipid control goals, which saw 43.4% attainment in the intervention group vs. 30.9% in the control group (23). This study did not examine differences between race/ethnicity.

Three studies reported lipid-lowering goals and glycemic control independent of other achieved goals, and all showed improvement in the intervention group, ranging from approximately 14–25 percentage points higher in lipid goal attainment versus the control group by the end of the studies (20, 21, 24). For attainment of glycemic goals, these were 10–35% higher in the intervention group versus the control group by the end of the studies (20, 21, 24).

In terms of absolute value change of patients’ BP measurements, the one study that examined healthcare disparities showed that intervention group patients, regardless of race/ethnicity, had average systolic blood pressure (SBP) measurements that were 13 mmHg lower than the control group by the end of the study (8). Another study reported the absolute change in BP, low-density lipoprotein (LDL) and fasting blood glucose (FBG), all of which were significantly lower by the end of the study in the intervention group, but only significantly lower for FBG in the control group (21).

Discussion

Based on our findings from all selected trials, the study team established foundational elements that have been included in these trials to facilitate the integration of CPs within interprofessional post-stroke team models with the aim of enhancing patient care (Figure 4). The proposed framework recognizes the differences among systems and suggests flexibility when implementing the practice model. However, the core element remains the same: integrating CP services with an advanced scope to promote interdisciplinary co-management.

Figure 4

Figure 4. Proposed foundational elements for integration of clinical pharmacists within post-stroke ambulatory care teams.

We found five completed RCTs (8, 21–24) and one RCT abstract that integrated CPs within outpatient secondary stroke prevention to provide value-based care (38) for patients (20). Of note, all trials enrolled fewer than 300 participants and none evaluated real-world effectiveness. Despite limited evidence, most trials showed improvements in clinical and patient-reported outcomes, particularly in surrogate markers (e.g., BP, glucose), and no studies reported harm from CP interventions.

Medication adherence outcomes were included in the majority of studies, but varied on if they were collected via medication fill history [e.g., Medication Possession Ratio (39)] or reported by the patient via questionnaires [e.g., Morisky Medication Adherence Scale (40)]. Future studies should consider combining both approaches for more robust adherence assessment.

CP integration has shown to be effective in managing chronic conditions, such as chronic kidney disease and mental health disorders (41–43). Of the studies included in this review, CPs primarily provided patient education, adherence support, and risk factor counseling. Few studies included CPs with prescribing authority, though such roles – often accredited through residency and/or board certification – have shown a positive impact on clinical and financial outcomes (44, 45).

Only four trials featured CPs with an advanced scope of practice, all in North America. One demonstrated a statistically significant improvement in BP and lipid control (23), while three are still pending results or are ongoing (26, 31, 32). Many countries may not have legislation to support collaborative agreements, which could affect the breadth of services that a CP can provide in team-based healthcare models globally. Regardless, this represents an opportunity to increase the utilization of CPs with appropriate training to take on expanded roles (41).

Three of the four trials that included CPs with prescribing authority also employed interdisciplinary models, suggesting these CP roles may complement team-based care. No trials included transdisciplinary models, where roles are shared across disciplines. While evidence is limited in stroke care, CPs have shown promise in transdisciplinary teams within ambulatory palliative care (46).

Telehealth has improved access to acute stroke management within healthcare systems, but inequities must be addressed in the delivery of ambulatory services (47). This mode of health service delivery has been shown to be equivalent or more clinically effective when compared to “usual care” across various disciplines and has been demonstrated to increase patient satisfaction with healthcare services (8, 48–50). Other studies have similarly demonstrated positive outcomes from incorporating CP services via telehealth for chronic disease management (51–53). The studies in this review also suggest that telehealth is a feasible mode of CP integration, with its use in over half (8 of 14 studies) (8, 20, 22, 24, 25, 28, 30, 31) of the included trials. Still, few studies assessed implementation feasibility or patient-centered outcomes, highlighting a gap in real-world applicability.

Barriers to CP integration may include regulatory limits, provider resistance, reimbursement issues, and lack of awareness of CP capabilities (54). Nonetheless, economic modeling from the 2015 RxACTION study, which assessed the impact of pharmacist-led antihypertensive medication management, showed that pharmacist interventions were associated with a cost savings of $1.137 trillion and could save an estimated 30.2 million patient life years over 30 years (45, 55). This study suggests that pharmacist-led care can produce significant cost savings and improve health outcomes, even if not specific to post-stroke care.

Most trials lacked data on patient race, ethnicity, socioeconomic status, or rural representation, underscoring the need for more inclusive research. Future analyses delineating CP contribution toward patient-oriented outcomes in multi-component interventions may help identify CP impact on reducing disparities and promoting healthcare equity in post-stroke secondary prevention.

Strengths and limitations

Our team members from different disciplines collaboratively contributed to this body of research through scientific teamwork (56). The scoping review included multiple electronic databases and searched terminologies to be comprehensive. To maximize the utility of the review, all relevant clinical trial findings are reported, including ongoing trials reported in clinical trials databases. We can only speculate that there may be negative findings or lack of follow-up leading to data not being captured and reported.

Additionally, the included trials were heterogeneous, from how “usual care” was delivered in control groups, to categories of CP interventions and prescribing privileges, which precluded recommendations of a standardized approach. Differences in study design, such as the care system employed, frequency and time frame of interventions, and how outcomes were assessed may have caused discrepancies in findings, such as CP impact on medication adherence. Further, the lack of consistent reporting on healthcare disparities made it challenging to interpret the generalizability of reported outcomes. Our review’s definitions of urban, suburban, and rural were based on United States census information (34), which may have not been accurate for analyzing the setting of trials in other countries.

Finally, some assumptions were made in reporting CP interventions in each trial, as most did not report CP services in specific detail. Therefore, we may not have captured all services performed by CPs. Future trials should quantify specific CP interventions contributing specifically to overall study outcomes.

Conclusion

Our review of the available evidence demonstrates that the addition of CPs may lead to improved clinical and patient-centered outcomes in secondary stroke prevention, but studies with fully reported results are limited. Team-based models have the potential to provide value-based care and optimize healthcare systems. It is evident that ambulatory CPs are being effectively integrated into different collaborative team-based models within these globally conducted trials. Herein lies an opportunity for purposeful utilization of CP services to reduce health inequities in post-stroke care and assess their impact in real-world settings. This should be informed by adequate trial reporting of study outcomes among minoritized populations to inform equitable health care policy.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

JT: Data curation, Formal analysis, Investigation, Methodology, Software, Writing – original draft. HL: Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – review & editing. IK: Methodology, Supervision, Validation, Writing – review & editing. IN: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing.

Funding

The author(s) declare that no financial support was received for the research and/or publication of this article.

Acknowledgments

The authors of this study would like to acknowledge Eugenio Solis de Ovando, MA, Yuliya Barratt, PharmD, and Nadine Dandan, PharmD.

Conflict of interest

IN reports funding from NIH National Institute of Neurological Disorders and Stroke (K23NS138698), and from American Heart Association Grant # 923718/Doris Duke Foundation/Columbia University Vagelos College of Physicians.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The authors declare that no Gen AI was used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

1. Martin, SS, Aday, AW, Almarzooq, ZI, Anderson, CAM, Arora, P, Avery, CL, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation. (2024) 149:e347–913. doi: 10.1161/CIR.0000000000001209

PubMed Abstract | Crossref Full Text | Google Scholar

2. Feigin, VL, Roth, GA, Naghavi, M, Parmar, P, Krishnamurthi, R, Chugh, S, et al. Global burden of stroke and risk factors in 188 countries, during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol. (2016) 15:913–24. doi: 10.1016/S1474-4422(16)30073-4

PubMed Abstract | Crossref Full Text | Google Scholar

3. Kleindorfer, DO, Towfighi, A, Chaturvedi, S, Cockroft, KM, Gutierrez, J, Lombardi-Hill, D, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. (2021) 52:e364–467. doi: 10.1161/STR.0000000000000375

PubMed Abstract | Crossref Full Text | Google Scholar

4. Ross, JS, Halm, EA, and Bravata, DM. Use of stroke secondary prevention services: are there disparities in care? Stroke. (2009) 40:1811–9. doi: 10.1161/STROKEAHA.108.539619

PubMed Abstract | Crossref Full Text | Google Scholar

5. Tuhrim, S, Cooperman, A, Rojas, M, Brust, JCM, Koppel, B, Martin, K, et al. The association of race and sex with the underuse of stroke prevention measures. J Stroke Cerebrovasc Dis. (2008) 17:226–34. doi: 10.1016/j.jstrokecerebrovasdis.2008.02.003

PubMed Abstract | Crossref Full Text | Google Scholar

6. Cruz-Flores, S, Rabinstein, A, Biller, J, Elkind, MS, Griffith, P, Gorelick, PB, et al. Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. (2011) 42:2091–116. doi: 10.1161/STR.0b013e3182213e24

PubMed Abstract | Crossref Full Text | Google Scholar

7. Bushnell, C. Achieving Blood Pressure Goals and Addressing Inequities in Blood Pressure Management After Stroke. J Am Heart Assoc. (2024) 13:e031307. doi: 10.1161/JAHA.123.031307

PubMed Abstract | Crossref Full Text | Google Scholar

8. Naqvi, IA, Strobino, K, Kuen Cheung, Y, Li, H, Schmitt, K, Ferrara, S, et al. Telehealth After Stroke Care Pilot Randomized Trial of Home Blood Pressure Telemonitoring in an Underserved Setting. Stroke. (2022) 53:3538–47. doi: 10.1161/STROKEAHA.122.041020

PubMed Abstract | Crossref Full Text | Google Scholar

9. Bureau UC. Demographic Turning Points for the United States: Population Projections for 2020 to 2060. (2024). Available online at: https://www.census.gov/library/publications/2020/demo/p25-1144.html (Accessed 27 December 2024).

Google Scholar

10. AAMC. The complexities of physician supply and demand: projections from 2021 to 2036. (2024). Available online at: https://www.aamc.org/media/75236/download?attachment (Accessed 27 December 2024).

Google Scholar

11. Majersik, JJ, Ahmed, A, Chen, IHA, Shill, H, Hanes, GP, Pelak, VS, et al. A Shortage of Neurologists – We Must Act Now: A Report From the AAN 2019 Transforming Leaders Program. Neurology. (2021) 96:1122–34. doi: 10.1212/WNL.0000000000012111

PubMed Abstract | Crossref Full Text | Google Scholar

12. Choi, BCK, and Pak, AWP. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med. (2006) 29:351–64.

Google Scholar

13. Tsuyuki, RT, Beahm, NP, Okada, H, and Al Hamarneh, YN. Pharmacists as accessible primary health care providers: Review of the evidence. Can Pharm J. (2018) 151:4–5. doi: 10.1177/1715163517745517

PubMed Abstract | Crossref Full Text | Google Scholar

14. Dunn, SP, Birtcher, KK, Beavers, CJ, Baker, WL, Brouse, SD, Page, RL II, et al. The role of the clinical pharmacist in the care of patients with cardiovascular disease. J Am Coll Cardiol. (2015) 66:2129–39. doi: 10.1016/j.jacc.2015.09.025

PubMed Abstract | Crossref Full Text | Google Scholar

15. Milfred-Laforest, SK, Chow, SL, Didomenico, RJ, Dracup, K, Ensor, CR, Gattis-Stough, W, et al. Clinical pharmacy services in heart failure: an opinion paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network. J Card Fail. (2013) 19:354–69. doi: 10.1016/j.cardfail.2013.02.002

PubMed Abstract | Crossref Full Text | Google Scholar

16. American College of Clinical Pharmacy. Standards of practice for clinical pharmacists. Pharmacotherapy. (2014) 34:794–7. doi: 10.1002/phar.1438

PubMed Abstract | Crossref Full Text | Google Scholar

17. Al-Qahtani, S, Jalal, Z, Paudyal, V, Mahmood, S, and Mason, J. The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis. Healthcare. (2022) 10:2315. doi: 10.3390/healthcare10112315

PubMed Abstract | Crossref Full Text | Google Scholar

18. Turner, BE, Steinberg, JR, Weeks, BT, Rodriguez, F, and Cullen, MR. Race/ethnicity reporting and representation in US clinical trials: A cohort study. Lancet Regional Health Am. (2022) 11:100252. doi: 10.1016/j.lana.2022.100252

PubMed Abstract | Crossref Full Text | Google Scholar

19. Tricco, AC, Lillie, E, Zarin, W, O'Brien, KK, Colquhoun, H, Levac, D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. (2018) 169:467–73. doi: 10.7326/M18-0850

PubMed Abstract | Crossref Full Text | Google Scholar

20. Nguyen, VHV, Poon, J, Tokuda, L, Sayers, J, Wallis, RA, Dergalust, S, et al. Pharmacist Telephone Interventions Improve Adherence to Stroke Preventive Medications and Reduce Stroke Risk Factors: A Randomized Controlled Trial. Philadelphia, PA, USA: Lippincott Williams and Wilkins (2011).

Google Scholar

21. Chiu, CC, Wu, SS, Lee, PY, Huang, YC, Tan, TY, and Chang, KC. Control of modifiable risk factors in ischemic stroke outpatients by pharmacist intervention: an equal allocation stratified randomized study. J Clin Pharm Ther. (2008) 33:529–35. doi: 10.1111/j.1365-2710.2008.00940.x

PubMed Abstract | Crossref Full Text | Google Scholar

22. Hedegaard, U, Kjeldsen, LJ, Pottegård, A, Bak, S, and Hallas, J. Multifaceted intervention including motivational interviewing to support medication adherence after stroke/transient ischemic attack: a randomized trial. Cerebrovasc Dis Extra. (2014) 4:221–34. doi: 10.1159/000369380

PubMed Abstract | Crossref Full Text | Google Scholar

23. McAlister, FA, Majumdar, SR, Padwal, RS, Fradette, M, Thompson, A, Buck, B, et al. Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial. CMAJ. (2014) 186:577–84. doi: 10.1503/cmaj.140053

PubMed Abstract | Crossref Full Text | Google Scholar

24. Wang, J, Wang, J, Qiu, S, Zhou, C, Zhang, H, Li, Q, et al. Pharmaceutical care program for ischemic stroke patients: a randomized controlled trial. Int J Clin Pharm. (2021) 43:1412–9. doi: 10.1007/s11096-021-01272-9

PubMed Abstract | Crossref Full Text | Google Scholar

25. Indredavik, B. Systematic Follow up of Drug Treatment by Pharmacists in Secondary Prevention After Transient Ischemic Attack. Available online at: https://clinicaltrials.gov/study/NCT02089074. (2017) (Accessed January 26, 2024).

Google Scholar

26. Olson, KL. An Evaluation of Clinical Pharmacist-led Intervention on Clinical Outcomes in Patients With Ischemic Stroke. (2018). Available online at: https://clinicaltrials.gov/study/NCT01876667 (Accessed January 26, 2024).

Google Scholar

27. Sancar, M. Effects of Pharmaceutical Care in Stroke Patients. (2023); Available online at: https://clinicaltrials.gov/study/NCT06129318 (Accessed January 26, 2024).

Google Scholar

28. Sharrief, A. Stroke Telemedicine Outpatient Prevention Program for Blood Pressure Reduction (STOP-Stroke). Available online at: https://clinicaltrials.gov/study/NCT03923790. (2022) (Accessed January 26, 2024).

Google Scholar

29. Bashier Imam, YZ, and El Khawad Mohamed Ahmed, NK. Prospective study to optimize the health of patients with TIAS (transient ischemic attack) and stroke admitted to the Hamad General Hospital (PROMOTE-HEALTH). (2018). Available online at: https://clinicaltrials.gov/study/NCT02868723 (Accessed January 26, 2024).

Google Scholar

30. Janoly-Dumenil, A, and Dupuis, M. Impact of a Pluriprofessional Intervention to Improve Medication Adherence (Secondary Preventive Medication) in Patients After Ischemic Stroke (ADMED-AVC). Available online at: https://clinicaltrials.gov/study/NCT02611440 (2019) (Accessed January 26, 2024).

Google Scholar

31. Sharrief, A. Video-based Intervention to Address Disparities in Blood Pressure Control After Stroke (VIRTUAL). Available online at: https://clinicaltrials.gov/study/NCT05264298. (2024) (Accessed January 26, 2024).

Google Scholar

32. Ayala-Rivera, M, Towfighi, A, and Casillas, A. Reducing Blood Pressure in Patients With High Cardiovascular Risk in the Safety-Net (BP-REACH). (2023); Available online at: https://clinicaltrials.gov/study/NCT05937685 (Accessed January 26, 2024).

Google Scholar

33. McAlister, FA, Grover, S, Padwal, RS, Youngson, E, Fradette, M, Thompson, A, et al. Case management reduces global vascular risk after stroke: secondary results from the the preventing recurrent vascular events and neurological worsening through intensive organized case-management randomized controlled trial. Am Heart J. (2014) 168:924–30. doi: 10.1016/j.ahj.2014.08.001

PubMed Abstract | Crossref Full Text | Google Scholar

34. Ratcliffe, M. Redefining Urban Areas following the 2020 Census. (2020) United States Census Bureau. Available online at: https://www.census.gov/newsroom/blogs/random-samplings/2022/12/redefining-urban-areas-following-2020-census.html. (Accessed 22 December 2020).

Google Scholar

35. White, CL, Pergola, PE, Szychowski, JM, Talbert, R, Cervantes-Arriaga, A, Clark, HD, et al. Blood Pressure After Recent Stroke: Baseline Findings From the Secondary Prevention of Small Subcortical Strokes Trial. Am J Hypertens. (2013) 26:1114–22. doi: 10.1093/ajh/hpt076

PubMed Abstract | Crossref Full Text | Google Scholar

36. Brenner, DA, Zweifler, RM, Gomez, CR, Kissela, BM, Levine, D, Howard, G, et al. Awareness, Treatment, and Control of Vascular Risk Factors among Stroke Survivors. J Stroke Cerebrovasc Dis. (2010) 19:311–20. doi: 10.1016/j.jstrokecerebrovasdis.2009.07.001

PubMed Abstract | Crossref Full Text | Google Scholar

37. Naqvi, IA, Strobino, K, Li, H, Schmitt, K, Barratt, Y, Ferrara, SA, et al. Improving Patient-Reported Outcomes in Stroke Care using Remote Blood Pressure Monitoring and Telehealth. Appl Clin Inform. (2023) 14:883–91. doi: 10.1055/s-0043-1772679

PubMed Abstract | Crossref Full Text | Google Scholar

38. Walsh, MM, Ackerman, DJ, Kropp, RM, and Eigenbrod, M. Developing a Value-Based Care Model for Neurology. Neurol Clin Pract. (2024) 14:e200234. doi: 10.1212/CPJ.0000000000200234

PubMed Abstract | Crossref Full Text | Google Scholar

39. Andrade, SE, Kahler, KH, Frech, F, and Chan, KA. Methods for evaluation of medication adherence and persistence using automated databases. Pharmacoepidemiol Drug. (2006) 15:565–74. doi: 10.1002/pds.1230

PubMed Abstract | Crossref Full Text | Google Scholar

40. Morisky, DE, Green, LW, and Levine, DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. (1986) 24:67–74. doi: 10.1097/00005650-198601000-00007

PubMed Abstract | Crossref Full Text | Google Scholar

41. Syrnyk, M, and Glass, B. Pharmacist interventions in medication adherence in patients with mental health disorders: a scoping review. Int J Pharm Pract. (2023) 31:449–58. doi: 10.1093/ijpp/riad037

PubMed Abstract | Crossref Full Text | Google Scholar

42. Li, H, and Radhakrishnan, J. A pharmacist-physician collaborative care model in chronic kidney disease. J Clin Hypertens. (2021) 23:2026–9. doi: 10.1111/jch.14372

PubMed Abstract | Crossref Full Text | Google Scholar

43. Calleja, L, Glass, BD, Cairns, A, and Taylor, S. Pharmacist-Led Interventions for Medication Adherence in Patients with Chronic Kidney Disease: A Scoping Review. Pharmacy. (2023) 11:185. doi: 10.3390/pharmacy11060185

PubMed Abstract | Crossref Full Text | Google Scholar

44. Adams, AJ. Regulating pharmacist services: Achieving a full scope of practice. Can Pharm J. (2023) 156:231–4. doi: 10.1177/17151635231188330

PubMed Abstract | Crossref Full Text | Google Scholar

45. Dixon, DL, Johnston, K, Patterson, J, Marra, CA, and Tsuyuki, RT. Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension in the United States. JAMA Netw Open. (2023) 6:e2341408. doi: 10.1001/jamanetworkopen.2023.41408

PubMed Abstract | Crossref Full Text | Google Scholar

46. Ma, JD, Tran, V, Chan, C, Mitchell, WM, and Atayee, RS. Retrospective analysis of pharmacist interventions in an ambulatory palliative care practice. J Oncol Pharm Pract. (2016) 22:757–65. doi: 10.1177/1078155215607089

PubMed Abstract | Crossref Full Text | Google Scholar

47. Naqvi, IA, Cohen, AS, Kim, Y, Harris, J, Denny, MC, Strobino, K, et al. Inequities in Telemedicine Use Among Patients With Stroke and Cerebrovascular Diseases: A Tricenter Cross-sectional Study. Neurol Clin Pract. (2023) 13:e200148. doi: 10.1212/CPJ.0000000000200148

PubMed Abstract | Crossref Full Text | Google Scholar

48. Snoswell, CL, Chelberg, G, De Guzman, KR, Haydon, HH, Thomas, EE, Caffery, LJ, et al. The clinical effectiveness of telehealth: A systematic review of meta-analyses from 2010 to 2019. J Telemed Telecare. (2023) 29:669–84. doi: 10.1177/1357633X211022907

Crossref Full Text | Google Scholar

49. Kruse, CS, Krowski, N, Rodriguez, B, Tran, L, Vela, J, and Brooks, M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. (2017) 7:e016242. doi: 10.1136/bmjopen-2017-016242

PubMed Abstract | Crossref Full Text | Google Scholar

50. Li, H, Naqvi, IA, Strobino, K, and Malhotra, S. Clinical telepharmacy: addressing care gaps in diabetes management for an underserved urban population using a collaborative care model. Telemed eHealth. (2024) 30:tmj.2023.0589. doi: 10.1089/tmj.2023.0589

PubMed Abstract | Crossref Full Text | Google Scholar

51. Iftinan, GN, Elamin, KM, Rahayu, SA, Lestari, K, and Wathoni, N. Application, Benefits, and Limitations of Telepharmacy for Patients with Diabetes in the Outpatient Setting. J Multidiscip Health. (2023) 16:451–9. doi: 10.2147/JMDH.S400734

PubMed Abstract | Crossref Full Text | Google Scholar

52. Li, H, Naqvi, IA, Tom, SE, Almeida, B, Baratt, Y, and Ulane, CM. Integrating neurology and pharmacy through telemedicine: A novel care model. J Neurol Sci. (2022) 432:120085. doi: 10.1016/j.jns.2021.120085

PubMed Abstract | Crossref Full Text | Google Scholar

53. Cigolle, C, and Phillips, K. Telepharmacy Model of Care. Clin Ther. (2023) 45:935–40. doi: 10.1016/j.clinthera.2023.08.009

PubMed Abstract | Crossref Full Text | Google Scholar

54. Tsuyuki, RT, and Rader, F. Pharmacist’s Role in the Success of Blood Pressure Control Interventions: Evidence Isn’t the Barrier…. Circ Cardiovasc Qual Outcomes. (2024) 17:e011175. doi: 10.1161/CIRCOUTCOMES.124.011175

PubMed Abstract | Crossref Full Text | Google Scholar

55. Tsuyuki, RT, Houle, SKD, Charrois, TL, Kolber, MR, Rosenthal, MM, Lewanczuk, R, et al. Randomized Trial of the Effect of Pharmacist Prescribing on Improving Blood Pressure in the Community: The Alberta Clinical Trial in Optimizing Hypertension (RxACTION). Circulation. (2015) 132:93–100. doi: 10.1161/CIRCULATIONAHA.115.015464

PubMed Abstract | Crossref Full Text | Google Scholar

56. Lotrecchiano, GR, Bennett, LM, and Vovides, Y. A framework for developing team science expertise using a reflective-reflexive design method (R2DM). Humanit Soc Sci Commun. (2023) 10:1–12. doi: 10.1057/s41599-023-02298-2

Crossref Full Text | Google Scholar