title: 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.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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).
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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. Electronic address: finlay.mcalister@ualberta.ca.
authors.forename: Finlay A
authors.initials: FA
authors.lastname: McAlister
authors.affiliation: McGill Cardiovascular Health Improvement Program, Division of General Internal Medicine, McGill University, Montreal, Canada. Electronic address: steven.grover@mcgill.ca.
authors.forename: Steven
authors.initials: S
authors.lastname: Grover
authors.affiliation: Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada. Electronic address: rpadwal@ualberta.ca.
authors.forename: Raj S
authors.initials: RS
authors.lastname: Padwal
authors.affiliation: Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada. Electronic address: erik.youngson@ualberta.ca.
authors.forename: Erik
authors.initials: E
authors.lastname: Youngson
authors.affiliation: The Epidemiology Coordinating and Research Centre, University of Alberta, Edmonton, Alberta, Canada. Electronic address: miriam.fradette@ualberta.ca.
authors.forename: Miriam
authors.initials: M
authors.lastname: Fradette
authors.affiliation: Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada. Electronic address: athompson@ualberta.ca.
authors.forename: Ann
authors.initials: A
authors.lastname: Thompson
authors.affiliation: Division of Neurology, University of Alberta, Edmonton, Alberta, Canada; Division of Neurology, Grey Nuns Hospital, Edmonton, Canada.
authors.forename: Brian
authors.initials: B
authors.lastname: Buck
authors.affiliation: Division of Internal Medicine, Royal Alexandra Hospital, Edmonton, Canada; Division of Neurology, University of Alberta, Edmonton, Alberta, Canada. Electronic address: Naeem.Dean@capitalhealth.ca.
authors.forename: Naeem
authors.initials: N
authors.lastname: Dean
authors.affiliation: The Epidemiology Coordinating and Research Centre, University of Alberta, Edmonton, Alberta, Canada. Electronic address: ross.tsuyuki@ualberta.ca.
authors.forename: Ross T
authors.initials: RT
authors.lastname: Tsuyuki
authors.affiliation: Division of Neurology, University of Alberta, Edmonton, Alberta, Canada. Electronic address: ashfaq.shuaib@ualberta.ca.
authors.forename: Ashfaq
authors.initials: A
authors.lastname: Shuaib
authors.affiliation: Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada. Electronic address: me2.majumdar@ualberta.ca.
authors.forename: Sumit R
authors.initials: SR
authors.lastname: Majumdar
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000209:etiology / Q000517:prevention & control* / Q000523:psychology; D019090:Case Management / Q000458:organization & administration*; D005260:Female; D006792:House Calls; D006801:Humans; D002546:Ischemic Attack, Transient / Q000150:complications / Q000453:epidemiology / Q000534:rehabilitation; D008297:Male; D009732:Nursing Care / Q000379:methods*; D017063:Outcome Assessment, Health Care; D010593:Pharmaceutical Services; D012307:Risk Factors; D040242:Risk Reduction Behavior; D055502:Secondary Prevention / Q000379:methods; D020521:Stroke / Q000150:complications / Q000453:epidemiology; D000071939:Stroke Rehabilitation