Introduction

Front. Neurol.

Frontiers in Neurology

Front. Neurol.

1664-2295

Frontiers Media S.A.

10.3389/fneur.2025.1666409

Neurology

Systematic Review

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

Thurston

James

¹ Li

Hanlin

¹ Kronish

Ian M.

² Naqvi

Imama A.

³ ^*

¹Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, United States ²Department of Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, United States ³Department of Neurology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, United States

Edited by: Aleksandras Vilionskis, Vilnius University, Lithuania

Reviewed by: Luis Rafael Moscote-Salazar, Colombian Clinical Research Group in Neurocritical Care, Colombia

Kayhan Nuri Cengiz, Suleyman Demirel Universitesi, Türkiye

*Correspondence: Imama A. Naqvi, ian2108@cumc.columbia.edu

17 09 2025

2025

1666409

15 07 2025 25 08 2025

2025

Thurston, Li, Kronish and Naqvi

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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.

clinical pharmacist stroke multidisciplinary interdisciplinary telehealth

section-at-acceptance

Stroke

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

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).

Symbols illustrating four types of academic approaches: Disciplinary (single blue circle), Multidisciplinary (adjacent blue and red circles), Interdisciplinary (overlapping blue and red circles), and Transdisciplinary (overlapping blue and red circles with a surrounding yellow shape).

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

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).

Flowchart detailing the identification and screening process for study selection. On the left, 132 records were identified from databases and registers, with 19 duplicates removed. Of 113 screened, 85 were excluded, leaving 28 reports. No reports were unretrieved. For eligibility, 23 reports were excluded for various reasons. Five published studies were included in the review, five remained unpublished, and four were studies in progress. The right section shows one record identified via citation searching, assessed, and not excluded. The process follows the PRISMA framework.

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

Secondary stroke prevention RCTs demographics report.

Article citation	Study location	Urban/suburban/rural Setting^#	Reported study demographics	Health insurance use	Education level	Primary language
Published clinical trials with results
Chiu CC, et al. (21)	Guishan District, Taoyuan City, Taiwan	Urban	50% femaleMean age 65.3 years	Not reported	46% illiterate	Not reported
Hedegaard U, et al. (22)	Odense, Denmark	Urban	61% femaleMean age 66 years	Not reported	Not reported	Not reported
McAlister FA, et al. CMAJ. 2014 (23)McAlister FA, et al. Am Heart J. 2014 (33)	Edmonton, Alberta, Canada	Urban	42% femaleMean age 67.6 years	Not reported	Not reported	Not reported
Naqvi IA, et al. (8, 37)	Washington Heights, New York City, NY, USA	Urban	36% femaleMean age 64.3 years44% Hispanic32% Black20% White	26% Medicare28% Medicaid30% private insurance8% uninsured	54% less than or equal to a high school education	English and Spanish
Wang J, et al. (24)	Shijiazhuang, Hebei Province, China	Urban	49% femaleMean age 60.7 years	46.4% insured53.6% uninsured	55% ≤ 9 years of education	Not reported
Complete clinical trials pending published data
Indredavik B, et al. (25)	Kristiansund, Levanger, Molde, Namsos,Trondheim, and Ålesund, Norway	Urban/suburban	Not reported	Not reported	Not reported	Not reported
Nguyen, VV, et al. [abstract]. (20)	Los Angeles, USA	Urban	Not reported	Not reported	Not reported	Not reported
Olson K, et al. (26)	Aurora, Colorado, USA	Urban	Not reported	Not reported	Not reported	Not reported
Sancar M, et al. (27)	Istanbul, Turkey	Urban	Not reported	Not reported	Not reported	Not reported
Sharrief A, et al. (STOP-Stroke) ID#: NCT03923790 (28)	Houston, Texas, USA	Urban	52% femaleMean age 54.5 years45% Black31% White24% Hispanic or Latino	68.7% uninsured	Not reported	Not reported
Ongoing clinical trials
Ayala-Rivera M, et al. (32)	Downey, Sylmar, Torrance, and Los Angeles California, USA	Urban/suburban	In progress	In progress	In progress	In progressOnly included patients who were able to speak English or Spanish
Imam YZ, et al. (29)	Doha, Qatar	Urban	In progress	In progress	In progress	In progress
Janoly-Dumenil A, et al. (30)	Bron, Cébazat, Echirolles, Paris, Saint Genis Laval, and Saint-Etienne, France	Urban/suburban	In progress	In progress	In progress	In progress
Sharrief A, et al. (VIRTUAL). ID#: NCT05264298 (31)	Houston, Texas, USA	Urban	In progress	In progress	In progress	In progress

^#Urban defined as >50,000 inhabitants with 1,000 people per square mile, suburban defined as 2,500–50,000 inhabitants, and rural defined as <2,500 inhabitants (34)^.

Figure 3

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

Flowchart illustrating the integration of clinical pharmacists in secondary stroke prevention trials. It shows care models (disciplinary, multidisciplinary, interdisciplinary) and pharmacist interventions like medication education and adherence. Outcome measures include medication adherence and morbidity/mortality. The study origin is represented by flags, and the status of the study (published, unpublished, ongoing) is marked by letters P, U, O. Individual studies are listed under various authors, each associated with specific interventions and outcomes. Icons visually represent types of interventions and outcomes for clarity.

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

Clinical pharmacist interventions in secondary stroke prevention trials.

Article citation	Clinical pharmacist visit model	Visit frequency	Did clinical pharmacist have scope to adjust medications	Types of clinical pharmacist interventions	Which phase of care for clinical pharmacist interventions
Published clinical trials with results
Chiu CC, et al. (21)	In-person outpatient	Monthly one-hour CP education program for up to 6 months	No	Disease state/treatment goal education Medication education Identification of med-related adverse effects Adherence assessment/education Lifestyle education/modification	>12 months post-stroke
Hedegaard U, et al. (22)	In-person at discharge In-person outpatient Telephone call visits	One in-person visit at hospital, followed by phone visits at 1 week, 2 months, and 6 months	No	Disease state/treatment goal education Medication education Identification of med-related adverse effects Medication reconciliation Adherence assessment/education Lifestyle education/modification	<3 months post-stroke 3–6 months post-stroke
McAlister FA, et al. CMAJ. 2014 (23)McAlister FA, et al. Am Heart J. 2014 (33)	In-person outpatient	Followed at monthly visits for up to 6 months	Yes	Disease state/treatment goal education Medication education Medication reconciliation Adherence assessment/education Lab assessment Medication titration Lifestyle education/modification	<3 months post-stroke 3–6 months post-stroke 6–12 months post-stroke >12 months post-stroke
Naqvi IA, et al. (8, 37)	Video visits	Two CP visits, at 4 and 8 weeks after hospital dischargeNP visit at 1–2 weeks and physician visits at 6 and 12 weeks	No	Disease state/treatment goal education Medication education Identification of med-related adverse effects Adherence assessment/education Lifestyle education/modification	<3 months post-stroke
Wang J, et al. (24)	In-person at discharge In-person outpatient Telephone call visits Video visits	One discharge consultation, followed by one monthly visit for 6 months	No	Disease state/treatment goal education Medication education Identification of med-related adverse effects Medication reconciliation Adherence assessment/education Lifestyle education/modification	<3 months post-stroke 3–6 months post-stroke
Complete clinical trials pending reported data
Indredavik B, et al. (25)	In-person at discharge Telephone call visits	Interview at discharge followed by visits after 1 week, 1 month, 2 months, and 3 months post-discharge	No	Medication education Identification of med-related adverse effects Medication reconciliation Adherence assessment/education	<3 months post-stroke
Nguyen, VV, et al. [abstract] (20).	Telephone call visits	One visit at 3 months and one visit at 6 months from time of randomization	No	Disease state/treatment goal education Medication education Adherence assessment/education	Unclear/not documented
Olson K, et al. (26)	Unclear/not documented	Unclear visit frequency	Yes	Medication education Identification of med-related adverse effects Medication reconciliation Adherence assessment/education Lab assessment Medication titration Lifestyle education/modification	Unclear/not documented
Sancar M, et al. (27)	In-person at discharge In-person outpatient	Discharge visit followed by outpatient visits every 3 months	No	Disease state/treatment goal education Medication education Identification of med-related adverse effects Medication reconciliation Adherence assessment/education Lifestyle education/modification	<3 months post-stroke 3–6 months post-stroke 6–12 months post-stroke
Sharrief A, et al. (STOP-Stroke) ID#: NCT03923790 (28)	In-person at discharge Telephone call visits Video visits	Discharge visit followed by visits after 1 week, 1 month, 3 months, and 5 months post-enrollmentMore frequent phone visits may be required based on BP measurements	Unclear	Medication education Identification of med-related adverse effects Adherence assessment/education Lab assessment Medication titration	<3 months post-stroke 3–6 months post-stroke
Ongoing clinical trials
Ayala-Rivera M, et al. (32)	Unclear/not documented	Monthly health coach calls, unclear how often pharmacist visits will be held for medication titration/management	Yes	Medication titration	<3 months post-stroke 3–6 months post-stroke 6–12 months post-stroke >12 months post-stroke
Imam YZ, et al. (29)	Unclear/not documented	Visits scheduled initially every month, then every three months, for one year	No	Disease state/treatment goal education Medication education Adherence assessment/education Lifestyle education/modification	<3 months post-stroke 3–6 months post-stroke 6–12 months post-stroke >12 months post-stroke
Janoly-Dumenil A, et al. (30)	In-person at discharge In-person outpatient Telephone call visits	Discharge visit followed by telephone visits after 3 months, 6 months, and 9 months post-discharge, then a final in-person interview at 12 months	No	Disease state/treatment goal education Medication education Identification of med-related adverse effects Adherence assessment/education Lifestyle education/modification	<3 months post-stroke 3–6 months post-stroke 6–12 months post-stroke
Sharrief A, et al. (VIRTUAL). ID#: NCT05264298 (31)	Telephone call visits (Control Group) Video visits (Intervention Group)	Intervention Group: Scheduled video appointments at 1–2 weeks, 1 month, 3 months, and 5 months with team PLUS remote telemonitoring of BP with BP med adjustments biweekly as needed by CPsControl Group:Scheduled independent telephone visits with CP once monthly for first 6 months	Intervention Group:YesControl Group:No	Medication education Identification of med-related adverse effects Medication reconciliation Lab assessment Medication titration Lifestyle education/modification	<3 months post-stroke 3–6 months post-stroke

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

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

Article citation	Study methods	Description of CP care integration	Outcomes measures	Results
Published clinical trials with results
Chiu CC, et al. (21)	Trial Design: Prospective RCTTime Frame: 6-monthsControl: 80 patients seen by PCPIntervention: 80 patients seen by PCP and CP	Independent CP and PCP visits	Primary:Differences in BP, A1c, BG, TG, TC, and LDL before and after studySecondary:Proportion of patients with pre-defined adequate management/improvement in these values	Primary:Improved BP, lipid, and glycemic values by the end of the study in the intervention group. Only glycemic values improved in the control group.SecondaryBP: 43 to 43% in control group vs. 31 to 65% in CP group (p=<0.001)Lipid: 26 to 26% in control group vs. 13 to 40% in CP group (p=0.01)Glycemic: 36 to 45% in control group vs. 21 to 35% in CP group (p=0.75)
Hedegaard U, et al. (22)	Trial Design: Prospective RCTTime Frame:6-monthsControl: 101 patients seen by PCP/NPsIntervention: 102 patients seen by CPs	Experimental group: Independent CP visitsControl Group: Either PCP follow-up or nurse-run clinic	Primary:Overall adherence to thrombo-preventative regimen based on medication possession ratio (MPR)Secondary:Adherence to individual medications within thrombo-preventative regimenMedication persistenceCombined endpoint of death, MI, or hemorrhagic or ischemic stroke	Primary:At 12 months, median MPRs were 0.95 in the intervention group vs. 0.91 in the control group—non-significantSecondary:No significant differences were found for adherence or persistence measuresNo significant differences were found for composite clinical endpoint
McAlister FA, et al. CMAJ. 2014 (23, 33)	Trial Design: Prospective RCTTime Frame: 6-monthsControl: 136 patients seen by nurse w/PCP coordinationIntervention: 143 patients seen by CP aloneSecondary analysis:136 control group patients and 139 experimental group patients	Independent CP visits, who faxed updates to PCPControl group included visits with RN who would screen patient and fax information/feedback to PCPNeurologist delegated care to PCP, who delegated care to nurse in RN group	Primary:Proportion of patients who attained BP/lipid control at 6 monthsSecondary:Mortality, self-reported medication adherence, BMI, smoking statusSecondary Analysis:10-year risk of any vascular event using the Framingham Risk Score (FRS) and Cardiovascular Disease Life Expectancy model (CDLEM)	Primary:Improved BP and lipid control in CP group at 6 months – 43.4% in CP group met both SBP and LDL targets vs. 30.9% in nurse-led group (12.5% absolute difference; NNT=8, p=0.03) Secondary:No appreciable differencesSecondary Analysis:FRS 10-year risk:At 6 months: median 4.8% for the CP group vs. 5.1% for the RN group (p= 0.44)At 12 months: median 6.4% vs. 5.5% (p = 0.83)CDLEM 10-year risk:At 6 months: median 10.0% for the CP group vs. 12.5% for the RN group (p = 0.37)At 12 months: median 8.4% vs. 13.1% (p = 0.20)
Naqvi IA, et al. (8, 37)	Trial Design: Parallel 2-armed prospective feasibility pilot RCTTime Frame: 3-monthsControl: 25 patients seen by stroke physician under “usual care”Intervention:25 intervention patients seen via telehealth by multidisciplinary team (including a CP)	Independent CP visits as part of multidisciplinary approachExperimental Group: NP visit at 2 weeks, CP visit at 4 and 8 weeks, physician visit at 6 and 12 weeksControl group: Only saw NP at 2 weeks and PCP at 6 and 12 weeks	Feasibility outcomes included recruitment, randomization, clinic adherence, and retentionClinical outcomes included change in systolic BPPatient-Reported Outcomes included Patient-Reported Outcomes Measurement Information System Managing Medications and Treatment (PROMIS-MMT), Patient Activation Measure (PAM), Neuro-QOL (Quality of Life in Neurological Disorders) Cognitive Function, Neuro-QOL Depression, and Patient Health Questionnaire-9 (PHQ-9)	Feasibility:At 3 months, adherence (91% vs. 75%, p=0.14) and retention (84% vs. 64%, p= 0.11) were higher in the intervention groupClinical Outcomes:Home SBP declined by 16±19 mmHg from baseline in the intervention group and increased by 3±24 mmHg in the control group (p=0.01)Patient-Reported Outcomes:Improved self-efficacy of medical management in all, and depressive symptoms in the intervention group
Wang J, et al. (24)	Trial Design: Prospective parallel RCTTime Frame: 6-monthsControl: 82 patients seen by PCP “(usual care”)Intervention: 84 patients seen by CPs in addition to PCPs (“usual care”)	Both groups: “Usual Care”: 1-month and 6-month post-discharge visit with physiciansInvestigational group: Independent CP visits plus “usual care”	Primary:Achievement of secondary prevention markers (BP < 140/90 mmHg, LDL-C <70 mg/dL, and HbA1c ≤ 7%)Achievement of medication adherence via Medication Adherence Report Scale (MARS-5)Secondary:Any event leading to hospitalization readmission	Primary:Improved risk factor control in CP group versus control group for A1c goal (88% vs. 53%, p = 0.038) and LDL-C goal (67% vs. 49%, p = 0.02). No significant difference in BP controlImproved medication adherence in CP group for anti-hypertensive drugs (93% vs. 79%, p = 0.031), anti-diabetic drugs (92% vs. 70%, p = 0.02), and lipid-lowering drugs (77% vs. 61%, p = 0.022)Secondary:Fewer re-admissions in CP group vs. control group (7% vs. 18%, p = 0.03)
Complete clinical trials pending reported data
Indredavik B, et al. (25)	Completed 06/2016Trial Design: Prospective parallel assignment RCTTime Frame: 1 yearControl: “standard of care” aloneIntervention: CP counseling visits plus “standard of care”	Intervention Group:Scheduled visits with hospital-based CPUnclear how information will be relayed to other health professionals	Primary:Self-reporting of adherence at 3 monthsSecondary:Self-reporting of adherence at 12 months, persistence (using prescription fill data), patient satisfaction, incidence of CV events and death, degree of disability or dependence in daily activities	Not posted or reported
Nguyen, VV, et al. [abstract] (20).	Completed date unknownTrial Design: Prospective RCTTime Frame: 6-months30 total patientsControl:” usual care”Intervention: CP intervention	Independent CP telephone callsCPs communicated with PCPs/stroke care provider to relay recommendations	Medication adherence based on pharmacy refill historyAchievement of stroke prevention goals (BP, BG, LDL-C goals)	Published as abstract (with results)Medication adherence:More likely to be fully adherent in CP intervention group vs. usual care at 6 months (56% vs. 36%)Adherence to antithrombotic therapy specifically increased in intervention group at 6 months (100% vs. 88%)Achievement of stroke prevention goals:Greater goal achievement in CP intervention group vs. usual care at 6 months: BP goal (73% vs. 57%) LDL-C goal (75% vs. 50%) BG control (75% vs. 50%) This goal achievement continued or improved by 1 year mark within intervention group
Olson K, et al. (26)	Completed 11/2018Trial Design: Prospective parallel-assignment RCTTime Frame: 3 yearsControl: standard of care through PCPIntervention: CP visits alone	Intervention Group:CPs will independently conduct visitsPatients requiring more in-depth dietary counseling can be referred to dieticians, or other appropriate resourcesPCPs will be informed of all medication initiations or dosage adjustments	Primary:Proportion of patients who attain LDL-C and BP goalsSecondary:Incidence of major cardiovascular events, hospitalizations and/or death over duration of study periodTertiary:Efficacy and safety of intervention compared to usual care	Not posted or reported
Sancar M, et al. (27)	Completed 4/2023Trial Design: Prospective parallel-assignment RCTTime Frame: 1 yearControl: “Standard of care” through PCP aloneIntervention: CP visits plus “standard of care” through PCP	Intervention Group:CPs will independently conduct visits in coordination with stroke neurologists (on the same day) every 3 months	Primary:BP, A1c, LDL, TG, BMI, and medication adherence (Morisky-Green-Levine adherence scale)Secondary:Change in QOLChange in NIHSSIncidence of stroke recurrence and drug-related problems	Not posted or reported
Sharrief A, et al. (STOP-Stroke) ID#: NCT03923790 (28)	Completed 10/2021Trial Design: Prospective parallel-assignment RCTTime Frame:5 monthsControl: 41 control patients with “usual care” aloneIntervention: 42 patients with “usual care” and seen at multi-disciplinary follow-up visits	Both Groups: Independent CP visit at dischargeNurse navigator call within 72 h post-discharge to assure that they have received their meds and follow-up appointmentsIntervention Only:Patient receives BP monitor7-day post-discharge f/u video visit attended by MD or NP, social worker, and CPNP and CP review BP data and adjust medsSW assesses need for resourcesNP and CP review BP via online portal every 2 weeks until the average BP is <130/80 mmHg, then review monthlyUncontrolled BP prompts call from CP to discuss adherence and med titrationSubsequent f/u visits occur 1 month, 3 months, and 5 months after enrollment	Primary:Differences in ambulatory daytime SBPSecondary:Differences in daytime DBP, nighttime BP, BMI, incidence of recurrent vascular events, and acute healthcare utilizationMedication adherence (via Morisky Medication Adherence Scale), caregiver burden (via Zarit Caregiver Burden Questionnaire)Self-efficacy for taking medication as prescribed (via Medication Adherence Self-Efficacy Scale)	Partially reported (clinicaltrials.gov) 11/2022Large number of patients in both groups without outcome measures collected – incomplete resultsNo statistical analysis
Ongoing clinical trials
Ayala-Rivera M, et al. (32)	Estimated completion 2026Trial Design: Prospective parallel-assignment RCTTime Frame: 12 monthsControl: “Usual care” aloneIntervention: Multidisciplinary visits with health coach and CP	Intervention Group:Patients receive a home BP monitor, have monthly phone calls from a health coach, and medication initiation and titration by a clinical pharmacistControl Group:“Usual care”	Primary:Change in SBPSecondary:“Life’s Essential 8” survey for cardiovascular healthBMI, total cholesterol, and HbA1cCalifornia Health Interview Survey for diet, Behavioral Risk Factor Surveillance System Survey Questionnaire for physical activities, and PATH wave 1 survey for smoking,	Reported as “In progress”
Imam YZ, et al. (29)	No recent updates: estimated completion 2019Trial Design: Prospective RCTTime Frame: 12 monthsControl: “Standard of care” by neurologist aloneIntervention: CP and stroke care NP visits plus “standard of care” by stroke neurologist	Intervention Group:Follow-up visits with CP or stroke care-trained NP who will coordinate care with stroke neurologist	Per Published Study Design (PMID: 32664066):Primary:Mean difference in BP and LDLSecondary:Incidence of stroke, MI, or deathCarotid plaque progression as measured by 3D Carotid Doppler imaging studies	No reported or available results
Janoly-Dumenil A, et al. (30)	No recent updates: estimated completion 06/2020Trial Design: Prospective parallel-assignment RCTTime Frame: 12 monthsControl: “Standard of care” through PCP aloneIntervention: CP visits plus “standard of care” through PCP	Intervention Group:Scheduled visits at discharge and outpatient with hospital-based CPInformation from visits will be shared with PCPs and community CPsControl Group:Pharmacist will meet with patients at discharge for medication review and meet with patients at 12 months for adverse effect identification	Primary:Composite measure of medication adherence using refill data and self-reported questionnaireSecondary:Incidence of readmission and CV eventsIncidence of drug-related adverse effectsAnalysis of pharmacy refillsSatisfaction of patients, providers and community pharmacistsIntervention profit estimationMeasure of glycemic and lipid tests	No reported or available results
Sharrief A, et al. (VIRTUAL). ID#: NCT05264298 (31)	Estimated completion 2025Trial Design: Prospective RCTTime Frame: 6 monthsControl: “Standard of care” PCP visits and monthly follow-up with CPIntervention: Telehealth interdisciplinary visit	Intervention Group:Scheduled follow-up visits with an interdisciplinary team member (Stroke provider, social worker, CP)Control Group:Follow-up with stroke provider within 2 weeks of discharge. Monthly BP follow-up with CP for 6 months. Follow-up with social worker following discharge	Primary:Percentage of patients with controlled BP (<125/75 mmHg)Secondary:Proportion of uninsured patients who obtain insuranceProportion of patients with controlled BPComposite incidence of recurrent vascular eventsIncidence of acute healthcare utilizationTertiary:Proportion of patients who quit or attempt to quit smoking; Ambulatory SBP and DBP at daytime and nighttime; PHQ-9 depressive symptoms	Reported as “In progress”

BG, blood glucose; BP, blood pressure; CP, clinical pharmacist; DBP, diastolic blood pressure; LDL; low-density lipoprotein; NP, nurse practitioner; PCP, primary care provider; RCT, randomized controlled trial; RN, registered nurse; SBP, systolic blood pressure; TC, total cholesterol; TG, triglycerides.

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

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

Flowchart illustrating a healthcare process. It starts with "Patient Population," highlighting identifying patients at higher risk due to poor healthcare access and low health literacy. Next is "Clinical Setting," detailing initial in-person or post-discharge visits, ongoing risk management, and medication titration for three to six months post-stroke. Finally, "Pharmacist Integration" involves authorizing advanced practice, integrating visits to increase access, and leveraging interprofessional collaboration for risk control.

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.

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.

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