Acute ischemic stroke (AIS) is a leading cause of mortality and long-term disability globally, with China bearing a disproportionately high burden due to its aging population and lifestyle shifts (Wang et al., 2017). While evidence-based therapies such as thrombolysis and antiplatelet agents form the cornerstone of AIS management, suboptimal medication practices—including excessive antibiotic use and unwarranted reliance on adjuvant therapies like Traditional Chinese Medicine (TCM) injections—persist in clinical settings (Powers et al., 2019; Huang et al., 2021b). Such practices not only escalate healthcare costs but also contribute to antimicrobial resistance (AMR) and drug related problems (DRPs), straining China’s rapidly evolving healthcare system (Formica et al., 2018; Huang et al., 2021b).

The integration of clinical pharmacists into healthcare teams has demonstrated significant success in chronic disease management, evidenced by reductions in drug-related adverse events and hospitalization costs through medication reconciliation, guideline adherence, and cost-benefit optimization (Renaudin et al., 2016; Basaraba et al., 2018). However, their role in acute neurological care, particularly in AIS, remains underexplored, despite the urgent need to address the complexities of AIS pharmacotherapy—such as time-sensitive anticoagulant/antiplatelet decision-making, post-stroke infection management, and avoidance of nonessential adjunctive therapies (Cengiz et al., 2025). This gap is compounded by China’s evolving healthcare landscape, where the 2020 introduction of the diagnosis-Intervention Packet (DIP) payment system standardized settlements based on predefined treatment bundles to curb cost inflation (Lai et al., 2022; Zhang et al., 2024; Fang and Jiang, 2025).

A significant challenge involves the extensive utilization of high-risk, low-value therapies, such as prolonged antibiotic regimens and unproven TCM injections (e.g., Ginkgolide, Danhong). These treatments constitute 15%–30% of urban hospital drug budgets, despite a lack of robust efficacy evidence (Wang et al., 2016; Li et al., 2018; Huang et al., 2021b). This misalignment underscores the necessity of pharmacist-driven stewardship programs to harmonize therapeutic practices with DIP’s value-based objectives (Phimarn et al., 2023). However, the current research predominantly emphasizes clinical endpoints (e.g., mortality, functional recovery), while overlooking comprehensive economic evaluations—such as drug-to-cost ratios, DIP balance (a metric linking diagnoses to standardized settlements), and per-case profitability—which are crucial for the scalable integration of pharmacists into acute care teams, especially in resource-constrained settings (Lai et al., 2022; Zhang et al., 2024).

To date, no studies have holistically assessed the clinical and economic impacts of pharmacist care in AIS within China’s DIP framework. This study aimed to evaluate the clinical and economic impacts of integrating clinical pharmacists into stroke care teams through a structured medication stewardship program. Specifically, we examined the program’s efficacy in optimizing high-risk medication use (antibiotics, PPIs, and TCM injections), resolving DRPs, shortening hospital stays, and reducing medical expenses.

Within China’s evolving DIP payment system—implemented in 2020 to standardize reimbursements and control healthcare costs—suboptimal medication practices in acute ischemic stroke AIS care, such as antibiotic overuse and unnecessary TCM injections, remain prevalent (Lai et al., 2022; Huang et al., 2021b). The study identified antibiotics as a major contributor to DRPs, with inappropriate dosing (3.14% vs. 4.17%) and prolonged therapy duration (2.24% vs. 2.78%) being the primary issues. These findings align with global antimicrobial stewardship literature, where 30%–50% of antibiotic prescriptions are deemed inappropriate due to dosing errors, unnecessary duration, or lack of indication (Tamma et al., 2017). Pharmacist-led interventions in this study reduced antibiotic treatment duration by 2.1 days (6.83 vs. 8.93 days, P = 0.019), corroborating the Infectious Diseases Society of America guidelines, which emphasize pharmacist roles in optimizing antibiotic use to curb resistance (Tamma et al., 2021; Dighriri et al., 2023). A meta-analysis by Davey et al. further supports this, showing that pharmacist interventions shorten antibiotic courses by 1.5–3 days and reduce Clostridium difficile infection rates by 18% (Davey et al., 2017). Excessive PPI use, particularly in the standard care group (7.41% vs. 4.48%, P < 0.05), mirrors global trends where 70% of PPI prescriptions lack appropriate indications (Scarpignato et al., 2016). Pharmacist interventions reduced PPI therapy duration by 2.21 days (7.29 vs. 9.50 days, P < 0.001), consistent with deprescribing trials by Reeve et al., which reported a 40% reduction in PPI use among elderly patients (Reeve et al., 2017). The economic burden of PPI overuse is substantial, costing 1.2–2.4 billion annually in the U.S. alone due to adverse events like fractures and renal dysfunction (Forgacs and Loganayagam, 2008). In this study, pharmacists lowered drug costs by 13.5%, aligning with Perez et al., who estimated $1,200 annual savings per patient through pharmacist-driven deprescribing (Mi et al., 2020).

Therapeutic duplication of Ginkgolide (8.52% vs. 10.65%) and Danhong injections (1.35% vs. 0.93%) underscores the need for evidence-based TCM prescribing. While Ginkgolide is widely used in Asia for ischemic stroke, its efficacy remains contentious. A Cochrane review by Wu et al. found insufficient evidence to support its superiority over placebo in improving neurological outcomes (Ji et al., 2020). While Danhong injection has shown modest benefits in microcirculation improvement (Shi et al., 2025), its use is often conflated with conventional therapies. It has been reported in the literature that 22% of TCM injections were prescribed without clear clinical indications, highlighting the critical need for comprehensive pharmacovigilance systems and strict adherence to clinical guidelines (Feng et al., 2019; Huang et al., 2021a).

Pharmacist interventions significantly reduced hospital stays by 0.96 days (9.54 vs. 10.5 days, P = 0.028), translating to an estimated cost saving of 1,200 perpatientbasedonper−diemhospitalizationcosts. This improved DIP settlement amounts ($660.2 ± 308.3 vs. $554.4 ± 360.3, P = 0.001), who reported cost savings via pharmacist involvement (Feldman et al., 2025)—and reimbursement efficiency driven by pharmacist adherence to standardized protocols under DIP system, a strategy shown by Yip et al. (2019) to increase reimbursements by 15%. The results of the multiple linear regression analysis indicated that pharmacist intervention was a significant independent predictor of both lower total hospitalization costs (B = −175.77, 95% CI: -281.6 to −69.9, P = 0.001) and shorter length of stay (B = −0.91, 95% CI: -1.61 to −0.22, P = 0.010), even after adjusting for potential confounding variables. However, the non-significant reduction in adverse drug reactions (8.07% vs. 11.57%, P = 0.201) underscores the need for integrating real-time ADR monitoring tools to harmonize cost containment with patient safety priorities (Buttigieg et al., 2020).

High satisfaction rates with pharmacist roles in drug preparation (87.93%) and patient education (86.26%) align with global trends, as exemplified by Zillich et al. (2004), who reported that 82% of physicians valued pharmacists’ input on dose adjustments—a finding consistent with the 86.4% acceptance rate for administration/dosage interventions observed in this study. However, systemic barriers persist, particularly in cost-reduction strategies (64.19% satisfaction) and indication-related interventions (63.6% acceptance). These challenges stem from hierarchical resistance, where physicians may perceive indication modifications as encroachments on clinical autonomy, as documented in Japanese healthcare settings (Tasaka et al., 2016), and communication gaps arising from siloed workflows that hinder multidisciplinary consensus on cost-saving measures (Bondesson et al., 2013). To address these barriers, models such as interprofessional co-management, shared cost-saving performance indicators, and interdisciplinary training programs have been introduced to enhance mutual understanding and cooperation among healthcare professionals. Expanding the scope of practice for pharmacists and further integrating them into healthcare teams can significantly reduce medication errors, thereby improving patient outcomes and the quality of healthcare delivery (Gillani et al., 2021). Another study found that embedding pharmacists within hospital wards improved team satisfaction by 22% in Australian contexts (Pouranayatihosseinabad et al., 2018). These strategies highlight the importance of structural collaboration in bridging disciplinary divides and enhancing the uptake of clinical interventions.

This study has limitations, including its single-center design, potential confounding from insurance-type disparities, and lack of long-term clinical outcome assessments (e.g., mortality, readmission rates). The imbalance in medical insurance types between groups (P = 0.015) may confound economic outcomes, as different insurance types entail varying reimbursement rates and patient cost-sharing structures. Although we adjusted for insurance type in regression analyses, residual confounding may remain. Future research should prioritize multicenter randomized controlled trials to validate generalizability, integrate societal cost-effectiveness analyses (e.g., productivity losses), and AI-enabled DRPs detection to enhance scalability and precision. These steps will strengthen the evidence base for pharmacist-led interventions in evolving healthcare systems.

The integrating clinical pharmacists into multidisciplinary care for acute ischemic stroke patients enhances drug therapy outcomes and resource efficiency, evidenced by reduced hospitalization costs, improved reimbursement under China’s DIP system, and shortened antibiotic/PPI durations. Their specialized knowledge in resolving DRPs and aligning therapeutic strategies with value-based care paradigms establishes clinical pharmacists as critical participants within contemporary healthcare systems.