Complexity of Medication Regimens for Children With Neurological Impairment

Abstract

IMPORTANCE Parents of children with severe neurological impairment (SNI) manage complex medication regimens (CMRs) at home, and clinicians can help support parents and simplify CMRs.OBJECTIVE To measure the complexity and potentially modifiable aspects of CMRs using the Medication Regimen Complexity Index (MRCI) and to examine the association between MRCI scores and subsequent acute visits. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study was conducted between April 1, 2019, and December 31, 2020, at a single-center, large, hospital-based, complex care clinic.Participants were children with SNI aged 1 to 18 years and 5 or more prescribed medications. EXPOSURE Home medication regimen complexity was assessed using MRCI scores. The total MRCI score is composed of 3 subscores (dosage form, dose frequency, and specialized instructions). MAIN OUTCOMES AND MEASURESPatient-level counts of subscore characteristics and additional safety variables (total doses per day, high-alert medications, and potential drug-drug interactions) were analyzed by MRCI score groups (low, medium, and high score tertiles). Associations between MRCI score groups and acute visits were tested using Poisson regression, adjusted for age, complex chronic conditions, and recent health care use. RESULTSOf 123 patients, 73 (59.3%) were male with a median (interquartile range [IQR]) age of 9 (5-13) years. The median (IQR) MRCI scores were 46 (35-61 [range, 8-139]) overall, 29 (24-35) for the low MRCI group, 46 (42-50) for the medium MRCI group, and 69 (61-78) for the high MRCI group.The median (IQR) counts for the subscores were 6 (4-7) dosage forms per patient, 7 (5-9) dose frequencies per patient, and 5 (4-8) instructions per patient, with counts increasing significantly across higher MRCI groups. Similar trends occurred for total daily doses (median [IQR],[31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] doses), high-alert medications (median [IQR], 3 [1-5] medications), and potential drug-drug interactions (median [IQR], 3 [0-6] interactions). Incidence rate ratios of 30-day acute visits were 1.26 times greater (95% CI, 0.57-2.78) in the medium MRCI group vs the low MRCI group and 2.42 times greater (95% CI, 1.10-5.35) in the high MRCI group vs the low MRCI group. CONCLUSIONS AND RELEVANCEHigher MRCI scores were associated with multiple dose frequencies, complicated by different dosage forms and instructions, and associated with subsequent acute visits. These findings suggest that clinical interventions to manage CMRs could target various aspects of these regimens, such as the simplification of dosing schedules.

Prevalence of polypharmacy and associated adverse outcomes and risk factors among children with asthma in the USA: a cross-sectional study

“…In addition, our results also suggested that poor health and increased healthcare utilisation were significantly and positively associated with polypharmacy. Although few studies evaluated outpatient polypharmacy in children with asthma, this finding aligns with a recent study by Feinstein et al suggesting medication regimen complexity is associated with increased acute visits among children with neurological impairment 37. Our results are also similar to the risk factors of polypharmacy among adults including multiple commodities and seeing multiple medical providers 38.…”

“…Although few studies evaluated outpatient polypharmacy in children with asthma, this finding aligns with a recent study by Feinstein et al suggesting medication regimen complexity is associated with increased acute visits among children with neurological impairment. 37 Our results are also similar to the risk factors of polypharmacy among adults including multiple commodities and seeing multiple medical providers. 38 Furthermore, another cross-sectional study suggested that adults with respiratory conditions had a lower prevalence of polypharmacy compared with other chronic condition groups, but prevalence increased as the number of comorbidities increased, including musculoskeletal or cardiometabolic diseases.…”

Pharmacogenetic profiling via genome sequencing in children with medical complexity

“…5,28 PGx data can also provide insight into drug-drug interactions, a common concern in polypharmacy. 29 The prevalence of polypharmacy in this study cohort was comparable to adults with psychiatric illness and the elderly, populations where PGx profiling is most common and best established. 30 As expected, PGx variants were as common in CMC as they are in the general population.…”

Opportunities for Comprehensive Medication Management (CMM) for Children with Special Healthcare Needs and Medical Complexity (CSHCN-CMC): The Methodology of a Prospective Case Series within a Collaborative Practice Agreement (CPA)

“…Feinstein and colleagues used a Medication Regimen Complexity Index (MRCI), comprised of 3 sub-scores for dosage form, dose frequency, and specialized instructions, to identify potentially modifiable factors associated with suboptimal therapies. They found a median (IQR) of 6 (4-7) dosage forms per patient, 7 (5-9) dose frequencies per patient, and 5 (4-8) instructions per patient, with significantly higher counts among higher MRCI groups [23]. Feinstein and Orth discussed provider-and system-level recommendations to improve medication safety in CSHCN-CMC [67].…”

“…CSHCN-CMC often are administered multiple medications, many of which are liquid compounded nonsterile preparations (pCNSPs) [16,17]. Assuring continuity of care at care transitions for safe medication management has been identified as an often-daunting task for parents, caregivers, and the patient's healthcare team [18][19][20][21][22][23][24][25][26][27]. Suggestions for implementing, sustaining, and improving medication management have been forwarded in order to encourage development of a child-friendly medication use system, including…”