Complexity of Medication Regimens for Children With Neurological Impairment

James A Feinstein,Allison B Blackmer,Hannah Friedman,Lucas E Orth,Allison Kempe,Chris Feudtner,Sadaf Samay

doi:10.1001/jamanetworkopen.2021.22818

Abstract

Parents of children with severe neurological impairment (SNI) manage complex medication regimens (CMRs) at home, and clinicians can help support parents and simplify CMRs. 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. This 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. 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). Patient-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. Of 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 [20-45] 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. Higher 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.

Highlights

Complex medication regimens (CMRs)—usually defined as the use of 5 or more medications and the presence of multiple different medication dosing schedules—are common among children with medically complex conditions, including children with severe neurological impairment (SNI).1-3 Amid other competing care activities, parents and nonmedical caregivers of children with SNI must manage and administer CMRs in the home setting.2 In prior studies of medication safety,4-8 parents have reported concerns about medication administration, adherence, and adverse drug events (ADEs)
Higher Medication Regimen Complexity Index (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

Summary

Introduction

Complex medication regimens (CMRs)—usually defined as the use of 5 or more medications (polypharmacy) and the presence of multiple different medication dosing schedules—are common among children with medically complex conditions, including children with severe neurological impairment (SNI). Amid other competing care activities, parents and nonmedical caregivers of children with SNI must manage and administer CMRs in the home setting. In prior studies of medication safety, parents have reported concerns about medication administration, adherence, and adverse drug events (ADEs). The difficulty of administering CMRs can be affected by a variety of clinically modifiable medication-related factors, including the total number of medications, different dose frequencies, dosage forms (such as pills vs liquids), and specialized instructions, yet many pediatric polypharmacy studies still only measure basic medication counts.. The MRCI score is intended to differentiate, for example, between a patient with lower complexity taking 10 medications, each as a single pill with once-daily dosing, and a patient with higher complexity taking 10 medications, but each with different dosage forms and requiring multiple doses per day. The total MRCI score is composed of 3 subscores calculated from commonly available elements of patients’ medication prescriptions: dosage form, dose frequency, and specialized instructions. MRCI scores have been used to identify adult patients most likely to benefit from pharmacist-led medication therapy management programs and have shown value in estimating subsequent health care utilization and ADEs.

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