Parental Factors Affecting Pediatric Medication Management in Underserved Communities

Community Caregivers' Perspectives on Health IT Use for Children With Medical Complexity: Qualitative Interview Study

BACKGROUND

Children with medical complexity represent a unique pediatric population requiring extensive health care needs and care coordination. Children with medical complexities have multiple significant chronic health problems that affect multiple organ systems and result in functional limitations and high health care needs or use. Often, there is a need for medical technology and total care for activities of daily living, much of which is provided at home by family and caregivers. Health IT (HIT) is a broad term that includes various technologies, such as patient portals, telemedicine, and mobile health apps. These tools can improve the care of children with medical complexity by enhancing communication, information exchange, medical safety, care coordination, and shared decision-making. In this study, we identified children with medical complexity as children aged <21 years who have >3 chronic health conditions. Community caregivers contribute to the care management of children with medical complexity, serving as advocates and coordinators, primary sources of information about children's needs, and facilitators of access to care. They are often the first point of contact for the families of children with medical complexity, particularly in vulnerable communities, including families in rural areas, low-income households, and non-English-speaking immigrant populations.

OBJECTIVE

This study aims to introduce the HIT needs and preferences for children with medical complexity from the perspective of community caregivers. By including their perspective on HIT development, we can better appreciate the challenges they face, the insights they offer, and the ways in which they bridge gaps in care, support, and resources.

METHODS

We conducted semistructured interviews (n=12) with formal community caregivers of children with medical complexity populations from a parent advocacy network on the US East Coast. Interviews were audio recorded via Zoom and then transcribed. An inductive thematic analysis was conducted to reveal HIT challenges and preferences for improving the care of children with medical complexity.

RESULTS

We categorized the interview results into themes and subthemes. There are four main themes: (1) telehealth transforming care for children with medical complexity during the COVID-19 pandemic, (2) suggested tools and technologies for care for children with medical complexity, (3) HIT feature preferences, and (4) transition to adult care. Each theme had multiple subthemes capturing all details related to design features of needed technologies.

CONCLUSIONS

The study emphasizes the need to develop and enhance HIT for the care of children with medical complexity. The identified themes can serve as design guidelines for designers by establishing a foundation for user-centered HIT tools to effectively support children with medical complexity and their families. Telehealth and mobile health apps could improve care management and quality of life for children with medical complexity.

Caregiver Experiences with Prescribed Antibiotic Access After a Pediatric Emergency Department Visit: A Qualitative Study

OBJECTIVE

Approximately one third of caregivers do not obtain a prescribed medication after their child's pediatric emergency department visit. We sought to explore the facilitators and barriers that caregivers experience in accessing prescribed antibiotics after their child's pediatric emergency department visit.

METHODS

We conducted semi-structured interviews with caregivers of children who presented to a quaternary academic pediatric emergency department and were discharged with prescribed antibiotics. An interview guide was developed by the study team based on literature review and expert opinion. Interviews were coded, and thematic analysis was performed. Descriptive statistical analysis was used for demographic characteristics and medication pick up rates.

RESULTS

Twenty-two interviews were completed. Caregivers unanimously felt that antibiotics were important. Themes pertaining to medication access included (i) pharmacy location and convenience, (ii) pharmacy efficiency, responsiveness, and medication availability, (iii) impact of receiving first dose of antibiotics in the ED, and (iv) clear verbal and written communication by healthcare providers regarding diagnoses, medication indication and discharge instructions.

CONCLUSIONS

Factors contributing to medication access have an underlying theme surrounding convenience and emphasis on the impact of first antibiotic dose administration during ED course. As such, consideration of systems changes that allows caregivers to leave the hospital with the entire course of antibiotics in hand may improve caregiver access to prescribed medications.

How often do parents administer medications to their children in hospital? A prospective direct observational study

Parents and carers play a critical role in supporting their children while in hospital. Multiple qualitative studies have explored parental involvement in the care of hospitalised children. Administration of medication to young children can be difficult and cause anxiety and stress for children. Parents are often willing and able to assist, yet little is known about how often parents are given responsibility for medication administration in hospital.We analysed data from a prospective direct observational study of nurses administering medication at a major paediatric referral hospital in Australia. Data from observations of 298 nurses preparing and administering 5137 medication doses to children on nine medical and surgical wards between 07:00 and 22:00 were analysed. Details of drugs administered, whether medications were left for parents/carers to administer, and if nurses observed the administration by parents, were recorded.Parents were at their child's bedside during 89.7% (n=4610) of observed medication administrations. Parents gave 20.3% (n=1045) of medications. In 14.3% (n=733), medications were left with parents to administer without a nurse present. In 6.1% (n=312) of doses, medications were given to parents, but the administration was observed by a nurse. Parents were most likely to be given medications to administer to young children (1-5 years), and the medications most frequently administered were analgesics and anti-epileptics.Parents/carers are integrally involved in the administration of many medications to children in hospital. The extent of parents' role and the impact on medication administration efficiency has been largely absent from the healthcare literature. Given that one in five medication doses is administered by parents, hospitals should recognise this contribution and consider if any additional support for parents is required.

Large language models: a new frontier in paediatric cataract patient education

BACKGROUND/AIMS

This was a cross-sectional comparative study. We evaluated the ability of three large language models (LLMs) (ChatGPT-3.5, ChatGPT-4, and Google Bard) to generate novel patient education materials (PEMs) and improve the readability of existing PEMs on paediatric cataract.

METHODS

We compared LLMs' responses to three prompts. Prompt A requested they write a handout on paediatric cataract that was 'easily understandable by an average American.' Prompt B modified prompt A and requested the handout be written at a 'sixth-grade reading level, using the Simple Measure of Gobbledygook (SMOG) readability formula.' Prompt C rewrote existing PEMs on paediatric cataract 'to a sixth-grade reading level using the SMOG readability formula'. Responses were compared on their quality (DISCERN; 1 (low quality) to 5 (high quality)), understandability and actionability (Patient Education Materials Assessment Tool (≥70%: understandable, ≥70%: actionable)), accuracy (Likert misinformation; 1 (no misinformation) to 5 (high misinformation) and readability (SMOG, Flesch-Kincaid Grade Level (FKGL); grade level <7: highly readable).

RESULTS

All LLM-generated responses were of high-quality (median DISCERN ≥4), understandability (≥70%), and accuracy (Likert=1). All LLM-generated responses were not actionable (<70%). ChatGPT-3.5 and ChatGPT-4 prompt B responses were more readable than prompt A responses (p<0.001). ChatGPT-4 generated more readable responses (lower SMOG and FKGL scores; 5.59±0.5 and 4.31±0.7, respectively) than the other two LLMs (p<0.001) and consistently rewrote them to or below the specified sixth-grade reading level (SMOG: 5.14±0.3).

CONCLUSION

LLMs, particularly ChatGPT-4, proved valuable in generating high-quality, readable, accurate PEMs and in improving the readability of existing materials on paediatric cataract.

Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

OBJECTIVE

To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period.

STUDY DESIGN

In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors.

RESULTS

Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall.

CONCLUSIONS

Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Changes in Provider Perceptions and Practices Regarding Dosing Units for Oral Liquid Medications

OBJECTIVE

A 2015 survey of primary care providers (PCPs) found that while many believed that milliliter (mL)-only dosing was safest for oral liquid medications, few would use mL alone in dosing instructions. Since 2015, many recommendations have promoted "mL-only" dosing. In 2019, a follow-up survey was conducted to assess if PCP perceptions and practices have changed.

METHODS

Pediatricians, family medicine physicians, nurse practitioners, and internists participating in the 2015 and 2019 DocStyles cross-sectional, web-based surveys were asked about their perceptions and practices regarding dosing units for oral liquid medications.

RESULTS

In 2019, among 1392 respondents, the proportion of PCPs who reported they believed using mL-only is the safest dosing instruction ranged from 55.1% of internists to 80.8% of pediatricians. While fewer PCPs believed patients/caregivers prefer dosing instructions in mL-only (23.9% of nurse practitioners to 48.4% of pediatricians), more held this belief in 2019 compared to 2015; pediatricians had the greatest absolute increase (+14.4%) and family medicine physicians had the smallest increase (+1.3%). While 61.6% of pediatricians reported they would use mL-only dosing, only 36.0% of internists, 36.6% of nurse practitioners, and 42.5% of family medicine physicians reported they would do so. After controlling for age, gender, region, and specialty, 2019 PCP survey participants were more likely to report that they would use mL-only dosing compared to 2015 participants (adjusted odds ratio 1.51, 95% confidence interval 1.29-1.77).

CONCLUSIONS

Broader educational efforts may be necessary to reach nonpediatricians, to encourage prescribing and communication with patients/caregivers using mL-only dosing.

Using machine learning to develop a clinical prediction model for SSRI-associated bleeding: a feasibility study

INTRODUCTION

Adverse drug events (ADEs) are associated with poor outcomes and increased costs but may be prevented with prediction tools. With the National Institute of Health All of Us (AoU) database, we employed machine learning (ML) to predict selective serotonin reuptake inhibitor (SSRI)-associated bleeding.

METHODS

The AoU program, beginning in 05/2018, continues to recruit ≥ 18 years old individuals across the United States. Participants completed surveys and consented to contribute electronic health record (EHR) for research. Using the EHR, we determined participants who were exposed to SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vortioxetine). Features (n = 88) were selected with clinicians' input and comprised sociodemographic, lifestyle, comorbidities, and medication use information. We identified bleeding events with validated EHR algorithms and applied logistic regression, decision tree, random forest, and extreme gradient boost to predict bleeding during SSRI exposure. We assessed model performance with area under the receiver operating characteristic curve statistic (AUC) and defined clinically significant features as resulting in > 0.01 decline in AUC after removal from the model, in three of four ML models.

RESULTS

There were 10,362 participants exposed to SSRIs, with 9.6% experiencing a bleeding event during SSRI exposure. For each SSRI, performance across all four ML models was relatively consistent. AUCs from the best models ranged 0.632-0.698. Clinically significant features included health literacy for escitalopram, and bleeding history and socioeconomic status for all SSRIs.

CONCLUSIONS

We demonstrated feasibility of predicting ADEs using ML. Incorporating genomic features and drug interactions with deep learning models may improve ADE prediction.

A cross-sectional survey among parents to report challenges and barriers in the administration of medicines to children in United Arab Emirates

Background: Lack of knowledge among parents can result in inappropriate administration practices.  After analyzing different studies among children, there was no data on challenges and barriers in the administration of medicines among children in this region because of the diverse environmental issues and challenges in the UAE. The objective of this study was to determine the reported administration practices of parents and challenges and barriers in the administration of medicines among children in UAE. Methods: A questionnaire-based survey was conducted. A convenience sampling technique was used to collect the data. An online Raosoft® sample size calculator was applied (n = 248). The inclusion criteria were parents who had a child under 10 years of age and gave consent to participate in this study. Children with vision problems, cognitive/physical disabilities, and caregivers other than parents were excluded from this study. Results: The study reported response rate of 73.2%. The mean ± S.D age of the parents in years was 35.5 ± 7.8, and the mean ± S.D of children aged years was 2.60 ± 1.54. 26.2% of parents reported treatment failure due to oral medicine administration. A total of 22.2% of parents reported that they gave medicines in doses higher than prescribed by the doctor to treat their children more quickly. Similarly, a total of 64.5% of the parents reported self-medication without consultation from a healthcare provider. Conclusions: The study concluded that there were inappropriate medicine administration practices among parents. Parents reported administration of higher doses to treat their children quickly.