Patient Safety in Ambulatory Pediatrics

A coordinated approach for managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication Therapy Management (pMTM) randomized controlled trial

BACKGROUND

Children with medical complexity (CMC) often rely upon the use of multiple medications to sustain quality of life and control substantial symptom burden. Pediatric polypharmacy (≥ 5 concurrent medications) is prevalent and increases the risk of medication-related problems (MRPs). Although MRPs are associated with pediatric morbidity and healthcare utilization, polypharmacy is infrequently assessed during routine clinical care for CMC. The aim of this randomized controlled trial is to determine if a structured pharmacist-led Pediatric Medication Therapy Management (pMTM) intervention reduces MRP counts, as well as the secondary outcomes of symptom burden and acute healthcare utilization.

METHODS

This is a hybrid type 2 randomized controlled trial assessing the effectiveness of pMTM compared to usual care in a large, patient-centered medical home for CMC. Eligible patients include all children ages 2-18 years old, with ≥ 1 complex chronic condition, and with ≥ 5 active medications, as well as their English-speaking primary caregivers. Child participants and their primary parental caregivers will be randomized to pMTM or usual care before a non-acute primary care visit and followed for 90 days. Using generalized linear models, the overall effectiveness of the intervention will be evaluated using total MRP counts at 90 days following pMTM intervention or usual care visit. Following attrition, a total of 296 CMC will contribute measurements at 90 days, which provides > 90% power to detect a clinically significant 1.0 reduction in total MRPs with an alpha level of 0.05. Secondary outcomes include Parent-Reported Outcomes of Symptoms (PRO-Sx) symptom burden scores and acute healthcare visit counts. Program replication costs will be assessed using time-driven activity-based scoring.

DISCUSSION

This pMTM trial aims to test hypotheses that a patient-centered medication optimization intervention delivered by pediatric pharmacists will result in lower MRP counts, stable or improved symptom burdens, and fewer cumulative acute healthcare encounters at 90 days following pMTM compared to usual care. The results of this trial will be used to quantify medication-related outcomes, safety, and value for a high-utilization group of CMC, and outcomes may elucidate the role of integrated pharmacist services as a key component of outpatient complex care programs for this priority pediatric population.

TRIAL REGISTRATION

This trial was prospectively registered at clinicaltrials.gov (NCT05761847) on Feb 25, 2023.

Making Polypharmacy Safer for Children with Medical Complexity

A 14-year-old patient who has severe cerebral palsy and seizures, requested that his parents speak to his pediatrician about a medication to help with sleep. He already uses 13 other medications, including anticonvulsants, analgesics, and respiratory medications, and 5 additional as needed (PRN) medications (Figure 1 ). He has a vagal nerve stimulator and a gastrostomy tube. His parents had researched several sleep medications, and they were interested in discussing trazodone therapy for his sleep issues. Clinicians who prescribe medications to children with medical complexity (CMC) frequently must consider the question: How does one safely prescribe a patient like ours a new medication, like the sleep medication trazodone, amidst an already complex background of polypharmacy?