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Jolliff A, Coller RJ, Kearney H, Warner G, Feinstein JA, Chui MA, O'Brien S, Willey M, Katz B, Bach TD, Werner NE. An mHealth Design to Promote Medication Safety in Children with Medical Complexity. Appl Clin Inform 2024; 15:45-54. [PMID: 37989249 PMCID: PMC10794091 DOI: 10.1055/a-2214-8000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Children with medical complexity (CMC) are uniquely vulnerable to medication errors and preventable adverse drug events because of their extreme polypharmacy, medical fragility, and reliance on complicated medication schedules and routes managed by undersupported family caregivers. There is an opportunity to improve CMC outcomes by designing health information technologies that support medication administration accuracy, timeliness, and communication within CMC caregiving networks. OBJECTIVES The present study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a codesign process to identify: (1) medication safety challenges experienced by CMC caregivers and (2) design requirements for a mobile health application to improve medication safety for CMC in the home. METHODS Study staff recruited family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program to participate in virtual codesign sessions. During sessions, the facilitator-guided codesigners in generating and converging upon medication safety challenges and design requirements. Between sessions, the research team reviewed notes from the session to identify design specifications and modify the prototype. After design sessions concluded, each session recording was reviewed to confirm that all designer comments had been captured. RESULTS A total of N = 16 codesigners participated. Analyses yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines. Supporting quotations from codesigners and prototype features associated with each design requirement are presented. CONCLUSION This study generated design requirements for a tool that may improve medication safety by creating distributed situation awareness within the caregiving network. The next steps are to pilot test tools that integrate these design requirements for usability and feasibility, and to conduct a randomized control trial to determine if use of these tools reduces medication errors.
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Affiliation(s)
- Anna Jolliff
- Department of Health and Wellness Design, Indiana University at Bloomington, Bloomington, Indiana, United States
| | - Ryan J. Coller
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Hannah Kearney
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Gemma Warner
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - James A. Feinstein
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Michelle A. Chui
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Steve O'Brien
- Noble Applications, Madison, Wisconsin, United States
| | - Misty Willey
- Noble Applications, Madison, Wisconsin, United States
| | - Barbara Katz
- Family Voices of Wisconsin, Madison, Wisconsin, United States
| | - Theodore D. Bach
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Nicole E. Werner
- Department of Health and Wellness Design, Indiana University at Bloomington, Bloomington, Indiana, United States
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Orth LE, Feudtner C, Kempe A, Morris MA, Colborn KL, Gritz RM, Linnebur SA, Begum A, Feinstein JA. A coordinated approach for managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication Therapy Management (pMTM) randomized controlled trial. BMC Health Serv Res 2023; 23:414. [PMID: 37120509 PMCID: PMC10148507 DOI: 10.1186/s12913-023-09439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023] Open
Abstract
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.
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Affiliation(s)
- Lucas E Orth
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Departments of Pediatrics and Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Allison Kempe
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Megan A Morris
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn L Colborn
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - R Mark Gritz
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sunny A Linnebur
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anowara Begum
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA
| | - James A Feinstein
- Adult & Child Center for Outcomes Research & Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 1890 N. Revere Court, 3Rd Level, Mail Stop F443, Aurora, CO, 80045, USA.
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Parrish RH, Ciarkowski S, Aguero D, Benavides S, Bohannon DZ, Guharoy R. Creating Data Standards to Support the Electronic Transmission of Compounded Nonsterile Preparations (CNSPs): Perspectives of a United States Pharmacopeia Expert Panel. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1493. [PMID: 36291429 PMCID: PMC9600984 DOI: 10.3390/children9101493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
The perspectives of the Compounded Drug Preparation Information Exchange Expert Panel of the United States Pharmacopeia (CDPIE-EP) on the urgent need to create and maintain data standards to support the electronic transmission of an interoperable dataset for compounded nonsterile preparations (CNSPs) for children and the elderly is presented. The CDPIE-EP encourages all stakeholders associated with the generation, transmission, and preparation of CNSPs, including standards-setting and informatics organizations, to discern the critical importance of accurate transmission of prescription to dispensing the final product and an urgent need to create and adopt a seamless, transparent, interoperable, digitally integrated prescribing and dispensing system benefiting of all patients that need CNSPs, especially for children with special healthcare needs and medical complexity (CSHCN-CMC) and for adults with swallowing difficulties. Lay summary: Current electronic prescription processing standards do not permit the complete transmission of compounded nonsterile preparations (CNSPs) from a prescriber to dispenser. This lack creates multiple opportunities for medication errors, especially at transitions of care for children with medical complexity and adults that cannot swallow tablets and capsules. The United States Pharmacopeia Expert Panel on Compounded Drug Preparation Information Exchange aims to reduce this source of error by creating ways and means for CNSPs to be transmitted within computer systems across the continuum of care. Twitter: Digitizing compounded preparation monographs and NDC-like formulation identifiers in computerized prescription systems will minimize error.
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Affiliation(s)
- Richard H. Parrish
- Department of Biomedical Sciences, School of Medicine, Mercer University, Columbus, GA 31207, USA
| | - Scott Ciarkowski
- Pharmacy Quality & Safety, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - David Aguero
- Medication Systems and Informatics, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA
| | | | - Donna Z. Bohannon
- Healthcare Quality and Safety, United States Pharmacopieal Convention, Rockville, MD 20852, USA
| | - Roy Guharoy
- Division of Infectious Diseases, School of Medicine, University of Massachusetts, Amherst, MA 01655, USA
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Feinstein JA, Friedman H, Orth LE, Feudtner C, Kempe A, Samay S, Blackmer AB. Complexity of Medication Regimens for Children With Neurological Impairment. JAMA Netw Open 2021; 4:e2122818. [PMID: 34436607 PMCID: PMC8391103 DOI: 10.1001/jamanetworkopen.2021.22818] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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 PARTICIPANTS 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. 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 MEASURES 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. RESULTS 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. CONCLUSIONS AND RELEVANCE 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.
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Affiliation(s)
- James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children’s Hospital Colorado, Aurora
- Department of Pediatrics, University of Colorado, Aurora
| | | | - Lucas E. Orth
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allison Kempe
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children’s Hospital Colorado, Aurora
- Department of Pediatrics, University of Colorado, Aurora
| | - Sadaf Samay
- Research Informatics, Analytics Resource Center, Children’s Hospital Colorado, Aurora
| | - Allison B. Blackmer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora
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Warda N, Rotolo SM. Virtual medication tours with a pharmacist as part of a cystic fibrosis telehealth visit. J Am Pharm Assoc (2003) 2021; 61:e119-e125. [PMID: 33931355 PMCID: PMC8056476 DOI: 10.1016/j.japh.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 01/08/2023]
Abstract
Background As a result of the coronavirus disease 2019 (COVID-19) pandemic, institutions needed innovative solutions to provide care. With implementation of telehealth, a cystic fibrosis (CF) pharmacist was able to incorporate a virtual medication tour during appointments. Objective The purpose of our study was to describe the uptake and impact of pharmacist-led virtual medication tours during telehealth visits in the CF clinic setting. Practice description Before the COVID-19 pandemic, a CF pharmacist participated in in-person multidisciplinary team visits to complete medication history reconciliation, assess adherence, assess efficacy and address possible adverse effects of medications, and work collaboratively with the CF care team and patient to create therapeutic plans. The virtual medication tour described in this study was completed in addition or as a complement to these pre-existing pharmacist roles and responsibilities. Practice innovation Patients seen via telehealth visit were asked to provide a virtual tour of their medications. A pharmacist completed medication history and evaluated whether storage conditions were appropriate in regard to temperature, humidity, light exposure, and accessibility to children. Evaluation methods A pharmacist recorded findings from the virtual medication tours and made interventions when appropriate. Descriptive statistics were used for analysis. Results Of 20 patients seen via telehealth for a quarterly visit during the first 3 months after implementation, 13 were willing to participate in a virtual medication tour. Before the visit, 25% had information missing from their medication list. Virtual medication tour allowed for resolution of this information 80% of the time. Three of the 4 participating patients with a child under 12 years old had medications stored in a location accessible to children. Conclusion A virtual medication tour led by a pharmacist can be successfully incorporated into telehealth visits and was accepted by a majority of patients. Most patients stored medications appropriately but might benefit from education on poison prevention practices.
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