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 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.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Feinstein reported being Chair of the State of Colorado Medicaid Pharmacy and Therapeutics Committee. Dr Blackmer reported receiving personal fees from Wolter-Kluwer Pediatric and Neonatal Lexi-drugs and the Drug Utilization Review Board for the Colorado Department of Health Care Policy and Financing. No other disclosures were reported.

Figures

Figure 1.. Distribution of Medication Regimen Complexity Index (MRCI) Subscores by Total MRCI Scores in Children With Severe Neurological Impairment

This graph displays fractional polynomial plots of MRCI mean subscores associated with total MRCI scores. The vertical reference lines display thresholds for the low, medium, and high MRCI total score tertiles. Shaded areas denote 95% CIs.

Figure 2.. Medication-Level Characteristics of Complex Medication Regimens Related to Medication Regimen Complexity Index (MRCI) Subscores in Children With Severe Neurological Impairment

Graphs show the percentage distribution of dosage forms among all medications (A), the percentage distribution of dose frequencies among all scheduled medications (B), the percentage distribution of dose frequencies among all as-needed (PRN) medications (C), and the percentage distribution of additional instructions among all medications (D). MDI indicates meter dose inhaler.

Figure 3.. Characteristics of Complex Medication Regimens at the Patient Level by Medication Regimen Complexity Index (MRCI) Tertile in Children With Severe Neurological Impairment

In the box plots, lines within boxes denote medians, ends of boxes denote interquartile ranges, and error bars denote the lower and upper adjacent values. Panel A displays counts for unique dosage forms per patient, dose frequencies per patient, and additional instructions per patient. Panel B displays counts for scheduled medication doses per patient per day excluding as-needed (PRN) medications, PRN medications per patient per day, and total doses per patient per day. Panel C displays counts for high-risk medications per patient, and moderate and major potential drug-drug interactions per patient. All comparisons across MRCI score groups were significant (P < .05, nonparametric tests of trend).