Pediatric Polypharmacy Management: A Mission to Improve Safety, Ease and Effectiveness

How can having an integrated pediatric pharmacist make life easier, safer and more cost effective for children, parents and caregivers needing to manage multiple medications per day?

For some families, managing their child’s rare or complex medical condition might turn their kitchen counter into a mini pharmacy — dozens of syringes, pill bottles, inhalers and more. Each medication has its own specific instructions and cadence of doses, all falling on different hour intervals throughout the day. In some cases, this can look like 31 different doses of medication per day for a child with medical complexity.

Children’s Hospital Colorado's complex care physician and Medical Director of the Colorado Child Health Research Institute, Jamie Feinstein, MD, MPH, has focused his research on polypharmacy in children for his entire career. He’s now taking a closer look at whether a geriatric medication therapy management (MTM) program, which targets medications for optimization, could be adapted for children. Dr. Feinstein earned a 5-year, $2 million, R01 award from the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) to support this work.

“Many of these children rely on outstanding multidisciplinary care — which we have here at Children’s Colorado,” Dr. Feinstein says. “With any medication use, there’s always safety risks like adverse drug effects. But with polypharmacy, when you have many prescribers layering medications on top of one another, then you’re looking at a much more complex scenario with multiple potential safety risks.”

Other such risks of polypharmacy include drug-drug interactions, suboptimal doses, legacy medications that are never discontinued, or duplications of medication working to treat similar symptoms if medications are prescribed by different subspecialists.

“How do we make sure every one of a child’s 15 or 20 medications is optimal? It’s really challenging,” Dr. Feinstein says.

Implementing pediatric medication therapy management

Children’s Colorado’s Special Care Clinic is the largest home for children with medical complexity in the country — caring for more than 6,000 kids. This comprehensive and integrated program offers primary care, co-management and consultation services to children with complex medical conditions and special healthcare needs.

Dr. Feinstein’s randomized control trial of Pediatric Medication Therapy Management (pMTM) is offering some children with polypharmacy a pharmacist-led intervention based on the geriatric model. These families receive a virtual meeting with a dedicated pharmacist to review their medication list, optimize the medications they are taking and how they are taking them, and create a digital EHR-based action plan tailored to the caregiver’s preferred learning style (visual list, table, text instructions, etc.) to keep track of the medication plan. The study pharmacist, Lucas Orth, PharmD, Associate Professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, is integrated in each child’s individual care plan and medication list to oversee medications on a high level. Dr. Feinstein and the team are also working closely with parents, caregivers and medical providers in interviews to evaluate the impact pMTM has on the people managing the medication routine at home, with early findings recently published in the Journal of the American Pharmacists Society.

The study is nearing its halfway point, and so far, the feedback from caregivers has been positive. They enjoy having this dedicated resource to help make life easier at home.

“It's extremely easy to make medication errors when you are sleep deprived or your routine gets disrupted,” one parent managing their child’s polypharmacy told Dr. Feinstein. “There is horrendous guilt when we make mistakes, especially ones that could harm our child. Having you understand what things look like at home empowers us to be successful by avoiding issues you see that we might not.”

Creating a sustainable solution

“Assuming pMTM is as we hypothesize — an effective solution for improving medication safety in children — my hope is that we are able to distribute it to other complex care clinics across the country,” Dr. Feinstein says. “We have a real opportunity to guide best practices for managing polypharmacy in children.”

Dr. Feinstein wants to ensure this new pediatric medication therapy management model is feasible and sustainable for other hospitals to implement. Another of his recent studies published in JAMA Network Open explored whether Colorado children prescribed one or more medications exceeded the Centers for Medicare and Medicaid Services (CMS) geriatric cost threshold to qualify for free MTM. The study found that five percent of Colorado children qualified based on the CMS cost threshold for MTM.

“Medicare provides medication therapy management free to seniors. We should also be making this type of service readily available to children with polypharmacy who need it,” Dr. Feinstein says. “We want to make pMTM an easy, effective intervention for parents and providers that can be implemented at a low cost to healthcare systems.”

Dr. Feinstein notes that this work showcases the importance and impact of having a dedicated, integrated pharmacist in multidisciplinary complex care clinics. “The only way to move this type of research and clinical care forward is through a collaborative team science approach.”