Transcript Document

Health Care Attitudes and Trends among the Pediatric Prescribing Community
Mahesh Narayan1 MB, MSE, Dimple Patel1 MS, Peter C. Adamson1,2,3 MD, Jeffrey S. Barrett1,3 PhD FCP.
of Clinical Pharmacology and Therapeutics, 2Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA.
3Department of Pediatrics, The University of Pennsylvania School of Medicine.
I : Pediatric Caregiver Demographics
General Pediatrics,
21%
Gastroenterology, 3%
100%
Anesthesia, 3%
Hematology, 3%
Pulmonary Medicine,
4%
Neurology, 12%
Endocrinology, 5%
Allergy / Immunology ,
6%
50%
40%
30%
Other Specialization,
8%
50%
40%
30%
10%
10%
0%
0%
Resident
Other
60%
20%
Physician Fellow
NeoFax
Calculator
70%
20%
Attending
Physician
SCM
80%
60%
Nurse Practioner
Attending
Physician
Low
Medium High
Physician
Fellow
Resident
Nurse
Practioner
Figure 7: Drawbacks associated with current pharmacotherapy tools
Figure 4: Ranking of criterions that affect dose adjustment in pediatrics
High
Medium Low
Too population-centric
100%
Too patient-centric
90%
Not userfriendly /
interactive / modifiable
80%
Percentage of Respondents
No drawbacks
70%
Information is variable and
inconsistant with other
sources
60%
No information on drug
metabolism & PK/PD
50%
Not error-proof
40%
Other
30%
20%
0%
5%
10%
15%
20%
25%
30%
35%
10%
Figure 8: Interest for a predictive dosing guidance tool that would individualize patient treatment
0%
II : Pharmacotherapy Resources
Age
Figure 1: Level of Information in the Existing Dosing Compendiums
BSA
BW
Height
Organ Function
80%
< 1% of patients
70%
1-20% of patients
20-50% of patients
Very Informative
Percentage of Respondents
Percentage of Respondents
70%
60%
50%
40%
60%
> 50% of patients
Other
50%
40%
Attending
Physician
10%
Nurse Practioner
Figure 2: Convenience of obtaining information pertaining to dosing guidance
Not Very Convenient
Somewhat Convenient
Very Convenient
80%
70%
Percentage of Respondents
60%
50%
40%
30%
20%
10%
0%
Attending Physician
Physician Fellow
Resident
Nurse Practioner
Physician
Fellow
Resident
N
40%
30%
Attending Physicians
N
Physician Fellows
N
Residents
Physician Fellow
Resident
Nurse Practioner
DISCUSSION AND CONCLUSIONS
Nurse
Practioner
Table 3: Medication classes most difficult to manage
Overall
50%
Attending Physician
0%
Resident
60%
0%
20%
Physician Fellow
70%
10%
20%
10%
Attending Physician
Maybe
20%
30%
30%
0%
No
80%
80%
Somewhat Informative
Yes
90%
Figure 5: Patients that receive dose modification outside the standard dose requirement
Not Very Informative
RESULTS
•A total of 313 responses were obtained (response rate 33%).
•There are a variety of sources for obtaining dosing information (Table 2).
•Existing Pharmacotherapy tools are far from perfect (Figure 1).
•The top 3 criterions affecting dose are body weight, organ function and age.
•~70% of pediatric caregivers modify doses in 1-20% of their patients (Figure 5).
•~75% of the respondents would like to have access to a predictive tool
that would allow personalized patient treatment (Figure 8)
Somewhat Important
Very Important
70%
Oncology, 9%
Lexi-Comp Online
90%
80%
Cardiology, 7%
Table 2: Pediatric Caregiver’s Source of dosing reference information
Figure 6: Pharmacotherapy tools commonly used to calculate dose requirements
Not Very Important
90%
Emergency Medicine,
8%
IV: Evaluation of Existing Tools
Figure 3: Importance of Dose Adjustment in pediatrics?
Other, 14%
DESIGN / METHODS
A 15 question survey was prepared with the guidance of clinical and
administrative thought-leaders at the Children’s Hospital of Philadelphia
(CHOP). The survey comprised of a mixture of six tick-box questions,
seven 3-4 point scale responses (seven of which allowed comments) and
two free text questions. An initial pilot questionnaire was conducted as
proof-of-concept for feedback purposes. The survey was distributed
through a web-application via internal email to roughly 900 hospitalbased pediatric care givers within the Division of Pediatrics at CHOP and
was kept open for a period of three weeks. Two reminders were sent
(once a week) during this period. The pediatric caregivers comprised of
Attending Physicians, Fellow Physicians, Residents, Nurse Practioners,
Clinical Pharmacists, Physician Assistants and Clinical Nurse Specialists.
Questionnaire categories included pediatric caregiver demographics,
pharmacotherapy resources, dose adjustment and management, and
evaluation of existing tools to provide improved pharmacotherapy
guidance. The results were analyzed and summarized in SAS using
simple descriptive statistics.
RESULTS
III : Dose Adjustment & Management
Table 1: Clinical role, specialization and setting of survey respondents
OBJECTIVES
•Assess pediatric caregiver’s knowledge regarding dosing guidance with
respect to the caregiver’s role, specialty and location.
•Identify caregiver’s level of satisfaction with available compendial sources
and the extent to which such sources are utilized.
•Detect the prevalence of dose adjustment within the pediatric practice and
assess the caregiver’s appreciation for dose adjustments in their patients.
•Ascertain which drug classes are more vulnerable with respect to
available dosing guidance and quantify the need for more dosing guidance.
•Identify the mechanism/comfort in calculating dose adjustments.
•Assess available resources for dosing guidance and need for additional tools.
RESULTS
Percentage of Respondents
There is a great deal of disparity in the way pediatric caregivers manage the
pharmacotherapy of their patients. Part of this is due to the diversity in the
caregiver community with respect to their background (e.g., nurse, pharmacist
or physician), area of specialization and clinical setting (inpatient vs.
outpatient). An important consideration is the extent to which caregivers
appreciate the need to adjust the dose in their patients and their satisfaction
with the resources and approaches used to guide such adjustments.
RESULTS
Percentage of Respondents
BACKGROUND
Percentage of Respondents
1Division
N
Nurse Practioners
N
Antibiotics
66
Antibiotics
36
Antibiotics
12
Anticonvulsant
12
ADHD
13
Anticonvulsants
54
Anticoagulants
29
Immunosuppressants
11
Antibiotics
10
Antianxiety
12
Anticoagulants
47
Other
26
Anticoagulants
10
Immunosuppressants
4
Anticonvulsant
10
Immunosuppressants
43
Anticonvulsant
25
Antiarrhythmic
7
Antiarrhythmic
3
Antibiotics
8
Other
43
CNS Agents
23
Anticonvulsant
7
Anticoagulants
3
Antidepressants
8
CNS Agents
40
Orphan Drugs
21
Antifungal
7
Antidepressants
3
Other
8
ADHD
36
Antifungal
18
Other
7
Antiemetic
2
Asthma
7
Antidepressants
32
Immunosuppressants
18
Antihypertensive
5
Asthma
2
Immunosuppressants
7
Orphan Drugs
30
ADHD
15
CNS Agents
5
CNS Agents
2
CNS Agents
6
Antiarrhthymics
28
Antiarrhythmic
15
Orphan Drugs
5
Other
2
Anticoagulants
5
Antiemetic
28
Antidepressants
15
Antidepressants
4
ADHD
1
Antihistamine
4
Antiviral
26
Antiemetic
14
Antineoplastic
4
Antifungal
1
Antiarrhythmic
3
Antineoplastic
24
Antihypertensive
14
ADHD
3
Antihypertensive
1
Antiinfectives
3
Antihypertensive
23
Antineoplastic
14
Antianxiety
3
Antineoplastic
1
Antihypertensive
3
Antiinfectives
21
Antiinfectives
10
Antiemetic
2
Antiviral
1
Antiemetic
2
Antianxiety
20
Antianxiety
9
Antiinfectives
2
Orphan Drugs
1
Antineoplastic
2
Asthma
17
Antiviral
8
AIDS
1
AIDS
1
Antifungal
15
Asthma
8
Antihistamine
1
Antiviral
1
AIDS
11
Antihistamine
5
Antiviral
1
Orphan Drugs
1
Antihistamine
10
AIDS
3
•Dosing guidance is generally viewed important in Pediatrics.
•There exists a difference in the way medicines are prescribed with respect to the
pediatric caregiver’s role, specialty and location.
•It is interesting to note that the responses of the Resident community closely
resembles that of the Nursing community. This is due to the fact that these two
groups do most of the ordering and prescribing.
•It is clearly evident that the existing dosing guidance resources are inadequate to
guide recommendations for most pediatric drugs.
•A predictive tool with decision support capabilities is an unmet need in the
pediatrics and will be well received if constructed properly. Our Pediatric
Knowledgebase effort aims at addressing many of these observations.
•We are seeking validation of these findings by extending the questionnaire to
regional, national and global centers of excellence.