Polypharmacy Exposure among Children Hospitalized in the United States

The 2002 Best Pharmaceuticals for Children Act (BPCA) was designed to help reduce pharmaceutical errors associated with dispensing drugs to hospitalized children; the BPCA was followed in 2003 with the Pediatric Research Equity Act. According to researchers, the efficacy and safety of many pediatric medications have not been well established, especially in the hospital setting, where medications are often used for off-label medications, increasing the potential for the medical errors. Researchers recently conducted a retrospective cohort study to evaluate the overall patterns of pediatric inpatient drug and therapeutic agent use, including the most commonly used drugs and therapeutic agents for hospitalized children, and differences in drug and agent use across different types of hospitals. The researchers combined data on hospital medication use from 2 large databases: one database comprised data from children’s hospitals and the other from general hospitals. The 2 data sets represented approximately 19.9% of pediatric hospitalizations in the United States. The current study focused on polypharmacy use, which has been associated with an increased risk of adverse reactions in adults in intensive care units and other acute care settings. Study results were reported online in Archives of Pediatrics & Adolescent Medicine [doi:10.1001/archpediatrics.2011.161].

The analysis included data from 411 general hospitals and 52 children’s hospitals nationwide on 587,427 patients <18 years of age hospitalized in 2006; healthy newborns were excluded. A total of 365,868 patients <18 years of age experienced 491,451 hospitalizations in the children’s hospitals and a total of 221,559 pediatric patients experienced 260,740 hospitalizations in the general hospitals. The cohort represented one-fifth of all pediatric admissions in the United States. The primary outcome measures were daily and cumulative exposures to drugs and therapeutic agents. In children’s hospitals, the median exposure of an infant patient on the first day of hospitalization was 4 distinct generic drugs and therapeutic agents. On day 2, the number dropped to 3 drugs and therapeutic agents, and then rose to 4 by hospital days 3 through 30. The numbers for the infant patient in the 90th percentile of exposures to daily drugs and therapeutic agents were 11 on hospital day 1 and 13 after the first week of hospitalization. For patients ≥1 year of age, the median level of exposure to drugs and therapeutic agents on the first day of hospitalization was 5, rising to 9 by day 30. For patients ≥1 year of age in the 90th percentile of exposure to drugs and therapeutic agents, the number was 13 on day 1, rising to 20 by day 30.

In general hospitals, the typical infant patient was exposed to 3 drugs and therapeutic agents on day 1 of hospitalization, a number that did not exceed 3 distinct drugs and therapeutic agents through 30 days of hospitalization. For infant patients in the 90th percentile of daily drug and therapeutic agent exposure in general hospitals, the number on day 1 was 8, rising to between 8 and 11 after hospital day 5. Corresponding numbers for patients ≥1 year of age in general hospitals were 5 on day 1 and 6 by day 30 (median); for those in the 90th percentile of exposure in general hospitals, the numbers were 12 distinct drugs and therapeutic agents on day 1 and 15 by day 30. The researchers also calculated the cumulative number of distinct generic drug and therapeutic agent exposures for each successive day of hospitalization: for the infant patient in a children’s hospital, the median cumulative number increased from 4 on day 1 to 25 by hospital day 30; for the infant patient in the 90th percentile of drug and therapeutic agent exposure, the numbers were 11 on the first hospital day, increasing to 51 by day 30. For patients ≥1 year of age in a children’s hospital, the median cumulative number was 5 on day 1, increasing to 42 by day 30; for those in the 90th percentile of exposure, the increase was from 13 to 66. For patients in a general hospital, the increase for infant patients at the median level of exposure was from 3 to 21; for those in the 90th percentile of exposure, the increase was from 8 to 35. Corresponding numbers for patients ≥1 year of age in a general hospital were from 5 to 25 (median) and 12 to 57 (90th percentile). The highest levels of cumulative drug and therapeutic agent exposures were for less common conditions (linear trend, P=.001 for children’s hospitals and P<.001 for general hospitals).