Medication burden persists for years after pediatric heart surgery
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Key takeaways:
- Nearly half of all teens with a history of cardiac surgery still used more than one medication.
- Clinicians must counsel patients with congenital heart disease on medication usage before and after surgery.
Children who underwent cardiac surgery had a high medication burden that often persisted throughout adolescence, with medication expenditures often 10-fold higher compared with those who did not have heart surgery, data show.
“Morbidity and mortality for children with congenital heart defects is highest in the first days to weeks after their surgery,” Joyce L. Woo, MD, MS, assistant professor of pediatrics (cardiology) and medical social sciences, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Katherine A. Nash MD, MHS, assistant professor of pediatrics in the division of critical care and hospital medicine at Columbia University Irving Medical Center, and Brett R. Anderson, MD, MBA, MS, associate professor of pediatrics at the Mindich Child Health and Development Institute; Icahn School of Medicine at Mount Sinai, told Healio. “This study demonstrates that medication burden, and likely chronic disease burden, for children with congenital heart defects extends for far longer — for years — after surgery. Nearly half of adolescents with a history of cardiac surgery used more than one medication.”
Higher expenditures after heart surgery
In a retrospective study, researchers analyzed data from 5,459 children who underwent cardiac surgery and 4.5 million children who did not, using data from the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). The primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using at least one and at least three medications, and medication expenditures per person-year.
The findings were published in the Journal of the American College of Cardiology.
More than four in 10 children who underwent cardiac surgery used at least one chronic medication compared with approximately one in 10 children who did not have cardiac surgery. On average, cardiac enrollees used one chronic medication per person-year vs. 0.3 chronic medications per person-year for those who did not undergo cardiac surgery.
Additionally, medication expenditures were 10 times higher per person-year for patients who underwent pediatric cardiac surgery vs. those who did not undergo surgery. Among those who underwent surgery, disease severity was associated with chronic medication use. The highest use of medication occurred in infants, but nearly half of adolescents used at least one chronic medication, according to the researchers.
The mean total medication expenditures for cardiac enrollees were $2,654 per person-year, with a median of $18 per person-year. For noncardiac enrollees, mean expenditures were $328 per person-year, with a median of $0 per person-year.
A single medication, palivizumab (Synagis, MedImmune), an antibody treatment given to at-risk infants to prevent respiratory syncytial virus, accounted for 42% of total medication expenditures for cardiac enrollees and 6% for noncardiac enrollees.
“When pediatric cardiologists and primary pediatricians counsel about surgery and the natural history and progression of their congenital heart defect, they may consider anticipatory guidance around chronic medication use, and that cardiovascular, renal, gastrointestinal and neuropsychiatric medications may be necessary even several years after surgery,” Woo, Nash and Anderson told Healio. “Fetal cardiologists may also counsel expectant parents about chronic medication burden for the baby after delivery. Even if a patient is far out from their congenital heart surgery, providers should thoroughly review the patient’s medications, even if they are prescribed by other providers. Discussing the list of medications with the patient, family and coordinating and clearly communicating with other specialists and general pediatric providers will help prevent adverse effects of polypharmacy, including medication interactions and administration errors, unnecessary medication use, and psychological burden for the patient.”
Differences by race, medication type
The researchers noted that the data showed use of neuropsychiatric medication was about 20% higher among children with a history of congenital heart surgery than those without. However, other studies have demonstrated a prevalence of neuropsychiatric disease that is 19% to 46% higher among children with congenital heart surgery.
“The reasons behind this discrepancy are unclear,” Woo, Nash and Anderson told Healio. “Is it because children with congenital heart surgery are less likely to be prescribed neuropsychiatric medication for the same conditions? Or is it because neuropsychiatric conditions associated with congenital heart defects are different than those in the general Medicaid population and are less likely to require medications? Or is it because patients with congenital heart disease do not want to take yet another medication?”
The researchers also observed differences in medication utilization by race and ethnicity. Hispanic children had higher chronic medication use and expenditures compared with all racial and ethnic groups except for white patients. Compared with Hispanic children, Black children had 26% (95% CI, 15-37) lower odds per person-year of using at least one chronic medication, 24% (95% CI, 4-51) lower odds per person-year of using at least three chronic medications and 31% (95% CI, 10-48) lower total medication expenditures.
“However, it is unclear if these are disparities (differences) or inequities (differences that are unfair or unjust),” Woo, Nash and Anderson said. “For example, disparities by race and ethnicity may be due to preference or may represent clinically insignificant overuse or underuse that are not tied to outcomes. Understanding whether differences in medication use are on the causal pathway toward inequities in outcomes is an area of future research.”
For more information:
Brett R. Anderson, MD, MBA, MS, can be reached at brett.anderson@mssm.edu; X (Twitter): @brettanders.
Katherine A. Nash MD, MHS, can be reached at kan2123@cumc.columbia.edu; X (Twitter): @katienasher
Joyce L. Woo, MD, MS, can be reached at jwoo@luriechildrens.org; X (Twitter): @jwoomdms
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