Medication Management in Primary and Secondary Schools: Assessing the Practices and Opinions of Pediatricians

INTRODUCTION

Children suffering from serious diseases are often mainstreamed into schools, leaving parents to rely on schools to play an increasing role in the management of their medications. Nearly 9 million children in the United States have asthma, 900,000 have epilepsy, 176,000 have diabetes, and approximately 2 million have attention deficit hyperactive disorder.1–4 The result of these realities is that many children are taking medications to treat their disorders while they are in school and are under the effects of medication during school, even if the dose was taken at home before school. Not all schools utilize nurses to dispense medications to students. Often, secretaries, health aides, teachers, parents, and others assist with medication management of the school-aged child. There is concern that lack of licensed personnel, drug information resources, and medication management knowledge, mean that school children may not be receiving optimum drug therapy.

In previous studies, school nurses, teachers, unlicensed assistive personnel, pharmacists, college of pharmacy faculty members, and parents have been surveyed regarding their knowledge of and attitudes toward medication management in schools.5–9 However, little is known about the views and prescribing habits of pediatricians as they relate to medication use in school. One way to make a contribution to this knowledge base, therefore, is to assess the views of pediatricians as they relate to the prescribing and use of medications taken before or during school hours. Indeed, office-based physicians, working in conjunction with community pharmacists, have an opportunity to reduce the risks associated with the use of medications in schools.

Pediatricians have a vested interest in the success of the therapies that they prescribe for their patients. Assessing the attitudes and knowledge of pediatricians regarding medications in schools allows for policy recommendations to improve the effectiveness of school health services, specifically medication management services. This paper assesses the prescribing habits and views of pediatricians in order to address this important drug therapy problem.

METHODS

A questionnaire was developed for pediatricians attending the annual meeting of the Illinois Chapter of the American Academy of Pediatrics (ICAAP). The questionnaire was a modified version of one used earlier to survey pharmacists and parents.79 All attendees of the ICAAP meeting were given the questionnaire with a cover letter explaining the importance of their input on issues related to medication management in schools. Of the approximately 100 attendees, only 29 pediatricians and 1 advanced practice nurse specializing in pediatrics responded to the 15 question survey estimated to take only 10 minutes to complete.

Given the low response rate, an attempt to increase sample size was made by attaching the survey to an electronic, monthly newsletter received by approximately 1,700 members of the ICAAP. In this newsletter, it was requested that any member that had not previously completed the questionnaire please do so. Again, information about the short survey emphasized the value of the pediatricians' input. In addition to the 30 original surveys, five more were submitted online (all from pediatricians), resulting in a total sample size of 35. Background information on these individuals is presented in Tables 1 and 2.

Table 1. Physician Demographics

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Table 2. Practice Characteristics

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RESULTS

All of the respondents reported that they have prescribed medications to children under the age of 18 that may affect the child while at school. When asked how common this was, 42.9% (n = 15) selected “Somewhat Common”, followed by “Quite Common” (34.3%; n = 12), “Occasional” (17.1%; n = 6), and “Rare” (2.9%, n = 1). Rescue inhalers were identified as medication most commonly prescribed for use in schools (79.4%, n = 27), followed by medications used to treat attention deficit hyperactivity disorder (8.8%, n = 3), over-the-counter medications (5.9%; n = 2), and antibiotics (2.9%, n = 1).

The majority (60%) of pediatricians responding to the survey believe that taking medications at school can create special problems with drug therapy. Twenty-one pediatricians gave examples of problems with drug therapy that can occur while a child is under the influence of a medication during school hours. These results are shown in Figure 1. (The total in Figure 1 is greater than 21, because some subjects identified multiple problems.)

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Table 3 presents actions that these physicians have taken in order to minimize problems with medications being taken before or during school. Other actions taken by pediatricians to avoid potential problems are included in Table 4 and are shown verbatim.

Table 3. Actions to Minimize Potential Problems

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Table 4. Verbatim Comments Regarding Actions Taken by Pediatricians to Avoid Potential Problems

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The majority of pediatricians surveyed, (59.4%; n = 19) disagreed with the statement that “Medications in Illinois schools are well managed by a trained agent (nurse or health care aide)”. Pysicians who disagreed with the above statement were not more likely to use additional actions taken to prevent possible problems with taking medications at school than those who agreed with the statement. In contrast, those physicians who thought that there can be special problems associated with taking medications at or before school used more actions, on average, than those who did not. The difference, however, was not statistically significant.

DISCUSSION

Research indicates a particular difficulty in collecting data from physicians, mainly because they are too busy to complete surveys, regardless of topic. Often, receptionists are asked to discard mail containing surveys.10 In one study, only 66 physicians out of 189 (34.9%) responded to a survey on ambulatory-care sensitive admissions.10 Another study conducted to further improve response rates by physicians found that only 19.6% of physicians responded to a pilot survey, but after a monetary incentive and several reminders to complete the survey were issued, the response rate jumped to 64.8%.11

The sample size for this study was small due to a low response rate from pediatricians who are members of the ICAAP. Possible reasons for this low response rate include the workload of the physician, no incentives or reminders to complete the survey, and the fact that members of ICAAP include not only physicians, but also pediatric dentists, students, retired pediatricians, and any healthcare professional with a specific interest in pediatrics (including those who cannot prescribe—pharmacists, physical therapists, occupational therapists, etc.).12 Our results might be biased, too, because practitioners who choose to belong to professional societies might be more involved in a broader range of patient care issues than those who do not. Also, five of our 35 surveys were submitted online (versus being completed at the conference), and this could have conceivably affected the results. In any case, the literature shows that physicians are generally unlikely to complete and return questionnaires; therefore our results, if only suggestive, add a degree of knowledge relating to our understanding of this important area of drug therapy.

Given these limitations, some conclusions and recommendations can be made. First, the majority of these respondents think that taking medications at school creates problems with drug therapy and about the same number do not think medications are well managed in Illinois schools. These pediatricians are aware of specific problems associated with children being under the influence of, or taking medications during, school hours. Their views along these lines are consistent with the literature.913 Perhaps most striking along these lines is that the problems identified most often by respondents have to do with the way the schools handle medications. Some of these concerns were general while others specifically mentioned school nurses. Clearly, school nurses would disagree, especially when they are so often required to delegate their duties to unlicensed personnel.14–16 There is an obvious need for better communication between these nurses and the physicians who treat their students.

Many of these prescribers have devised ways to reduce or prevent potential problems. This was generally true regardless of years of experience, practice setting, types and frequency of medication prescribed, the belief that medications are well managed in schools, and the belief that medications can potentially cause problems for children during school hours. Though results were not statistically significant, most responses followed predictable patterns. The most common intervention was writing prescriptions for sustained release products so that taking doses at school is not necessary.

A 2003 survey of 569 licensed pharmacists with community pharmacy experience presented the same list of interventions (using pharmacist terms) as presented to respondents in the present study.7 The pharmacists provided an average of 3.34 interventions, the most common of which was providing additional labeled containers (over 90%). In the present survey, over half of the pediatricians indicated that they suggest parents ask for additional labeled containers. Therefore, this is one area in which prescribers and pharmacists can work together to reduce the risks associated with students needing to take medications at school. The most commonly reported intervention by far (94.3%) from respondents in the present study was writing prescriptions for sustained release products. (This was also the third most common intervention reported by pharmacists in the 2003 study, with 50% of subjects reporting that they recommended sustained release products. Again, this is an area where prescribers and pharmacists can stay up-to-date and try to identify safe and effective sustained release products, which can help reduce the number of doses taken at school.)

Finally, it is worth noting a substantial proportion of both groups (46.3% of pharmacists and 65.7% of pediatricians) report that they make an effort to stay current regarding medications that are most likely to be used at school. In general, larger proportions of pediatricians than pharmacists report making helpful interventions. Pharmacists need to increase efforts by lending their expertise to decrease risks associated with this important area of drug therapy.

In summary, responding pediatricians seem well-aware of the problems associated with students using medication before or during school hours. These doctors tend to not be satisfied with the way that schools handle this issue, and they employ a variety of strategies to help ameliorate the associated risks. Because these physicians might be more engaged in their work than the average pediatrician, it is not wise to extrapolate these conclusions. The ICAAP does have a School Health sub-section, and it would be worthwhile to consider incorporating some education regarding these concerns into regular meetings and newsletters. (Of course, such actions would probably be a helpful practice in other states and professional organizations, too.) Another implication of this research is that there is a real opportunity (and need) for pediatricians, community pharmacists, and school nurses to work together to improve drug therapy in the schools. An intervention as simple as suggesting to the patients or their parents that they ask the pharmacist for a separate labeled container for school use could pay dividends in terms of safer and more effective therapy in the schools.