Managed Care - November 2008 - (Page RSV11)

home-based delivery of palivizumab can be a highly successful strategy for ensuring that immunoprophylaxis is provided to high-risk infants. SCH NICU gave our general pediatric practice a discharge summary and indications for palivizumab for all patients who would receive follow-up care in our practice. We then entered these patients into a database and tracked them from the beginning to the end of the RSV season. We also notified the insurance providers and the parents of the children who required immunoprophylaxis. We developed a screening tool for use with all other children coming to our practice, and we dedicated a nurse and a physician to track all the patients. We assigned office staff to resolve insurance and health care provider issues. Working with our home pharmacy provider, we started to obtain palivizumab 2 or 3 weeks before the anticipated start of the RSV season. We also worked closely with home care companies. Because MCOs were concerned about anaphylaxis, an anaphylaxis protocol for the home care nurses was put in place whereby nurses were supplied with epinephrine and a procedure to follow if a child developed anaphylaxis. As severe reactions with palivizumab are rare, we have had no cases of anaphylaxis. I would recommend that an anaphylaxis protocol be part of any home care program for palivizumab immunoprophylaxis. During 5 RSV seasons, 401 patients received prophylaxis. Their distribution by GA was: Less than 29 weeks (36 percent), 29–32 weeks (29 percent), 32–35 weeks (25 percent), and greater than 35 weeks (9 percent). One third of this population had CLD. Because of RSV activity in our region, tracked locally, full protection required a series of five and sometimes up to seven palivizumab injections for each infant born at the start of the season, or less, depending on their date of birth within the season. Infants who had been admitted to the NICU received a first injection of palivizumab in the hospital. During five consecutive RSV seasons, the average number of injections per patient increased each year. Over the course of five seasons, there were only eight hospital admissions for RSV lower respiratory infection in the 395 patients available for follow-up. The hospitalization rate of 2 percent was well below the expected rate of 10.6 percent. We believe this program, with a greater than 90 percent compliance rate in terms of number of injections administered in seasons 2 to 5 and with a significant numbers of patients receiving home care, establishes a workable, coordinated approach for palivizumab immunoprophylaxis that can be duplicated by other pediatric practices. ated with reduced hospitalization rates (Frogel 2008). The registry enrolled 19,548 patients who received at least one dose of palivizumab during four RSV seasons at 256 pediatric sites in 41 states and the District of Columbia. Doses were administered at clinics, physician offices, or at home. Subjects receiving doses in more than one season were counted as separate enrollments. Across all four seasons, 40 percent of patients were born at a GA less than 32 weeks, 48 percent between 32 and 35 weeks, and 12 percent after 35 weeks gestation. In addition to prematurity, common risk factors among the patients in the registry included childcare attendance, CLD, and CHD. Follow-up information was available for 19,474 patients. Over all four seasons, the confirmed RSV hospitalization rate was 1.3 percent. Higher hospitalization rates were associated with male gender, birth before 32 weeks’ gestation, a history of CLD or CHD, congenital airway abnormalities or neuromuscular disease, and the presence of two or more children in the household. In the fourth season, CHD was the most common reason listed for palivizumab immunoprophylaxis in children whose GA exceeded 35 weeks. In terms of timely administration — receipt of a dose within 35 days of the previous one — and the number of doses administered, the compliance rate ranged from 65 to 69 percent, and 59 percent of patients were compliant with palivizumab immunoprophylaxis by both measures. Patients in the mixed group (office/home) had lower compliance than either group alone. In comparison with clinic- or office-based administration of palivizumab, home care improved compliance by both measures (number of doses, 88 versus 81 percent; P<.0001); timely administration, 76 versus 69 percent; P<.0001). The home care-only group admission rate was 0.4 percent versus 1.2 percent for the clinic office-only group. Summary Pharmacologic options in the treatment of RSV infection have no or minimal effectiveness. Therefore, for infants at high risk of RSV infection, proper hand hygiene, limiting exposure to infection, and immunoprophylaxis with palivizumab is paramount. The first injection of palivizumab must be given prior to the start of the local RSV season and subsequent injections should be administered every 30 days to provide protective levels until the end of the RSV season. Pediatricians should anticipate the start of the RSV season and attend to reimbursement issues and obtain all necessary approvals well in advance of the time when the first injections will be given. Compliance is the key to providing protection for high-risk infants. Compliance has a positive association with decreasing RSV hospitalization rates; however, it is difficult for pediatricians to achieve optimal compliance on their own. A collaborative effort involving the hospi- Real-world experience A recent analysis of a nationwide palivizumab registry showed that palivizumab immunoprophylaxis is associ- SUPPLEMENT / RSV 11

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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