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Despite oversight, palivizumab improperly prescribed
Perrin KM. Pediatrics. 2011;doi:10.1542/peds.2010-2991.
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Interventions that encourage education and physician oversight of palivizumab use improved patient selection for treatment but not prescription rates, according to study results published online.
Keith M. Perrin, MD, of the Children’s Hospital of New Orleans, and Rodolfo E. Bégué, MD, of the Louisiana State University Health Sciences Center, reviewed the effect a clinician education program had on use of palivizumab (Synagis, MedImmune) for patients with bronchiolitis during two respiratory syncytial virus seasons.
Inappropriate requests for palivizumab decreased about 33% during the 2009-2010 and 2010-2011 respiratory syncytial virus seasons after intervention, according to the researchers. However, only 29% of children received the recommended number of doses, even after the intervention.
“In a primary practice, use of palivizumab outside of the AAP guidelines was frequent and manifested as inadequate indications or inadequate number of doses,” the researchers wrote. “The former improved with education and standardization of care (suggesting provider problems), while the latter did not (suggesting system problems). Additional interventions are required.”
Disclosure: The researchers report no relevant financial disclosures.
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In 1998, the American Academy of Pediatrics (AAP) recommended palivizumab use for young children with a history of prematurity and/or chronic lung disease (CLD) who fulfilled specific criteria based on age, gestational age at birth, need of therapy for CLD and additional risk factors. These recommendations were first revised in 2003 to include children with hemodynamically significant congenital heart disease (HSCHD) and children with severe immunodeficiency and again revised in 2009.
The latest revision specified, among other things, that injections should begin on Nov. 1 for all states except Florida and instituted a sliding scale for the number of monthly injections to be given based on underlying disease (CLD, HSCHD) and gestational age. The latest revisions created much controversy (many of the recommendations were not based on clinical studies) and potential confusion. Therefore, it was not entirely surprising that the study of Perrin and Bégué found that palivizumab use in a large children’s hospital-associated primary practice was often outside the AAP guidelines. Indeed nearly half of the children who received palivizumab in the 2009-2010 RSV season did not conform with AAP guidelines. Systematic identification of eligible children and auditing of all requests for palivizumab the following season increased the percentage of children in whom palivizumab administration conformed with the AAP guidelines to 86%, yet less than one-third of the children in both seasons received the appropriate number of doses (most children received fewer than the number of appropriate doses).
The data suggest that standardization of practice was very effective in limiting palivizumab use to those children who fulfilled AAP criteria but failed to lead to improvements in the percentage of children who received the appropriate number of doses. Inadequate dosing results in decreased cost effectiveness of an already expensive intervention. Further efforts should target system-based approaches to maximize administration rates.
Jeffrey S. Kahn, MD, PhD
Professor of
Pediatrics and Microbiology
Director, Infectious Diseases, Department of
Pediatrics
University of Texas Southwestern Medical Center
Dallas
Disclosure: Dr. Kahn reports no relevant financial disclosures.
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