Idaho AAP

 

Synagis Consensus Criteria

A group of pediatricians and pediatric subspecialists from Idaho met annually 2006-2012. These pediatricians decided to come together because they were vitally interested in prevention of RSV infection and ensuring access to Synagis (palivizumab) for high-risk infants during RSV season. Because Synagis is an expensive measure with challenging logistics for administration, cost-effective use was paramount in the minds of the pediatricians. The group sought to clarify criteria for use of Synagis, to define the season in the Intermountain West and Idaho, and to devise solutions to overcome obstacles to Synagis delivery.

I. RSV Season

Synagis dosing in most years should begin early December. Preauthorization should be completed substantially earlier.

Potential for an unusually early season with need for dosing before December has been addressed by pediatric infectious diseases specialists at St. Luke Children’s Hospital and state epidemiologist at Idaho Health & Welfare. There has not been an instance where early dosing was needed during use of RSV immunoprophylaxis since the late 1990s. If state and regional epidemiology services indicate that dosing should be initiated before December 1, then the state epidemiologist will authorize this change and clinic providers will be notified.

The end of RSV season rarely occurs before April 15, but five monthly doses are expected to provide sufficient antibody levels for the RSV season (that is, dosing ends in April even if RSV season persists in May or later).

Historical data for RSV season from St. Luke's Health System laboratory in Boise is attached. The onset of the season is defined as the first of at least 2 consecutive weeks with greater than 10% of tests positive for RSV, and the end of season is the last of at least 2 consecutive weeks with greater than 10% of tests positive, concordant with CDC definition. In addition, we do not notify of end of the season until no new hospitalizations for RSV bronchiolitis are observed.

Within Idaho weekly data by health district is available online from the Idaho Epidemiology program: http://healthandwelfare.idaho.gov/Health/DiseasesConditions/RSV/tabid/201/Default.aspx

Epidemiology services from neighboring states can be accessed online: https://intermountainphysician.org/gw/Pages/default.aspx for Utah http://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/Pages/RespiratorySyncytialVirusSurveillanceData.aspx for Oregon. Providers that want additional data representative of Northern Idaho can contact the neonatology office at Sacred Heart Children’s Hospital in Spokane to be included on the email listserve.

Providers are encouraged to consult data from the geographically representative center in order to make decisions appropriate to their localities. Occasionally, the season differs between centers, and the timing of Synagis use should reflect the most geographically representative data.

The Idaho AAP Chapter provides online recommendations based on current epidemiology data: http://www.idahoaap.org/monitor.htm

II. Selection of High-risk Infants

Most health insurance plans follow the current national AAP Committee on Infectious Diseases guidelines, published 2014 Pediatrics 134:415-420. These recommendations are significantly more restrictive than earlier AAP guidelines. The following points should be taken into account:

  • Infants with a variety of medical problems should be considered on a case-by-case basis, as it is not possible to make uniform recommendations with regard to immune deficiency and other cardiopulmonary diseases. For infants that do not fit a strict reading of guidelines but yet merit prophylaxis, a letter from provider to petition insurance preauthorization is appropriate.
  • The consensus group reinforces the statewide standard that Synagis dosing is not given to children older than 24 months at the start of RSV season. Note that a second season of prophylaxis is reserved for chronic lung disease of prematurity continuing to require medical support and for profound immunosuppression.
  • For determining eligibility, the start of RSV season is interpreted as December 1 to allow uniform preauthorization in advance of the actual season onset for that year.

III. Logistics

Role of NICU/Special Care Nurseries: Maintain list of infants who received Synagis before discharge and infants for whom further Synagis dosing should be considered. Identify primary care clinic prior to discharge. Communicate the list of infants to primary care clinics in discharge summaries and by letters in the fall.

Role of primary care clinics: Make ultimate decision to order Synagis in view of risk factors and clinical status in the fall. Preauthorization may be completed by the specialty pharmacy that supplies Synagis to the primary care clinic, but some insurers require that the ordering physician submit the preauthorization. When indications for an infant do not automatically fit AAP guidelines, the ordering physician will need to provide support for a preauthorization, such as in the form of a letter.

Role of epidemiology services: Provide accessible updates on current RSV activity and when high-risk infants should be receiving doses. When there is an unusually early RSV season detected, changes are communicated to the patient care coordinators at the NICUs, to the specialty pharmacies providing Synagis, and to as many primary care clinics as possible. Pediatric infectious diseases physicians at St. Luke’s in Boise confer with state epidemiologists, and recommendations are communicated through the Idaho AAP chapter and its website.

Appeal of decisions in preauthorization: For denials of preauthorization that have been appealed, a review by a pediatric specialist practicing in Idaho (neonatologist, pediatric cardiologist, or infectious diseases pediatrician) is encouraged.

IV. Historical onset and end of RSV season in Boise, Idaho

RSV activity monitored at St. Luke’s Regional Medical Center Laboratory Boise, Idaho

Season

Onset

End

2000-2001January 14May 6
2001-2002January 13May 12
2002-2003January 19April 13
2003-2004December 21March 28
2004-2005January 9April 24
2005-2006December 11April 10
2006-2007January 15May 28
2007-2008December 31May 5
2008-2009December 22May 24
2009-2010Janary 11May 9
2010-2011January 3May 7
2011-2012January 21June 9
2012-2013December 15April 13
2013-2014January 25May 10

V. Contributors to consensus criteria:

  • Travis Anschutz MD (Idaho Falls)
  • Carl Bodenstein MD (Spokane)
  • Perry Brown MD (Boise)
  • David Christensen MD (Boise)
  • Creighton Hardin MD (Pocatello)
  • Nick Harper MD (Boise)
  • Stewart Lawrence MD (Boise)
  • Shannon Jenkins DO (Idaho Falls)
  • Joseph Kiehl MD (Boise)
  • Don McInturff MD (Pocatello)
  • Jennifer Merchant MD (Boise)
  • Terrence Neff MD (Coeur d’Alene)
  • Thomas Patterson MD (Nampa)
  • Thomas Rand MD PhD (Boise)
  • Scott Snyder MD (Boise)
  • Katherine Stevens MD (Boise)
  • Benjamin Tippets DO (Boise)
  • Eloisa Walker MD (Boise)
  • Aaron Weiss MD (Boise)
  • Michael Womack MD (Boise)
  • Noreen Womack MD (Boise)
AAP-Idaho Chapter
 
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