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RSV is the most common cause of bronchiolitis in infants and infects most children by age 2 years. Occurrence is seasonal, varying by geography and climate. Palivizumab is the only pharmacologic option for prevention of serious RSV infection. The American Academy of Pediatrics (AAP) has recommendations on RSV prophylaxis, updated in July 2014 with regard to eligible risk groups. In the NYS Medicaid Program, palivizumab use is subject to criteria which historically were influenced by AAP recommendations.
Objectives:
We sought to determine changes in palivizumab utilization and RSV-related outcomes in the NYS Medicaid population, comparing RSV seasons prior to and after publication of the 2014 AAP guidance.
Study Design:
Retrospective analysis of NYS Medicaid claims data.
Methods:
NYS Medicaid enrollees with a paid prescription claim for palivizumab between October 16, 2012 and October 15, 2015 were identified from the Medicaid Data Warehouse. The RSV season was defined as October 16 to March 31, according to CDC surveillance data. Overall utilization was assessed for the 2012, 2013, and 2014 RSV seasons. The number of beneficiaries with hospitalizations attributed to RSV or respiratory illness during these periods was determined using inpatient claims data and ICD-9 codes.
Results:
In 2012, there were 2,613 beneficiaries with 8,023 claims for palivizumab; in 2013, there were 2,498 beneficiaries with 8,129 claims and in 2014, 1,333 beneficiaries with 4,551 claims. In all periods, >97% of palivizumab users were aged 0-12 months at the start of the season. There was a decrease in beneficiaries with hospitalization from 267 in 2012 to 266 in 2013 and 166 in 2014.
Conclusions:
Observed trends in palivizumab utilization and RSV-related outcomes among NYS Medicaid members appeared to be in-line with the 2014 AAP recommendations. NYS Medicaid clinical criteria for palivizumab were later revised to be more consistent with these recommendations.