Conclusion:
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Study 1
Study 2
Study 3 Study
4 Conclusion
Implications for Social
Workers
Post-Test
Respiratory syncytial virus (RSV) can be devastating to
premature infants, children with chronic lung disease and congenital heart
disease. It infects almost all children by two years of age,
resulting in a large number of hospital admissions in infants. It has been
proven that the incidence of serious RSV illness can be reduced with
prophylaxis and therefore, seems prudent for those patients in the high-risk
group. palivizumab (Synagis) is the preferred drug because of its ease of administration,
safety and effectiveness.
However, several issues complicate its use and
effectiveness. Cost is at the top of the list. This journal club
reinforces the use of prophylaxis proving that it is not only less costly on
the health care system, but also greatly improves the quality of life of
those patients who fall prey to RSV.
Of note, this journal club brings to light what is
perhaps the most telling debate over the use of palivizumab to date. Not whether
to use it or how to administer it, but where to administer it. The
medical community sees this as a home injection therapy. The payers see this
as a depot-type product that should be administered in a physician's or
homecare office. And paradoxically, the patient and their family see their
satisfaction levels higher when they are more involved and having to bring
their infant into the office for their monthly injections. However, in the
Paul study, compliance levels were found to be higher with the home
injection group due to the author's assumption that a measure of control was
taken out of the parent's hands by bringing the nurse to the home to give
the injections. But this is also the study that found higher satisfaction
levels in the group that brought their children into the local homecare or
physician's office for injections.
And lastly, that compliance issue. With palivizumab,
success was found to be directly tied to compliance. If an infant received
all of their injections in their series, they had a very low chance of
contracting RSV. And with each injection that was poorly timed or missed
altogether, the infant's chances of succumbing to infection increased
sharply. Parents that had more control (therefore, those that brought their
children into an office setting for their injections), had lower compliance
due to the parent's decision to opt their child out of therapy. Parents that
were financially challenged by the therapy's cost were more likely to forgo
a larger percentage of the injections when having to bring their child in
for therapy, as opposed to those that were visited by the nurse at home. And
transportation issues also played a part in some children missing
injections. On the other side of the debate, those children that were
visited at home for their injections had a higher chance of other factors
causing them not to comply with the full course of therapy for reasons that
go somewhat unexplained. Reasons mentioned, but not fully explained, point
to the fact that parents that did not get the full court press on the
benefits of palivizumab therapy and the necessity of following through with the
full series of injections, (like they did more often at the homecare or
physician's office) were more likely to miss injections, and in some cases
to not complete therapy after just the first or second injection.
All authors laud the effectiveness of palivizumab therapy.
And all authors point to a need for payers to reform their thinking on this
issue and recognize the need for home injections of palivizumab. Paul et
al. demonstrate the need for further research in the area of non-compliance
triggers, so that a formalized strategy can be developed further supporting
adherence to the full course of therapy, therefore avoiding hospitalization. Schrand et al. points cost-effectiveness realized in her study when
injections were given in a hospital (office) setting.
And while Garzon et al. do not broach the financial
implications of palivizumab therapy, they do emphasize the ease of
administration and minimal impact on the patient's quality of life.
Simoes et al. also do not examine the financial
implications of palivizumab therapy, but do look at the effectiveness of the
drug, ease of administration and the importance of compliance. These authors
point out the importance of preventing the infant's first exposure to RSV
from progressing to clinical symptomatology of RSV infection. Many children
are re-exposed to RSV, as are
older children, adults and the
elderly. And with this re-exposure come further complications (pneumonia and bronchiolitis) that
may affect
quality of life and overall healthcare costs.
Implications for Social Workers
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