Section on Epidemiology
of the Outstanding Achievement Award in the Application
Congratulations to Richard Paul Lipman, MD, winner of the AAP Sections on Community Pediatrics and Epidemiology Second Annual Outstanding Achievement Award. This award was established to recognize pediatricians who have made outstanding contributions toward advocating for children and child health in the community through the effective use of epidemiologic information.
Dr Lipman was nominated by a parent, Jeanne Sullivan--Toomey, for effectively used epidemiologic information to advocate first for one patient and then for an enteric class of children in negotiating with a local health plan to overturn the denial of Synergis (palivizumab). He showed in an elegant manner a graphic example of variation in the timing of respiratory syncytial virus (RSV) in colder climates. He also demonstrated that the serum concentrations dipped below the therapeutic level of 40 mcg 20 days after the last injection. Both pieces of information were essential to his argument that one must accommodate to the natural history of RSV.
In early 2003, Dr Lipman became concerned about a ruling by the Medicaid (MassHealth) program in Massachusetts that approval for palivizumab injections to prevent potentially fatal RSV infections in high-risk infants would be granted only for the months of November through March. His clinical experience was that major outbreaks of RSV bronchiolitis and pneumonia in his communities typically began in October and continued at least into April. Moreover, every major private insurance company and HMO in Massachusetts was funding the injections inclusive of October through April.
Dr. Lipman and many other pediatricians and neonatologists unsuccessfully requested a liberalization of this ruling on behalf of their high-risk newborns. He then resolved to take an epidemiologic approach, encouraged by the AAP's statement in its 2003 edition of the Red Book: "To understand the epidemiology of RSV in their area, physicians should consult with...diagnostic virology laboratories...if such information is not available locally," and "Decisions about the specific duration of prophylaxis should be individualized according to the RSV season."
Dr Lipman contacted the laboratory directors of three nearby community hospitals and obtained data on RSV testing for the years 2002 and 2003. He also obtained RSV data for those years from a large regional pediatric hospital in Boston. Dr. Lipman analyzed the distribution of the 1,917 RSV tests by month and by incidence of positivity. He found that outbreaks ( 10% positive RSV tests) consistently began each October and continued through each April. He then prepared a carefully documented and referenced 8-page monograph on the epidemiology of RSV infection in his region, with appropriate tables and graph. The monograph concluded that, in order to adequately protect high-risk newborns in eastern Massachusetts, it was necessary to begin RSV prophylaxis in October and continue it through April each year.
Dr. Lipman forwarded his monograph to the Medical Directors of MassHealth, to the Associate Director of Drug Utilization Review for MassHealth, and to their pediatric infectious disease consultant, and followed this up with telephone calls. The response was positive and gratifying: MassHealth would permit antiRSV injections to continue through mid-April and was willing to consider a resumption date in October, contingent upon the results of further epidemiologic data as it became available. The health needs of an important segment of the pediatric population in Massachusetts were thereby well served.
Dr Lipman has been a primary care pediatrician for over 35 years. He received his medical degree from Tufts University School of Medicine and completed his pediatric residency training at Boston's New England Medical Center. Following military service as a pediatrician at the 130th Station Hospital, Heidelberg, Germany, Dr Lipman completed a research fellowship in pediatric infectious disease at the University of North Carolina Medical Center in Chapel Hill. He then returned to the Boston area to practice general pediatrics. Dr Lipman currently is senior physician and cofounder of a large pediatric group practice and is Associate Clinical Professor at Tufts University Medical School. He has served on numerous committees at local hospitals and has been published extensively.