Hospital Pharmacy - June 2017 - 426

426

Hospital Pharmacy 52(6)

Table 1. Doses Identified as Opportunities for Outpatient Administration by Entity.
Entity 1
Drug
Rituximab
Bevacizumab
Trastuzumab
Total

Entity 2

Total

Opportunities

Doses

Opportunities

Doses

Opportunities

Doses

305
4
6
315

969
8
7
984

31.5
50
85.7
32

56
8
8
72

131
10
8
149

42.7
80
100
48.3

361
12
14
387

1100
18
15
1133

32.8
66.7
93.3
34.2

Table 2. Doses With Opportunity for Outpatient Administration and Established Outpatient Presence by Entity.
Entity 1
Drug
Rituximab
Bevacizumab
Trastuzumab
Total

Entity 2

Total

Outpatient
presence

Total

Outpatient
presence

Doses

Outpatient
presence

Doses

196
3
5
204

305
4
6
315

64.2
75
83.3
64.7

25
6
6
37

56
8
8
72

44.6
75
75
51.4

221
9
11
241

361
12
14
387

61.2
75
78.6
62.3

033 657. Thus, the financial effect of the distribution model
change was $1 393 606.

Opportunity Analysis
The doses identified as opportunities using the algorithm are
displayed in Table 1. Of the 3 entities included in the analysis,
Entity 3 did not have any administrations with opportunity for
administration for outpatient setting. A total of 387 (34.2%)
administrations of rituximab, bevacizumab, and trastuzumab
were determined to be opportunities to be shifted to the outpatient setting. One of the institutions did not have any inpatient administrations within the 2-year period.
The majority of administrations identified as opportunities for administration in the outpatient setting were rituximab, with 361 doses identified. For all 3 drugs, a total of 387
administrations were determined to be opportunities, and
62.3% of patients who received one of the agents had established outpatient presence in a health system clinic. These
results are described in detail in Table 2. Interrater agreement
was 100% after discussion for all identified discrepancies.
During the study period, the total opportunity cost was $1
766 049.

Discussion
Access to products as they reach market maturity is key for
patients to receive optimal care. However, individual priorities between manufacturers and providers may conflict.
Hospitals and health systems seek to provide their patients
with extensive access to care using the most clinically effective and affordable treatment options. On the contrary, manufacturers want to ensure the integrity of their product and

maintain prices at a level that can sustain the drug development process. It is critical that manufacturers and providers
work together to optimize access to drugs and maintain fair
pricing to minimize costs throughout the pharmacy supply
chain.
The change in Genentech's distribution model on October
1, 2014, for rituximab, trastuzumab, and bevacizumab raised
strong concerns among hospitals nationwide that it would
cause an increase in drug expenditure that significantly outweighed Genentech's claim for patient benefits. Our health
system financial analysis demonstrates results consistent
with nationwide concerns.
There are study limitations to note regarding both financial
and opportunity analyses. Financial analyses were limited to
historical information from a single wholesaler used by the
health system. In addition, the cost minus discount could not
be calculated for entities which did not have any purchases
prior to the distribution model change. Therefore, a standard
cost minus was applied to these entities in the study period
with the lower limit of the calculated cost minus. It is also
important to note that this study only assessed the financial
impact of the loss of the cost minus discount on rituximab,
bevacizumab, and trastuzumab and not on the total cost of
goods sold for the health system. Because rituximab, bevacizumab, and trastuzumab could no longer be purchased from
the wholesaler, they did not contribute to the volume component of the cost minus discount. This may have reduced the
cost minus discount in the study period for all purchases. By
only assessing the financial impact of the loss of the cost
minus discount on the 3 drugs, the total financial impact of the
distribution model change is underestimated. In addition, the
cost of the opportunity analysis was limited to assessment of
administrations based on EHR implementation timelines for

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