[PPT] - PHARMACOECONOMICS OF RESTRICTING RITUXIMAB USE IN THE INPATIENT PowerPoint Presentation

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PHARMACOECONOMICS OF RESTRICTING RITUXIMAB USE IN THE INPATIENT SETTING

Paul Hardy PGY1 Pharmacy Resident Providence Alaska Medical Center Anchorage, Alaska

IRB Approval: 09 Oct 2019

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DISCLOSURE

Paul Hardy has no conflicts to disclose and received no funding to

support this research

This research is subject to different interpretation
This presentation abides by applicable non-commercial guidelines

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LEARNING OBJECTIVES

Characterize the basic differences between inpatient and outpatient billing practices for biologic medications. Differentiate between the common indications for rituximab in the inpatient setting. Compare net costs for rituximab before and after implementation

f an inpatient restriction policy

for oncologic indications.

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STUDY SITE LOCATION

Providence Alaska Medical

Center

401 bed tertiary care hospital
12-bed oncology section of

general medicine inpatient unit with dedicated nursing and ancillary staff

Lee Sheffield Infusion Center:

Adjoining 15 chair outpatient infusion center

Oncologists and

hematologists not directly employed by the hospital

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PRE-ASSESSMENT QUESTION #1

1. Under which of the following billing methods is rituximab routinely reimbursed in the inpatient setting?

a. Diagnosis-related groups (DRGs) b. Direct service billing c. Fee-for-service d. Outpatient Prospective Payment Systems (OPPS) e. Ambulatory Payment Classifications (APCs)

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PRE-ASSESSMENT QUESTION #2

2. Common uses for rituximab use include: (Select all that apply)

a. Non-Hodgkin’s Lymphomas b. Rheumatoid arthritis c. Thrombotic thrombocytopenic purpura (TTP) d. Post-transplant lymphoproliferative disorders e. Microscopic polyangiitis and granulomatosis with polyangiitis f. Pemphigus vulgaris

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PRE-ASSESSMENT QUESTION #3

3. Benefits of outpatient administration of rituximab for oncologic indications includes: (Select all that apply)

a. Reduced drug acquisition costs for the facility b. Significantly reduced inpatient length of stay for multidrug chemotherapy regimens c. Possibly increased volume of outpatient administrations of rituximab using 340b acquired medication

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STUDY OBJECTIVES

Evaluate the pharmacoeconomic impact
f the site policy restricting rituximab in

the inpatient setting for oncologic indications

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RITUXIMAB INDICATIONS

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Oncologic Indications Non-Oncologic Indications Posttransplant Conditions Graft-versus-Host Disease Lymphoproliferative Disorders Nephrologic Indications Lupus Nephritis Other Nephropathies Hematologic Indications TTP Rheumatologic Indications Pemphigus Vulgaris Rheumatoid Arthritis Wegener’s Granulomatosis Microscopic Polyangiitis

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BACKGROUND (CONT.)

Cost versus reimbursement for biologic

medications in the inpatient setting

Medication billing differences in inpatient

and outpatient settings

Advantageous drug acquisition costs in the

ambulatory setting (340b)

Previous data on potential benefits and

safety of implementing restriction policies

PAMC restriction policy implemented

September 2019

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OBJECTIVES

Primary Outcome:

Evaluate drug acquisition costs saved per patient admission following implementation

f the site policy.

Secondary Outcome:

Evaluate change in average length of stay in days for the inpatient population.

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STUDY CRITERIA

Inclusion Criteria:

≥ 18 years of age
Billing code associated with a rituximab administration for an oncologic indication

Exclusion Criteria:

Pregnant
Incarcerated
< 18 years of age
Rituximab administrations for any non-oncologic indications (auto-immune, transplant, etc.)

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METHODS

Data obtained by running report for all

J9312 or Q5115 CPT/HCPCS codes for the study date ranges

Data narrowed for oncologic indication

by ICD9/ICD-10 code and prescribing provider group (hematology, nephrology, rheumatology, etc.)

2-sided t-test to assess primary and

secondary outcomes

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Study Group Date Range From: T

:

Pre-Policy 01 Feb 2019 31 Aug 2019 Post-Policy 01 Sep 2019 31 Mar 2020

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STUDY POPULATION

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Pre-Policy Inpatient n=26 Outpatient n=17 Post-Policy Inpatient n=41 4 Exempt Administrations 37 Admissions with Rituximab Restricted Outpatient n=21

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RESULTS

37 inpatient administrations restricted

ver post-policy study period
Total rituximab cost for these admissions:

$245,858.03

Average cost savings per inpatient admission post-policy

$6,300.84 (p=<0.01)

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RESULTS: AVERAGE LENGTH OF STAY

Pre-Policy
Post-Policy (length of stay WITHOUT rituximab)

Regimen Number of Admissions Average Length of Stay (Days) Overall Average Length of Stay (SD) High-Dose Methotrexate + Rituximab 19 4.7

4.92 (0.91)

R-EPOCH 18 5.7 Regimen: Number of Admissions Average Length of Stay (Days) Overall Average Length of Stay (SD) High-Dose Methotrexate + Rituximab 14 3.6

5.20 (2.26)

R-Hyper-CVAD 6 3.3 TLS (emergent rituximab) 1 5 R-EPOCH 5 6.8

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RESULTS: AVERAGE LENGTH OF STAY (CONT.)

Average length of stay difference:
0.28 days shorter stay per patient admission in the post-policy study group

(p=0.57)

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CONCLUSION

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The restriction policy reduced rituximab administrations in the inpatient setting. Average cost for rituximab per admission was significantly reduced in the post-policy study group. A nonsignificant decrease in the average length of stay per inpatient admission was observed in the post-policy group.

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DISCUSSION

Clinical/operational environment of this study Possible causes for nonsignificant findings

n secondary outcome

Cost savings associated with restriction policy Future directions:

As appropriate and feasible, restricting biologic

medication administrations for non-oncologic indications

Downstream effects of the restriction policy on patient

satisfaction with the different scheduling for inpatient and outpatient delivery of chemotherapy regimens

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