Frequency analysis
Excluding iron sucrose prescriptions, there were a total of 1,274 iron infusions prescribed at the study site in 2018, the majority comprising of FCM infusions (1,136 or 89.16%), and specifically PBS-reimbursed FCM infusions (1,100, 86.34%, N=1,274). The next most common form of iron infusion was the premix IPM bags (105, 8.24%), followed by IPM infusions made on site from ampoules (33, 2.59%).
Forty patients received FCM repeat doses within a month (31 days) of their first dose. Taking into account FCM’s 1g limit per week,[10] these were defined as part of their initially prescribed dose. No patients who received an IPM infusion received a repeat dose within the month of their first dose. The most common doses prescribed for any iron infusion (i.e. IPM and FCM combined) were 1g (1,042 infusions (84.44%)), 500mg (115 infusions (9.32%)), 2g (45 infusions (3.65%)) and finally, 1.5g (17 infusions, (1.38%), N=1,234); these four dose points accounted for approximately 98.78% of doses.
Direct costs comparison
The average labour times associated with each infusion type are listed in Table 1. Table 2 outlines the total direct cost breakdown for each infusion protocol at the four aforementioned common dose points. PBS reimbursements were greater than the drug acquisition costs for FCM at all doses, making it the lowest costing infusion at all dose points. Conversely, when not attracting PBS subsidies it was the most expensive protocol; IPM Ampoules Rapid had the lowest total direct cost at all common dose points for non-subsidised infusions.
Budget-impact analysis
The annual cost of FCM-NPBS was approximately $11,804.94 (Table 3). If these infusions were changed to IPM Ampoules Rapid infusions (assuming no clinical contraindications to IPM existed), the projected annual cost would be reduced to $4,312.65, amounting to a total of up to $7,492.29 in saving.
The annual costs of IPM Ampoules Slow and IPM Premix Slow were $4,717.62 and $17,926.30 respectively (Table 4). Converting these to IPM Ampoules Rapid infusions would reduce the projected annual cost to $18,158.78 i.e. a saving of $4,485.14 annually.
Together the budget impact of swapping all infusions that did not attract PBS subsidies to IPM Ampoules Rapid infusions would amount to a saving of up to $11,977.43. Cost-savings of approximately $7,053 annually would still be possible in an alternate scenario where all FCM-NPBS and IPM slow infusions were switched to IPM rapid infusions, using IPM premix bags in place of FCM bags and IPM ampoules only where they are currently used (Appendix B).
Table 1: Average labour time for single infusions (hours).
Infusion protocola
|
Mean time spent (in hours) ± Standard Deviation
|
Total labour (Hours)
|
Technicians
|
Pharmacists
|
Nurses
|
FCM 1.0gb
|
-
|
-
|
0.45 ± 0.14
|
0.45
|
IPM Ampoules Slow ≤0.5gc
|
-
|
-
|
1.17 ± 0.26
|
1.17
|
IPM Ampoules Slow >0.5 to 2.5gc
|
0.77 ± 0.34
|
0.19 ± 0.07
|
0.96 ± 0.19
|
1.92
|
IPM Ampoules Rapid ≤0.5gc
|
-
|
-
|
0.97 ± 0.23
|
0.97
|
IPM Ampoules Rapid >0.5 to 1.5gc
|
0.77 ± 0.34
|
0.19 ± 0.07
|
0.76 ± 0.17
|
1.72
|
IPM Ampoules Rapid >1.5 to 2gc
|
0.77 ± 0.34
|
0.19 ± 0.07
|
0.90 ± 0.19
|
1.86
|
IPM Premix Slow ≤2.0gd
|
-
|
-
|
0.96 ± 0.19
|
0.96
|
IPM Premix Rapid ≤1.5gd
|
-
|
-
|
0.76 ± 0.17
|
0.76
|
IPM Premix Rapid >1.5 to 2gd
|
-
|
-
|
0.90 ± 0.19
|
0.90
|
aTwenty FCM infusions were observed (both manufacturing + administration) and six IPM Ampoules Slow were time-stamped (manufacturing only). The labour time for the remaining infusion protocols were extrapolated from the FCM observations and IPM protocol data. bTime for nurses to prepare, administer and monitor one infusion. cTime for technicians to prepare one infusion, pharmacists to check one infusion, and nurses to administer and monitor one infusion. dTime for nurses to administer and monitor one infusion.
The time spent by pharmacy staff dispensing stock to patients’ names was not included, as this process is consistent across all protocol types. NB: FCM = Ferric Carboxymaltose; IPM = Iron Polymaltose
Table 2: Breakdown of direct costs per infusion of each infusion protocol at commonly prescribed doses.
Dose point (mg)
|
Infusion protocol
|
Drug cost (AUD)
|
Labour Cost (AUD)
|
Consumables cost (AUD)
|
Total cost (AUD)
|
Nurses
|
Pharmacy staff
|
Manufacture
|
Administration
|
500
|
FCM-NPBS
|
142.80
|
18.07
|
-
|
3.81
|
17.18
|
181.86
|
|
FCM-PBS
|
-11.14**
|
18.07
|
-
|
3.81
|
17.18
|
27.92
|
|
IPM Amp Slow-NPBS
|
12.50
|
38.54
|
-
|
15.52
|
17.38
|
83.94
|
|
IPM Amp Slow-PBS
|
-11.58**
|
38.54
|
-
|
15.52
|
17.38
|
59.86
|
|
IPM Amp Rapid-NPBS
|
12.50
|
30.51
|
-
|
15.52
|
17.38
|
75.91
|
|
IPM Amp Rapid-PBS
|
-11.58**
|
30.51
|
-
|
15.52
|
17.38
|
51.83
|
|
IPM Premix Slow*
|
101.30
|
38.54
|
-
|
-
|
17.38
|
157.22
|
|
IPM Premix Rapid*
|
101.30
|
30.51
|
-
|
-
|
17.38
|
149.19
|
1000
|
FCM-NPBS
|
285.60
|
18.07
|
-
|
3.81
|
17.18
|
324.66
|
|
FCM-PBS
|
-22.27**
|
18.07
|
-
|
3.81
|
17.18
|
16.79
|
|
IPM Amp Slow
|
25.00
|
38.54
|
37.10
|
15.52
|
17.38
|
133.54
|
|
IPM Amp Rapid
|
25.00
|
30.51
|
37.10
|
15.52
|
17.38
|
125.51
|
|
IPM Premix Slow
|
101.30
|
38.54
|
-
|
-
|
17.38
|
157.22
|
|
IPM Premix Rapid
|
101.30
|
30.51
|
-
|
-
|
17.38
|
149.19
|
1500
|
FCM-NPBS
|
428.40
|
36.14
|
-
|
7.63
|
34.35
|
506.52
|
|
FCM-PBS
|
-33.41**
|
36.14
|
-
|
7.63
|
34.35
|
44.71
|
|
IPM Amp Slow
|
37.50
|
38.54
|
37.10
|
15.52
|
17.38
|
146.04
|
|
IPM Amp Rapid
|
37.50
|
30.51
|
37.10
|
15.52
|
17.38
|
138.01
|
|
IPM Premix Slow*
|
202.60
|
38.54
|
-
|
-
|
17.38
|
258.52
|
|
IPM Premix Rapid*
|
202.60
|
30.51
|
-
|
-
|
17.38
|
250.49
|
2000
|
FCM-NPBS
|
571.20
|
36.14
|
-
|
7.63
|
34.35
|
649.32
|
|
FCM-PBS
|
-44.54**
|
36.14
|
-
|
7.63
|
34.35
|
33.58
|
|
IPM Amp Slow
|
50.00
|
38.54
|
37.10
|
15.52
|
17.38
|
158.54
|
|
IPM Amp Rapid
|
50.00
|
36.14
|
37.10
|
15.52
|
17.38
|
156.14
|
|
IPM Premix Slow
|
202.60
|
38.54
|
-
|
-
|
17.38
|
258.52
|
|
IPM Premix Rapid
|
202.60
|
36.14
|
-
|
-
|
17.38
|
256.12
|
*Assuming full-bags are dispensed patients, but only part-bags administered. **Negative figures represent net profits considering 2019 October PBS reimbursement and patient co-payments.
NB: AUD = Australian Dollars; FCM = Ferric Carboxymaltose; FCM-NPBS = Non-PBS subsidised FCM; FCM-PBS = PBS-subsidised FCM; IPM Amp Slow-NPBS = Non-PBS subsidised IPM Ampoules Slow; IPM Amp Slow-PBS = PBS-subsidised IPM Ampoules Slow; IPM Amp Rapid-NPBS = Non-PBS subsidised IPM Ampoules Rapid; IPM Amp Rapid-PBS = PBS-subsidised IPM Amp Rapid; IPM = Iron Polymaltose; PBS = Pharmaceutical Benefits Scheme.
Table 3: Projected budget implications of switching FCM-NPBS infusions to IPM Ampoules Rapid infusions (PBS) at the study site.
Dose (mg)
|
Number of FCM-NPBS infusions conducted in 2018
|
Cost per infusion (AUD)
|
Annual cost of FCM-NPBS infusions (AUD)
|
Projected annual cost if switched to IPM Ampoules Rapid (AUD)
|
FCM-NPBS
|
IPM Ampoules Rapid
|
500
|
6
|
181.86
|
75.91*
|
1,091.16
|
455.46
|
1000
|
27
|
324.66
|
125.51
|
8,765.82
|
3,388.77
|
1500
|
-
|
506.52
|
138.01
|
-
|
-
|
2000
|
3
|
649.32
|
156.14
|
1,947.96
|
468.42
|
|
|
|
|
11,804.94
|
4,312.65
|
NB: AUD = Australian Dollars; FCM-NPBS = Non-PBS subsidised Ferric Carboxymaltose; IPM = Iron Polymaltose.
*IPM-NPBS figure was used.
Table 4: Projected budget implications of switching current slow IPM infusions to IPM Ampoules Rapid infusions at the study site.
Dose
(mg)
|
No of infusions
|
Cost per infusion (AUD)
|
Actual annual cost of
|
Projected annual cost if switched to IPM Ampoules Rapid**
|
IPM Amp Slow
|
IPM
Premix
Slow
|
Totala
|
IPM Amp Slow
|
IPM Premix
Slow
|
IPM Ampoules
Rapidb
|
IPM ampoules slow (AUD)
|
IPM Premix slow (AUD)
|
2450
|
1
|
-
|
1
|
171.04
|
-
|
168.63
|
171.04
|
-
|
168.63
|
2000
|
1
|
14
|
15
|
158.54
|
258.52
|
156.13
|
158.54
|
3,619.28
|
2,341.95
|
1950
|
1
|
-
|
1
|
158.54
|
-
|
156.13
|
158.54
|
-
|
156.13
|
1850
|
2
|
-
|
2
|
156.04
|
-
|
153.63
|
312.08
|
-
|
307.26
|
1800
|
3
|
-
|
3
|
153.54
|
-
|
151.13
|
460.62
|
-
|
453.39
|
1650
|
2
|
-
|
2
|
151.04
|
-
|
148.63
|
302.08
|
-
|
297.26
|
1600
|
1
|
-
|
1
|
148.54
|
-
|
146.13
|
148.54
|
-
|
146.13
|
1500
|
11
|
-
|
11
|
146.04
|
-
|
138.01
|
1,606.44
|
-
|
1,518.11
|
1250
|
1
|
-
|
1
|
141.04
|
-
|
133.01
|
141.04
|
-
|
133.01
|
1200
|
2
|
-
|
2
|
138.54
|
-
|
130.51
|
277.08
|
-
|
261.02
|
1150
|
1
|
-
|
1
|
138.54
|
-
|
130.51
|
138.54
|
-
|
130.51
|
1000
|
5
|
91
|
96
|
133.54
|
157.22
|
125.51
|
667.70
|
14,307.02
|
12,048.96
|
800
|
1
|
-
|
1
|
91.44
|
-
|
120.51
|
91.44
|
-
|
120.51
|
500
|
1
|
-
|
-
|
83.94
|
-
|
75.91
|
83.94
|
-
|
75.91
|
|
4,717.62
|
17,926.30
|
18,158.78
|
**Projected annual costs for IPM Ampoules Rapid by multiplying atotal number of current IPM infusions and bcost per IPM Ampoules Rapid (NB: none of the infusions in this table attracted PBS subsidies).
NB: IPM= Iron Polymaltose; AUD= Australian Dollars.