Subcutaneous vs intravenous rituximab in patients with non-Hodgkin lymphoma: a time and motion study in the United Kingdom

Figures & data

Figure 1. Design of the time and motion sub-study.

Figure 2. Rituximab IV and SC administration process flow. *Rituximab syringe can be prepared in the hospital pharmacy, drug preparation area, or treatment room.

Table 1. Base unit costs.

Staff type	Gross annual salary, £	Other employer expenses, £	Final value of salary^a, £	Hours per annum	Unit cost (£/min)
Registered nurse12	26,600	37,811	64,411	1573	0.69^b
Junior doctor12	55,600	90,296	145,896	2041	1.21^b
Pharmacist12	30,500	44,745	75,245	1611	0.79^b
Senior pharmacy technician13	24,312	30,647	54,959	1650	0.56
Pharmacy technician	20,638	26,016	46,654	1650	0.47
Assistant pharmacy technician13	17,794	22,431	40,225	1650	0.41
Senior assistant technical officer^c	17,794	22,431	40,225	1650	0.41
Assistant technical officer^d12	16,600	17,498	34,098	1593	0.36^b

^aIncludes qualifications, on-going training, and overheads (staff, non-staff, and capital).

^bAdjusted to 2012/2013 level using factor 1.0177.

^cAssumed to be the same level as assistant pharmacy technician.

^dAssumed to be the same level as clinical support worker.

Table 2. Characteristics of centers in the UK time and motion sub-study.

	Plymouth	London	Oxford
Number of previously untreated follicular non-Hodgkin lymphoma patients
On induction therapy	16*	8	5
On maintenance therapy	48*	16	12
Number of relapsed/refractory indolent NHL
On induction therapy	16*	6	3
On maintenance therapy	48*	12	5
Treatment location	Day oncology unit	Day oncology unit	Day oncology unit
Opening hours	08:30–17:30	09:00–19:00	08:00–18:00
Number of patients a nurse is typically responsible for at any given time	3–4	3–4	3–4
Number of beds/chairs	5 chairs	1 bed/25 chairs	4 beds/15 chairs
Type of IV access (for IV rituximab induction patient)
Peripheral access	100%	100%	98%
Permanent line	0%	0%	2%
Type of IV access (for IV rituximab maintenance patient)
Peripheral access	100%	100%	98%
Permanent line	0%	0%	2%
Location where rituximab is prepared
IV	Hospital pharmacy	Not applicable	Hospital pharmacy
SC	Hospital pharmacy	Drug preparation area	Hospital pharmacy

*Estimate based on response ‘4 per week’, assuming induction therapy every 4 weeks, and maintenance therapy every 3 months.

Table 3. Number of observations of rituximab administration.

Centre	IV		SC
	Treatment room	Drug preparation area	Treatment room	Drug preparation area
Plymouth	14	11	21	11
London	5	0	7	6
Oxford	19	2	3	3
Pooled	38	13	31	20

Table 4. Comparison of active HCP time and costs per patient for IV rituximab infusion and SC rituximab injection for the base case analysis.

	IV infusion		SC injection		Difference (IV – SC)*
	Mean time, min (95% CI)	Mean costs, £ (95% CI)	Mean time, min (95% CI)	Mean costs, £ (95% CI)	Mean time, min (95% CI)	Mean costs, £ (95% CI)
Treatment room tasks
Install peripheral access/ line flushing	10.5 (8.8–12.7)	7.27 (6.08–8.79)	–	–	10.5 (8.8–12.7)	7.27 (6.08–8.79)
Pre-medication administration	8.3 (6.8–10.2)	5.77 (4.71–7.06)	2.1 (1.6–3.0)	1.51 (1.12–2.10)	6.1 (5.2–7.2)	4.26 (3.58–4.97)
Infusion initiation/injection administration and monitoring	12.8 (10.6–15.6)	8.88 (7.37–10.83)	12.9 (11.5–14.6)	8.99 (7.99–10.15)	−0.2 (−0.9–1.0)	−0.11 (−0.62–0.68)
Monitoring during infusion	147.6 (133.1–164.3)	102.51 (92.44–114.10)	–	–	147.6 (133.1–162.7)	102.51 (92.44–114.10)
Disconnect infusion line/ flush line/dispose of materials	5.3 (4.5–6.3)	3.68 (3.14–4.35)	–	–	5.3 (4.5–6.3)	3.68 (3.14–4.35)
Monitoring post-infusion/ post-injection	0.0	0.00	0.1 (0.0–1.6)	0.10 (0.00–1.08)	−0.1 (0.0−1.6)	−0.10 (0.00–−1.08)
Sub-total	184.4 (163.8–209.0)	128.10 (113.74–145.13)	15.2 (13.1–19.1)	10.60 (9.12–13.32)	169.2 (150.6–189.8)	117.51 (104.62–131.81)
Drug preparation area tasks (dispensing and preparation)	38.9 (26.1–61.7)	18.33 (12.28–29.08)	33.3 (28.9–38.6)	20.67 (17.95–23.96)	5.6 (–2.9–23.1)	–2.34 (−5.67–5.12)
Total process duration	223.3 (218.0–228.7)	146.43 (126.02–174.21)	48.5 (45.5–51.6)	31.26 (27.07–37.28)	174.8 (172.5–177.1)	115.17 (98.95–136.93)

*Positive values represent cost and time savings favouring SC rituximab; negative values represent cost and time savings favouring IV rituximab.

Table 5. Comparison of patient time in the treatment room associated with IV and SC rituximab treatment.

Mean time, minutes (95% CI)	IV infusion	SC injection	Difference (IV – SC)
Patient time in bed/chair	238.8 (213.1–267.5)	45.7 (35.2–60.9)	193.1 (177.9–206.6)
Patient time in treatment room for infusion/injection	263.8 (236.6–294.3)	70.0 (57.1–87.2)	193.8 (179.5–207.1)
Patient time in hospital	303.8	110.0	193.8

Table 6. Comparison of active HCP time and costs per patient for IV rituximab infusion and SC rituximab injection for scenario 1.

	IV infusion		SC injection		Difference (IV – SC)*
	Time, min (95% CI)	Costs, £ (95% CI)	Time, min (95% CI)	Costs, £ (95% CI)	Time, min	Costs, £
Treatment room tasks
Install peripheral access/line flushing	10.5 (8.8–12.7)	7.27 (6.08–8.79)	–	–	10.5 (8.8–12.7)	7.27 (6.08–8.79)
Pre-medication administration	8.3 (6.8–10.2)	5.77 (4.71–7.06)	2.1 (1.6–3.0)	1.51 (1.12–2.10)	6.1 (5.2–7.2)	4.26 (3.58–4.97)
Infusion initiation/injection administration and monitoring	12.8 (10.6–15.6)	8.88 (7.37–10.83)	12.9 (11.5–14.6)	8.99 (7.99–10.15)	−0.2 (−0.9–1.0)	−0.11 (−0.62–0.68)
Monitoring during infusion	42.2 (38.0–46.9)	29.29 (26.41–32.60)	–	–	42.2 (38.0–46.9)	29.29 (26.41–32.60)
Disconnect infusion line/flush line/dispose of materials	5.3 (4.5–6.3)	3.68 (3.14–4.35)	–	–	5.3 (4.5–6.3)	3.68 (3.14–4.35)
Monitoring post-infusion/post-injection	0.0	0	0.1 (0.0–1.6)	0.10 (0.00–1.08)	−0.1 (0.0–−1.6)	−0.10 (0.00–−1.08)
Subtotal	79.0 (68.7–91.6)	54.88 (47.71–63.63)	15.2 (13.1–19.1)	10.60 (9.12–13.32)	63.8 (55.6–72.5)	44.29 (38.59–50.31)
Drug preparation area tasks (dispensing and preparation)	38.9 (26.1–61.7)	18.33 (12.28–29.08)	33.3 (28.9–38.6)	20.67 (17.95–23.96)	5.6 (−2.9–23.1)	−2.34 (−5.67–5.12)
Total process duration	117.9 (112.5–123.2)	73.21 (59.99–92.71)	48.5 (45.5–51.6)	31.26 (27.07–37.28)	69.4 (67.1–71.7)	41.94 (32.92–55.43)

*Positive values represent cost and time savings favouring SC rituximab; negative values represent cost and time savings favouring IV rituximab.

Table 7. Comparison of active HCP time and costs per patient for IV rituximab infusion and SC rituximab injection for scenario 2.

	IV infusion		SC injection		Difference (IV – SC)*
	Time, min (95% CI)	Costs, £ (95% CI)	Time, min (95% CI)	Costs, £ (95% CI)	Time, min	Costs, £
Treatment room tasks
Install peripheral access/line flushing	10.5 (8.8–12.7)	7.27 (6.08–8.79)	–	–	10.5 (8.8–12.7)	7.27 (6.08–8.79)
Pre-medication administration	8.3 (6.8–10.2)	5.77 (4.71–7.06)	2.1 (1.6–3.0)	1.51 (1.12–2.10)	6.1 (5.2–7.2)	4.26 (3.58–4.97)
Infusion initiation/injection administration and monitoring	12.8 (10.6–15.6)	8.88 (7.37–10.83)	12.9 (11.5–14.6)	8.99 (7.99–10.15)	−0.2 (−0.9–1.0)	−0.11 (−0.62–0.68)
Monitoring during infusion	3.7 (2.7–5.2)	2.57 (1.88–3.63)	–	–	3.7 (2.7–5.2)	2.57 (1.88–3.63)
Disconnect infusion line/flush line/dispose of materials	5.3 (4.5–6.3)	3.68 (3.14–4.35)	–	–	5.3 (4.5–6.3)	3.68 (3.14–4.35)
Monitoring post-infusion/post-injection	0.0	0.0	0.1 (0.0–1.6)	0.10 (0.00–1.08)	−0.1 (0.0–−1.6)	−0.10 (0.00–−1.08)
Subtotal	40.5 (33.4–49.9)	28.16 (23.18–34.66)	15.2 (13.1–19.1)	10.60 (9.12–13.32)	25.3 (20.3–30.7)	17.56 (14.06–21.33)
Drug preparation area tasks (dispensing and preparation)	38.9 (26.1–61.7)	18.33 (12.28–29.08)	33.3 (28.9–38.6)	20.67 (17.95–23.96)	5.6 (−2.9–23.1)	−2.34 (−5.67–5.11)
Total process duration	79.4 (74.0–84.8)	46.49 (35.46–63.74)	48.5 (45.5–51.6)	31.26 (27.07–37.28)	30.9 (28.5–33.2)	15.22 (8.39–26.46)

*Positive values represent cost and time savings favouring SC rituximab; negative values represent cost and time savings favouring IV rituximab.

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