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Executive Summa.ES1

Report

Introduction and Background 1

Approach and Methodology 1

Current Situation! Hypotheses of Client 2

Findings and Conclusions 2

Correlations 2

Charge Breakdown 3

Diagnosis Breakdown 4

Shortcomings of Information Systems Used S

Recommendations 6

Graph 1 Diagnosis Sample Size

Graph 2 Drug Charge/Day per Day of Transplant

Graph 3 Drug Charge/Day per Day of Transplant

Graph 4 Drug Charge/Day per Day of Transplant

Graph 5 Drug Charge/Day per Day of Transplant

Graph 6 Drug Charge/Day per Day of Transplant

Graph 7 Average Total of Charges per Diagnosis

Graph 8 Top 20 Drug Charges tr Patient Sample

Graph 9 Top 5 Drugs as Percentage of Total Charges

Graph 10 Top 20 Drug Charges per Patient

Graph 11 Top 5 Average Charges per Dose

Graph 12 Citrullinemia: Top 5 Drug Charges

Graph 13 Cryptogenic Cirrhosis: Top 5 Drug Charges

Graph 14 Chronic Hepatitis B: Top 5 Drug Charges

Graph 15 Hemochromatosis: Top 5 Drug Charges

Graph 16 Hepatitis Auto Chro: Top 5 Drug Charges

Graph 17 Primary Biliary Cirrhosis: Top 5 Drug Charges

Graph 18 Chronic Hepatitis C: Top 5 Drug Charges

Graph 19 Alcoholic Cirrhosis: Top 5 Drug Charges

Appendix A. Top 30 Drugs by Average Drug Charges per Patient

Appendix B. Breakdown of Drug Charges by Diagnosis

Executive Summary

In the past year the Pharmacy Department has exceeded its budget by $3.7million. Much of this has been attributed to the Transplant Department. Inorder to better understand these allegations, the Transplant Department isinterested in determining its drug expenditures. A student group wasorganized to obtain and analyze drug charge information for a sample ofliver transplant patients. The goals of this student project were to:

• Combine drug charge information for a representative sample ofpatients from the MCS and OTiS database systems into a joint Foxprodatabase containing information linked by patient registration number.

• Utilize this combined database system in order to analyze livertransplant drug charges based on factors such as age, diagnosis, lengthof stay, and individual drug usage.

• Correlate the data into a usable form to help the transplant departmentinvestigate its needs in the area of drug charges/utilization.

• Develop a protocol for obtaining the necessary information so thisprocess can be duplicated for future drug cost analyses.

Key findings of the project were grouped into three areas of particularinterest:

• Correlations based on the aforementioned factors:1. Age, length of stay, and diagnosis are not well correlated to drug

charges, i.e. no tangible relationships exist between combinations ofthese three factors and charges per day.

2. A noticeable trend of decreasing charges per day in the latter stagesof the patient’s visit (approximately last quarter of stay)

3. The highest drug charge per day is within a two day window of thetransplant date.

• Concrete charge data for liver transplant drugs1. Discounting one outlier, the average total drug charges per diagnosis

display little variance (standard deviation of $7200).2. Discounting one outlier, the average range of drug charges per

patient for all visits was approximately $35,000-$45,000.3. Atgam, Methyiprednisolone IVPB, and Aiprostadil are consistently

among the top five drug charges regardless of patient diagnosis.4. Top five drugs based on charge per dose are Atgam ($1181 per

dose), H BIG ($934), Cyclosporine Injections ($266), Aiprostadil($264), and Albumin 25% ($158).

5. H BIG accounts for 31% of total drug charges for Chronic HepatitisB patients for all visits (second highest is Atgam 17%).

1

7. Total Atgam charges for all diagnoses is over 200% greater than thesecond most costly drug (Cyclosporine).

8. Atgam accounts for 17%-47% of total drug charges per livertransplant patient depending on the diagnosis.

9. Atgam account for 32% of total transplant visit drug charges for theliver transplant patient sample (second highest is Cyclosporine 14%).

10. Atgam accounts for an average of $9592 in drug charges per livertransplant patient (next highest drug charge per patient is $4086).

11. If combined (all types), Cyclosporine is the second most expensivedrug by total charges at an average of $4086/per patient.

12. Five of the top ten drug charges involved some sort of IV (eitherpiggy-back, IV starts/restarts/supplies, and Heparmn).

13. IV starts/restarts/supplies, and Heparin combined were the 7th mostexpensive charge (see Appendix A for list)

Shortcomings in the current information systems used by the transplantdepartment and Pharmacy department:

1. Inconsistency in definition of length of stay between OTIS and MCSleading to unreliable data concerning average charges per day

2. Inability of transplant department to directly access its own drugcharge data.

3. General incompatibility of the two database systems resulting ininefficient use of valuable data resources.

Several Recommendations are offered by the student group to decreasespending as well as increase quality of information for the Transplantdepartment:

• Investigate earlier patient discharge to decrease unnecessary hospitalspending when it appears the patient can be treated on an out-patientbasis.

• Investigate the inconsistencies in the length of stay in variousinformation systems concerning the definition of length of stay.

• Investigate better access for the Transplant Department to its owncharge records to help provide it with a tool for continuousimprovement.

• Investigate Atgam usage for all diagnoses pertaining to number of dosesand alternative drugs when possible.

• Investigate Cyclosporine usage and possible alternatives.• Investigate high charges of IV drugs which may be administered orally.

2

Introduction and Background

In the past year, the hospital pharmacy drug spending has exceededits budget by over $3.7 million. Much of this has been allegedly attributedto the hospital’s Transplant Department. Much of this excess spending mayin fact be due to the increasing number of transplants performed in recentyears that is not adequately reflected in the budgeting process. In order tobetter understand these allegations, the Transplant Department would liketo obtain a better grasp of its drug expenditures. This student group wasformed to obtain and analyze drug charge information for a sample ofliver patients. In particular, the answers to several key issues were to beconsidered:

• Possible correlations between length of stay and increased drug charges• Possible correlations between age and drug charges• Possible correlation between diagnosis and drug charges• Possible variation in drug charges per patient (various factors)• Possible variation in drug charges per day• Variation in administrations of specific drugs

This report contains information about the findings regarding livertransplant drug expenditures for a sample of 25 patients from the fourmonth time period of January 1, 1995 to April 30, 1995. Factors analyzedinclude correlations between patient diagnosis, length of stay, and age.Analysis of individual drug charges and total drug charges were alsoconsidered, both on an overall basis and by diagnosis.

Approach and Methodology

Initial background information and support were provided by bothNancy Durance, administer of the Transplant Department, and Roy More,Senior Management Systems Coordinator of the Program and OperationsAnalysis Department.

In order to obtain drug charge and patient information, the MCS(Pharmacy Database) and OTIS (Organ Transplant Information System)databases were used. More specifically, MCS contains the followinginformation: regnumber, visit number, name, drug startdate/enddate,drugname, dose, and charge for drug. OTIS contains regnumber, name,diagnosis, transplant date, length of stay, possible retransplant, possibledeath of patient, and patient age. Floppy disks containing information aboutthe representative sample were obtained from the Transplant Department(OTIS) and Pharmacy Information Systems (MCS) and inputted into

Foxpro tables, linked by patient regnumber. This allowed a merging ofdata so all information about a particular patient could be accessed.

The new joint Foxpro database was queried to obtain the necessaryinformation to address the key issues. From these queries, relevant graphsand tables relating to the key issues were generated. Conclusions weredrawn based on information from these tools.

Current Situation! Hypotheses

At this time of this project, the Transplant Department had limitedaccess to its own charge data. However, administration in the TransplantDepartment had made several hypotheses relating to drug charges that wereto be examined by this student group. These included the hypotheses thatincreased length of stay led to increased drug charges, that Atgam wassuspected to be the leading culprit relating to the Transplant’s portion ofthe Pharmacy budget, and large suspected variation in drug charges due todiagnosis. The purpose of the project was to examine and test thesehypotheses, as well as create a benchmark for future cost analysis projects.

Findings and Conclusions

Conclusions were grouped into three areas of particular interest,these being correlations based on age, length of stay, and diagnosis;relevant drug charge findings and trends; and shortcomings of theinformation systems as a whole. The sample size of 25 liver transplantpatients consisted of 8 Alcoholic Cirrhosis patients, 5 CryptogenicCirrhosis patients, 1 Primary Biliary Cirrhosis patient, 1 Citrullinemiapatient, 1 Hemochromatosis patient, 2 Chronic Hepatitis B patients, 5Chronic Hepatitis C patients, and 2 Hepatitis Auto Chro patients (seeGraph 1).

Correlations

Several regressions as well as a variety of scatter plots involvingcombinations of the various factors were constructed to analyze possibletrends relating age, length of stay, and diagnosis to drug charges. Theresults of the data analysis provided conclusive evidence that these threefactors are not well correlated to drug charges. In all cases, R2 values forthe regressions did not exceed .3, indicating a very low (if any) degree ofexisting correlation. However, a relationship exists between decreasingcharges per day for each day of the transplant visit for the latter quarter ofthe stay. A graph of charges/day versus day of stay reveals that the highest

2

drug charges are within a two day window of the day of transplant.Charges/day versus day of stay generally decrease after the transplant.Graphs 2 through 6 display charges/day versus day of stay for five patients.

Charge Breakdown

The average total drug charge per diagnosis over all visits relating tothe transplant displayed little variation with a range of approximately$35,000-$45,000 per patient (discounting one outlier). The mean drugcharge for the sample was $43,634 with a standard deviation of $7200.Note again that this figure includes charges for all visits prior to andfollowing the transplant visit, because it was assumed that these chargesrelated to the transplant in some form. In addition, some inconsistenciesexisted in the transplant visit length of stay data. Graph 7 displays averagetotal drug charges per diagnosis. These totals reflect all visits relating tothe transplant. Note the outlier ($125,000 case) in Chronic Hepatitis Bwhich accounts for its higher average.

Among individual drugs, Atgam, Methylprednisolone TVPB, andAlprostadil are among the top five drug charges regardless of diagnosis.Graph 8 illustrates the top 20 total drug charges for the patient sample (allvisits). Note that Atgam is number one and is over 400% more costly thanthe second highest drug.

Graph 9 shows the top five drugs as a percentage of the average totaldrug charges for the transplant visit which has a total of $29,594. Thisnumber was obtained by summing the charges of patients over the

;:. transplant visit. A sample size of 20 was used due to inconsistenciesbetween OTIS and MCS. Atgam ($9592) accounts for 32% of all drugcharges in the transplant visit, followed by Cyclosporine ($4086-14%),Albumin ($2259-8%), Aiprostadil ($2197-7%), and H BIG ($1 868-6%).Graph 10 illustrates the top 20 drug charges per patient (all visits). Atgamaccounts for 17%-47% of total drug charges per patient depending ondiagnosis).

Concerning charges per dose, Atgam is the most expensive at $1181per dose. The rest of the top five are as follows: H BIG-$934/dose,Cyclosporine Inj ections-$266/dose, Alprostadil-$264/dose, and Albumin$158/dose. Graph 11 summarizes top five average charges per dose.

3

Diagnosis Breakdown: Top Five Drugs as Percent of Total Charge

For each diagnosis in the patient sample, the top five drugs (bycharge) have been calculated and graphed as their respective percentage ofthe average total charge for all visits.

*Appendix B contains actual charge data for each of the followingdiagnoses.

Citrullinemia-Graph 12Atgam-25%Arginine-20%Midazolam Injection-7%Methyiprednisolone 1VPB-4%Cyclosporine Neoral Ped. Liq.-4%

*Note that this sample size is one and was a pediatric case.

Cryptogenic Cirrhosis-Graph 13Atgam-14%Albumin-9%Cyclosporine-7%Fluconazole-5%Methyiprednisolone IVPB-4%

Chronic Hepatitis B-Graph 14H BIG-31%Atgam- 17%Ampicillin/Sulbactam WPB-5%Methylprednisolone IVPB-4%Cyclosporine Capsules-4%

Hemochromatosis-Graph 15Atgam-47 %Alprostadil-9%Cyclosporine Neoral Adult Liq.-8%Methyiprednisolone [VPB-4%Ganciclovir IVPB-4%

4

Hepatitis Auto Chro-Graph 16Atgam-20%Alprostadil-9 %Ampicillin/Sulbactam IVPB-5%Cyclosporine Capsules-4%Methylprednisolone WPB-4%

Primary Biliary Cirrhosis-Graph 17Atgam-22%Alprostadil- 12%Cyclosporine Capsules-8%Acyclovir TVPB-6%Methyiprednisolone IVPB-4%

Chronic Hepatitis C-Graph 18Atgam-23 %Orthoclone-6 %Alprostadil-5 %Ampicillin/Sulbactam IVPB-5%Methyiprednisolone IVPB-4%

Alcoholic Cirrhosis-Graph 19Atgam-23 %Albumin-7 %Alprostadil-7 %Methyiprednisolone TVPB-4%Cyclosporine Capsules-4%

In this analysis some interesting trends were discovered. Theseventh highest individual drug charge total for the sample related to theadministration of IV’s: IV starts/restarts/supplies, and Heparin. Inaddition, five of the top ten drug charges are due to IVs. Appendix A liststhe top 200 drugs by average charge per patient.

Shortcomings of the Information Systems Used

In the course of our investigations the project group noticed severalshortcomings concerning the information systems used by the hospital. Inparticular, there is inconsistency between systems in their respectivedefinitions of length of stay. Pharmacy (MCS) develops charges using allvisit numbers and hence determines length of stay to be the sum of allvisits. OTIS only uses the visit corresponding to the transplant as thelength of stay. In addition, data for OTIS length of stay was often found to

5

be inconsistent when compared to the length of stay for the transplant visitnumber in the Pharmacy (MCS) database. This was found by manuallycounting the number of days in the transplant visit number in the Pharmacy(MCS) database. This generated some problems concerning averagecharges where length of stay was used in calculations.

Another factor which appears to cause problems for the TransplantDepartment is the difficulty involved in accessing its own charge data. Atthis point, the information is relayed back from Pharmacy in a time framethat is not beneficial for improvement or analysis of current drug chargetrends. If the Transplant Department was to have direct access to chargedata, continuous improvements could be made on a daily basis if necessaryas opposed to in hindsight, and thus would be much easier to implement.

Recommendations

Graphs 2-6 show a trend of noticeable decrease in drug charges forthe latter quarter of a transplant visit, sometimes as low as $10/day in drugcharges. Obviously there are other reasons for the patient to remain in thehospital during this period, but future investigations could be made as towhether a patient could be discharged earlier and treated on an out-patientbasis. Much of the decreased charges are due to the patients switchingfrom IV to oral medicines. Can these be given on an outpatient basis?

Atgam usage needs investigation both for possible alternatives andamount of doses. At this point there is no clear correlation betweennumber of doses and age, diagnosis, etc. (based on regressions and scatterplots). From our data it appears that the number of Atgam doses isarbitrary. At an average of over $9500 per patient in drug charges, Atgamusage is a serious monetary concern. Our recommendation would be todevelop some sort of protocol for administration of Atgam, as well asinvestigate usage in a future study.

At present Cyclosporine is the second most costly liver transplantdrug. We recommend investigation of Cyclosporine usage, both foralternatives and more efficient usages.

It has been noted that IV drugs are substantially more expensive thanoral drugs. Currently five of the top ten drugs by charge are IV drugs.We recommend investigations be made into greater usage of oral drugs ifpossible.

In the future the hospital may want to consider a joint database inwhich all records are accessible to all departments. In addition to savingtime, a joint database would allow departments to view their costs on aregular basis instead of only periodic reviews. At this point it is a furtherinconvenience that some database systems are on a Macintosh platform

6

while others are on an IBM/DOS platform. For the future the hospital maywant to consider consistency in its computing systems.

The inconsistencies between the OTIS length of stay and Pharmacytransplant visit length of stay is also a serious concern. Approximately halfof the patients we examined had different values in each of these twoinformation systems. For future analysis and calculations, some sort ofscreening should be done to ensure correct data is in the system.

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Appendix A: Top 30 Drugs by Average Drug Charges per Patient

Transplant drugs rated by average cost per patient (all diagnoses). Alsoincluded is the total charges for each drug for the entire sample of25 patients.*Note that these charges are for all visits

Avg $ Per Sum Charges forRank DRUGNAME Patient Sample

I ATGAM $9,592 $239,811

2 CYCLOSPORINE (all types) $4,086 $102,158

3 ALBUMIN 25% $2,259 $56,471

4 ALPROSTADIL $2,197 $54,932

5 HEPATiTIS B IMMUNE GLOBULIN $1,868 $46,695

6 METHYLPREDNISOLONE IVPB $1,418 $35,447

7 IV START/SUPPLIES/HEPARIN $1,150 $28,762

8 GANCICLOVIR P/PB $995 $24,887

9 AMPICILLIN/ SULBACTAM IVPB $985 $24,616

10 CEFOTETAN IVPB $842 $21,043

11 FLUCONAZOLE $830 $20,755

12 CEFAZOLIN P/PB $828 $20,707

13 AZTREONAM $660 $16,489

14 PIPERACILLIN/TAZOBACTAM P/PB $563 $14,064

15 VANCOMYCIN P/PB $549 $13,718

16 ORTHOCLONE $546 $13,659

17 IMMUNE SERUM GLOBULIN-SANDO $475 $11,866

18 MORPHINE SULFATE INJ $450 $11,259

19 TPN - ADULT NON-STANDARD $443 $11,068

20 OFLOXACIN P/PB $388 $9,711

21 ACYCLOVIR $350 $8,744

22 ARGININE 10% $331 $8,276

23 RANEITIDINE P/PB $309 $7,724

24 FUROSEMIDE $287 $7,182

25 PIPERACILLIN IVPB $284 $7,112

26 POTASSIUM CHLORIDE P/PB $248 $6,203

27 AZATHIOPRINE $235 $5,880

28 ACYCLOVIR P/PB $232 $5,803

29 GENTAMICIN P/PB $229 $5,723

30 POTASSIUM CHLORIDE $225 $5,613

31 NAFCILLIN P/PB $199 $4,987

32 PREDNISONE $192 $4,805

33 BUMETANIDE INJECTION $188 $4,70834 SODIUM BICARBONATE $177 $4,42635 ACETAZOLAMIDE IVPB $173 $4,31436 METRONIDAZOLE IVPB $172 $4,31037 MIDAZOLAM INJ $168 $4,20238 URSODIOL CAPSULE $165 $4,12939 OMEPRAZOLE CAPSULE $156 $3,90840 DIPHENHYDRAMINE HCL $154 $3,85241 FLUCONAZOLE - TABLET $151 $3,78042 LACTULOSE $151 $3,76343 MULTIVITAMINS $147 $3,68344 TICARCILLIN/CLAVULANATE IVPB $147 $3,68345 FILGRASTIM $141 $3,51746 SUCRALFATE ORAL TABLET $134 $3,35247 DOCUSATE SODIUM $127 $3,16448 LIPIDS 10% - ADULT $119 $2,96849 RANITIDINE $117 $2,93450 LMINSERTION $113 $2,82151 HYDROCORTISONE 1VPB $113 $2,82052 ERYTHROMYCIN IVPB $112 $2,81053 CO-TRIMOXAZOLE DS $105 $2,62154 SPIRONOLACTONE $102 $2,54355 CEFTRIAXONE IVPB $97 $2,42656 CEFTAZIDIME IVPB $93 $2,32857 OXYCODONE HCL/ACETAMINOPHEN $87 $2,17158 VANCOMYCIN U D $84 $2,09959 TPN - ADULT STANDARD PERIPH. $81 $2,01760 AMPHOTERICINB $78 $1,94061 LIPIDS 20%-ADULT $75 $1,88062 TOBRAMYCIN IVPB $75 $1,87563 CALCIUM CHLORIDE 10% $75 $1,87364. ACYCLOVIR SUSPENSION $74 $1,85565 SUCRALFATE ORAL LIQUID $71 $1,77866 FUROSEMIDE IVPB $70 $1,74767 PHYTONADIONE $68 $1,69868 ACETAZOLAMIDE $65 $1,61569 MULTIVITAMIN INJ {M.V.C. 9÷3) $64 $1,61170 ISRADIPINE $60 $1,49571 P1CC DRESSING CHANGE $54 $1,34972 DILTJAZEM $50 $1,26273 TPN - ADULT STANDARD CENTRAL $50 $1,24274 OFLOXACIN $47 $1,173

75 ACETAMINOPHEN $47 $1,17076 CALCIUM CARBONATE $46 $1,160

77 HEPARIN SODIUM $46 $1,15778 BUMETANIDE $45 $1,126

79 POLYSTYRENE LIQUID $45 $1,11680 ESTROGENS-CONJUGATED IVPB $44 $1,10981 TACROLIMUS $44 $1,09282 CO-TRIMOXAZOLE $43 $1,07683 P1CC INSERTION $43 $1,06684 AZATHIOPRINE SUSPENSION $43 $1,06685 FERROUS SULFATE ORAL TABLET $40 $98986 ATRACURILTM $38 $95487 ARGININE HCL 10% ORAL SOLN $38 $94688 NEPHRO-V1TE $37 $93789 MAGNESIUM SULFATE IVPB $37 $93590 FLUCYTOSINE $37 $92991 CREON-lO $36 $91192 SODIUM CHLORIDE 4MEQ/ML $33 $82793 NYSTATIN $33 $81694 NORFLOXACIN ORAL TABLET $32 $80295 AMOXICIILIN/CLAVULANIC ACID $32 $79996 EPOETIN ALFA INJECTION $32 $79697 AMPICILLIN IVPB $31 $77098 CLINDAMYCIN PROS P/PB $27 $68499 CEFUROXIME IVPB $27 $682100 LEVOTHYROXINE SODIUM $27 $668101 IMIPENEM-CILASTATIN SODIUM $26 $660102 MEPERIDINE HYDROCHLORIDE $26 $656103 CISAPRIDE $26 $650104 CEFTRIAXONE SODIUM $25 $633105 ACETAMINOPHEN MULTI ROUTE $25 $621106 CEFOTAXIME SODIUM $25 $615107 SODIUM PHENYLACETATE $25 $614108 DOPAMINE $24 $610109 VANCOMYCIN HYDROCHLORIDE $24 $596110 HYPAQUE TO MAKE 1.5% $24 $589111 AMPHOTERICIN B P/PB $23 $585112 LORAZEPAM $23 $584113 INSULIN/HUMULIN/REGULAR $23 $575114 DILTIAZEM HYDROCHLORIDE $23 $569115 PROCAINAMIDE HCL 500MG/ML $23 $568116 FLUCONAZOLE - INJECTION $22 $557

117 FAMOTIDINE $21 $536118 DIPYRIDAMOLE $21 $533119 CALC1TONIN $21 $515120 SODIUM BENZOATE $20 $509121 MORPHINE 3OMG/3OML INJ *PCA* $20 $507122 ETIDRONATE IVPB $20 $505123 ALBUMIN IVPB $20 $497124 INSULIN REGULAR HUMAN-NOVOLTh $20 $494125 IVDRESSING/SITEEVAL $19 $476126 OXYCODONE TABLET $18 $455127 DESMOPRESSIN IVPB $17 $437128 *VffMThJ K INJECTION $17 $436129 ACETAMINOPHEN W/CODEINE #3 $17 $433130 AMINOCAPROIC ACID $17 $427131 RANITIDINE INJECTION - PEDS $17 $423132 SULBACTAM/AMPICILLIN INJECTION $16 $410133 DILTIAZEM INJECTION $16 $409134 INSULIN/NOVOLIN 70/30 $16 $408135 METHYLPREDNISOLONE SOD SUCC $16 $402136 METOCLOPRAMIDE HCL $16 $392137 ASPIRIN CHEWABLE CHILDRENS $16 $390138 FLUCONAZOLE ORAL LIQUID $16 $389139 LIDOCAINE1% $15 $383140 METOLAZONE $15 $383141 PREDNISONE LIQ. 5MG/ML $15 $366142 QUININE SULFATE ORAL CAPSULE $14 $359143 LEVO - CARNITINE ORAL LIQUID $14 $358144 RANTTIDINE-TPN $14 $356145 PHENYTOIN SODIUM $14 $350146 SODiUM PHOSPHATE $14 $346147 ETIDRONATE DISODIUM $14 $340148 PENTAMIDINE INHALATION-RT $13 $336149 ALUMINUM HYDROXIDE $13 $336150 DESMOPRESSIN $13 $330151 NIZATIDINE $13 $324152 SERTRAL1NE $12 $311153 ONDANSETRON HCL $12 $309154 HYDRALAZINE LIQUID $12 $302155 DIGOXIN $12 $298156 GOLYTELY SOLUTION $12 $297157 INSULIN/HUMULININPH $12 $297158 PROCAINAMIDE HCL $12 $292

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159 NAFCILLIN $11 $274160 DIPHENOXYLATE/ATROP SULF $11 $274161 KAOLIN/PECTIN $11 $273162 FLUMAZENIL $11 $271163 ONDANSETRON TVPB $11 $268164 HEPARINSODIUM10000UfML $11 $267165 NOREP]NEPHRINE BITARTRATE $11 $265166 BISACODYL $10 $255167 PROPRANOLOL HYDROCHLORIDE $10 $254168 LUMEN CATHETER $10 $253169 SPIRONOLACTONE ORAL LIQUID $10 $246170 PROCAINAMIDE HCL SR $10 $240171 SIMETHICONE CHEWABLE TABLET $9 $227172 CYCLOSPORINE MICROEMULSION C? $9 $226173 HYDROXYZINE HYDROCHLORIDE $9 $226174 SODIUM PHOSPHATE IVPB $9 $225175 PROCHLORPERAZINE EDISYLATE INJ $9 $222176 FOLIC ACID $9 $222177 PROCHLOPERAZINE MULTI ROUTE $9 $216178 PSYLLIUM ORAL POWDER $8 $212179 CIPROFLOXACIN IVPB $8 $212180 SODIUM CHLORIDE $8 $211181 ATGAMSKINTEST $8 $210182 LABETALOL $8 $209183 DIPHENHYDRAMINE MULTI ROUTE $8 $209184 CALCITRIOL $8 $205185 GLYBURIDE $8 $198186 MAGNESIUM OXIDE $8 $193187 CALCIUM GLUCONATE IVPB $8 $189188 POTASSIUM CHLORIDE K LOR $8 $189189 SODIUM CITRATE/CITRIC ACID $7 $187190 CEPHALEXIN $7 $181191 PREDNISONE LIQ. 1MGIML $7 $176192 ASPIRIN $7 $169193 PHYTONADIONE INJ 1MG/0.5ML $7 $168194 MAALOXTC $6 $162195 HYDROMORPHONE HYDROCHLORID] $6 $160196 AMITRIPTYLINE HCL $6 $154197 SOD BENZOATE $6 $153198 ERYTHROMYCIN $6 $150199 THIAMINE HYDROCHLORIDE $6 $150200 RANITIDINE MULTIROUTE $6 $148

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Appendix B: Breakdown of Drug Charges by Diagnosis

Top five drugs (by charge) for each diagnosis. Note that totalcharges are the average drug charges for the particular drugper patient. All charge data relates to drugs only.*Note that total charges are for fl visits

Alcoholic Cirrhosis% Total Charge

Atgam - 32.17% $13,483Albumin 25% 7.50% $3,143Aiprostadil 6.76% $2,832Methyiprednisolone IVPB 4.34% $1,821Cyclosporine Capsules 4.30% $1,803Others [ 44.93% $18,830

Average Total per Patient 100% $41,910

Chronic Hepatitis BDrug % Total Charge Total Charges

HBIG 31.12% $23,347Atgam 17.30% $12,979Ampicillin/Sulbactam IVPB 5.3 5% $4,011PiperacillinlTazobactam IVPB 4.67% $3,500Cyclosporine Capsules 3.6 1% $2,711Others 37.95% $28,468

Drug Total Charges

Average Total per Patient 100% $75,016

Chronic Hepatitis C% Total Charge

Atgam 23.39% $10,880Orthoclone 5.87% $2,732Cyclosporine 5.56% $2,586Albumin 25% 5.46% $2,541Alprostadil 4.65% $2,161Others 55.07% $25,614

Average Total per Patient 100% $46,514

CitrullinemiaDrug % Total Charge Total Charges

Atgam 25.29% $10,316Arginine 10% 20.29% $8,276Midazolam Inj. 6.66% $2,717TPN-Adult Non-Standard 4.05% $1,651Cyclosporine Neoral Ped. Liq. 3.54% $1,445Others 40.17% $16,383

Average Total per Patient 100% $40,788

Cryptogenic CirhosisDrug % Total Charge Total Charge

Atgam 14.11% $6,496Albumin 25% 8.52% $3,921Cyclosporine 6.70% $3,086Aiprostadil 5.88% $2,706Fluconazole 4.53% $2,084Others 60.25% $27,732

Average Total per Patient 100% $46,025

Drug Total Charges

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HemochromatosisDrug % Total Charge Total Charges

Atgam 46.33% $19,205Aiprostadil 8.95% $3,708Cyclosporine Neoral Adult Liq 8.26% $3,426AmpicillinlSulbactan IVPB 4. 12% $1,707GanciclovirlVPB 4.11% $1,704Others 28.23% $11,703Average Total per Patient 100% $41,453

Hepatitis Auto ChroDrug % Total Charge Total Charge

Atgam 20.41% $6,832Alprostadil 9.18% $3,072Fluconazole 5.93% $1,987Cyclosporine 4.76% $1,594Cyclosporine Capsules 4.48% $1,501Others 55.24% $18,494

Average Total per Patient 100% $33,480

Primary Biliary CirrhosisDrug % Total Charge Total Charges

Atgam 21.46% $7,630Aiprostadil 12.10% $4,302Cyclosporine Capsules 8.09% $2,875CH3prednisolone IVPB 7.43% $2,643Acyclovir TVPB 6.48% $2,304Others 44.45% $15,808Average Total per Patient 100% $35,562

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