A 2018 position statement from the Hematology/Oncology Pharmacy Association (HOPA) evaluates consensus recommendations for dose rounding of biologic and cytotoxic anticancer therapies. Developed by the HOPA Standards Committee with input from a dedicated work group of oncology pharmacists, the statement reviews primary literature on dose rounding practices, incorporating clinical, pharmacokinetic, formulation, and economic considerations to inform institutional policy development. HOPA recommends rounding doses within 10% of the ordered amount for routine clinical care, noting that this margin is substantially smaller than typical dose modifications made for toxicity or efficacy (often 20–30%) and is unlikely to compromise safety or effectiveness. Evidence from the literature demonstrates meaningful cost savings and reduced drug waste, with reported annual cost avoidance ranging from approximately $124,000 to $338,000 USD when doses are rounded to the nearest vial size. [1]
The position statement emphasizes that, when possible, dose rounding should be automated within the electronic health record (EHR) in accordance with institutional policy. Automated dose rounding minimizes manual entry, thereby reducing opportunities for human error, and may occur at the time of order entry; if rounding occurs later in the process, appropriate documentation should be included to ensure transparency and consistency across the medical record and product labeling. HOPA also advises caution in specific populations, including patients with significant organ dysfunction, poor performance status, extensive prior therapy, relevant enzyme deficiencies, or known genetic polymorphisms, in whom small dose increases may lead to clinically significant pharmacokinetic or pharmacodynamic changes. For patients who have previously required dose reductions due to toxicity, institutions may consider rounding doses downward only. Additionally, institutions are encouraged to carefully evaluate dose rounding practices for monoclonal antibodies when rounding to the nearest vial size results in a greater than 10% deviation from the prescribed dose. Overall, HOPA concludes that dose rounding represents a viable cost-containment strategy in oncology, while underscoring the need for continued evaluation of its impact on clinical outcomes. [1]
A 2025 retrospective health system study evaluated automated EHR-based dose rounding rules for intravenous anticancer drugs as a strategy to standardize dosing and reduce single-dose vial waste and costs across more than 90 oncology agents. Within the EHR, doses were automatically rounded to the nearest vial size when within a 10% threshold of the calculated dose, with an alternate rule to round to a conveniently measurable amount and use of dose banding when vial size and concentration mismatches prevented direct vial based rounding. Doses administered from 2019 to 2021 were analyzed by comparing ordered versus rounded doses. Overall, 36.1% of doses were rounded down, 35.8% rounded up, and 28.1% unchanged, resulting in 62,065 vials saved. Rounding down within the 10% threshold generated $39.76M in cost savings by avoiding opening additional vials, and rounding up to fully use vials accounted for $9.95M in waste avoided; drugs that could not be rounded within 10% still led to $25.12M in documented waste. The findings demonstrate that automated dose rounding reduced but did not eliminate oncology drug waste, and additional policy and manufacturing strategies are needed to address persistent waste from vial size mismatches. [2]
A 2025 single-center, retrospective chart review quality improvement study was executed within a chemotherapy infusion pharmacy at an academic medical center to assess the impact of an automated EHR-based chemotherapy dose-rounding program on cost-savings and drug waste reduction. This investigation, spanning from July 5, 2023, to October 4, 2023, focused on the administration of three high-cost biologic chemotherapy agents: bevacizumab, bevacizumab-awwb, and paclitaxel protein-bound, piloted in alignment with an internal dose-rounding policy of 10%. Administration data were extracted via a medication utilization report within the EHR system. The study aimed at determining cost-savings achieved by rounding patient doses down to the nearest vial, thus averting the opening of an additional vial, while also evaluating reduced drug waste from rounding up. During the three-month period, 240 administrations of the study medications were identified, with 182 doses applying the automated dose rounding. Bevacizumab-awwb accounted for 102 administrations, with 55 doses rounded down, saving 57 vials, while paclitaxel protein-bound saw 34 of its 80 doses rounded down, each saving one vial. No administrations of bevacizumab were dose-rounded. The total cost-savings from automatic dose rounding down was determined to be $66,631.74. Additionally, prevention of drug waste resulted in 820.25 mg of bevacizumab-awwb and 216.25 mg of paclitaxel protein-bound saved, correlating to a cost avoidance of approximately $11,019.77. The findings underscore the substantial impact of automated dose rounding on cost efficiency and drug waste reduction when applied to high-cost chemotherapy medications. [3]
A 2021 analysis evaluated the financial impact of an automated dose-rounding initiative on oncology drug expenditures at Michigan Medicine, implemented to address the rising costs of cancer care. The initiative incorporated a dose-rounding algorithm into the computerized physician order entry system, targeting 24 biologic and cytotoxic medications. These medications were automatically rounded to the nearest vial size if they fell within 10% of the prescribed dose, in accordance with the Hematology/Oncology Pharmacy Association's guidelines. The study spanned from July 2018 through June 2019 and involved administering 10,206 doses, with dose rounding occurring in 49.7% of cases. Among these, 49.6% were rounded down to available vial sizes, resulting in the substantial cost savings of approximately $3.6 million USD, predominantly achieved in the outpatient setting. This initiative demonstrated significant financial benefits, with the most considerable savings observed for trastuzumab and ipilimumab, which contributed $756,780 USD and $494,517 USD, respectively. The integration of this automated process minimized the risk of medication errors and ensured a seamless workflow between prescriber order entry and pharmacy verification, thereby enhancing operational efficiency. The initiative's successful implementation provides a compelling case for adopting automated dose rounding across other institutions to reduce healthcare expenditures and minimize drug waste, while maintaining patient care standards. Further research is suggested to assess clinical outcomes associated with dose rounding and explore expanded medication inclusion for greater economic impact. [4]
According to a 2022 publication, a comprehensive institutional initiative implemented automated chemotherapy dose rounding rules within the electronic health record (EHR) system to optimize drug utilization in oncology settings. The primary method involved rounding chemotherapy doses to the nearest vial size, provided the adjustment remained within 10% of the originally calculated dose. Otherwise, the dose was rounded to a practical measurable volume based on the drug's concentration. This system-wide decision required considerable consensus and collaboration among oncology pharmacists, pharmacy leaders, and clinical informatics, who reviewed all injectable oncology drugs in the EHR to establish these dose rounding rules. Once developed, these rules were integrated into the EHR's dosing algorithms at the calculation stage prior to provider approval. The results of this initiative demonstrated substantial impacts, with approximately 40,000 cancer treatment doses administered over a six-month period from January to June 2019. This led to the conservation of 9,814 vials, translating to a total cost saving of $7,284,796. Biologic agents accounted for $5,727,402 of these savings, with oncolytic drugs contributing $1,557,394. The findings underscore the efficacy of automated dose rounding in reducing drug waste and achieving significant cost efficiencies. This approach not only alleviated financial burdens on healthcare systems but also indicated the potential for reducing patient expenses indirectly by minimizing overall drug wastage. [5]
In a 2020 publication researchers implemented an automated parenteral chemotherapy dose-banding system within an EHR to enhance patient safety and reduce drug costs. The method involved transitioning from a manual, pharmacist-driven workflow to an automated process, initially focusing on bevacizumab, rituximab, and trastuzumab. Dose-banding tables were constructed to standardize the rounding of doses within a 10% parameter, and these tables were integrated into the EHR following multidisciplinary approval. This integration allowed prescribers to view dose-banding logic prior to order authorization. A retrospective chart review was later conducted to compare drug and cost savings between the previous manual process and the new automated system. The study also evaluated improvements in medication safety by analyzing the reduction in clicks required for pharmacist verification and monitoring event submissions related to dosing errors. The findings indicated that, after implementing automated dose-banding, medication errors associated with chemotherapy dose rounding decreased significantly. Reported errors dropped from four instances in the pre-implementation period to none post-implementation. Automation also resulted in saving pharmacists at least 9,297 additional clicks and 11,363 keystrokes. Notable increases in drug savings were observed, with manual rounding yielding 994 mg in net drug savings compared to 24,571 mg achieved through automated dose-banding. This translated to substantial cost savings, with automated dose-banding leading to an estimated $224,746 in savings, highlighting the efficiency and safety benefits of the automated dose-banding system. [6]
A 2020 abstract focused on cost avoidance through automated dose rounding of biological and cytotoxic anticancer drugs within an integrated delivery network. The research outlined the alarming rise in cancer care costs projected to hit $172.8 billion by 2020, emphasizing the rapid increase in oncology drug expenses. The authors highlighted that novel drugs were priced at a median of $115,981 annually between 2009 and 2013, necessitating effective cost-control measures. The Hematology/Oncology Pharmacy Association recommends dose rounding, a practice endorsed by the National Comprehensive Cancer Network, which involves rounding drug doses to the nearest vial size, provided the difference remains within an accepted percentage. This method was instituted manually by oncology pharmacists in January 2020, later transitioning to an automated system in June 2020, facilitated by Epic Beacon, a chemotherapy software. The implementation of this protocol across 13 providers in 8 infusion centers resulted in significant cost avoidance between January and July 2020, amounting to $679,780.02. The automation phase initiated in June 2020 generated savings of $112,994.12 within seven weeks, with biological drugs contributing 89.4% of the total savings. Trastuzumab, in particular, was responsible for $147,194.44 in cost avoidance, accounting for 21.65% of the total savings. Dose rounding to the nearest vial demonstrated variability, with a median increase of 3.52% when rounded up and a median decrease of 3.36% when rounded down. The 2020 publication illustrates the practicality and financial benefits of automated dose rounding for oncology drugs, recommending priority be given to biologics due to their cost and utilization. [7]
A 2016 study evaluated the impact of the automatic rounding-off function of a computerized physician order entry (CPOE) system on the ordering time and dose dispersion of chemotherapeutic drugs in regimens for hematologic malignancies. The study involved 12 hematologists ordering five predefined chemotherapeutic regimens for a hypothetical patient with standardized parameters. The five regimens selected were among the most commonly used for hematologic malignancies in Japan, including IDA/AraC, Flu/BU16, R-CHOP, Hyper-CVAD, and R-ESHAP. The trial was designed to compare the ordering time and the accuracy of the dosages prescribed under the different CPOE system versions. The results demonstrated a significant reduction in ordering time with EGMAIN-GX version 4, which incorporated an automatic rounding-off function, compared to version 2, with times reducing from a median of 635 seconds to 259 seconds (p <0.01). Additionally, version 4 achieved a higher median ratio of actual to ideal doses and a lower standard deviation, indicating reduced dose dispersion (1.0097 and 0.0275, respectively, versus 0.9997 and 0.0290; p <0.01). These outcomes suggest that the automatic rounding-off function effectively streamlines the prescribing process while maintaining dosing accuracy, potentially promoting the standardization of chemotherapy regimens in clinical practice. [8]
Finally, a 2018 retrospective analysis examined the impact of standardized infliximab dose rounding on cost and efficiency at an outpatient infusion center in a community teaching hospital. This study reviewed the electronic charts of 72 patients diagnosed with Crohn’s disease or ulcerative colitis over a six-month period, focusing on 45 patients in the standardized dose rounding arm and 69 patients in the nonstandardized arm. The study revealed that implementing standardized infliximab dose rounding resulted in significant theoretical cost savings, estimated at $104,640 annually or $218 per patient per month, by reducing drug waste and improving vial utilization efficiency. Standardized dosing also enhanced pharmacy workflow, slightly reducing the mean order verification time from 12 to 10 minutes despite the initial learning curve. Both dosing arms showed similar rates of adverse effects and therapy adjustments, suggesting comparable clinical outcomes. This data underscores the potential economic benefits and efficiency gains of adopting standardized infliximab dose rounding in healthcare settings. [9]