Cohort study of allocation policy implementation during a severe chemotherapy shortage

Cancer drug shortages require health systems to rapidly develop and enact allocation policies, yet little is known about how such policies perform in practice. A cohort study evaluated clinical implementation of a formal allocation policy during a carboplatin shortage at a 7-site health system in Massachusetts and New Hampshire that lasted from June 1 to July 17, 2023. Patients with cancer who were eligible for carboplatin during the shortage were assigned priority categories using predetermined criteria based on treatment intent, inferior or contraindicated alternative treatments, clinical trial participation, and ongoing versus new breatment; these categories were assigned collectively by clinical groups and disease-specific pharmacists after a training session. A structured process conducted between September and November 2025 was used to review medical records and independently reassign categories post hoc. In this cohort study comprising 483 patients, 26% of the patients’ allocation decisions were not aligned with policy intent, chiefly due to poor documentation justifying allocation decisions. Male gender and treatment at the main campus (versus regional sites) were associated with observed chemotherapy allocation; these associations were not significant in models assessing allocation if decisions had been concordant with policy intent. The authors conclude that this study suggests that chemotherapy allocation policy implementation gaps were observed that may have introduced bias; improving implementation is vital to fair allocation.