A recent article (behind a password firewall at Pharmacy Practice News) has the explosive headline: Ca Rx has a Billion-Dollar Drug Waste Problem! This article is derived from a study by Memorial Sloan Kettering and University of Chicago that focusses on discarded cancer medication because of single-dose vials. The study focusses on the top 20 high use specialty cancer drugs which are dosed by patient weight and are sold in single use vials. The article lays out the problem:
Although reducing waste has become a priority in health care, little has been done about the expensive infused cancer drugs that are packaged in larger quantities than needed, which is especially problematic when a drug comes in a single-dose package and the dosing is based on a patient’s weight or body size. These drugs must be either administered or discarded promptly once open, and because a patient’s body size is unlikely to match the amount of drug included in the vial, there is nearly always some left over. U.S. Pharmacopeial Convention Chapter permits sharing of drug from a single vial, but only if it is used within six hours and only if stored appropriately
A major suggestion of the article is guidance to drug manufacturers should be required to provide different vial sizes to help pharmacists more accurately prepare proper dosing for patients without creating waste of unused drugs in the vial. For example, a patient prescribed 900MG of a particular drug would require that a pharmacy used 2 500MG vials – leaving 100MG of the drug “wasted”. If manufacturers were to provide 100MG vials, the dose could be filled by 1 500MG vial and 4 100MG vials. Obviously the extra work and packaging and storage capacity would not make sense unless the drugs are very expensive – but these drugs are VERY expensive and it may justify the extra packaging and labor to control waste.
The article also points out an “inconvenient truth” of the current system, that is, medication waste is often “revenue” to the manufacturer who would be required to effect the change:
In essence, drug companies are increasing the amount of drug they sell per patient through their packaging, Mr. Muller (co-author of the study) noted. Pharmacists can use a number of strategies for reducing the amount of leftover drug, but this practice is limited. Currently, clinicians can bill the Centers for Medicare & Medicaid Services (CMS) and some insurance companies for waste, but that still increases drug-related health care costs.
The impact of the Pharmacist is mentioned in the Pharmacy Practice and News article as well and provides some current strategies for addressing the vial medication waste problem:
“We perform dose rounding on some of our monoclonal antibodies to eliminate drug waste; many practices do this,” said Steven D’Amato, BSPharm, the executive director of New England Cancer Specialists, in Scarborough, Maine. “If a dose is 103 mg and a single-dose vial is 100 mg, we will round down to the vial size unless a protocol dictates otherwise.” Many centers stay within a 10% rounding range, he noted.
Scott Soefje, PharmD, MBA, BCOP, FCCP, the director of pharmacy at the University Medical Center Brackenridge, in Austin, Texas, said the US Pharmacopeia Convention USP permits sharing of drug from a single vial, only if it is used within six hours and only if stored appropriately. “In a clinic, six hours might be enough to get you through that whole vial.” Dr. Soefje pointed out that some drugs are stable longer if they are mixed in the IV bag in advance. “If a person is going to get two days’ worth of a drug, instead of wasting the drug, mix both days in advance, store the second day in the pharmacy under appropriate conditions and then just dispense it the next day,” he said.
Cohorting patients also can reduce drug waste. “With this approach, all patients who are being treated with the same type of drug come in on the same day,” Dr. Soefje said. “If you have two patients today, none tomorrow and two patients on Wednesday, you can’t save the single-dose vial for Wednesday, because the six-hour time frame is up. We try to cohort when we can. But it’s a lot more complicated than it sounds.”
I believe one very significant area where pharmacists can dramatically impact the business of pharmacy is by working to reduce medication waste. Medication waste is costly to health system because of the costs of buying medication that is unused, disposing of the medication properly and managing the process of reporting on unused medication to various regulatory agencies. I recently came across a EPA study that discusses medication waste in hospitals and long term care facilities. In this lengthy and detailed study, the costs of the waste are quantified for several different health care providers. The study also addresses recommendations for reducing waste including “managing inventory, stock rotation, and limiting the amount of pharmaceuticals dispensed at one time.”
Here at Talyst, we work with customers every day to help them better manage their inventory of drugs on hand, tracking the expiration dates of those drugs and helping customers route orders from remote locations through central pharmacy for effective stock rotation. Our AutoPharm Enterprise software solution was recently called out by KLAS as the best at managing medication spending and our “just in time” automation solutions have been recognized by Seattle business magazine for leadership in reducing medication waste with in facility dispensing system in long term care.
How big of a problem is waste in your pharmacy? What does your pharmacy do about medication waste management? Looking forward to your thoughts!