Drug shortages: a complex health care crisis

Community pharmacists' perceptions and experiences of medicine shortages in disruptive situations: a qualitative study

BACKGROUND

Medicine shortages are a challenge in upper, lower and middle-income countries, including South Africa. In recent years, community pharmacists, in Durban, South Africa, have experienced the COVID-19 pandemic, flooding, civil unrest and electricity disruptions. Little is known about the impact of these disruptions on medicine shortages in community pharmacies.

AIM

To explore community pharmacists' perceptions and their experiences with medicine shortages during the COVID-19 pandemic and other disruptive situations.

METHOD

Convenience and snowball sampling were used to recruit participants. Semi-structured interviews were conducted in person or via an online video conferencing platform, which were audio-recorded and transcribed verbatim. Using the Framework Method, the transcripts were analysed thematically on NVivo 14 software.

RESULTS

Fifteen community pharmacists were interviewed. Five major themes emerged from thematic analysis: general perceptions of medicine shortages, the impact of disruptive situations, the consequences of medicine shortages, mitigation strategies; and further suggestions and resources. Disruptive situations were perceived to exacerbate shortages. Participants perceived a negative financial impact on patients and pharmacies, with out-of-pocket costs affecting the former and loss of income affecting the latter. The mitigation strategies used were contacting stakeholders, medicine substitution and stock management.

CONCLUSION

Community pharmacists felt that improved communication, collaboration, policies, notification systems and guidelines would mitigate shortages.

Effective Supply Chain Strategies in Addressing Demand and Supply Uncertainty: A Case Study of Ethiopian Pharmaceutical Supply Services

BACKGROUND

Ensuring the consistent availability of essential medicines is crucial for effective healthcare systems. However, Ethiopian public health facilities have faced frequent stockouts of crucial medications, highlighting systemic challenges such as inadequate forecasting, prolonged procurement processes, a disjointed distribution system, suboptimal data quality, and a shortage of trained professionals. This study focuses on the Ethiopian Pharmaceutical Supply Services (EPSS), known for its highly unstable and volatile supply chain, aiming to identify risks and mitigation strategies.

METHODS

Using a mixed-method approach involving surveys and interviews, the research investigates successful and less successful strategies, key success factors, and barriers related to pharmaceutical shortages.

RESULTS

Proactive measures such as communication, stock assessment, supervision, and streamlined procurement are emphasized as vital in mitigating disruptions, while reactive strategies like safety stock may lack long-term efficacy. The study highlights the importance of aligning supply chain strategies with product uncertainties, fostering collaboration, and employing flexible designs for resilience. Managerial implications stress the need for responsive structures that integrate data quality, technology, and visibility.

CONCLUSIONS

This study contributes by exploring proactive and reactive strategies, elucidating key success factors for overcoming shortages in countries with unstable supply chains, and offering actionable steps for enhancing supply chain resilience. Embracing uncertainty and implementing proactive measures can help navigate volatile environments, thereby enhancing competitiveness and sustainability.

The empty code cart: Drug shortages over time

PURPOSE

In high-acuity situations such as cardiac arrest, clinicians rely on prepared medications stocked in code carts to provide timely and accurate pharmacotherapy. We examined shortage trends for medications commonly used in code carts.

METHODS

Drug shortage data from 2001 to 2022 were retrieved from the University of Utah Drug Information Service (UUDIS) to characterize shortages reported for commonly used code cart medications. Data extracted included the number of shortages, shortage duration, drug characteristics, and reason for the shortage.

RESULTS

From 2001 to 2022, 71 drug shortages for code cart medications were reported. The number of new shortages peaked in 2010, and the number of total shortages peaked in 2010. At the end of the study period, 61 (84.7%) shortages had been resolved. For resolved shortages, the mean shortage duration was 18.2 months. The drug with the greatest number of reported shortages was dextrose (10 total), the drug with the longest resolved shortage was calcium chloride injection (116 months), and the drug with the longest active shortage was atropine injection (165 months at the end of the study period). Throughout the entire study period, only 2 suppliers provided commercially available prefilled syringes of dextrose for stocking on code carts. The most common reason for shortages, when reported, was manufacturing delays.

CONCLUSION

Medications commonly used in code carts were frequently impacted by drug shortages, which have the potential to impact patient care. Institutional protocols for mitigation and larger efforts to promote a more resilient drug supply chain are critical to ensure patient safety and quality care.

Cheaper is not always better: Drug shortages in the United States and a value-based solution to alleviate them

Drug shortages threaten patients' access to medications and are associated with adverse health outcomes and increased costs. Drug shortages disproportionately occur among generic drugs of limited profitability, most notably drugs administered by injection. In this perspective, we discuss how reimbursement and purchasing practices that were meant to create an efficient marketplace for generics have generated strong price pressure that threatens profitability in certain markets. We further explain how, faced with limited profitability, manufacturers lack incentives to invest in resilient supply chains, and in some cases, engage in cost-containment strategies or decide to exit the market, ultimately contributing to shortages. We propose the development and implementation of value-based reimbursement to provide needed incentives for drug purchasers and manufacturers to establish a more reliable supply chain as part of the policy solution to reduce the number and extent of drug shortages. This reimbursement model would necessitate the development of a rating system that measures supply chain resilience and maturity for each generic product. This rating would then be applied as a value-based modifier to reimbursement rates for generic products. The proposed model would result in higher reimbursement rates for generic products from more dependable supply chains, generating incentives for manufacturers to invest in supply chain resiliency. We propose the application of this reimbursement system originally in Medicare given Congressional interest on reforming Medicare payment to prevent drug shortages.

Medicines Shortages Reporting Systems (MSRS): An exploratory review of access and sustainability

BACKGROUND

The efficacy of medicines depends on their accessibility and availability. Dedicated medicine shortage reporting systems (MSRS) have been set up in different countries, either mandatory or voluntary, following the recommendations of the World Health Organisation to ensure these.

OBJECTIVES

To explore how the Medicine Shortages Reporting System (MSRS) can tackle medicine shortages through improved access and sustainability.

METHODS

Personnel directly involved in the reporting mechanisms for medicine shortages in eight (8) countries participated in semi-structured interviews. An interview protocol based on the Dynamic Capabilities View and Organisational Information Processing Theory (OIPT) was developed. It contained questions related to participant's views on the process involved in MSRS and how it was used to tackle shortages. Data were thematically analysed.

RESULTS

Three core elements were identified to influence MSRS's ability to tackle shortages and ensure sustainability; (1) the ability to identify what information requirements the reporting system needs, (2) identify information processing capabilities, and (3) the ability to match requirements and information processing capabilities through a dynamic capability decision-making process. The dynamic decision-making process involves reiteratively sensing shortages by understanding and validating information received.

CONCLUSION

Building MSRS to tackle shortages for accessibility and sustainability is a systemic process that entails understanding the various elements and processes of MSRS. It includes defining medicine shortages, reconfiguring resources, defining accessibility and ensuring the system's sustainability. Our study provides insights into MSRS developed for mitigating medicine shortages and provides a framework for a sustainable MSRS. The findings extend the literature on medicine shortage management by identifying the various elements required to set up an MSRS. It also provides practical implications for countries that seek to establish MSRS to mitigate medicine shortages. Further studies could extend the number of participating countries to provide a clearer picture of the MSRS and how it can reduce medicine shortages.

Seizure control and complications in patients switching from clobazam to clonazepam due to drug shortage

BACKGROUND

Antiseizure medication (ASM) shortages are a global problem that have a negative impact on outcomes such as seizure control in patients with epilepsy (PWE). In the case of clobazam (CLB) shortage, there is no study regarding the management strategy. This study aims to investigate the alteration in seizure frequency and the occurrence of side effects in PWE undergoing an abrupt switch from clobazam (CLB) to clonazepam (CLZ), during CLB shortage.

MATERIAL AND METHODS

A retrospective study was conducted from electronic health records at our neurology outpatient clinic from January to July 2022. Change in seizure frequency and percentage of CLZ-associated side effects were determined as primary and secondary outcomes, respectively. Potential drug-drug interactions (Level C and above) were evaluated by using Lexicomp Drug Interaction Checker.

RESULTS

The analysis included a total of 29 adult patients (15F, median age: 29). The switching ratio was 10 mg CLB for every 1 mg CLZ (10:1). Seizure frequency was higher during the CLZ period compared to the CLB period (p < 0.05), but no status epilepticus cases were observed. All patients exhibited potential drug-drug interactions, leading to reduced CLZ levels in 12 cases. A total of 36 CLZ-associated side effects were identified, with fatigue (19.4 %), drowsiness (16.6 %), and somnolence (13.8 %) being the most prevalent. A positive and strong correlation was found between CLZ dose and the number of side effects (r: 0.556; p: 0.002).

CONCLUSION

The abrupt switch from CLB to CLZ was observed to increase seizure frequency without leading to status epilepticus in PWE. CLZ-associated side effects were found to be tolerable despite the abrupt switch. Future studies may explore the effect of alternative switching ratios.

Implementation of a tier system for IVIG indications to address IVIG shortage at a tertiary care pediatric medical center

BACKGROUND

Drug shortages are a common issue that healthcare systems face and can result in adverse health outcomes for patients requiring inferior alternate treatment. The United States recently experienced a national drug shortage of intravenous immunoglobulin (IVIG). Several reported strategies to address the IVIG and other drug shortages have been proposed; however, there is a lack of evidence-based methods for protocol development and implementation.

OBJECTIVE

To evaluate the efficacy of introducing a multidisciplinary task force and tier system of indications and to minimize adverse effects during a shortage of IVIG.

METHODS

Faculty members across disciplines with expertise in IVIG use were invited to participate in a task force to address the shortage and ensure adequate supply for emergent indications. A tier system of IVIG indications was established according to the severity of diagnosis, urgency of indication, and quality of supporting evidence. Based on inventory, indications in selected tiers were auto-approved. Orders that could not be automatically approved were escalated for task force review.

RESULTS

Overall, there were 342 distinct requests for IVIG during the study period (August 1, 2019 to December 31, 2019). All Tier 1 indications were approved. Of all requests, only 2.6% (9) of requests were denied, none of which resulted in adverse effects based on retrospective chart review. Seven patients who regularly receive IVIG had possible adverse effects due to dose reduction or spacing of treatment; however, each complication was multifactorial and not attributed to the shortage or tier system implementation alone.

CONCLUSION

Implementation of a multidisciplinary task force and tier system to appropriately triage high-priority indications for limited pharmaceutical agents should be considered in health institutions faced with a drug shortage.

Managing the risk of shortages and medication errors with curares during the COVID-19 pandemic: a hospital pharmacy experience

BACKGROUND

Coronavirus disease 2019 (COVID-19) has spread rapidly around the world. Like many clinical teams, hospital pharmacies have widely contributed in preventing and containing the COVID-19 pandemic. Pharmacies were thus involved in the management of overuse of specific drugs, medication shortages and risk of medication errors.

OBJECTIVES

To assess the use of curares during the COVID-19 crisis and to highlight the lessons to be learnt from this overuse.

METHODS

The use of curares (Atracurium, Cisatracurium and Rocuronium) was compared with the usual use levels in our hospital. Supply issues have been identified and investigated. The risk of medication errors was clearly established and considered.

RESULTS

Despite an increased demand, our hospital has not experienced any disruption in the supply of curare medications. But the risk of curare shortages has led to the registration of new pharmaceutical forms and dosages never used before. We also observed necessary switches between different curares. All of this has contributed to an increased risk of medication errors.

CONCLUSIONS

During the COVID-19 pandemic, the pharmaceutical management of curare medications has been particularly critical. The risk of medication errors and unsafe medication practices was high. This analysis must lead to a high level of vigilance in the next few months.

Adherence to treatment and harmful effects of medication shortages in the context of severe crises: scale validation and correlates

BACKGROUND

Medication shortage is a public health problem, affecting patients' outcomes mainly through the difficulty in maintaining adherence, particularly in the context of a severe economic crisis. There is a need for a new scale that assesses the effect of medication shortage on adherence.

AIM

To develop and validate a scale to evaluate the harmful impact of medication shortage among the general Lebanese population and assess its correlates and association with medication adherence.

METHODS

A questionnaire was used to assess medication shortage harmful effects and patients' adherence, allowing to generate the Harmful Impact of Medication Shortage scale (HIMS). The factor analysis, convergent validity and reliability of the generated scale were assessed, followed by multivariable regressions to evaluate its correlates.

RESULTS

The developed HIMS scale is a 9-item tool, used to assess how difficult it was for people to deal with medication shortages and their harmful effects on treatment. It was significantly and inversely linked to treatment adherence and affected by the patients' socioeconomic status and the type of chronic disease.

CONCLUSION

The Harmful Impact of Medication Shortage scale could be an efficient tool to measure the detrimental effects of medication shortages among the Lebanese adult population with chronic diseases, particularly affecting treatment adherence. Future studies and evidence are still needed to confirm our findings and help build global mitigation policies addressing medication shortages.

The impact of drug shortages on drug prices: evidence from China

Introduction

Drug shortages pose a serious global public health challenge, affecting China and other countries. Evidence from USA shows that short-supplied drugs demonstrated a very high price growth during and after a shortage. However, the effect of shortages on drug prices in China remains unknown. This paper aims to understand the impact of drug shortages on prices and explore implications for shortage prevention policy.

Methods

We collected the purchase prices and delivery rates of 120 drugs from April 2019 to December 2021 across whole China. We examined price progression of affected drugs using linear mixed-effects models and performed subgroup analyses based on the number of manufacturers and the severity of shortage.

Results

Non-shortage cohort had an annual price growth of 11.62% (95% confidence interval [CI] 8.34 to 14.98). Shortage cohort demonstrated an annual price growth of 8.08% (95%CI 0.12 to 16.77) in the period preceding a shortage, 27.57% (95%CI 6.17 to 52.87) during a shortage, and 9.38% (95%CI -12.64 to 36.39) in the post-shortage period. Drug shortages' impact on prices varied across subgroups. Compared with that of drug markets supplied by a single manufacturer, the price growth rate of markets supplied by more than one manufacture declined more after the shortage resolution.

Conclusion

Shortages resulted in significant price increases of study markets, especially the low-priced markets, while the shortage resolution slowed the growth. The primary shortage driver has shifted from the low price to others drivers, such as unavailability of active pharmaceutical ingredients. For currently sole-supplied drugs, the expedited review of applications from other manufacturers should be considered.

Exploring Drug Shortages in the United Kingdom

Drugs can become short in supply for many reasons including increased demand and reduced production. Drug shortages have the potential to impact patients and pharmacists. This study aimed to highlight the challenges pharmacists face and the constraints of how they manage drug shortages. An online survey was designed with its link distributed electronically to community pharmacists in the UK with the assistance of pharmacy organizations during the period from September to December 2021. Survey data were analysed using descriptive statistics. A total of 83% of the respondents (n= 100) were experiencing drug shortages three or more times per week, and more than 70% of these spent 1-3 h per week dealing with them. A total of 93% of the respondents indicated that the issue of drug shortages was a problem for them, and 61% reported that it has worsened since the start of the pandemic. In addition, 65% of the respondents believed that drug shortages had had an impact on patient care. Drug shortages were shown to impact on the pharmacists' workloads with a potential to affect the quality of patient care. There was a variation between how pharmacists dealt with drug shortages, which needs to be explored further with the reasons behind it.

Career decisions, training priorities, and perceived challenges for anesthesiology residents in the United States

STUDY OBJECTIVE

This study sought to understand the timing and important factors identified by residents regarding their decision to pursue a career in anesthesiology, training areas deemed important to their future success, perceived greatest challenges facing the profession of anesthesiology, and their post-residency plans.

DESIGN

The American Board of Anesthesiology administered voluntary, anonymous, repeated cross-sectional surveys to residents who began clinical anesthesia training in the U.S. from 2013 to 2016 and were subsequently followed up yearly until the completion of their residency. The analyses included data from 12 surveys (4 cohorts from clinical anesthesia years 1 to 3), including multiple-choice questions, rankings, Likert scales, and free text responses. Free responses were analyzed using an iterative inductive coding process to determine the main themes.

MAIN RESULTS

The overall response rate was 36% (6480 responses to 17,793 invitations). Forty-five percent of residents chose anesthesiology during the 3rd year of medical school. "Nature of the clinical practice of anesthesiology" was the most important factor influencing their decision (average ranking of 5.93 out of 8 factors, 1 [least important] to 8 [most important]), followed by "ability to use pharmacology to acutely manipulate physiology" (5.75) and "favorable lifestyle" (5.22). "Practice management" and "political advocacy for anesthesiologists" (average rating 4.46 and 4.42, respectively, on a scale of 1 [very unimportant] to 5 [very important]) were considered the most important non-traditional training areas, followed by "anesthesiologists as leaders of the perioperative surgical home" (4.32), "structure and financing of the healthcare system" (4.27), and "principles of quality improvement" (4.26). Three out of 5 residents desired to pursue a fellowship; pain medicine, pediatric anesthesiology, and cardiac anesthesiology were the most popular choices, each accounting for approximately 20% of prospective fellows. Perceived greatest challenges facing the profession of anesthesiology included workforce competition from non-physician anesthesia providers and lack of advocacy for anesthesiologist values (referenced by 96% of respondents), changes and uncertainty in healthcare systems (30%), and personal challenges such as psychological well-being (3%).

CONCLUSIONS

Most residents identified anesthesiology as their career choice during medical school. Interest in non-traditional subjects and fellowship training was common. Competition from non-physician providers, healthcare system changes, and compromised psychological well-being were perceived concerns.

Impact of histamine-2 antagonist shortage on the incidence of hypersensitivity reactions to paclitaxel: a reconsideration of premedication protocols in France (PACLIREACT Study)

PURPOSE

An international shortage of ranitidine led to adjustments in premedication regimens for paclitaxel-based chemotherapy in early October 2019. In this study, we implemented and evaluated an anti-allergic protocol without histamine-2 antagonists (H2As) and aimed to assess the risk of hypersensitivity reactions (HSRs) to the different premedication regimens used.

METHODS

We conducted a single-center observational retrospective study of paclitaxel administrations (7173 administrations in 831 patients). Between January 2019 and December 2020, all allergies reported were recorded. A mixed logistic regression model was implemented to predict the risk of allergy at each injection and to account for repeated administration per patient.

RESULTS

A total of 27 HSRs occurred in 24 patients. No protective effect was observed for H2A when comparing paclitaxel injections with H2A premedication versus without H2A (OR = 1.12, p = 0.84). There was also no significant difference in risk of HSR for famotidine versus ranitidine (OR = 0.79, p = 0.78). However, the risk of HSRs was significantly lower for paclitaxel injections with corticosteroids than for those without (OR = 0.08, p = 0.03). In addition, the risk of HSR was significantly higher for the first, second, or third paclitaxel injections than for the subsequent injections (OR = 10.1, p < 0.001).

CONCLUSION

We did not find substantial evidence of an increased risk of HSR due to the absence of H2A in the premedication protocols for paclitaxel. Thus, in contrary to the existing literature on paclitaxel, our findings support the use of a premedication protocol without H2A.

Perceived Role, Identity and Experiences of Pharmacists and the Potential Impact on COVID-19 Vaccine Uptake per Louisiana Region: A Prospective Cohort Study

Some of the lowest COVID-19 community vaccination rates in America are found in Louisiana. This study investigated: (1) barriers that Louisiana pharmacists encountered during the pandemic; and (2) the effect of pharmacists' role and identity confidence on willingness to enforce vaccine mandates, and COVID-19 vaccine uptake. Fifty-four community pharmacists from nine regions of Louisiana participated in the study. Pharmacists completed questionnaires about: personal demographics, patient population, vaccination encouragement, COVID-19 concerns, and vaccination administration rates. The importance of feeling like a trusted voice in the community, as well as professional perception and self-assurance, were measured using Likert scale questions. During focus groups, participants discussed experiences with the COVID-19 vaccination rollout and vaccination-related obstacles. As the pandemic progressed, pharmacists reported being overworked, understaffed, and overburdened with new responsibilities. In regions with lower vaccination rates, pharmacists were less likely to feel at ease enforcing vaccine mandates. Independent pharmacists were less comfortable enforcing vaccine mandates than chain pharmacists but had more positive perceptions of their role and identity. This study contributes to further understanding of pharmacy workflow obstacles and pharmacists' perceptions of their professional roles and identities in the community.

Local causes of essential medicines shortages from the perspective of supply chain professionals in Saudi Arabia

Background

The global supply chains of essential medicines faced frequent disruptions over the past five years, particularly during the COVID-19 pandemic. Different causes of prescription drug supply interruptions have been identified in Saudi Arabia. However, studies have yet to explore the views of pharmaceutical supply chain personnel regarding the causes of these interruptions. Therefore, this study aimed to survey individuals working in the pharmaceutical supply chains about their views on the observed interruptions in the supply of some essential drugs.

Methods

This was a questionnaire-based cross-sectional study. The 10-item questionnaire was created based on the findings of previously published research that investigated the root causes of essential drug shortages and the impact of COVID-19 pandemic on the supply chains of essential drugs in Saudi Arabia. Purposive sampling was used to identify individuals with at least one year of experience in the area of the pharmaceutical supply chain, and the data collection occurred between April 19th, 2022 and October 23rd, 2022. In addition, descriptive statistics (e.g., frequencies and percentages) were conducted to present the views of the respondents.

Results

Seventy-nine pharmaceutical supply chain specialists accepted the invitation and completed the questionnaire. About two-thirds (69.62%) of the respondents reported that centralized pharmaceutical procurement negatively affected the supply chain of essential drugs. Procurement of unregistered medications by the Saudi Food and Drug Authority (SFDA), as well as generic drugs with a history of recalls, and failure to supply requested quantities were the three most commonly reported reasons behind the observed interruptions in the supply of some essential drugs according to those respondents with a negative view of the centralized procurement. Furthermore, failure of pharmaceutical companies to inform SFDA of potential drug shortages, manufacturing issues, poor demand forecasting, unpredictable increase in demand, and low prices of essential drugs were also believed to be behind the observed interruptions in the supply of some essential medicines.

Conclusion

The majority of surveyed pharmaceutical supply chain professionals held negative views about the role of centralized pharmaceutical procurement in exacerbating the issues with essential medicines supply chain. Future research should examine different strategies to improve purchasing and procurement practices in Saudi Arabia.

Inflationary Rebates For Generic Drugs Sold Through Medicaid Saved Billions During 2017-20

State Medicaid programs cover nearly all Food and Drug Administration-approved prescription drugs in exchange for mandatory manufacturer rebates, including rebates that offset price increases beyond inflation. These inflationary rebates originally applied to brand-name drugs only, but in 2017 Congress expanded them to include generics. Using public Medicaid medication spending and utilization data and three different measures of drug prices, we found that nearly half of generic drugs were subject to inflationary rebates during the period 2017-20, offsetting 2-12 percent of the $53.6 billion in generic drug spending during that time. Rebates were larger among non-orally administered drugs and those with the highest prices. Generic inflationary rebates offset substantial Medicaid spending during that period, suggesting that many generic prices increased above inflation despite the new policy. This might change now that inflationary rebates have been expanded to Medicare under the Inflation Reduction Act of 2022, although additional policies that ensure competitive markets would better protect all US patients from rising generic drug prices.

Drug shortages in China: a cross-sectional study

BACKGROUND

Drug shortages significantly threaten public health and medical service provision worldwide. Research evidence on the complete picture of drug shortages is currently scant in China. This study aimed to provide a descriptive overview and a reference for alleviating of drug shortages in China.

METHODS

National and provincial lists of drug shortages issued in China from 2018 to 2021 were collected and summarized. The information on essential medicines, medical insurance drugs, emergency drugs, and volume-based purchasing drugs was then matched with a drug shortage list to analyse the characteristics, proportion and incidence of drug shortage on each list based on the analysis of information such as dosage form, shortage frequency, and Anatomical Therapeutic Chemical (ATC) classification of the drugs in shortage.

RESULTS

A total of 24 provinces issued drug shortages lists involving 408 drugs from 2018 to 2021. All 58 drugs in the national drug list were included on the provincial drug shortage list. Among all the drugs in shortage, the most significant shortage involved injections, accounting for 45.3% (185/408). Ninety-five drugs (23.3%) were in shortage 5 times (annual shortage > 1 time) or more in the provincial lists, and 199 drugs (48.8%) were on the shortage list only once. In terms of therapeutic property, nearly all categories of drugs had been reported in shortage, among which cardiovascular drugs, nervous system drugs, anti-tumor and immunomodulatory drugs, and blood and hematopoietic organ drugs accounted for more than 10%. There is no significant difference in drug shortage among economic regions. Comparing drugs in shortage and various lists, 81.9% (334/408), 51.0% (208/408) and 67.9% (277/408) fell on the National Medical Insurance Drug List, National Essential Medicines List, and WHO Model List of Essential Medicines, respectively, while the volume-based purchasing drugs accounted for 3.4% (14 drugs). The incidence of drug shortages on NEML, WHO Model List of Essential Medicines and medical insurance category A was significantly higher than that of medical insurance category B and volume-based purchasing drugs (P < 0.05). Of the Emergency Drugs List, 72.0% (36/50) also experienced shortages, significantly higher than all the above categories (P < 0.05).

CONCLUSIONS

In China, drug shortages were severe and complicated. Drug shortages vary among economic regions but are not significant. In comparison, the national procurement pattern of volume-based drug purchasing may be conducive to alleviating the drug shortage problem. Collaboration of all partners was recommended to ensure the supply of clinically necessary drugs.

Medicine shortages: impact behind numbers

INTRODUCTION

Current research to assess the impact that medicine shortages have on patients is limited to general aspects, such as the prevalence of shortages and product characteristics. The aim of this study is to assess the overall impact that medicine shortages have on economic, clinical, and humanistic outcomes.

METHODS

A cohort of all known products in shortage in the Netherlands between 2012 and 2015 were characterized by their route of administration, anatomical therapeutic chemical class, and whether they were originator or generic products. A representative sample of 324 shortages (18% of all shortages) was rated as having low, medium, or high impact on the five elements that determine the impact of shortages on patients: availability of an alternative product, underlying disease, susceptibility of the patient, costs (for patients and society at large), and number of patients affected. Ratings were converted into numerical scores per element and multiplied to obtain an overall impact score.

RESULTS

Two elements were most frequently rated as having a high impact: disease (29%) and costs (20%). Nearly half of the shortages (47%) rated high on at least one element, while nearly 10% rated high on multiple elements. Thirty percent of the shortages rated high on direct impact, which is represented by these elements: alternative product and disease. An additional 17% of the shortages rated high on indirect impact, which is represented by these elements: costs, susceptibility, and number of patients. High impact scores could not significantly be attributed to characteristics of the products in shortage.

CONCLUSIONS

An assessment of the medicine shortages' impact using a framework based on economic, clinical, and economic outcomes showed that all three outcomes affect the overall impact that medicine shortages have on patients.

Outcomes of Patients With Thyroid Eye Disease Partially Treated With Teprotumumab

PURPOSE

In response to the coronavirus (COVID-19) pandemic, teprotumumab production was temporarily halted with resources diverted toward vaccine production. Many patients who initiated treatment with teprotumumab for thyroid eye disease were forced to deviate from the standard protocol. This study investigates the response of teprotumumab when patients receive fewer than the standard 8-dose regimen.

METHODS

This observational cross-sectional cohort study included patients from 15 institutions with active or minimal to no clinical activity thyroid eye disease treated with the standard teprotumumab infusion protocol. Patients were included if they had completed at least 1 teprotumumab infusion and had not yet completed all 8 planned infusions. Data were collected before teprotumumab initiation, within 3 weeks of last dose before interruption, and at the visit before teprotumumab reinitiation. The primary outcome measure was reduction in proptosis more than 2 mm. Secondary outcome measures included change in clinical activity score (CAS), extraocular motility restriction, margin reflex distance-1 (MRD1), and reported adverse events.

RESULTS

The study included 74 patients. Mean age was 57.8 years, and 77% were female. There were 62 active and 12 minimal to no clinical activity patients. Patients completed an average of 4.2 teprotumumab infusions before interruption. A significant mean reduction in proptosis (-2.9 mm in active and -2.8 mm in minimal to no clinical activity patients, P < 0.01) was noted and maintained during interruption. For active patients, a 3.4-point reduction in CAS ( P < 0.01) and reduction in ocular motility restriction ( P < 0.01) were maintained during interruption.

CONCLUSIONS

Patients partially treated with teprotumumab achieve significant reduction in proptosis, CAS, and extraocular muscle restriction and maintain these improvements through the period of interruption.

On the drivers of drug shortages: empirical evidence from Germany

Purpose

Disruptions and shortages of drugs have become severe problems in recent years, which has triggered strong media and public interest in the topic. However, little is known about the factors that can be associated with the increased frequency of shortages. In this paper, the authors analyze the drivers of drug shortages using empirical data for Germany, the fourth largest pharmaceutical market.

Design/methodology/approach

The authors use a dataset provided by the German Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte [BfArM]) with 425 reported shortages for drug substances (DSs) in the 24-month period between May 2017 and April 2019 and enrich the data with information from additional sources. Using logistic and negative binomial regression models, the authors analyze the impact of (1) market characteristics, (2) drug substance characteristics and (3) regulatory characteristics on the likelihood of a shortage.

Findings

The authors find that factors like market concentration, patent situation, manufacturing processes or dosage form are significantly associated with the odds of a shortage. The authors discuss the implications of these findings to reduce the frequency and severity of shortages.

Originality/value

The authors contribute to the empirical research on drug shortages by analyzing the impact of market characteristics, DS characteristics and regulatory characteristics on the reported shortages. The authors’ analysis provides a starting point for better prioritizing efforts to strengthen drug supply as it is currently intensely discussed healthcare authorities.

National and transnational drug shortages: a quantitative descriptive study of public registers in Europe and the USA

Background

Drug shortages are a growing global problem, posing clinical and economic challenges. To understand them better, we conducted an inventory of national public drug shortage registers and their comparability in Europe and the USA.

Methods

The study was based on openly accessible drug shortage notifications published by national drug authorities. These data were obtained from all national data sources mentioned on the European Medicines Agency’s (EMA’s) web page and FDA in the USA. After selection of the countries with comparable data, descriptive statistics were used to present characteristics of the shortages both across countries and within countries for 9 months (January–September) in 2020. We studied whether the shortages that occurred in these countries were the same, and how shortages were distributed by therapeutic uses and formulations. We also investigated price variation between the United States and Finland among drugs in shortage in one formulation category (creams and gels).

Results

Finland, Sweden, Norway, Spain, and the United States had suitable registers and were included. Altogether 5132 shortage reports from Finland (n = 1522), Sweden (n = 890), Norway (n = 800), Spain (n = 814), and the United States (n = 1106) were published during the study period. Of active ingredient level shortages 54% occurred in only one country, and 1% occurred in all five. However, at the country level, where there was one or more shortage notifications in an ATC active ingredient category, 19–41% were in a single country.

The distributions by ATC therapeutic class and drug formulation differed substantially between countries, particularly between the USA and European countries. Injectables had a high shortage risk in the USA (57% of all shortages versus 17–31% of all shortages in the European countries). By contrast, shortages in gels and creams occurred only in European data (4–6% of all shortages). In the price comparison, creams and gels in shortage in Finland were 160% more expensive in the USA where these shortages were not detected.

Conclusions

Public drug shortage registers are vital data sources for proactively maintaining and managing a reliable drug supply. However, our study demonstrates that much work remains to standardize the contents and quality of public register data.

Shortages may not be solely a consequence of manufacturing disruptions but may reflect other contributing factors in the international drug distribution and supply mechanisms, including price differences and profit margins between national pharmaceutical markets. Data to perform practical and useful international comparisons to understand these shortages are required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08309-3.

Impact of medicine shortages on patients - a framework and application in the Netherlands

Background

Medicine shortages are often described in plain numbers, suggesting all shortages have a uniform impact. However, some shortages have a direct and serious effect on patients and need a prompt reaction from stakeholders. This study aims to create a broad framework to assess the impact of a shortage.

Method

We identified high impact shortages and selected exemplary shortages which we considered our learning cases. From five learning cases, we identified elements that had a potentially profound impact on one or more of these cases. We tested data saturation on the elements with another five test cases. Based on these elements, we created a framework to assess impact of shortages on patients and presented practical examples how to rate these different elements. Subsequently, we visualised the impact of these five learning cases on patients in radar charts.

Results

The five elements which we identified as potentially having a large impact were 1) alternative product, 2) disease, 3) susceptibility, 4) costs and 5) number of patients affected. The five learning cases rated high on different elements, leading to diverse and sometimes even opposite patterns of impact.

Conclusion

We created a framework for assessing the impact of a medicine shortage on patients by means of five key elements. By rating these elements, an indication of the impact can be obtained.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08765-x.

Supply chain risk factor assessment of Indian pharmaceutical industry for performance improvement

Purpose

The purpose of the present work is to improve the industry performance by identifying and quantifying the risks faced by the Indian pharmaceutical industry (IPI). The risk values for the prominent risks and overall industry are determined based on the four risk parameters, which would help determine the most contributive risks for mitigation.

Design/methodology/approach

An extensive literature survey was done to identify the risks, which were also validated by industry experts. The finalized risks were then evaluated using the fuzzy synthetic evaluation (FSE) method, which is the most suitable approach for the risk assessment with parameters having a set of different risk levels.

Findings

The three most contributive sub-risks are counterfeit drugs, demand fluctuations and loss of customers due to partners' poor service performance, while the main risks obtained are demand, financial and logistics. Also, the overall risk value indicates that the industry faces medium to high risk.

Practical implications

The study identifies the critical risks which need to be mitigated for an efficient industry. The industry is most vulnerable to the demand risk category. Therefore, the managers should minimize this risk by mitigating its sub-risks, like demand fluctuations, bullwhip effect, etc. Another critical sub-risk, the counterfeit risk, should be managed by adopting advanced technologies like blockchain, artificial intelligence, etc.

Originality/value

There is insufficient literature focusing on risk quantification. Therefore, this work addresses this gap and obtains the industry's most critical risks. It also discusses suitable mitigation strategies for better industry performance.

Issues affecting supply of palliative medicines into community pharmacy: A qualitative study of community pharmacist and pharmaceutical wholesaler/distributor perspectives

Background

Patient access to medicines in the community at end-of-life (pertaining to the last year of life) is vital for symptom control. Supply of such medicines is known to be problematic, but despite this, studies have failed to examine the issues affecting community pharmacy access to palliative medicines.

Objective

To identify community pharmacists' and pharmaceutical wholesalers'/distributors' views on supply chain processes and challenges in providing access to medicines during the last year of life, to characterise supply in this UK context.

Methods

Qualitative design, with telephone interviews analysed using Framework Analysis. Coding frames were developed iteratively with data analysed separately and then triangulated to examine differences in perspectives.

Findings

Thirty-two interviews (24 community pharmacists and 8 wholesalers/distributors) were conducted. To ensure appropriate palliative medicines were available despite occasional shortages, community pharmacists worked tirelessly. They navigated a challenging interface with wholesalers/distributors, the Drug Tariff to ensure reimbursement, and multiple systems. IT infrastructures and logistics provided by wholesalers/distributors were often helpful to supply into community pharmacies resulting in same or next day deliveries. However, the inability of manufacturers to predict operational issues or accurately forecast demand led wholesalers/distributors to encounter shortages with manufactured stock levels, reducing timely access to medicines.

Conclusions

The study identifies for the first time how palliative medicines supply into community pharmacy, can be improved. A conceptual model was developed, illustrating how influencing factors affect responsiveness and speed of medicines access for patients. Work is required to strengthen this supply chain via effective relationship-building and information-sharing, to prevent patients facing disruptions in access to palliative medicines at end-of-life.

Community Pharmacy Staff Knowledge, Opinion and Practice toward Drug Shortages in Saudi Arabia

Drug shortages continue to pose a significant threat to public health and safety. Drug shortages not only worsen patient outcomes, but also significantly burden healthcare systems with additional costs. This study aimed to assess community pharmacy staff knowledge, opinion, and practice toward drug shortages in Saudi Arabia from November 2019 to March 2020. This was a cross-sectional study carried out among 1,008 community pharmacists from Saudi Arabia using a validated, self-administered and Internet-based survey. Analysis was done using chi square and fisher exact tests. Most participants were males (97.2%), less than 30 years old (48.1%), and non-Saudi citizens (94.4%), and 72.0% had good knowledge of drug shortages (score = 4–5). Around 36.0% reported that it takes 1–3 days to receive a response to the shortage report. There was a statistically significant association between the professional level of the community pharmacists and their opinion about reporting drug shortages (P < .05). Most community pharmacies (56.2%) did not receive any notification about drug shortages. In conclusion, most community pharmacists are knowledgeable and have good practice regarding drug shortages, but their opinions about drug shortages differ according to each pharmacy reporting policy.

Perceptions of pharmacists towards drug shortages in the healthcare system of Pakistan and its impact on patient care: findings from a cross-sectional survey

OBJECTIVE

This study aimed to explore pharmacists' perceptions on drug shortages and its impingement on the Pakistani healthcare system, in particular on patient care.

DESIGN

Online questionnaire survey.

SETTING AND PARTICIPANTS

Hospital pharmacists from five out of seven regions of Pakistan were approached; including the federal territory (Islamabad) and four provinces (Khyber Pakhtunkhwa, Balochistan, Punjab and Sindh).

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence and type of shortages were identified along with strategies to reduce its effect on patient care.

METHOD

A validated questionnaire was distributed through various online platforms to 800 registered hospital pharmacists. A convenience sampling technique was used to obtain information on drug shortages, the reporting system for shortages, the impact on patients and policy solutions for managing drug shortages.

RESULTS

Out of 800 hospital pharmacists, 708 completed the questionnaire (response rate: 88.5%). Of these hospital pharmacists, 47% came from hospitals of Punjab, 26% from Khyber Pakhtunkhwa, 13% from Sindh, 11% from Balochistan and 4% from Islamabad; 72% and 28% worked in tertiary and secondary hospitals, respectively. The majority (32%) interacted with shortages daily. The top three drug categories reported in shortage were oncology drugs (54%), cardiovascular drugs (53%) and antimicrobials (42%). 58% of the respondents have seen care delayed as a negative consequence of shortages. 'Creating new communication system' (65%) and 'readjust budget plans' (41%) were the two most frequently indicated recommendations for shortages management at hospital, while 'circulars or alerts from the regulatory authority' (60%) and 'time to time directives from local health statuaries' (48%) were two most widely suggested policy solutions.

CONCLUSION

Drug shortage is a serious concern in Pakistani hospitals, experienced on a daily basis endangering patients' health. Enhanced communication is required, connecting the key stakeholders. Health policies should be reviewed; adequate funds should be allocated to the health sector preventing future shortages.

Low Efficacy of Medication Shortage Clinical Decision Support Alerts

OBJECTIVE

 We examined clinical decision support (CDS) alerts designed specifically for medication shortages to characterize and assess provider behavior in response to these short-term clinical situations.

MATERIALS AND METHODS

 We conducted a retrospective analysis of the usage of medication shortage alerts (MSAs) that included at least one alternative medication suggestion and were active for 60 or more days during the 2-year study period, January 1, 2018 to December 31, 2019, in a large health care system. We characterized ordering provider behavior in response to inpatient MSAs. We then developed a linear regression model to predict provider response to alerts using the characteristics of the ordering provider and alert frequency groupings.

RESULTS

 During the study period, there were 67 MSAs in use that focused on 42 distinct medications in shortage. The MSAs suggested an average of 3.9 alternative medications. Adjusting for the different alerts, fellows (p = 0.004), residents (p = 0.03), and physician assistants (p = 0.02) were less likely to accept alerts on average compared with attending physicians. Further, female ordering clinicians (p < 0.001) were more likely to accept alerts on average compared with male ordering clinicians.

CONCLUSION

 Our findings demonstrate that providers tended to reject MSAs, even those who were sometimes flexible about their responses. The low overall acceptance rate supports the theory that alerts appearing at the time of order entry may have limited value, as they may be presented too late in the decision-making process. Though MSAs are designed to be attention-grabbing and higher impact than traditional CDS, our findings suggest that providers rarely change their clinical decisions when presented with these alerts.

Real-time concentration monitoring using a compact composite sensor array for in situ quality control of aqueous formulations

Recent advancements have demonstrated the feasibility of refrigerator-sized pharmaceutical manufacturing platforms (PMPs) for integrated end-to-end manufacturing of active pharmaceutical ingredients (APIs) into formulated drug products. Unlike typical laboratory- or industrial-scale setups, PMPs present unique requirements for process analytical technology (PAT) with respect to versatility, flexibility, and physical size to fit into the PMP space constraints. In this proof of principle study, a novel compact composite sensor array (CCSA) combining ultraviolet (UV) and near infrared (NIR) features at four different wavelengths (280, 340, 600, 860 nm) with temperature measuring capability in a 380 × 30 mm housing (length x diameter, 7 mm diameter at the probe head), were evaluated. The results indicate that the CCSA prototype is capable of measuring the solution and suspension concentrations in aqueous formulations of four model APIs (warfarin sodium isopropanol solvate, lidocaine hydrochloride monohydrate, 6-mercaptopurine monohydrate, acetaminophen) in situ and in real-time with similar accuracy as an established Raman spectrometer commonly applied for method development.

Discovery of TGFBR1 (ALK5) as a potential drug target of quercetin glycoside derivatives (QGDs) by reverse molecular docking and molecular dynamics simulation

Quercetin glycoside derivatives (QGDs) are a class of common compounds with a wide range of biological activities, such as antitumor activities. However, their molecular targets associated with biological activities have not been investigated. In this study, four common QGDs with mutual bioconversion were selected, and studied in the large-scale reverse docking experiments. Network pharmacology analysis showed that most of the four QGDs can bind several potential protein targets that were closely related to breast cancer disease. Among them, a druggable protein, transforming growth factor beta receptor I (TGFBR1/ALK5) was screened via high docking scores for the four QGDs. This protein has been proven to be an important target for the treatment of breast cancer by regulating the proliferation and migration of cancer cells in the past. Subsequently, the molecular dynamics (MD) simulation and MM/GBSA calculation demonstrated that all QGDs could thermodynamically bind with TGFBR1, indicating that TGFBR1 might be one of the potential protein targets of QGDs. Finally, the cytotoxicity test and wound-healing migration assay displayed that isoquercetin, which can perform best in MD experiment, might be a promising agent in the treatment of breast cancer metastasis.

Generic versus reference listed ropivacaine for peripheral nerve blockade: A randomised, triple-blinded, crossover, equivalence study in volunteers

BACKGROUND

Generic drug preparations do not require the same degree of scrutiny as the originally licensed preparation before they can be approved for clinical use. The permitted tolerance limits for bioequivalent preparations might be associated with clinically relevant differences for drugs with a narrow therapeutic index, such as local anaesthetics.

OBJECTIVE

We compared pharmacokinetic and pharmacodynamic characteristics of generic and reference listed or original preparations of ropivacaine.

DESIGN

The current healthy volunteer study used a randomised, triple-blinded, cross-over equivalence design.

SETTING

Tertiary university hospital, Medical University of Vienna.

SUBJECTS

Healthy male volunteers (N=18) aged 18 to 60 years.

INTERVENTIONS

A series of three ultrasound-guided ulnar nerve blocks separated by at least 6 days were carried out on each volunteer. Reference listed ropivacaine (NaropinTM) was used for two blocks and a generic preparation of ropivacaine was used for the other block. Sensory block onset and duration were evaluated using loss of pinprick sensation.

MAIN OUTCOME MEASURES

Duration of sensory block was the primary outcome. Secondary outcomes included time-to-onset of sensory block, ropivacaine pharmacokinetics from venous blood samples and pH of the preparations. Equivalence was evaluated using the ratios of means and 90% confidence intervals (CIs) of log transformed data.

RESULTS

Equivalence was demonstrated for the primary outcome measure, the duration of sensory block [original : generic ratio 1.01 (90% CI 0.87 to 1.16); P < 0.007] and all pharmacokinetic variables. Equivalence could not be concluded for time-to-onset of sensory block [reference : generic ratio 0.80 (90% CI 0.63 to 1.03); P = 0.27], although reproducibility of this variable using our experimental model was lower than for other variables. The generic preparation was significantly more alkaline [difference 0.06 pH units (95% CI 0.04 to 0.07); P < 0.0001].

CONCLUSION

Our finding of equivalence for sensory block duration and key pharmacokinetic variables between a generic and original preparation of ropivacaine is reassuring. The significant, but small, difference in pH is not clinically important.

TRIAL REGISTRATION

EudraCT 2019-003148-61, German Clinical Trials Register (DRKS 00017750).

Patients perspectives on drug shortages in six European hospital settings - a cross sectional study

Background

It is known that drug shortages represent a major challenge for all stakeholders involved in the process, but there is little evidence regarding insights into patients′ awareness and perspectives. This study aimed to investigate the patients-perceived drug shortages experience and their view on outcomes in different European hospital settings. Furthermore, we wanted to explore information preferences on drug shortages.

Methods

A retrospective, cross sectional, a mixed method study was conducted in six European hospital settings. One hospital (H) from each of this country agreed to participate: Bosnia and Herzegovina (H-BiH), Croatia (H-CR), Germany (H-GE), Greece (H-GR), Serbia (H-SE) and Poland (H-PO). Recruitment and data collection was conducted over 27 months from November 2017 until January 2020. Overall, we surveyed 607 patients which completed paper-based questionnaire. Questions related to: general information (demographic data), basic knowledge on drug shortages, drug shortages experienced during hospitalization and information preferences on drug shortage. Differences between hospital settings were analyzed using Chi-squared test or Fisher’s exact test. For more complex contingency tables, Monte Carlo simulations (N = 2000) were applied for Fisher’s test. Post-hoc hospital-wise analyses were performed using Fisher’s exact tests. False discovery rate was controlled using the Bonferroni method. Analyses were performed using R: a language and environment for statistical computing (v 3.6.3).

Results

6 % of patients reported experiences with drug shortages while hospitalized which led to a deterioration of their health. The majority of affected patients were hospitalized at hematology and/or oncology wards in H-BiH, H-PO and H-GE. H-BiH had the highest number of affected patients (18.1 %, N = 19/105, p < 0.001) while the fewest patients were in H-SE (1 %, N = 1/100, p = 0.001). In addition, 82.5 %, (N = 501/607) of respondents wanted to be informed of alternative treatment options if there was a drug shortage without a generic substitute available. Majority of these patients (66.4 %, N = 386/501) prefer to be informed by a healthcare professional.

Conclusions

Although drug shortages led to serious medical consequences, our findings show that most of the patients did not perceive shortages as a problem. One possible interpretation is that good hospital management practices by healthcare professionals helped to mitigate the perceived impact of shortages. Our study highlights the importance of a good communication especially between patients and healthcare professionals in whom our patients have the greatest trust.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06721-9.

Development and validation of a predictive model to predict and manage drug shortages

PURPOSE

Pharmacy departments across the country are problem-solving the growing issue of drug shortages. We aim to change the drug shortage management strategy from a reactive process to a more proactive approach using predictive data analytics. By doing so, we can drive our decision-making to more efficiently manage drug shortages.

METHODS

Internal purchasing, formulary, and drug shortage data were reviewed to identify drugs subject to a high shortage risk ("shortage drugs") or not subject to a high shortage risk ("nonshortage drugs"). Potential candidate predictors of drug shortage risk were collected from previous literature. The dataset was trained and tested using 2 methods, including k-fold cross-validation and a 70/30 partition into a training dataset and a testing dataset, respectively.

RESULTS

A total of 1,517 shortage and nonshortage drugs were included. The following candidate predictors were used to build the dataset: dosage form, therapeutic class, controlled substance schedule (Schedule II or Schedules III-V), orphan drug status, generic versus branded status, and number of manufacturers. Predictors that positively predicted shortages included classification of drugs as intravenous-only, both oral and intravenous, antimicrobials, analgesics, electrolytes, anesthetics, and cardiovascular agents. Predictors that negatively predicted a shortage included classification as an oral-only agent, branded-only agent, antipsychotic, Schedule II agent, or orphan drug, as well as the total number of manufacturers. The calculated sensitivity was 0.71; the specificity, 0.93; the accuracy, 0.87; and the C statistic, 0.93.

CONCLUSION

The study demonstrated the use of predictive analytics to create a drug shortage model using drug characteristics and manufacturing variables.

Drug Shortage: Causes, Impact, and Mitigation Strategies

Drug shortage is a global issue affecting low, middle, and high-income countries. Many countries have developed various strategies to overcome the problem, while the problem is accelerating, affecting the whole world. All types of drugs, such as essential life-saving drugs, oncology medicines, antimicrobial drugs, analgesics, opioids, cardiovascular drugs, radiopharmaceutical, and parenteral products, are liable to the shortage. Among all pharmaceutical dosage forms, sterile injectable products have a higher risk of shortage than other forms. The causes of shortage are multifactorial, including supply issues, demand issues, and regulatory issues. Supply issues consist of manufacturing problems, unavailability of raw materials, logistic problems, and business problems. In contrast, demand issues include just-in-time inventory, higher demand for a product, seasonal demand, and unpredictable demand. For regulatory issues, one important factor is the lack of a unified definition of drug shortage. Drug shortage affects all stakeholders from economic, clinical, and humanistic aspects. WHO established global mitigation strategies from four levels to overcome drug shortages globally. It includes a workaround to tackle the current shortage, operational improvements to reduce the shortage risk and achieve early warning, changes in governmental policies, and education and training of all health professionals about managing shortages.

Strategies to improve pharmaceutical supply chain resilience under politico-economic sanctions: the case of Iran

Background

Given the impact of politico-economic sanctions on the pharmaceutical supply chain, this study aims to identify practical strategies to improve the resilience of the Iranian supply chain in pharmaceutical procurement under politico-economic sanctions.

Methods

This is a qualitative content analysis study conducted in 2018. Semi-structured interviews were conducted using snowball sampling, and saturation was achieved after 18 interviews. Guba and Lincoln's criteria, namely credibility, confirmability, transferability, and dependability, were considered to ensure the validity and transparency of the study. A five-step framework analysis was applied to analyze the data using MAX QDA10.

Results

The results led to the identification of nine main themes and 26 subthemes as strategies to improve the resilience of the pharmaceutical chain. According to the thematic map, some of these strategies have an extra-sectoral character: ‘insurance organizations’, ‘strengthening relations with other countries’, ‘mechanization of the distribution system’, and ‘suppliers and manufacturers’. At the same time, some inter-sectoral strategies can help the pharmaceutical chain maintain its resilience: ‘healthcare management and policy’, ‘exploiting local potential’, ‘pricing’, and ‘integrated health information systems.’ As a strategy, ‘Medical community and consumers’ also plays a crucial role in this regard. According to the subthemes, revisions of health management, more supervision, privatization, clinical policies, strategic purchasing, improvement of the referral system, inter-sectoral cooperation, support of indigenous medicines, rational pricing, insurance system, improvement of medical coverage, and development of electronic prescription should be considered by health systems. Sufficient support for indigenous medication and supervision of the distribution system should be considered by the pharmaceutical industry, taking into account the cooperation between consumers and patients.

Conclusions

Integration of the pharmaceutical supply chain and modern technologies, more attention to business complexity, economic development, intense competition, rapid changes in customer needs, and appropriate relationship between manufacturers, distributors, prescribers, and insurance organizations as purchasers should be considered by policymakers to improve supply chain resilience.

Personalized ß-lactam dosing in patients with coronavirus disease 2019 (COVID-19) and pneumonia: A retrospective analysis on pharmacokinetics and pharmacokinetic target attainment

ABSTRACT

Pathophysiological changes are important risk factors for critically ill patients with pneumonia manifesting sub-therapeutic antibiotic exposures during empirical treatment. The effect of coronavirus disease 2019 (COVID-19) on antibiotic dosing requirements is uncertain. We aimed to determine the effect of COVID-19 on ß-lactam pharmacokinetics (PK) and PK target attainment in critically ill patients with a personalized dosing strategy.Retrospective, single-center analysis of COVID-19 ± critically ill patients with pneumonia (community-acquired pneumonia or hospital-acquired pneumonia) who received continuous infusion of a ß-lactam antibiotic with dosing personalized through dosing software and therapeutic drug monitoring. A therapeutic exposure was defined as serum concentration between (css) 4 to 8 times the EUCAST non-species related breakpoint).Data from 58 patients with pneumonia was analyzed. Nineteen patients were tested COVID-19-positive before the start of the antibiotic therapy for community-acquired pneumonia or hospital-acquired pneumonia. Therapeutic exposure was achieved in 71% of COVID-19 patients (68% considering all patients). All patients demonstrated css above the non-species-related breakpoint. Twenty percent exceeded css above the target range (24% of all patients). The median ß-lactam clearance was 49% compared to ß-lactam clearance in a standard patient without a significant difference regarding antibiotic, time of sampling or present COVID-19 infection. Median daily doses were 50% lower compared to standard bolus dosing.COVID-19 did not significantly affect ß-lactam pharmacokinetics in critically ill patients. Personalized ß-lactam dosing strategies were safe in critically ill patients and lead to high PK target attainment with less resources.

Drug shortage management: A qualitative assessment of a collaborative approach

Drug shortages frequently and persistently affect healthcare institutions, posing formidable financial, logistical, and ethical challenges. Despite plentiful evidence characterizing the impact of drug shortages, there is a remarkable dearth of data describing current shortage management practices. Hospitals within the same state or region may not only take different approaches to shortages but may be unaware of shortages proximate facilities are facing. Our goal is to explore how hospitals in Michigan handle drug shortages to assess potential need for comprehensive drug shortage management resources. We conducted semi-structured interviews with diverse stakeholders throughout the state to describe experiences managing drug shortages, approaches to recent shortages, openness to inter-institutional engagement, ideas for a shared resource, and potential obstacles to implementation. To solicit additional feedback on ideas for a shared resource gathered from the interviews, we held focus groups with pharmacists, physicians, ethicists, and community representatives. Among participants representing a heterogeneous sample of institutions, three themes were consistent: (1) numerous drug shortage strategies occurring simultaneously; (2) inadequate resources and lead time to proactively manage shortages; and (3) interest in, but varied attitudes toward, a collaborative approach. These data provide insight to help develop and test a shared drug shortage management resource for enhancing fair allocation of scarce drugs. A shared resource may help institutions adopt accepted best practices and more efficiently access or share finite resources in times of shortage.

An application of multi-criteria decision-making approach to sustainable drug shortages management: evidence from a developing country

Background

Drug shortage is a significant public health problem, especially for drugs related to life threatening conditions. Almost all countries affected by variety of supply problems and spent a considerable amount of time and resources responding to shortage. The aim of present study is to determine and prioritize strategies to achieve best solutions for these considerable healthcare system challenges and to evaluate this strategies base on practical criteria.

Methods

To achieve the study objectives, the research was conducted in two phases. Determining of the strategies to control drug shortage, and comprehensive assessments of priority of possible strategies. For each phase, a self-design questionnaire was developed. The five main managerial strategies dimensions including: regulatory, financial, supply chain, information system and policy-making were set out. Forty-five alternatives were elicited from literature, and were evaluated and trimmed to 37 strategies based on experts’ opinion. The Multiple criteria decision-making (MCDM) methods were applied in second phase. Five important criteria including cost, time, labor, compliance with law and culture were weighed by Analytic Hierarchy Process (AHP) technique. Then, 37 alternatives have been rated base on the five criteria on the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) technique.

Results

“Creating integrated Supply chain information system to manage medicines inventory in the country”, “Creating and using the databases to predict the shortage of medicines”, “Using track and trace system” are alternatives 20th, 24th and 25th, which related to supply chain (SC) and information system (IS) dimensions have higher priority in the experts’ point of view. The results show IS dimension has 100 percentage of priority; following that policy and supply chain have higher priority, respectively.

Conclusion

Health systems rely on consistent supplying of pharmaceuticals to support patient care. The results show that information system, policy-making and supply chain are in the top-ranking priorities. Warning system needs to be improved to the advance system via better collaboration with stakeholders, publish precise and explicit national guidelines for drug shortage management, enforce the guidelines, and improve Iran FDA’s pharmaceutical market control capability.

Medicine Shortages in Serbia: Pharmacists' Standpoint and Potential Solutions for a Non-EU Country

Medicine shortages in Serbia have evidently been present for several decades, but literature data are scarce. The aim of our study was to get an insight on the present situation in Serbia, review the EU actions when managing shortages, and discern a set of potential measures. A short survey was conducted among 500 pharmacists in public pharmacies, in 23 cities in Serbia. The survey questions addressed frequency of drug shortages, professional actions in the event of shortages, main consequences to patients and pharmacies, putative causes, and pivotal measures for the prevention/mitigation of drug shortages under current conditions. Moreover, a Panel of Experts was organized, whose suggestions and opinions were used to analyze the present situation and to form a set of potential solutions and effective measures to mitigate shortages of medicines. In-depth analysis of current Serbian legislation was conducted, with emphasis on specific steps to be made within the actual legal framework. Examples of good practice in the EU, applicable to a country such as Serbia, were examined. Our research showed that although Serbia is, in some aspects, behind EU countries regarding the approaches to overcome medicine shortages, progress can be made within short period of time, by specific well-targeted actions. Both patients and pharmacists would benefit from it.

Implementation of pharmacist-managed early switch from intravenous to oral therapy using electronic identification at a tertiary academic hospital

Overutilization of intravenous (IV) medications can result in drug shortages, which is one of the major health care crisis, in addition to increasing costs, length of hospital stays (LOS) and the associated complications. We hypothesized that IV therapy was overused at our hospital where oral (PO) was applicable, and that the implementation of IV-PO protocol could result in a cost-effective practice. Hence, we aimed at assessing impact and outcomes of implementing such a protocol. A single center, prospective quasi-interventional study conducted at tertiary academic hospital. A protocol was implemented targeting 17 medications, with educational sessions to medical staff during a 5-month phase. IV orders of 48 h or more, among adult patients at medical or surgical wards with no contraindication to PO route were eligible. Once eligible, pharmacists send interventions using hospital's computerized order entry system, and physicians' responses were monitored on daily basis. Efficacy was estimated by percentage of switch recommendations that resulted in effective switch to PO medication. Cost-minimization analysis was used for course cost between the control phase and intervention phase. Length of hospital stay (LOS), readmissions within 90 days and in-hospital mortality were analyzed as secondary outcomes. During intervention phase, 781 patients had at least one IV order switched to PO. Gastric acid-reducing agents (GARAs) accounted for the most IV prescriptions (50.4%), followed by antibiotics (39.6%). Pharmacists carried out 2677 interventions to which switch recommendations were issued in 1185 (44.3%). Primary switch recommendations (N = 677) led to effective switch in 60.7% cases. These included per protocol switch (8.9%), switch to another PO (2.5%), spontaneous switch by physician (17.6%) and IV discontinuation (31.8%). The overall efficacy was estimated as 62.8%. The intervention was associated with reduced IV consumption from 4,574-18,597 vials in control phase to 3,654-15,546 vials in intervention phase, which resulted in overall cost saving of 50,960.8 SAR ($13,589.5), with an average monthly cost saving of 10,192.2 SAR ($2,717.9). Pharmacist-managed early switch from IV-PO therapy, with physicians' education, showed significant reduction in IV medication use in our hospital. By reducing unnecessary IV use, this strategy enabled considerable cost savings, besides the potential advantages of convenience and safety.

Optimization of Inventory Management to Prevent Drug Shortages in the Hospital Supply Chain

Drug shortage is always a critical issue of inventory management in healthcare systems since it potentially invokes several negative impacts. In supply chain management, optimization goes hand-in-hand with inventory control to address several issues of the supply, management, and use of drugs. However, it is difficult to determine a shortage situation in a hospital due to multiple unpredictable reasons, such as manufacturing problems, supply and demand issues, and raw material problems. To avoid the shortage problem in a hospital, efficient inventory management is required to operate the system in a sustainable way and maximize the profit of the organization in the Hospital Supply Chain (HSC). In this work, we study a drug refilling optimization problem, a general model for drug inventory management in a hospital. We then investigate a Deep Reinforcement Learning (DRL) model to address this problem under an online solution that can automatically make a drug refilling decision in order to prevent a drug shortage. We further present a numerical result to verify the performance of the proposed algorithm, which outperforms the baselines (e.g., over-provisioning, ski-rental, and max-min) in terms of the refilling cost and the shortage rate.

The evolving role of community pharmacists during COVID-19 in the UAE; assessing preparedness and knowledge

OBJECTIVES

To investigate community pharmacists' knowledge about COVID-19 and their preparedness for the pandemic.

METHODS

This cross-sectional online survey was conducted (in community pharmacies in the United Arab Emirates) over 3 weeks (24 May 2020 to 14 June 2020). A proportionate random sample of 491 participants was invited to take part. The SPSS version 26 was used for data management and analysis.

KEY FINDINGS

The majority of participants (n = 400) had good knowledge about COVID-19 and high level of preparedness for the pandemic control. Most pharmacists agreed (212, 53.0%) or strongly agreed (91, 22.8%) that they have a major role in the management of the ongoing crisis. Most participants had good awareness about the most common methods of COVID-19 transmission (359, 89.7%) and symptoms encountered (368, 92.0%). However, approximately a quarter of participants (103, 25.7%) incorrectly thought COVID-19 was caused by a DNA virus. Participants who had 5-10 and >10 years of experience were 3.95 (P = 0.03) and 1.59 (P = 0.01) times, respectively, were more likely to have good knowledge compared to participants with less than 2 years of experience. Those with good knowledge were more likely to have a specific area for customers with suspected COVID-19 symptoms compared to those with poor knowledge (P = 0.031).

CONCLUSION

This study indicates that years of experience and good knowledge on COVID-19 were significant determinants of pharmacists' preparedness for the pandemic control.

Molecular Insights into Warfarin Sodium 2-Propanol Solvate Solid Form Changes and Disproportionation Using a Low Volume Two-Stage Dissolution Approach

The current research work focuses on understanding the reported discrepancies and our observations in the dissolution profiles of warfarin sodium tablets and potential patient-based failure modes during oral warfarin therapy. It was hypothesized that freely soluble crystalline warfarin sodium (WAR_C) at first transforms into noncrystalline warfarin sodium (WAR_NC) under stress conditions. The WAR_C → WAR_NC conversion facilitates the rapid formation of the poorly soluble unionized form, which could lead to dissolution failures and potential poor in vivo performance. Depressed warfarin concentrations locally in the gastrointestinal tract (GIT) may in turn lead to inadequate absorption and thereby affect bioavailability. A low volume two-stage dissolution method was developed to mimic in vivo GIT conditions. Warfarin sodium tablets exposed to room temperature and 75% relative humidity for 1 week showed approximately 23% decrease in drug release. The decline in drug release supports the hypothesis that WAR_NC is converted to the unionized form faster than WAR_C does under the same conditions. Solid state characterization (powder X-ray diffractometry and differential scanning calorimetry) data demonstrated the disproportionation of warfarin sodium to unionized warfarin after solubility and dissolution studies. The findings support the hypothesis and a possible failure mode of warfarin sodium tablets. This work is a second case study from our laboratory on narrow therapeutic index drug products in which the instability of the solid state of the drug substance is potentially responsible for observed clinical failures.

Rural healthcare providers coping with clinical care delivery challenges: lessons from three health centres in Ghana

Background

Rural settings in low- and middle-income countries are bedeviled with poverty and high disease burden, and lack adequate resources to deliver quality healthcare to the population. Drug shortage and inadequate number and skill-mix of healthcare providers is very common in rural health facilities. Hence, rural healthcare providers have no choice but to be innovative and introduce some strategies to cope with health delivery challenges at the health centre levels. This study explored how and why rural healthcare providers cope with clinical care delivery challenges at the health centre levels in Ghana.

Methods

This study was a multiple case studies involving three districts: Bongo, Kintampo North, and Juaboso districts. In each case study district, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and the study participants. The authors conducted 11 interviews, 9 focus group discussions (involving 61 participants), and 9-week participant observation (in 3 health centres). Transcription of the voice-recordings was done verbatim, cleaned and imported into the Nvivo version 11 platform for analysis. Data was analysed using the inductive content analysis approach. Ethical clearance was granted by the Ethics Review Committee of the Ghana Health Service.

Results

The study found three main coping strategies (borrowing, knowledge sharing and multi-tasking). First, borrowing arrangements among primary health care institutions help to address the periodic shortage of medical supplies at the health centres. Secondly, knowledge sharing among healthcare providers mitigates skills gap during service delivery; and finally, rural healthcare providers use multi-tasking to avert staff inadequacy challenges during service delivery at the health centre levels.

Conclusion

Borrowing, knowledge sharing, and multi-tasking are coping strategies that are sustaining and potentially improving health outcomes at the district levels in Ghana. We recommend that health facilities across all levels of care in Ghana and other settings with similar challenges could adopt and modify these strategies in order to ensure quality healthcare delivery amidst delivery challenges.