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Weber DJ, Malani AN, Shenoy ES, Banach DB, Batshon LJ, Branch-Elliman W, Dumyati G, Haessler S, Hsu VP, Jump RLP, Mathew TA, Murthy RK, Pergam SA. Society for Healthcare Epidemiology of America position statement on pandemic preparedness for policymakers: mitigating supply shortages. Infect Control Hosp Epidemiol 2024:1-5. [PMID: 38835229 DOI: 10.1017/ice.2024.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
The COVID-19 has had major direct (e.g., deaths) and indirect (e.g., social inequities) effects in the United States. While the public health response to the epidemic featured some important successes (e.g., universal masking ,and rapid development and approval of vaccines and therapeutics), there were systemic failures (e.g., inadequate public health infrastructure) that overshadowed these successes. Key deficiency in the U.S. response were shortages of personal protective equipment (PPE) and supply chain deficiencies. Recommendations are provided for mitigating supply shortages and supply chain failures in healthcare settings in future pandemics. Some key recommendations for preventing shortages of essential components of infection control and prevention include increasing the stockpile of PPE in the U.S. National Strategic Stockpile, increased transparency of the Stockpile, invoking the Defense Production Act at an early stage, and rapid review and authorization by FDA/EPA/OSHA of non-U.S. approved products. Recommendations are also provided for mitigating shortages of diagnostic testing, medications and medical equipment.
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Affiliation(s)
- David Jay Weber
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | | | - Erica S Shenoy
- Mass General Brigham, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David B Banach
- University of Connecticut School of Medicine, Farmington, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | | | - Westyn Branch-Elliman
- Harvard Medical School, Boston, MA, USA
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Ghinwa Dumyati
- University of Rochester Medical Center, Rochester, NY, USA
- Center for Community Health, Rochester, NY, USA
| | - Sarah Haessler
- Baystate Medical Center, Springfield, MA, USA
- University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - Vincent P Hsu
- AdventHealth, Altamonte Springs, FL, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC), Pittsburgh Veteran Affairs Healthcare System, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Trini A Mathew
- HealthTAMCycle3, PLLC, Troy, MI, USA
- Corewell Health, Taylor, MI, USA
- School of Medicine, Wayne State University, Detroit, MI, USA
- Oakland University William Beaumont, Rochester, MI, USA
| | - Rekha K Murthy
- Cedars-Sinai, Los Angeles, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
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Hantel A, Spence R, Camacho P, Bradbury AR, Denburg AE, Jagsi R, Moy B, Rathmell WK, Rosenberg AR, Symington B, Marron JM, Peppercorn J. ASCO Ethical Guidance for the Practical Management of Oncology Drug Shortages. J Clin Oncol 2024; 42:358-365. [PMID: 38061010 DOI: 10.1200/jco.23.01941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 01/19/2024] Open
Affiliation(s)
| | | | - Polo Camacho
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | - Reshma Jagsi
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Banu Symington
- Memorial Hospital of Sweetwater County, Rock Springs, WY
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Berens N, Buchbinder M. How Should We Allocate Divisible Resources? An Overlooked Question. THE JOURNAL OF CLINICAL ETHICS 2024; 35:59-64. [PMID: 38373335 DOI: 10.1086/728143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
AbstractThe ethical allocation of scarce medical resources has received significant attention, yet a key question remains unaddressed: how should scarce, divisible resources be allocated? We present a case from the COVID-19 pandemic in which scarce resources were divided among patients rather than allocated to some patients over others. We assess how widely accepted allocation principles could be applied to this case, and we show how these principles provide insufficient guidance. We then propose alternatives that may help guide decision-making in such cases, and we evaluate the possibility of treating patients equally by dividing resources equally. Resource scarcity is not limited to pandemic situations, and many healthcare resources are divisible. This question-how to allocate these divisible resources-deserves greater attention from bioethics.
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Parkes J, Dodhia V, Ziter S, Olson N, Ghose A, Cracknell ANV, Wendy Ng HW. Post COVID availability of oncology drugs - Is this the new normal on both sides of the Atlantic? J Oncol Pharm Pract 2023; 29:2045-2048. [PMID: 37728148 DOI: 10.1177/10781552231202212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Affiliation(s)
- Joanne Parkes
- Worcestershire Oncology Centre, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
- British Oncology Pharmacy Association, UK
- Immuno-Oncology Clinical Network, UK
| | - Vikash Dodhia
- British Oncology Pharmacy Association, UK
- Mount Vernon Cancer Centre, East and North Hertfordshire Trust, Northwood, UK
- Aseptic Services, NHS England East of England, UK
| | - Stephen Ziter
- National Community Oncology Dispensing Association, New York, USA
| | - Natasha Olson
- National Community Oncology Dispensing Association, New York, USA
| | - Aruni Ghose
- Immuno-Oncology Clinical Network, UK
- Mount Vernon Cancer Centre, East and North Hertfordshire Trust, Northwood, UK
- National Community Oncology Dispensing Association, New York, USA
- Barts Cancer Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Medical Oncology, Medway NHS Foundation Trust, Gillingham, UK
- United Kingdom and Ireland Global Cancer Network, UK
| | - Annette Netty V Cracknell
- British Oncology Pharmacy Association, UK
- Ramsay Health Care, London, UK
- International Society of Oncology Pharmacy Practitioners, North Vancouver, BC, Canada
| | - Hei Wan Wendy Ng
- British Oncology Pharmacy Association, UK
- Mount Vernon Cancer Centre, East and North Hertfordshire Trust, Northwood, UK
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Hantel A, McManus ML, Wadleigh M, Cotugno M, Abel GA. Impact of Allocation on Survival During Intermittent Chemotherapy Shortages: A Modeling Analysis. J Natl Compr Canc Netw 2022; 20:335-341.e17. [PMID: 35390765 PMCID: PMC10983800 DOI: 10.6004/jnccn.2021.7047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intermittent shortages of chemotherapeutics used to treat curable malignancies are a worldwide problem that increases patient mortality. Although multiple strategies have been proposed for managing these shortages (eg, prioritizing patients by age, scarce treatment efficacy per volume, alternative treatment efficacy difference), critical clinical dilemmas arise when selecting a management strategy and understanding its impact. PATIENTS AND METHODS We developed a model to compare the impact of different allocation strategies on overall survival during intermittent chemotherapy shortages and tested it using vincristine, which was recently scarce for 9 months in the United States. Demographic and treatment data were abstracted from 1,689 previously treated patients in our tertiary-care system; alternatives were abstracted from NCCN Clinical Practice Guidelines in Oncology for each disease and survival probabilities from the studies cited therein. Modeled survival was validated using SEER data. Nine-month shortages were modeled for all possible supply levels. Pairwise differences in 3-year survival and risk reductions were calculated for each strategy compared with standard practice (first-come, first-served) for each 50-mg supply increment, as were supply thresholds above which each strategy maintained survival similar to scenarios without shortages. RESULTS A strategy prioritizing by higher vincristine efficacy per volume and greater alternative treatment efficacy difference performed best, improving survival significantly (P<.01) across 86.5% of possible shortages (relative risk reduction, 8.3%; 99% CI, 8.0-8.5) compared with standard practice. This strategy also maintained survival rates similar to a model without shortages until supply fell below 72.2% of the amount required to treat all patients, compared with 94.3% for standard practice. CONCLUSIONS During modeled vincristine shortages, prioritizing patients by higher efficacy per volume and alternative treatment efficacy difference significantly improved survival over standard practice. This approach can help optimize allocation as intermittent chemotherapy shortages continue to arise.
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Affiliation(s)
- Andrew Hantel
- Division of Population Sciences, Dana-Farber Cancer Institute
- Division of Inpatient Oncology, Dana-Farber Cancer Institute
| | | | - Martha Wadleigh
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute
| | - Michael Cotugno
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gregory A. Abel
- Division of Population Sciences, Dana-Farber Cancer Institute
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute
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Classifying healthcare warehouses according to their performance. A Cluster Analysis-based approach. INTERNATIONAL JOURNAL OF LOGISTICS MANAGEMENT 2021. [DOI: 10.1108/ijlm-02-2020-0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe objective of this paper is to propose an approach to comparatively analyze the performance of drugs and consumable products warehouses belonging to different healthcare institutions.Design/methodology/approachA Cluster Analysis is completed in order to classify warehouses and identify common patterns based on similar organizational characteristics. The variables taken into account are associated with inventory levels, the number of SKUs, and incoming and outgoing flows.FindingsThe outcomes of the empirical analysis are confirmed by additional indicators reflecting the demand level and the associated logistics flows faced by the warehouses at issue. Also, the warehouses belonging to the same cluster show similar behaviors for all the indicators considered, meaning that the performed Cluster Analysis can be considered as coherent.Research limitations/implicationsThe study proposes an approach aimed at grouping healthcare warehouses based on relevant logistics aspects. Thus, it can foster the application of statistical analysis in the healthcare Supply Chain Management. The present work is associated with only one regional healthcare system.Practical implicationsThe approach might support healthcare agencies in comparing the performance of their warehouses more accurately. Consequently, it could facilitate comprehensive investigations of the managerial similarities and differences that could be a first step toward warehouse aggregation in homogeneous logistics units.Originality/valueThis analysis puts forward an approach based on a consolidated statistical tool, to assess the logistics performances in a set of warehouses and, in turn to deepen the related understanding as well as the factors determining them.
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Hantel A, Peppercorn J, Abel GA. Model solutions for ethical allocation during cancer medicine shortages. Lancet Haematol 2021; 8:e246-e248. [PMID: 33770477 PMCID: PMC10975648 DOI: 10.1016/s2352-3026(21)00055-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Andrew Hantel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Division of Inpatient Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Harvard Medical School Center for Bioethics, Boston, MA, USA
| | - Jeff Peppercorn
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory A Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; Harvard Medical School Center for Bioethics, Boston, MA, USA.
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Nakamura ZM, MacKay DP, Davis AM, Brassfield ER, Joyner BL, Rosenstein DL. Reconsidering scarce drug rationing: implications for clinical research. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106739. [PMID: 33246996 DOI: 10.1136/medethics-2020-106739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/15/2020] [Accepted: 10/27/2020] [Indexed: 06/12/2023]
Abstract
Hospital systems commonly face the challenge of determining just ways to allocate scarce drugs during national shortages. There is no standardised approach of how this should be instituted, but principles of distributive justice are commonly used so that patients who are most likely to benefit from the drug receive it. As a result, clinical indications, in which the evidence for the drug is assumed to be established, are often prioritised over research use. In this manuscript, we present a case of a phase II investigational trial of intravenous thiamine for delirium prevention in patients undergoing haematopoietic stem cell transplantation to emphasise several shortcomings in the overarching prioritisation of clinical over research uses of scarce drugs. Specifically, we present the following considerations: (1) clinical use may not have stronger evidence than research use; (2) a strong scientific rationale for research use may outweigh the claim for clinical indications in which there is weak evidence; (3) treatment within the context of a clinical trial may be the standard of care; and (4) research use may not only benefit patients receiving the treatment but also offers the prospect of improving future clinical care. In summary, we argue against allocation schemes that prohibit all research uses of scarce drugs and instead recommend that allocation schemes include a balanced approach that weighs risks and benefits of access to scarce drugs irrespective of the research versus clinical use designation.
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Affiliation(s)
- Zev M Nakamura
- Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Douglas P MacKay
- Public Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Center of Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Arlene M Davis
- Center of Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth R Brassfield
- Philosophy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Benny L Joyner
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Donald L Rosenstein
- Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Sinow C, Burgart A, Char DS. How Anesthesiologists Experience and Negotiate Ethical Challenges from Drug Shortages. AJOB Empir Bioeth 2020; 12:84-91. [PMID: 33124970 DOI: 10.1080/23294515.2020.1839596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In the face of ongoing drug shortages, anesthesiologists have been described as having to become "Iron Chefs, challenged to create safe patient outcomes with missing ingredients. Unfortunately, developing responsive ethical guidance for how anesthesiologists should best handle ethical concerns with ongoing and mutable drug shortages is limited by the dearth of studies examining how bedside clinicians actually experience drug shortages and what ethical challenges they encounter. In order to better understand what ethical concerns individual anesthesiologists experience around drug shortages and how they negotiate them, we undertook this qualitative interview study. Methods: We conducted semi-structured interviews with anesthesiologists at three field sites: an academic tertiary care adult hospital that performs approximately 46,000 anesthetics annually comprising cases ranging across all surgical disciplines; the affiliated veteran's affairs hospital that performs 12,000 anesthetics annually; and, the affiliated children's hospital that performs 20,500 anesthetics annually. Results: 29 anesthesiologists were interviewed (17 adult and 12 pediatric anesthesiologists), representing a spectrum of practice areas in clinical anesthesia: general, pediatric, regional, pain, critical care, obstetrics, liver transplant, and palliative medicine. Three themes emerged: (1) uncertainty about responsibility for clinical decisions made in consequence to a shortage; (2) creativity, and its limits, in choosing anesthetic plans; and, (3) disclosure of concerns about shortages (to patients and colleagues). Conclusions: Our data suggests anesthesiologists have unmet needs for ethical guidance on how to approach drug shortages. First is managing responsibility for decisions stemming from a drug shortage. Second, interviewees struggled with disclosure of their concerns, both to patients and to surgical colleagues. A formal shared decision making approach may present the best solution, since the act of structuring a shared decision making conversation or creating a decision making tool will have to incorporate the views of all stakeholders around shortages and their potential clinical consequences.
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Affiliation(s)
- Carolyn Sinow
- Division of Obstetrics and Gynecology, Kaiser Permanente Santa Clara, Santa Clara, California, USA
| | - Alyssa Burgart
- Department of Anesthesiology, School of Medicine Division of Pediatric Anesthesia, Stanford University, Stanford, California, USA.,Center for Biomedical Ethics, School of Medicine, Stanford University, Stanford, California, USA
| | - Danton S Char
- Department of Anesthesiology, School of Medicine Division of Pediatric Cardiac Anesthesia, Stanford University, Stanford, California, USA.,Center for Biomedical Ethics, School of Medicine, Stanford University, Stanford, California, USA
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Hantel A, Hlubocky FJ, Siegler M, Daugherty CK. A Qualitative Analysis of Oncology Patient Awareness of Medication Shortages and Their Preferences for How Shortages Should Be Managed. JCO Oncol Pract 2020; 16:e1098-e1111. [DOI: 10.1200/jop.19.00608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Medication shortages in US hospitals are ongoing, widespread, and frequently involve antineoplastic and supportive medications used in cancer care. The ways shortages are managed and the ways provider-patient communication takes place are heterogeneous, but the related preferences of oncology patients are undefined. This study sought to qualitatively evaluate patient preferences. METHODS: A cross-sectional, semi-structured interview study was conducted from January to June 2019. Participants were adult oncology inpatients who received primary cancer care at the University of Chicago, had undergone treatment within 2 years, and had 1 or more previous hospitalizations during that period. Participants (n = 54) were selected consecutively from alternating hematology and oncology services. The primary outcome was thematic saturation across the domains of awareness of medication shortages, principle preferences regarding decision makers, preferences regarding allocation of therapy drugs, and allocation-related communication. RESULTS: Thematic saturation was reached after 39 participants completed the study procedures (mean age, 59.6 years [standard deviation, 14.5 years]; men made up 61.5% of the study population [mean age, 24 years]; response rate, 72.0%). In all, 18% of participants were aware of institutional medication shortages. Patients preferred having multiple decision makers for allocating medications in the event of a shortage. A majority of patients named oncologists (100%), ethicists (92%), non-oncology physicians (77%), and pharmacists (64%) as their preferred decision makers. Participants favored allocation of drugs based on their efficacy (normalized weighted average, 1.3), and they also favored prioritizing people who were already receiving treatment (1.8), younger patients (2.0), sicker patients (3.1), and those presenting first for treatment (5.3). Most participants preferred preferred disclosure of supportive care medication shortages (74%) and antineoplastic medication shortages (79%) for equivalent substitutions. CONCLUSION: In a tertiary-care center with medication shortages, few oncologic inpatients were aware of shortages. Participants preferred having multiple decision makers involved in principle-driven allocation of scarce medications. Disclosure was preferred when their usual medications needed to be substituted with equivalent alternatives. These preliminary data suggest that preferences do not align with current management practices for medication shortages.
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Affiliation(s)
- Andrew Hantel
- Division of Population Sciences and Inpatient Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Fay J. Hlubocky
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL
- The MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL
| | - Mark Siegler
- The MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL
| | - Christopher K. Daugherty
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL
- The MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL
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Rosoff PM. Healthcare Rationing Cutoffs and Sorites Indeterminacy. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2020; 44:479-506. [PMID: 31356664 DOI: 10.1093/jmp/jhz012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as "beneficial," "effective," or even "futile," the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient Greek philosophical conundrum known as the "sorites paradox." I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing).
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Affiliation(s)
- Philip M Rosoff
- Duke University School of Medicine, Durham, North Carolina, USA
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12
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Hantel A. A Cross-Sectional Survey of Medical Trainee Experiences During Medication Shortages. J Grad Med Educ 2020; 12:38-43. [PMID: 32089792 PMCID: PMC7012528 DOI: 10.4300/jgme-d-19-00385.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/27/2019] [Accepted: 11/21/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Medication shortages prevent patients from receiving optimal care. Despite the frequency with which medical trainees care for inpatients, no assessment of their experiences in medication shortage management has been performed. OBJECTIVE We evaluated trainees' experiences managing medication shortages. METHODS We performed a cross-sectional survey of trainees postgraduate year 2 (PGY-2) and above in medicine, anesthesiology, and emergency medicine departments at 2 academic centers in 2018-2019. Categorical and ordinal assessments evaluated shortage awareness, substitution availability, pharmacy and therapeutics committee-based restrictions, communication, and education. Regressions were performed to determine effect of PGY, department, and institution on responses. RESULTS A total of 168 of 273 subjects completed the survey (62% response rate). Most (95%, 159 of 168) reported managing medication shortages during training; 51% (86 of 168) described managing clinically relevant shortages daily or weekly. Seventy-seven percent (129 of 168) noted equivalent alternatives were unavailable at least one-quarter of the time, and 43% (72 of 168) reported clinically necessary medications were restricted at least weekly. Fifty-four percent (89 of 168) and 64% (106 of 167) of respondents discussed clinically relevant shortages with supervising physicians or patients "some of the time" or less, respectively. Most respondents (90%, 151 of 168) reported they would benefit from shortage management training, but few (13%, 21 of 168) reported prior training. CONCLUSIONS Although trainees reported frequent involvement in clinically impactful shortage management, medication shortage communication between trainees and supervising physicians or patients appears sporadic. Medication shortage management training is uncommon but perceived as beneficial.
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13
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Hantel A, Abel GA, Siegler M. Practical allocation system for the distribution of specialised care during cellular therapy access scarcity. JOURNAL OF MEDICAL ETHICS 2019; 45:532-537. [PMID: 31217227 DOI: 10.1136/medethics-2018-105339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 04/05/2019] [Accepted: 04/27/2019] [Indexed: 06/09/2023]
Abstract
Novel cellular therapy techniques promise to cure many haematology patients refractory to other treatment modalities. These therapies are intensive and require referral to and care from specialised providers. In the USA, this pool of providers is not expanding at a rate necessary to meet expected demand; therefore, access scarcity appears forthcoming and is likely to be widespread. To maintain fair access to these scarce and curative therapies, we must prospectively create a just and practical system to distribute care. In this article, we first review previously implemented medical product and personnel allocation systems, examining their applicability to cellular therapy provider shortages to demonstrate that this problem requires a novel approach. We then present an innovative system for allocating cellular therapy access, which accounts for the constraints of distribution during real-world oncology practice by using a combination of the following principles: (1) maximising life-years per personnel time, (2) youngest and robust first, (3) sickest first, (4) first come/first served and (5) instrumental value. We conclude with justifications for the incorporation of these principles and the omission of others, discuss how access can be distributed using this combination, consider cost and review fundamental factors necessary for the practical implementation and maintenance of this system.
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Affiliation(s)
- Andrew Hantel
- Department of Medicine, Section of Hematology/Oncology and The MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA
| | - Gregory A Abel
- Division of Population Science and Hematologic Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mark Siegler
- Department of Medicine, The MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA
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14
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Hantel A, Siegler M, Hlubocky F, Colgan K, Daugherty CK. Prevalence and Severity of Rationing During Drug Shortages: A National Survey of Health System Pharmacists. JAMA Intern Med 2019; 179:710-711. [PMID: 30907925 PMCID: PMC6503559 DOI: 10.1001/jamainternmed.2018.8251] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study examines national survey results from hospital pharmacy managers to investigate current drug allocation and rationing practices of US hospitals during drug shortages.
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Affiliation(s)
- Andrew Hantel
- The Maclean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois.,Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Mark Siegler
- The Maclean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois
| | - Fay Hlubocky
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Kevin Colgan
- Department of Pharmacy, The University of Chicago Hospital, Chicago, Illinois
| | - Christopher K Daugherty
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
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15
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Unguru Y, Bernhardt MB, Berg SL, Johnson LM, Pyke-Grimm K, Woodman C, Fernandez CV. Chemotherapy and Supportive Care Agents as Essential Medicines for Children With Cancer. JAMA Pediatr 2019; 173:477-484. [PMID: 30830204 DOI: 10.1001/jamapediatrics.2019.0070] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In resource-rich countries, 5-year survival rates for children with cancer approach 85%. This impressive statistic is largely the result of integrating research with clinical care. At the core of this endeavor are multiagent combination chemotherapy and supportive care agents (CASCA). Most CASCAs belong to the class of sterile injectable drugs, which make up the backbone of many proven and life-saving pediatric oncology regimens. There are few if any alternative agents available to treat most life-threatening childhood cancers. In the United States, shortages of CASCAs are now commonplace. The consequences of drug shortages are far reaching. Beyond the economic costs, these shortages directly affect patients' lives, and this is especially true for children with cancer. Drug shortages in general and shortages of CASCAs specifically result in increased medication errors, delayed administration of life-saving therapy, inferior outcomes, and patient deaths. One way to mitigate drug shortages is to adopt an essential medicines list and ensure that these medications remain in adequate supply at all times. We argue for creation of a CASCA-specific essential medicines list for childhood cancer and provide ethical and policy-based reasoning for this approach. We recognize that such a call has implications beyond pediatric cancer, in that children with other serious disease should have an equal claim to access to guaranteed evidence-based medicines. We provide these arguments as an example of what should be claimed for medical indications that are deemed essential to preserve life and function.
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Affiliation(s)
- Yoram Unguru
- Division of Pediatric Hematology-Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, Maryland.,Johns Hopkins University, Berman Institute of Bioethics, Baltimore, Maryland
| | - Melanie Brooke Bernhardt
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stacey L Berg
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | | | - Kimberly Pyke-Grimm
- Bass Center for Childhood Cancer and Blood Diseases, Lucile Packard Children's Hospital, Stanford, California
| | | | - Conrad V Fernandez
- Pediatric Hematology-Oncology, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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Yang C, Cai W, Li Z, Page AT, Fang Y. The current status and effects of emergency drug shortages in China: Perceptions of emergency department physicians. PLoS One 2018; 13:e0205238. [PMID: 30300412 PMCID: PMC6177176 DOI: 10.1371/journal.pone.0205238] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 09/22/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The shortage of emergency drugs in China is severe. This study aimed to characterize emergency drug shortages in China and to measure their effects. METHODS An online questionnaire based on a literature review was sent to emergency department physicians in Chinese secondary and tertiary hospitals from November 2016 to February 2017. The survey asked physicians questions about their experiences with emergency drug shortages. RESULTS In total, 236 physicians from 29 provinces participated in the survey. According to their responses, 90.7% of the respondents experienced drug shortages during the last year. More than half of the physicians (65.7%) reported that drug shortages occurred at least once a month. Hospitals in the eastern and western regions of China had more emergency drugs in shortage than hospitals in central China, especially those with many inpatient beds (≥800). In addition, the shortage situation was more serious in secondary hospitals than in tertiary hospitals. More respondents agreed that original medicines, injections, essential medicines, medicines without alternative agents and cheap medicines were more susceptible to shortages than generics, oral medicines, nonessential medicines, medicines with alternative agents and expensive medicines, respectively. Most respondents thought that drug shortages always, often or sometimes affected patients [delayed therapy (62.6%), longer rescue and recovery times (58.9%) and higher costs (58.7%)] and physicians [inconvenience (81.0%), higher pressure (76.5%) and harm to patient-doctor relationships (72%)] and compromised hospital reputations (55.1%). CONCLUSIONS The shortage of emergency drugs in China is serious, especially in secondary hospitals located in eastern and western China. Emergency drug shortages have significant effects on patients and physicians.
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Affiliation(s)
- Caijun Yang
- The Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi’an, China
- The Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi’an, China
| | - Wenfang Cai
- The Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi’an, China
- The Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi’an, China
| | - Zongjie Li
- The Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi’an, China
- The Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi’an, China
| | - Amy Theresa Page
- Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Australia
- Centre for Medicine Use and Safety, Monash University, Perth, Australia
| | - Yu Fang
- The Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi’an, China
- The Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi’an, China
- * E-mail:
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Ziesenitz VC, Mazer-Amirshahi M, Zocchi MS, Fox ER, May LS. U.S. vaccine and immune globulin product shortages, 2001-15. Am J Health Syst Pharm 2017; 74:1879-1886. [PMID: 28970246 DOI: 10.2146/ajhp170066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Trends in shortages of vaccines and immune globulin products from 2001 through 2015 in the United States are described. METHODS Drug shortage data from January 2001 through December 2015 were obtained from the University of Utah Drug Information Service. Shortage data for vaccines and immune globulins were analyzed, focusing on the type of product, reason for shortage, shortage duration, shortages requiring vaccine deferral, and whether the drug was a single-source product. Inclusion of the product into the pediatric vaccination schedule was also noted. RESULTS Of the 2,080 reported drug shortages, 59 (2.8%) were for vaccines and immune globulin products. Of those, 2 shortages (3%) remained active at the end of the study period. The median shortage duration was 16.8 months. The most common products on shortage were viral vaccines (58%), especially hepatitis A, hepatitis B, rabies, and varicella vaccines (4 shortages each). A vaccine deferral was required for 21 shortages (36%), and single-source products were on shortage 30 times (51%). The most common reason for shortage was manufacturing problems (51%), followed by supply-and-demand issues (7%). Thirty shortages (51%) were for products on the pediatric schedule, with a median duration of 21.7 months. CONCLUSION Drug shortages of vaccines and immune globulin products accounted for only 2.8% of reported drug shortages within a 15-year period, but about half of these shortages involved products on the pediatric vaccination schedule, which may have significant public health implications.
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Affiliation(s)
- Victoria C Ziesenitz
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland .,Department of Pediatric Cardiology, University Children's Hospital, Heidelberg, Germany
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC.,Georgetown University School of Medicine, Washington, DC
| | - Mark S Zocchi
- Center for Healthcare Innovation and Policy Research, George Washington University, Washington, DC
| | - Erin R Fox
- Drug Information Service, University of Utah Health Care, Salt Lake City, UT.,College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Larissa S May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA
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Beck JC, Chen B, Gordon BG. Physician approaches to drug shortages: Results of a national survey of pediatric hematologist/oncologists. World J Clin Oncol 2017; 8:336-342. [PMID: 28848700 PMCID: PMC5554877 DOI: 10.5306/wjco.v8.i4.336] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 05/04/2017] [Accepted: 07/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate personnel involved in scarce drug prioritization and distribution and the criteria used to inform drug distribution during times of shortage among pediatric hematologists/oncologists.
METHODS Using the American Society of Pediatric Hematology/Oncology (ASPHO) membership list, a 20 question survey of pediatric hematologists/oncologists was conducted via email to evaluate personnel involved in scarce drug prioritization and distribution and criteria used to inform scarce drug distribution.
RESULTS Nearly 65% of the 191 study respondents had patients directly affected by drug shortages. Most physicians find out about shortages from the pharmacist (n = 179, 98%) or other doctors (n = 75, 41%). One third of respondents do not know if there is a program or policy for handling drug shortages at their institution. The pharmacist was the most commonly cited decision maker for shortage drug distribution (n = 128, 70%), followed by physicians (n = 109, 60%). One fourth of respondents did not know who makes decisions about shortage drug distribution at their institution. The highest priority criterion among respondents was use of the shortage drug for curative, rather than palliative intent and lowest priority criterion was order of arrival or first-come first-served.
CONCLUSION Despite pediatric hematology/oncology physicians and patients being heavily impacted by drug shortages, institutional processes for handling shortages are lacking. There is significant disparity between how decisions for distribution of shortage drugs are currently made and how study respondents felt those decisions should be made. An institution-based, and more importantly, a societal approach to drug shortages is necessary to reconcile these disparities.
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Mazer-Amirshahi M, Goyal M, Umar SA, Fox ER, Zocchi M, Hawley KL, Pines JM. U.S. drug shortages for medications used in adult critical care (2001-2016). J Crit Care 2017. [PMID: 28622641 DOI: 10.1016/j.jcrc.2017.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We describe trends in U.S. shortages impacting critical care drugs from 2001 to 2016. MATERIALS AND METHODS Shortages within the scope of critical care were identified using data from the University of Utah Drug Information Services. Shortage characteristics were described using standard descriptive statistics and regression analysis. RESULTS Of 1969 shortages reported, 1004 (51%) were for drugs used in critical care. New shortages fell from 2001 to 2004, then increased, peaking in 2011 (116). For critical care shortages, 247 (24.6%) involved drugs used for high acuity conditions. The majority of drugs on shortage were parenteral, (720; 71.7%) and 393 (39.1%) were single source drugs. Alternatives were available for 887 (88.3%) drugs, although 250 (24.9%) alternatives were impacted by shortages. Infectious disease drugs were the most common drugs on shortage, with 200 (19.9%) shortages, with a median duration of 7.7months (IQR=2.8-17.3). By the end of the study, 896 (89.2%) shortages were resolved and 108 (10.8%) remained active. The median duration for active shortages was 13.6months (IQR=5.8-58.4) while the duration for resolved shortages was 7.2months (IQR=2.8-17.3). CONCLUSIONS Although the number of new shortages peaked in 2011 and is now declining, there remain a substantial number of active shortages impacting critical care drugs.
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Affiliation(s)
- Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, United States; Georgetown University School of Medicine, 3900 Reservoir Road, Washington, DC 20007, United States.
| | - Munish Goyal
- Department of Emergency Medicine, MedStar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, United States; Georgetown University School of Medicine, 3900 Reservoir Road, Washington, DC 20007, United States
| | - Suleman A Umar
- Department of Internal Medicine, MedStar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, United States
| | - Erin R Fox
- Department of Pharmacy and Drug Information Services, University of Utah, 50 N. Medical Drive A050, Salt Lake City, UT 84132, United States.
| | - Mark Zocchi
- Center for Healthcare Innovation and Policy Research, the George Washington University, 2300 Eye Street NW, Washington, DC 2007, United States.
| | - Kristy L Hawley
- Department of Surgery, MedStar Union Memorial Hospital, 201 E. University Parkway, Baltimore, MD 21218, United States
| | - Jesse M Pines
- Center for Healthcare Innovation and Policy Research, the George Washington University, 2300 Eye Street NW, Washington, DC 2007, United States; Department of Emergency Medicine, the George Washington University, 900 23rd Street NW, Washington, DC 20007, United States
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Current Situation, Determinants, and Solutions to Drug Shortages in Shaanxi Province, China: A Qualitative Study. PLoS One 2016; 11:e0165183. [PMID: 27780218 PMCID: PMC5079602 DOI: 10.1371/journal.pone.0165183] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 10/08/2016] [Indexed: 11/22/2022] Open
Abstract
Objective Drug shortages were a complex global problem. The aim of this study was to analyze, characterize, and assess the drug shortages, and identify possible solutions in Shaanxi Province, western China. Methods A qualitative methodological approach was conducted during May–June 2015 and December 2015–January 2016. Semi-structured interviews were performed to gather information from representatives of hospital pharmacists, wholesalers, pharmaceutical producers, and local health authorities. Results Thirty participants took part in the study. Eight traditional Chinese medicines and 87 types of biologicals and chemicals were reported to be in short supply. Most were essential medicines. Five main determinants of drug shortages were detected: too low prices, too low market demands, Good Manufacturing Practice (GMP) issues, materials issues, and approval issues for imported drugs. Five different solutions were proposed by the participants: 1) let the market decide the drug price; 2) establish an information platform; 3) establish a reserve system; 4) enhance the communication among the three parties in the supply chain; and 5) improve hospital inventory management. Conclusions Western China was currently experiencing a serious drug shortage. Numerous reasons for the shortage were identified. Most drug shortages in China were currently because of “too low prices.” To solve this problem, all of the stakeholders, especially the government, needed to participate in managing the drug shortages.
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Iyengar S, Hedman L, Forte G, Hill S. Medicine shortages: a commentary on causes and mitigation strategies. BMC Med 2016; 14:124. [PMID: 27683105 PMCID: PMC5041339 DOI: 10.1186/s12916-016-0674-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
Shortages of medicines and vaccines have been reported in countries of all income levels in recent years. Shortages can result from one or multiple causes, including shortages of raw materials, manufacturing capacity problems, industry consolidation, marketing practices, and procurement and supply chain management. Existing approaches to mitigate shortages include advance notice systems managed through medicine regulatory authorities, special programmes that track medicines, and interventions to improve efficiency of the medicine supply chain. Redistribution of supplies at the national level can mitigate some shortages in the short term. International redistribution and exceptional regulatory approvals may be used in limited circumstances, with the understanding that such approaches are complex and may introduce cost and quality risks. If it is necessary to prioritise patients to receive a medicine that is in shortage, evidence-based practice should be used to ensure optimal allocation. Important steps in reducing medicine shortages and their impact include identifying medicines that are most at risk, developing reporting systems to share information on current and emerging shortages, and improving data from medicine supply chains.
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Affiliation(s)
- Swathi Iyengar
- World Health Organization, 20 27 Avenue Appia, Geneva, CH-1211, Switzerland
| | - Lisa Hedman
- World Health Organization, 20 27 Avenue Appia, Geneva, CH-1211, Switzerland
| | - Gilles Forte
- World Health Organization, 20 27 Avenue Appia, Geneva, CH-1211, Switzerland
| | - Suzanne Hill
- World Health Organization, 20 27 Avenue Appia, Geneva, CH-1211, Switzerland.
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The impact of drug shortages on patients with cardiovascular disease: causes, consequences, and a call to action. Am Heart J 2016; 175:130-41. [PMID: 27179732 DOI: 10.1016/j.ahj.2016.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 02/10/2016] [Indexed: 11/22/2022]
Abstract
Shortages of cardiovascular drugs have become increasingly common, representing an ongoing public health crisis. Given few therapeutic alternatives to many of the drugs in short supply, these shortages also pose a major challenge for cardiovascular care professionals. Although changes in the regulatory environment have led to some improvements in recent years, problems involving manufacturing processes remain the most common underlying cause. Because of the complex nature of drug shortages, sustainable solutions to prevent and mitigate them will require collaboration between regulatory agencies, drug manufacturers, and other key stakeholder groups. In this report, we describe the scope of the cardiovascular drug shortage crisis in the United States, including its underlying causes and the efforts currently being made to address it. Furthermore, we provide specific recommendations for how cardiovascular care professionals can be involved in efforts to limit the impact of drug shortages on patient care as well as policy changes aimed at preventing and mitigating them.
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Shank BR, Seung AH, Kinsman K, Newman MJ, Donehower RC, Burton B. Effects of the leucovorin shortage: Pilot study investigating cost, efficacy, and toxicity comparison of low fixed-dose versus body surface area-adjusted leucovorin dosing in patients with resectable colon or metastatic colorectal cancer. J Oncol Pharm Pract 2016; 23:163-172. [PMID: 26763004 DOI: 10.1177/1078155215624262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose As a result of the leucovorin shortage, we switched from BSA-adjusted to low fixed-dose leucovorin in patients with colon cancer receiving fluorouracil-containing therapy. Methods A retrospective, pilot study of adults receiving intravenous leucovorin as part of a fluorouracil-containing treatment was conducted including individuals with stage II or III colon or newly diagnosed metastatic colorectal cancer. One low fixed-dose (leucovorin 50 mg) patient was matched by the investigator to one BSA-adjusted (leucovorin 200-500 mg/m2/dose) patient on disease stage and age. The objectives were to compare cost of alternative dosing strategies as well as efficacy and adverse event rates. Only patients being treated in the first-line metastatic colorectal cancer setting were included in the efficacy analysis. Results Fifty-eight patients were included. Leucovorin cost was reduced by 7- to 14-fold, and we were able to conserve a total of 1580-3400 doses of leucovorin by changing to fixed-dose (estimated from 200 mg/m2 or 400 mg/m2 dosing strategies, respectively). No statistically significant differences in progression-free survival ( p = 0.254), overall survival ( p = 0.923), or complications resulted. Conclusion Our decision to reduce the dose of leucovorin allowed us to conserve supply and control cost. The small sample size did not allow us to detect differences in efficacy or adverse event rates, and thus a larger study would be required to confirm our findings that efficacy was not compromised nor adverse effects greater.
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Affiliation(s)
- Brandon R Shank
- 1 Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy H Seung
- 2 Physician Resource Management, Ann Arbor, MI
| | - Katharine Kinsman
- 3 Department of Pharmacy Services, The University of Washington Medical Center/Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Matthew J Newman
- 4 Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ross C Donehower
- 5 Division of Medical Oncology, Johns Hopkins Kimmel Cancer Center, Baltimore, MD, USA
| | - Bradley Burton
- 4 Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
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25
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Beck JC, Smith LD, Gordon BG, Garrett JR. An ethical framework for responding to drug shortages in pediatric oncology. Pediatr Blood Cancer 2015; 62:931-4. [PMID: 25732614 DOI: 10.1002/pbc.25461] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/16/2015] [Indexed: 12/15/2022]
Abstract
The frequency of drug shortages has increased considerably over the last decade. Important ethical issues arise whenever the supply of an effective drug is insufficient to meet demand. Using the ethical principles of beneficence, non-maleficence, and justice, institutions can guide prioritization of drug distribution before a shortage occurs to avoid unfair and unethical distribution of resources. This analysis will give a historical context for drug shortages, identify, and explore the central ethical concerns raised by drug shortages, and propose an ethical framework for addressing them in the context of pediatric oncology.
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Affiliation(s)
- Jill C Beck
- University of Nebraska Medical Center, Omaha, Nebraska
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Mazer-Amirshahi M, Hawley KL, Zocchi M, Fox E, Pines JM, Nelson LS. Drug shortages: Implications for medical toxicology. Clin Toxicol (Phila) 2015; 53:519-24. [PMID: 25951876 DOI: 10.3109/15563650.2015.1043441] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Drug shortages have significantly increased over the past decade. There are limited data describing how shortages impact medical toxicology of drugs. OBJECTIVE To characterize drug shortages affecting the management of poisoned patients. MATERIALS AND METHODS Drug shortage data from January 2001 to December 2013 were obtained from the University of Utah Drug Information Service. Shortage data for agents used to treat poisonings were analyzed. Information on drug type, formulation, reason for shortage, shortage duration, marketing, and whether the drug was available from a single source was collected. The availability of a substitute therapy and whether substitutes were in shortage during the study period were also investigated. RESULTS Of 1,751 shortages, 141 (8.1%) impacted drugs used to treat poisoned patients, and as of December 2013, 21 (14.9%) remained unresolved. New toxicology shortages increased steadily from the mid-2000s, reaching a high of 26 in 2011. Median shortage duration was 164 days (interquartile range: 76-434). Generic drugs were involved in 85.1% of shortages and 41.1% were single-source products. Parenteral formulations were often involved in shortages (89.4%). The most common medications in shortage were sedative/hypnotics (15.6%). An alternative agent was available for 121 (85.8%) drugs; however, 88 (72.7%) alternatives were also affected by shortages at some point during the study period. When present, the most common reasons reported were manufacturing delays (22.0%) and supply/demand issues (17.0%). Shortage reason was not reported for 48.2% of drugs. DISCUSSION Toxicology drug shortages are becoming increasingly prevalent, which can result in both suboptimal treatment and medication errors from using less familiar alternatives. CONCLUSION Drug shortages affected a substantial number of critical agents used in the management of poisoned patients. Shortages were often of long duration and for drugs without alternatives. Providers caring for poisoned patients should be aware of current shortages and implement mitigation strategies to safeguard patient care.
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Rosoff PM. Caring for the suffering: meeting the Ebola crisis responsibly. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:26-32. [PMID: 25856595 DOI: 10.1080/15265161.2015.1010995] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The current Ebola virus epidemic in Western Africa appears to be spiraling out of control. The worst-case projections suggested that the unchecked spread could result in almost 1.4 million cases by the end of January 2015 with a case fatality rate of at least 50%. The United States and European nations have begun to respond in earnest with promises of supplies, isolation beds, and trained health care personnel in an effort to contain the epidemic and care for the sick. However, there is neither a vaccine nor specific treatment for Ebola infection, and therapy is ideally centered on supportive care. I have previously argued that the provision of palliative care is obligatory during an overwhelming health catastrophe, notably pandemic influenza. Since affected Ebola patients have best outcomes with technologically advanced intensive care--resources in scarce supply in the area--I suggest that the only acceptable approach to large numbers of very sick, dying, and suffering Ebola patients who overwhelm the resources available to successfully manage them is effective palliative care. However, this could hasten death in this vulnerable population and hence, while ethically and medically justifiable, is not without social risk.
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Mazer-Amirshahi M, Pourmand A, Singer S, Pines JM, van den Anker J. Critical drug shortages: implications for emergency medicine. Acad Emerg Med 2014; 21:704-11. [PMID: 25039558 DOI: 10.1111/acem.12389] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 01/21/2014] [Accepted: 01/23/2014] [Indexed: 11/29/2022]
Abstract
Prescription drug shortages have become increasingly common and more severe over the past decade. In addition, reported shortages are longer in duration and have had a greater effect on patient care. Some of the causes of current drug shortages are multifactorial, including the consolidation of drug manufacturers, quality problems at production plants that restrict the supply of drugs, and a lack of financial incentives for manufacturers to produce certain products, particularly generic medications. Generic injectable medications are most commonly affected by shortages because the production process is complex and costly for these drugs, and profit margins are often smaller than for branded medications. Many commonly used emergency department (ED) generic injectables have been affected by shortages, including multiple resuscitation and critical care drugs. Several reports have shown that shortages can potentially have major effects on the quality of medical care, including medication errors, treatment delays, adverse outcomes, and increased health care costs. Currently, no published data exist outside of case reports that directly link ED-based drug shortages to overall patient safety events; however, there are several examples in the ED where first-line therapies for life-saving medications have been in short supply, and alternatives have higher rates of adverse events, narrower therapeutic indexes, or both. Aside from increasing notification about shortages, the U.S. Food and Drug Administration has little power to coerce manufacturers to produce medications during a shortage. Therefore, ED providers must learn to mitigate the effects of shortages locally, through active communication with pharmacy staff to identify safe and effective alternatives for commonly used medications when possible. Particularly given the effect on critical care medications, therapeutic alternatives should be clearly communicated to all staff so that providers have easy access to this information during resuscitations. This review focuses on the etiology of drug shortages, their effect on the ED, and potential solutions and mitigation strategies.
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Affiliation(s)
- Maryann Mazer-Amirshahi
- Department of Emergency Medicine; The George Washington University; Washington DC
- The Department of Clinical Pharmacology; Children's National Medical Center; Washington DC
| | - Ali Pourmand
- Department of Emergency Medicine; The George Washington University; Washington DC
| | - Steven Singer
- Department of Emergency Medicine; The George Washington University; Washington DC
| | - Jesse M. Pines
- Department of Emergency Medicine; The George Washington University; Washington DC
| | - John van den Anker
- The Department of Clinical Pharmacology; Children's National Medical Center; Washington DC
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Hantel A. A Protocol and Ethical Framework for the Distribution of Rationed Chemotherapy. THE JOURNAL OF CLINICAL ETHICS 2014. [DOI: 10.1086/jce201425203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Chaar BB. Medicine shortages: Implications for the Australian healthcare system. Australas Med J 2014; 7:161-3. [PMID: 24719652 DOI: 10.4066/amj.2014.1943] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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DeCamp M, Joffe S, Fernandez CV, Faden RR, Unguru Y. Chemotherapy drug shortages in pediatric oncology: a consensus statement. Pediatrics 2014; 133:e716-24. [PMID: 24488741 PMCID: PMC3934344 DOI: 10.1542/peds.2013-2946] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Shortages of essential drugs, including critical chemotherapy drugs, have become commonplace. Drug shortages cost significant time and financial resources, lead to adverse patient outcomes, delay clinical trials, and pose significant ethical challenges. Pediatric oncology is particularly susceptible to drug shortages, presenting an opportunity to examine these ethical issues and provide recommendations for preventing and alleviating shortages. We convened the Working Group on Chemotherapy Drug Shortages in Pediatric Oncology (WG) and developed consensus on the core ethical values and practical actions necessary for a coordinated response to the problem of shortages by institutions, agencies, and other stakeholders. The interdisciplinary and multiinstitutional WG included practicing pediatric hematologist-oncologists, nurses, hospital pharmacists, bioethicists, experts in emergency management and public policy, legal scholars, patient/family advocates, and leaders of relevant professional societies and organizations. The WG endorsed 2 core ethical values: maximizing the potential benefits of effective drugs and ensuring equitable access. From these, we developed 6 recommendations: (1) supporting national polices to prevent shortages, (2) optimizing use of drug supplies, (3) giving equal priority to evidence-based uses of drugs whether they occur within or outside clinical trials, (4) developing an improved clearinghouse for sharing drug shortage information, (5) exploring the sharing of drug supplies among institutions, and (6) developing proactive stakeholder engagement strategies to facilitate prevention and management of shortages. Each recommendation includes an ethical rationale, action items, and barriers that must be overcome. Implemented together, they provide a blueprint for effective and ethical management of drug shortages in pediatric oncology and beyond.
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Affiliation(s)
- Matthew DeCamp
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland;,Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Conrad V. Fernandez
- Division of Pediatric Hematology/Oncology, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia; and
| | - Ruth R. Faden
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
| | - Yoram Unguru
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland;,Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children’s Hospital at Sinai, Baltimore, Maryland
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Fox ER, Sweet BV, Jensen V. Drug shortages: a complex health care crisis. Mayo Clin Proc 2014; 89:361-73. [PMID: 24582195 DOI: 10.1016/j.mayocp.2013.11.014] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 12/15/2022]
Abstract
National tracking of drug shortages began in 2001. However, a significant increase in the number of shortages began in late 2009, with numbers reaching what many have termed crisis level. The typical drug in short supply is a generic product administered by injection. Common classes of drugs affected by shortages include anesthesia medications, antibiotics, pain medications, nutrition and electrolyte products, and chemotherapy agents. The economic and clinical effects of drug shortages are significant. The financial effect of drug shortages is estimated to be hundreds of millions of dollars annually for health systems across the United States. Clinically, patients have been harmed by the lack of drugs or inferior alternatives, resulting in more than 15 documented deaths. Drug shortages occur for a variety of reasons. Generic injectable drugs are particularly susceptible to drug shortages because there are few manufacturers of these products and all manufacturers are running at full capacity. In addition, some manufacturers have had production problems, resulting in poor quality product. Although many suppliers are working to upgrade facilities and add additional manufacturing lines, these activities take time. A number of stakeholder organizations have been involved in meetings to further determine the causes and effects of drug shortages. A new law was enacted in July 2012 that granted the Food and Drug Administration additional tools to address the drug shortage crisis. The future of drug shortages is unknown, but there are hopeful indications that quality improvements and additional capacity may decrease the number of drug shortages in the years to come.
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Affiliation(s)
- Erin R Fox
- University of Utah Hospitals and Clinics, Salt Lake City.
| | | | - Valerie Jensen
- Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
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Jagsi R, Spence R, Rathmell WK, Bradbury A, Peppercorn J, Grubbs S, Moy B. Ethical considerations for the clinical oncologist in an era of oncology drug shortages. Oncologist 2014; 19:186-92. [PMID: 24449096 DOI: 10.1634/theoncologist.2013-0301] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Shortages of injectable drugs affect many cancer patients and providers in the U.S. today. Scholars and policymakers have recently begun to devote increased attention to these issues, but only a few tangible resources exist to guide clinical oncologists in developing strategies for dealing with drug shortages on a recurring basis. This article discusses existing information from the scholarly literature, policy analyses, and other relevant sources and seeks to provide practical ethical guidance to the broad audience of oncology professionals who are increasingly confronted with such cases in their practice. We begin by providing a brief overview of the history, causes, and regulatory context of oncology drug shortages in the U.S., followed by a discussion of ethical frameworks that have been proposed in this setting. We conclude with practical recommendations for ethical professional behavior in these increasingly common and challenging situations.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA; American Society of Clinical Oncology, Alexandria, Virginia, USA; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; University of Pennsylvania, Philadelphia, Pennsylvania USA; Duke University, Durham, North Carolina, USA; Medical Oncology Hematology Consultants, Newark, Delaware, USA; Massachusetts General Hospital, Boston, Massachusetts, USA
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Valgus J, Singer EA, Berry SR, Rathmell WK. Ethical challenges: managing oncology drug shortages. J Oncol Pract 2013; 9:e21-3. [PMID: 23814521 DOI: 10.1200/jop.2012.000779] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This vignette highlights the ethical issues surrounding restricted access to oncology drugs caused by drug shortages. A review of selected literature and a framework for creating institutional guidelines for reacting to shortage is provided.
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Affiliation(s)
- John Valgus
- North Carolina Cancer Hospital; University of North Carolina Lineberger Cancer Center, Chapel Hill, NC, USA
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Allmark P, Tod AM. Can a nudge keep you warm? Using nudges to reduce excess winter deaths: insight from the Keeping Warm in Later Life Project (KWILLT). J Public Health (Oxf) 2013; 36:111-6. [PMID: 23873728 PMCID: PMC3935492 DOI: 10.1093/pubmed/fdt067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Nudges are interventions that aim to change people's behaviour through changing the environment in which they choose rather than appealing to their reasoning. Nudges have been proposed as of possible use in relation to health-related behaviour. However, nudges have been criticized as ethically dubious because they bypass peoples reasoning and (anyway) are of little help in relation to affecting ill-health that results from social determinants, such as poverty. Reducing the rate of excess winter deaths (EWDs) is a public health priority; however, EWD seems clearly to be socially determined such that nudges arguably have little role. This article defends two claims: (i) nudges could have a place in tackling even the heavily socially determined problem of EWD. We draw on evidence from an empirical study, the Keeping Warm in Later Life Project (KWILLT), to argue that in some cases the risk of cold is within the person’s control to some extent such that environmental modifications to influence behaviour such as nudges are possible. (ii) Some uses of behavioural insights in the form of nudges are acceptable, including some in the area of EWD. We suggest a question-based framework by which to judge the ethical acceptability of nudges.
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Affiliation(s)
- Peter Allmark
- Health and Social Care Research Centre, Sheffield Hallam University, 32 Collegiate Crescent, Sheffield S10 2BP, UK
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Landry MD, Goldstein M, Stokes E. Physiotherapy health services research (PHSR): the road 'that must now be taken'. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2012; 17:63-5. [PMID: 22674860 DOI: 10.1002/pri.1528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Greenbaum D. Patents and drug shortages: will the new congressional efforts save us from impending drug shortages? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:18-20. [PMID: 22220953 DOI: 10.1080/15265161.2011.635835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Bamford R, Brewer CD, Bucknell B, DeGrote H, Fabry L, Hammerlund MEM, Weisbrod BM. A paradoxical ethical framework for unpredictable drug shortages. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:16-18. [PMID: 22220952 DOI: 10.1080/15265161.2011.634958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Ozdemir V, Joly Y, Dove ES, Karalis A, Avard D, Knoppers BM. Are we asking the right ethics questions on drug shortages? Suggestions for a global and anticipatory ethics framework. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:13-15. [PMID: 22220951 DOI: 10.1080/15265161.2011.634952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Goodman A. The tensions and challenges of unpredictable drug shortages. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:20-22. [PMID: 22220954 DOI: 10.1080/15265161.2012.634667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Hurst SA. Interventions and persons. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2012; 12:10-11. [PMID: 22220949 DOI: 10.1080/15265161.2011.634954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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