Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England

[Recommendations for Reducing the Environmental Impact of Inhalers in Portugal: Consensus Document]

This consensus document addresses the reduction of the environmental impact of inhalers in Portugal. It was prepared by the Portuguese Council for Health and the Environment and the societies representing the specialties that account for these drugs' largest volume of prescriptions, namely the Portuguese Society of Pulmonology, the Portuguese Society of Allergology and Clinical Immunology, the Portuguese Society of Pediatrics, the Portuguese Society of Internal Medicine, the Portuguese Association of General and Family Medicine and also a patient association, the Respira Association. The document acknowledges the significant impact of pressurized metered-dose inhalers on greenhouse gas emissions and highlights the need to transition to more sustainable alternatives. The carbon footprint of pressurized metered-dose inhalers and dry powder inhalers in Portugal was calculated, and the level of awareness among prescribing physicians on this topic was also estimated. Finally, recommendations were developed to accelerate the reduction of the ecological footprint of inhalers.

Thoughtful prescription of inhaled medication has the potential to reduce inhaler-related greenhouse gas emissions by 85

INTRODUCTION

Both physicians and patients are increasingly aware of the environmental impacts of medication. The shift of treatment paradigm towards MART-treatment (Maintenance and Reliever Therapy) in asthma affects the treatment-related emissions. The carbon footprint of inhaled medication is also tied to the type of the device used. Today the most commonly used propellant-containing pressurised metered-dose inhalers (pMDIs) have a carbon footprint typically 20-40-fold higher than propellant-free dry powder inhalers (DPIs) and soft mist inhalers.

METHODS

We analysed the carbon footprint of inhaled medications in Europe using published life cycle analyses of marketed inhalers and comprehensive 2020 European sales data. In addition, we give an estimate on treatment-related emissions of different treatment regimens on Global Initiative for Asthma (GINA) step 2.

RESULTS

There is potential to reduce the carbon footprint of inhaled medications by 85% if DPIs are preferred over pMDIs. Emissions from pMDIs in the EU were estimated to be 4.0 megatons of carbon dioxide equivalent (MT CO2e) and this could be reduced to 0.6 MT CO2e if DPIs were used instead. In the treatment of moderate asthma with DPI, an as-needed combination of inhaled corticosteroid and long-acting beta-agonist in a single inhaler had a substantially lower annual carbon footprint (0.8 kg CO2e) than the more traditional maintenance therapy with an inhaled corticosteroid alone with as-needed short-acting beta-agonist (2.9 kg CO2e).

DISCUSSION

There has been an urgent call for healthcare to reduce its carbon footprint for appropriate patients with asthma and chronic obstructive pulmonary disease (COPD), changing to non-propellant inhalers can reduce the carbon footprint of their treatment by almost 20-fold.

Climate change from the Asia-Pacific perspective: What an allergist needs to know and do

Allergic diseases such as asthma, atopic dermatitis, and food allergies are a burgeoning health challenge in the Asia-Pacific region. Compounding this, the region has become increasingly susceptible to the impacts of climate change. The region has weathered extreme precipitation, intense heat waves, and dust storms over the recent decades. While the effects of environmental and genetic factors on allergic diseases are well understood, prevailing gaps in understanding the complex interactions between climate change and these factors remain. We aim to provide insights into the various pathways by which climate change influences allergic diseases in the Asia-Pacific population. We outline practical steps that allergists can take to reduce the carbon footprint of their practice on both a systemic and patient-specific level. We recommend that allergists optimize disease control to reduce the resources required for each patient's care, which contributes to reducing greenhouse gas emissions. We encourage the responsible prescription of metered dose inhalers by promoting the switch to dry powder inhalers for certain patients, at each clinician's discretion. We also recommend the utilization of virtual consultations to reduce patient travel while ensuring that evidence-based guidelines for rational allergy management are closely adhered to. Finally, eliminating unnecessary testing and medications will also reduce greenhouse gas emissions in many areas of medical care.

The carbon footprint of as-needed budesonide/formoterol in mild asthma: a post hoc analysis

INTRODUCTION

The use of pressurised metered-dose inhalers (pMDIs) and asthma exacerbations necessitating healthcare reviews contribute substantially to the global carbon footprint of healthcare. It is possible that a reduction in carbon footprint could be achieved by switching patients with mild asthma from salbutamol pMDI reliever-based therapy to inhaled corticosteroid-formoterol dry powder inhaler (DPI) reliever therapy, as recommended by the Global Initiative for Asthma.

METHODS

This post hoc analysis included all 668 adult participants in the Novel START trial, who were randomised 1:1:1 to treatment with as-needed budesonide/formoterol DPI, as-needed salbutamol pMDI or maintenance budesonide DPI plus as-needed salbutamol pMDI. The primary outcome was carbon footprint of asthma management, expressed as kilograms of carbon dioxide equivalent emissions (kgCO2e) per person-year. Secondary outcomes explored the effect of baseline symptom control and adherence (maintenance budesonide DPI arm only) on carbon footprint.

RESULTS

As-needed budesonide/formoterol DPI was associated with 95.8% and 93.6% lower carbon footprint compared with as-needed salbutamol pMDI (least-squares mean 1.1 versus 26.2 kgCO2e; difference -25.0, 95% CI -29.7 to -20.4; p<0.001) and maintenance budesonide DPI plus as-needed salbutamol pMDI (least-squares mean 1.1 versus 17.3 kgCO2e; difference -16.2, 95% CI -20.9 to -11.6; p<0.001), respectively. There was no statistically significant evidence that treatment differences in carbon footprint depended on baseline symptom control or adherence in the maintenance budesonide DPI arm.

CONCLUSIONS

The as-needed budesonide/formoterol DPI treatment option was associated with a markedly lower carbon footprint than as-needed salbutamol pMDI and maintenance budesonide DPI plus as-needed salbutamol pMDI.

Environmental, healthcare and societal impacts of asthma: a UK model-based assessment

Background

This study aimed to assess the broader environmental, healthcare and societal impacts across the entire asthma pathway from diagnosis to treatment in the UK.

Methods

A comprehensive cost-of-illness framework was developed considering the effects of the full asthma patient pathway, including greenhouse gas emissions generated from inhalers, National Health Service (NHS) costs, health-related quality of life and productivity losses. The model was based on published literature and clinical expert opinion to accurately estimate, in monetary terms, the net present value of the asthma pathway impacts for 2022-2031.

Results

The estimated net present value of the environmental, healthcare and societal impacts of the asthma pathway was £47 billion over the 2022-2031 period in the UK. Loss of disease control was a key contributor to higher greenhouse gas emissions and NHS costs. In 2022, a patient with non-severe uncontrolled asthma was estimated to incur 22% higher NHS costs than a patient with controlled asthma, while generating 0.1 t more of CO2 equivalent emissions. In the same year, the total direct impacts per patient with severe asthma were four times higher than for a patient with non-severe controlled asthma, with 0.54 t CO2 equivalent of greenhouse gas emissions. Moreover, as much as 77% of the total economic impact was driven by worsening health-related quality of life and productivity impacts occurring when patients' symptoms were uncontrolled.

Conclusions

Uncontrolled asthma significantly impacts patients, the economy and the environment in the UK. Our results emphasise the need for a holistic approach in controlling asthma and should be carefully considered when developing policies to mitigate the overall burden of the disease.

Methods to Include Environmental Impacts in Health Economic Evaluations and Health Technology Assessments: A Scoping Review

OBJECTIVES

The environmental impacts of healthcare are important factors that should be considered during health technology assessments. This study aims to summarize the evidence that exists about methods to include environmental impacts in health economic evaluations and health technology assessments.

METHODS

We identified records for screening using an existing scoping review and a systematic search of academic databases and gray literature up to September 2023. We screened the identified records for eligibility and extracted data using a narrative synthesis approach. The review was conducted following the JBI Manual for Evidence Synthesis and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews checklist.

RESULTS

We identified 2898 records and assessed the full text of 114, of which 54 were included in this review. Ten methods were identified to include environmental impacts in health economic evaluations and health technology assessments. Methods included converting environmental impacts to dollars or disability-adjusted life years and including them in a cost-effectiveness, cost-utility, or cost-benefit analysis, calculating an incremental carbon footprint effectiveness ratio or incremental carbon footprint cost ratio, incorporating impacts as one criteria of a multi-criteria decision analysis, and freely considering impacts during health technology assessment deliberation processes.

CONCLUSIONS

Methods to include environmental impacts in health economic evaluations and health technology assessments exist but have not been tested for widespread use by health technology assessment agencies. Further research and implementation work is needed to determine which method can best aid decision makers to choose low environmental impact healthcare interventions.

The role of the health sector in tackling climate change: A narrative review

Climate change is one of the largest threats to population health and has already affected the ecosystem, food production, and health and wellbeing of populations all over the world. The healthcare sector is responsible for around 5 % of greenhouse gas emissions worldwide and can play a key role in reducing global warming. This narrative review summarized the information on the role of healthcare systems in addressing climate change and strategies for reducing its negative impact to illustrate different types of actions that can support the ecological transformation of healthcare systems to help reaching sustainable development goals. A wide range of green interventions are shown to be effective to reduce the carbon footprint of healthcare and can have a meaningful impact if implemented systematically. However, these would not suffice unless accompanied by systemic mitigation strategies altering how healthcare is provided and consumed. Sustainable healthcare strategies such as reducing waste and low-value care will have direct benefits for the environment while improving economic and health outcomes. The healthcare sector has a unique opportunity to leverage its position and resources to provide a comprehensive strategy for fighting climate change and improving population health and the environment on which it depends.

Challenges to decarbonizing medication prescribing and use practices: A call to action

Climate change undeniably impacts the social and environmental determinants of one's health. The healthcare sector, encompassing medications and the pharmaceutical industry supply chain, accounts for a significant portion of global health care contributions to greenhouse gas (GHG) and waste production. Despite these realities, healthcare professionals - physicians, pharmacists, nurses, and others - may be unaware of GHG emissions and the long-term environmental effects of the medications they prescribe, dispense, and administer daily. In this commentary, we identify existing challenges and explore potential strategies to recognize and reduce the climate change impacts associated with medication use.

Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study

BACKGROUND

Poorly controlled asthma is associated with increased morbidity and healthcare resource utilisation (HCRU). Therefore, to quantify the environmental impact of asthma care, this retrospective, cohort, healthCARe-Based envirONmental cost of treatment (CARBON) study estimated greenhouse gas (GHG) emissions in the UK associated with the management of well-controlled versus poorly controlled asthma.

METHODS

Patients with current asthma (aged ≥12 years) registered with the Clinical Practice Research Datalink (2008‒2019) were included. GHG emissions, measured as carbon dioxide equivalent (CO2e), were estimated for asthma-related medication use, HCRU and exacerbations during follow-up of patients with asthma classified at baseline as well-controlled (<3 short-acting β2-agonist (SABA) canisters/year and no exacerbations) or poorly controlled (≥3 SABA canisters/year or ≥1 exacerbation). Excess GHG emissions due to suboptimal asthma control included ≥3 SABA canister prescriptions/year, exacerbations and any general practitioner and outpatient visits within 10 days of hospitalisation or an emergency department visit.

RESULTS

Of the 236 506 patients analysed, 47.3% had poorly controlled asthma at baseline. Scaled to the national level, the overall carbon footprint of asthma care in the UK was 750 540 tonnes CO2e/year, with poorly controlled asthma contributing excess GHG emissions of 303 874 tonnes CO2e/year, which is equivalent to emissions from >124 000 houses in the UK. Poorly controlled versus well-controlled asthma generated 3.1-fold higher overall and 8.1-fold higher excess per capita carbon footprint, largely SABA-induced, with smaller contributions from HCRU.

CONCLUSIONS

These findings suggest that addressing the high burden of poorly controlled asthma, including curbing high SABA use and its associated risk of exacerbations, may significantly alleviate asthma care-related carbon emissions.

Cradle-to-Grave Emission Reduction for Easyhaler Dry Powder Inhaler Product Portfolio

INTRODUCTION

There is increasing pressure to prefer propellant-free inhaler devices over pressurized metered-dose inhalers (pMDI) due to environmental considerations. In this work, we present results from three life cycle assessments (LCAs) on Easyhaler dry powder inhaler product portfolio and assess the changes in environmental impact and carbon footprint (CF) of the products over time.

METHODS

Three cradle-to-grave LCAs were conducted in 2019, 2021, and 2023. The 2019 assessment covered four products while 2021 and 2023 assessments included all six products in the portfolio. LCA for the protective cover sometimes used with Easyhaler was conducted in 2023. In addition to CF, nine other environmental impact categories were assessed to ensure that no burden shifting occurs.

RESULTS

During the study period, the non-weighted average CF of the Easyhaler decreased by 11.2%. For individual products, the decrease varied from 5.0 to 6.8% between the assessments. In the latest assessment, the average CF of Easyhaler was 547 gCO2e with a range of 452-617 gCO2e. The LCA of the protective cover was assessed for the first time in 2023 and had a CF of 66 gCO2e.

CONCLUSIONS

Our results show that the climate impact of pharmaceutical products can be reduced without making changes to the product itself. The CF of Easyhaler products is in agreement with the lower end of the CF range previously reported for dry powder inhalers. Climate impact from the protective cover was one-tenth compared to the climate impact from the product itself.

Greenhouse Gas Emissions from Respiratory Treatments: Results from the SABA CARBON International Study

INTRODUCTION

Healthcare systems are looking to reduce their carbon impact. Short-acting β2-agonist (SABA) overuse (≥ 3 canisters/year) is common in asthma and linked to poor outcomes; however, its environmental impact remains unknown. As part of the CARBON programme, this study retrospectively quantified the carbon footprint of SABA and controller inhalers across all respiratory indications and SABA overuse in asthma in lower-middle-income countries (LMICs), upper-middle-income countries and high-income countries across Africa, Asia Pacific, Latin America and the Middle East.

METHODS

Two data sources were utilised to evaluate the carbon contribution of inhalers to respiratory care. To quantify greenhouse gas (GHG) emissions associated with total inhaler use across all respiratory indications, inhaler sales data were obtained from IQVIA MIDAS® (Q4/2018-Q3/2019) and compared by dose to prevent confounding from differences in canister actuation counts. GHG emissions associated with SABA overuse in asthma were evaluated using prescription and self-reported over-the-counter purchase data from the SABA use IN Asthma (SABINA) III study (2019-2020). Inhaler-related GHG emissions were quantified using published data and product life cycle assessments.

RESULTS

SABA accounted for > 50% of total inhaler use and inhaler-related emissions in most countries analysed. The total SABA-related emissions were estimated at 2.7 million tonnes carbon dioxide equivalents, accounting for 70% of total inhaler-related emissions. Among the countries, regions and economies analysed, per capita SABA use and associated emissions were higher in Australia, the Middle East and high-income countries. Most SABA prescriptions for asthma (> 90%) were given to patients already overusing SABA.

CONCLUSIONS

Globally, SABA use/overuse is widespread and is the greatest contributor to the carbon footprint of respiratory treatment, regardless of the economic status of countries. Implementing evidence-based treatment recommendations, personalising treatment and reducing healthcare inequities, especially in LMICs, may improve disease control and patient outcomes, thereby reducing SABA overuse and associated carbon emissions beyond SABA use alone.

UK health researchers' considerations of the environmental impacts of their data-intensive practices and its relevance to health inequities

BACKGROUND

The health sector aims to improve health outcomes and access to healthcare. At the same time, the sector relies on unsustainable environmental practices that are increasingly recognised to be catastrophic threats to human health and health inequities. As such, a moral imperative exists for the sector to address these practices. While strides are currently underway to mitigate the environmental impacts of healthcare, less is known about how health researchers are addressing these issues, if at all.

METHODS

This paper uses an interview methodology to explore the attitudes of UK health researchers using data-intensive methodologies about the adverse environmental impacts of their practices, and how they view the importance of these considerations within wider health goals.

RESULTS

Interviews with 26 researchers showed that participants wanted to address the environmental and related health harms associated with their research and they reflected on how they could do so in alignment with their own research goals. However, when tensions emerged, their own research was prioritised. This was related to their own desires as researchers and driven by the broader socio-political context of their research endeavours.

CONCLUSION

To help mitigate the environmental and health harms associated with data-intensive health research, the socio-political context of research culture must be addressed.

Estimating the national carbon footprint of inhalers in healthcare

BACKGROUND

Metered dose inhalers (MDIs) contain greenhouse gases which have a disproportionate effect on the carbon footprint of healthcare. There are more environmentally friendly alternatives such as dry powder inhalers (DPIs) or soft mist inhalers (SMIs).

AIMS

This study aims to approximate the carbon footprint of inhalers dispensed in Irish healthcare.

METHODS

Health Market Research data was used to examine the number of inhalers sold in Ireland in 2019 via dispensing data from pharmacy IT systems. The carbon footprint per inhaler data was then used to calculate the total carbon footprint of each drug class, and an estimate for the total carbon footprint of inhalers sold in Ireland was generated.

RESULTS

4,427,287 inhalers were dispensed in Ireland in 2019 of which 2,608,433 (59%) were MDIs and 1,818,854 were DPIs/SMIs (41.1%). The total carbon equivalent of these inhalers was estimated to be 54,765 tCO2. MDIs account for 59% of inhaler units dispensed but account for 97% of inhaler-related carbon emissions.

CONCLUSION

Targeting inhaler prescribing offers the potential to significantly improve the carbon footprint of Irish healthcare. Establishing the current carbon footprint of the inhalers that are prescribed, dispensed, and disposed in Ireland is a necessary baseline to inform moving towards a net zero health service.

Air Pollution and Lung Cancer: A Review by International Association for the Study of Lung Cancer Early Detection and Screening Committee

INTRODUCTION

The second leading cause of lung cancer is air pollution. Air pollution and smoking are synergistic. Air pollution can worsen lung cancer survival.

METHODS

The Early Detection and Screening Committee of the International Association for the Study of Lung Cancer formed a working group to better understand issues in air pollution and lung cancer. These included identification of air pollutants, their measurement, and proposed mechanisms of carcinogenesis. The burden of disease and the underlying epidemiologic evidence linking air pollution to lung cancer in individuals who never and ever smoked were summarized to quantify the problem, assess risk prediction models, and develop recommended actions.

RESULTS

The number of estimated attributable lung cancer deaths has increased by nearly 30% since 2007 as smoking has decreased and air pollution has increased. In 2013, the International Agency for Research on Cancer classified outdoor air pollution and particulate matter with aerodynamic diameter less than 2.5 microns in outdoor air pollution as carcinogenic to humans (International Agency for Research on Cancer group 1) and as a cause of lung cancer. Lung cancer risk models reviewed do not include air pollution. Estimation of cumulative exposure to air pollution exposure is complex which poses major challenges with accurately collecting long-term exposure to ambient air pollution for incorporation into risk prediction models in clinical practice.

CONCLUSIONS

Worldwide air pollution levels vary widely, and the exposed populations also differ. Advocacy to lower sources of exposure is important. Health care can lower its environmental footprint, becoming more sustainable and resilient. The International Association for the Study of Lung Cancer community can engage broadly on this topic.

Identifying Environmental Impact Factors for Sustainable Healthcare: A Scoping Review

The healthcare industry has a substantial impact on the environment through its use of resources, waste generation and pollution. To manage and reduce its impact, it is essential to measure the pressures of healthcare activities on the environment. However, research on factors that can support these measurement activities is unbalanced and scattered. In order to address this issue, a scoping review was conducted with the aims of (i) identifying and organizing factors that have been used to measure environmental impact in healthcare practice and (ii) analyzing the overview of impact factors in order to identify research gaps. The review identified 46 eligible articles publishing 360 impact factors from original research in PubMed and EBSCO databases. These factors related to a variety of healthcare settings, including mental healthcare, renal service, primary healthcare, hospitals and national healthcare. Environmental impacts of healthcare were characterized by a variety of factors based on three key dimensions: the healthcare setting involved, the measurement component or scope, and the type of environmental pressure. The Healthcare Environmental Impact Factor (HEIF) scheme resulting from this study can be used as a tool for selecting measurable indicators to be applied in quality management and as a starting point for further research. Future studies could focus on standardizing impact factors to allow for cross-organization comparisons and on expanding the HEIF scheme by addressing gaps.

Translated impact on carbon footprint from choice of inhaled therapy: a Danish scenario

With increasing climate change, all sources of greenhouse gases must be considered. Hydrofluorocarbon (HFC) propellants are used in all pressurised metered dose inhalers (pMDIs) and, although they are not as ozone-depleting as the earlier chlorofluorocarbons (CFCs), they are potent greenhouse gases and there is a general ask for reduction in their use [1]. In this respect, respiratory doctors indirectly affect climate change through their prescription patterns [2], something only few are aware of, and which may be difficult to translate and explain to patients. To illustrate the impact of switching from pMDIs to dry powder inhalers (dMDIs) we wanted to compare climate impact of inhaler switching to climate costs of well-known items and activities in Denmark, a country with a population of 6 million inhabitants.

Carbon footprint of MDIs can be translated into measures that are intuitive to both patients and health professionals https://bit.ly/45iVbHC

Reductions in inhaler greenhouse gas emissions by addressing care gaps in asthma and chronic obstructive pulmonary disease: an analysis

INTRODUCTION

Climate change from greenhouse gas (GHG) emissions represents one of the greatest public health threats of our time. Inhalers (and particularly metred-dose inhalers (MDIs)) used for asthma and chronic obstructive pulmonary disease (COPD), constitute an important source of GHGs. In this analysis, we aimed to estimate the carbon footprint impact of improving three distinct aspects of respiratory care that drive avoidable inhaler use in Canada.

METHODS

We used published data to estimate the prevalence of misdiagnosed disease, existing inhaler use patterns, medication class distributions, inhaler type distributions and GHGs associated with inhaler actuations, to quantify annual GHG emissions in Canada: (1) attributable to asthma and COPD misdiagnosis; (2) attributable to overuse of rescue inhalers due to suboptimally controlled symptoms; and (3) avoidable by switching 25% of patients with existing asthma and COPD to an otherwise comparable therapeutic option with a lower GHG footprint.

RESULTS

We identified the following avoidable annual GHG emissions: (1) ~49 100 GHG metric tons (MTs) due to misdiagnosed disease; (2) ~143 000 GHG MTs due to suboptimal symptom control; and (3) ~262 100 GHG MTs due to preferential prescription of strategies featuring MDIs over lower-GHG-emitting options (when 25% of patients are switched to lower GHG alternatives). Combined, the GHG emission reductions from bridging these gaps would be the equivalent to taking ~101 100 vehicles off the roads each year.

CONCLUSIONS

Our analysis shows that the carbon savings from addressing misdiagnosis and suboptimal disease control are comparable to those achievable by switching one in four patients to lower GHG-emitting therapeutic strategies. Behaviour change strategies required to achieve and sustain delivery of evidence-based real-world care are complex, but the added identified incentive of carbon footprint reduction may in itself prove to be a powerful motivator for change among providers and patients. This additional benefit can be leveraged in future behaviour change interventions.

The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures

PURPOSE

To report the contribution to carbon dioxide equivalent mass [CO2EM] of various types of VR surgery performed across three tertiary referral centres, according to their indication and fluorinated gas used. We secondarily reported on the difference in tamponade choice, and CO2EM between the different centres.

MATERIALS

Retrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital and Birmingham and Midland Eye Centre, and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire.

RESULTS

Across 4877 procedures, the use of fluorinated gases produced 284.2 tonnes (71.2 tonnes annually) CO2EM; an annual consumption of 30,330 l of gasoline. Rhegmatogenous-retinal-detachment (RRD) and macular hole repair had the highest CO2EM by indication, accounting for 191.4 tonnes CO2EM (67.3%) and 28.6 tonnes CO2EM (10.1%); a mean 60.0 kg and 32.0 kg of CO2EM produced per surgery respectively. The use of fluorinated gases and their respective CO2EM contributions were significantly different across all three centres (p < 0.001) for all indications. SF6, despite being used in 1883 procedures (38.6%), contributed to 195.5 tonnes CO2EM (68.8%). Relative to C2F6, procedures using C3F8 and SF6 produced 1.9 and 4.4 times more CO2EM.

CONCLUSION

We demonstrated that SF6 causes significantly higher carbon emissions relative to C2F6 and C3F8 with RRD and macular hole repair having the greatest environmental impact. We also reported large variations between different large VR centres in fluorinated gas use, and therefore in carbon emission contributions depending on indications for surgery. Evidence-based protocols might help in making VR surgery "greener".

Inclusion of Environmental Spillovers in Applied Economic Evaluations of Healthcare Products

OBJECTIVES

Climate change and environmental factors have an impact on human health and the ecosystem. The healthcare sector is responsible for substantial environmental pollution. Most healthcare systems rely on economic evaluation to select efficient alternatives. Nevertheless, environmental spillovers of healthcare treatments are rarely considered whether it is from a cost or a health perspective. The objective of this article is to identify economic evaluations of healthcare products and guidelines that have included any environmental dimensions.

METHODS

Electronic searches of 3 literature databases (PubMed, Scopus, and EMBASE) and official health agencies guidelines were conducted. Documents were considered eligible if they assessed the environmental spillovers within the economic evaluation of a healthcare product or provided any recommendations on the inclusion of environmental spillovers in the health technology assessment process.

RESULTS

From the 3878 records identified, 62 documents were deemed eligible and 18 were published in 2021 and 2022. The environmental spillovers considered were carbon dioxide (CO₂) emissions, water or energy consumption, and waste disposal. The environmental spillovers were mainly assessed using the lifecycle assessment (LCA) approach while the economic analysis was mostly limited to costs. Only 9 documents, including the guidelines of 2 health agencies presented theoretical and practical ways to include environmental spillovers into the decision-making process.

CONCLUSIONS

There is a clear lack of methods on whether environmental spillovers should be included in health economic evaluation and how this should be done. If healthcare systems want to reduce their environment footprint, the development of methodology which integrates environmental dimensions in health technology assessment will be key.

Disposal Methods of Used Pressurized Metered Dose Inhalers and Spacers by Families of Children With Asthma

The choice of disposal method of used pressurized metered dose inhalers and spacers by families of children with asthma were evaluated by a questionnaire. The disposal methods used for inhalers and spacers by the 120 children enrolled included giving to plastic/metal waste collectors (28.3% and 33.3%), burning (15.8% and 8.3%), general waste (9.2% and 6%), burial (5.8% and 2.4%), hospital waste (1.7% and 1.2%), rivers (0.8% and 1.2%) and open dumping (0.8% and 0%), respectively. Further, 37.5% of inhalers and 47.6% of spacers were awaiting disposal after use, and were stored at home.

Main Challenges of Incorporating Environmental Impacts in the Economic Evaluation of Health Technology Assessment: A Scoping Review

Health technology assessment (HTA) provides evidence-based information on healthcare technology to support decision making in many countries. Environmental impact is a relevant dimension of a health technology's value, but it has been poorly addressed in HTA processes in spite of the commitment that the health sector must have to contribute to mitigating the effects of climate change. This study aims to identify the state of the art and challenges for quantifying environmental impacts that could be incorporated into the economic evaluation (EE) of HTA. We performed a scoping review that included 22 articles grouped into four types of contribution: (1) concepts to draw up a theoretical framework, (2) HTA reports, (3) parameter designs or suitable indicators, and (4) economic or budgetary impact assessments. This review shows that evaluation of the environmental impact of HTAs is still very incipient. Small steps are being taken in EE, such as carbon footprint estimations from a life-cycle approach of technologies and the entire care pathway.

Temporal and geographical variation in low carbon inhaler dispensing in England, 2016 to 2021: an ecological study

OBJECTIVES

In 2019-2020, four national recommendations were published in the United Kingdom to encourage use of low carbon inhalers. This study aimed to investigate whether these were associated with a change in primary care dispensing in England and to explore associations between geographical variation and clinical commissioning group (CCG) characteristics.

DESIGN

Ecological study using aggregated publicly available data.

SETTING

All CCGs in England (March 2016 to February 2021).

PARTICIPANTS

not applicable.

MAIN OUTCOME MEASURES

Percentage of low carbon inhalers dispensed.

RESULTS

The percentage of low carbon inhalers dispensed was 26.3% in 2020-2021 (of 8.8 million inhalers). This decreased over the study period for short-acting beta-agonist (SABA), inhaled corticosteroid (ICS) and ICS+long-acting beta-agonist (LABA) inhalers. The same trend was seen for LABA and ICS+LABA+long-acting muscarinic antagonist inhalers from 2019. The SABA and ICS classes were less often dispensed as low carbon inhalers (⁓6% versus 35-45%). Interrupted time series analyses found slight increases in low carbon inhaler percentage in the SABA, LABA and ICS classes after April 2019, which were soon erased by the long-term trend. There was also geographical variation, with the north-west, Birmingham and London consistently dispensing more low carbon inhalers. The presence of advice on climate change in CCG formularies/guidelines, the prevalence of asthma and population age profile were associated with significant variation in low carbon inhaler percentage for some classes.

CONCLUSIONS

The percentage of low carbon inhalers dispensed in England remains low and continues to decrease. Greater use of low carbon inhalers is achievable, but is more likely with locally implemented initiatives.

Barriers to green inhaler prescribing: ethical issues in environmentally sustainable clinical practice

The National Health Service (NHS) was the first healthcare system globally to declare ambitions to become net carbon zero. To achieve this, a shift away from metered-dose inhalers which contain powerful greenhouse gases is necessary. Many patients can use dry powder inhalers which do not contain greenhouse gases and are equally effective at managing respiratory disease. This paper discusses the ethical issues that arise as the NHS attempts to mitigate climate change. Two ethical issues that pose a barrier to moving away from metered-dose inhalers are considered: patients who decline an inhaler with a smaller carbon footprint and increased cost. I argue that while a patient is not morally justified in refusing a more environmentally sustainable inhaler due to the expected harms, a doctor may still prescribe a metered-dose inhaler if they believe that switching without consent might undermine trust or substantially worsen the patient's health. Turning to cost, I argue that the imperative to combat climate change means the NHS should accept small increased financial costs for lower carbon inhalers, even though this provides no additional direct benefit for the patient. I then go on to consider the implications of the preceding analysis for policy and practice. I argue for a policy that minimises the impact of inhalers on the climate by advocating for a principle of environmental prescribing and explore decision-making in practice. While the arguments here pertain primarily to inhalers, the discussion has broader implications for debates around healthcare's responsibility to be environmentally sustainable.

Environmental impact of inhaler devices on respiratory care: a narrative review

Climate change is a huge and present threat to human health. This article aims to deepen the knowledge about the environmental impact of inhaler devices on their carbon footprint for patients and health professionals, providing information that allows a better choice of the type of device to be prescribed for the treatment of asthma and COPD. This narrative and nonsystematic review was carried out by searching databases (PubMed, Google Scholar, SciELO, and EMBASE) for articles published between 2017 and 2022, written in Portuguese or in English, using the search words "inhalation device" OR "environmental." The review showed that global warming cannot be addressed by focusing only on inhaler devices. However, the devices that we use to treat respiratory diseases such as asthma and COPD, which are diseases that are aggravated by climate change, are also causing that change. Therefore, health professionals, patient organizations, and industries should take a lead in health policies to offer affordable alternatives to inhalers containing hydrofluoroalkane.

Dry powder inhalation, part 2: the present and future

INTRODUCTION

The manufacture of modern dry powder inhalers (DPIs), starting with the Spinhaler (Fisons) in 1967, was only possible thanks to a series of technological developments in the 20^th century, of which many started first around 1950. Not until then, it became possible to design and develop effective, cheap and mass-produced DPIs. The link between these technological developments and DPI development has never been presented and discussed before in reviews about the past and present of DPI technology.

AREAS COVERED

The diversity of currently used DPIs with single dose, multiple-unit dose and multi-dose DPIs is discussed, including the benefits and drawbacks of this diversity for correct use and the efficacy of the therapy. No specific databases or search engines otherwise than PubMed and Google have been used.

EXPERT OPINION

Considering the relatively poor efficacy regarding lung deposition of currently used DPIs, the high rates of incorrect inhaler use and inhalation errors and the poor adherence to the therapy with inhalers, much effort must be put in improving these shortcomings for future DPI designs. Delivered fine particle doses must be increased, correct inhaler handling must become more intuitive and simpler to perform, and the use of multiple inhalers must be avoided.

Self-sealing MEMS spray-nozzles to prevent bacterial contamination of portable inhalers for aqueous drug delivery

Pulmonary drug delivery by portable inhalers is the gold standard in lung disease therapy. An increasing focus on environmentally friendly inhalation currently spurs the development of propellant-free devices. However, the absence of propellants in the drug creates a need for suitable sealing systems that can ensure the pathogenic safety of devices. Traditionally, liquid drug inhalers incorporate a spray nozzle and a separate check valve. Here we show a fully integrated MEMS-based spray system for aqueous drug solutions and demonstrate its bacterial safety. The device comprises a thin silicon membrane with spray orifices, which self-seal against a compliant parylene valve seat underneath. This sealing system prevents bacterial ingrowth in its default closed state, while actuation lifts the membrane from the valve seat upon pressurization and sprays an inhalable aerosol from the nozzles. To seal against bacterial contamination effectively, we found that a contact force between the valve seat and the membrane (featuring the spray nozzles) is needed. In our testing, both self-sealing and an otherwise identical unvalved version of the spray chip can be bacterially safe in continued use when thoroughly cleaned of excess fluids and subjected to low bacterial loads for brief periods. However, when directly exposed to \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$10^{7}$$\end{document}107 CFU/ml of our test organism Citrobacter rodentium for 24 h, unvalved systems become contaminated in nearly 90% of cases. In contrast, self-sealing spray chips reduced contamination probability by 70%. This development may enable preservative-free drug formulations in portable inhalers that use propellant-free aqueous drug solutions.

Improving the environmental sustainability of paediatric care

Accelerated global warming is directly related to greenhouse gas (GHG) emissions. In order to achieve international and national set targets on reducing GHG emissions, paediatricians should aim to decrease GHG emissions associated with paediatric care, when this is not in conflict with patient outcomes. In this article, we review literature on practical ways to encourage environmentally sustainable paediatric care and identify areas where more evidence is required. Finally, we introduce readers to the principles of sustainable healthcare which may be used to help guide further efforts to reduce the environmental impact of paediatric care.

Development of excipients free inhalable co-spray-dried tobramycin and diclofenac formulations for cystic fibrosis using two and three fluid nozzles

This study aims to investigate the effect of physicochemical properties and aerosol performance of two (2FN) and three-fluid nozzles (3FN) on the inhalable co-formulation of tobramycin and diclofenac dry powders. Combination formulations of tobramycin and diclofenac at 2:1 and 4:1 w/w ratios were prepared at a laboratory scale using a spray dryer in conjunction with a 2FN or 3FN. Powder size, morphology, solid-state characteristics, and aerodynamic and dissolution properties were characterised. The nozzle types and the formulation composition influenced the yield, particle size, solid-state properties, aerosolization behaviour and dissolution of the co-spray dried formulations. In particular, using the 2FN the co-spray dried formulation of tobramycin and diclofenac at 2:1 w/w showed smaller particle size (D50, 3.01 ± 0.06 μm), high fine particle fractions (FPF) (61.1 ± 3.6% for tobramycin and 65.92 ± 3 for diclofenac) and faster dissolution with approx. 70% diclofenac released within 3 h and approx. 90% tobramycin was released within 45 min. However, the 3FN for the co-spray dried formulation of tobramycin and diclofenac at a 2:1 w/w ratio showed a larger particle size (D50, 3.42 ± 0.02 μm), lower FPF (40.6 ± 3.4% for tobramycin and 36.9 ± 0.84 for diclofenac) and comparative slower dissolution with approx. 60% diclofenac was released within 3 h and 80% tobramycin was released within 45 min. A similar trend was observed when the tobramycin to diclofenac ratio was increased to 4:1 w/w. Overall results suggest that spray drying with 2FN showed a superior and viable approach to producing excipients-free inhalable co-spray dried formulations of tobramycin and diclofenac. However, the formulation produced using the 3FN showed higher enrichment of hydrophobic diclofenac and an ability to control the tobramycin drug release in vitro.

The environmental impact of inhaled therapy: making informed treatment choices

When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual or organisation is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of carbon dioxide equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered-dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives.

Turning green: the impact of changing to more eco-friendly respiratory healthcare - a carbon and cost analysis of Dutch prescription data

OBJECTIVES

Dry powder inhalers (DPIs) and soft mist inhalers have a substantially lower global warming potential than pressurised metered-dose inhalers (pMDIs). To help mitigate climate change, we assessed the potential emission reduction in CO₂ equivalents when replacing pMDIs by non-propellant inhalers (NPIs) in Dutch respiratory healthcare and estimated the associated cost.

DESIGN

We performed a descriptive analysis of prescription data from two national databases of two independent governmental bodies. First, we calculated the number of patients with chronic obstructive pulmonary disease (COPD) and asthma that were using inhalation medication (2020). Second, we calculated the number and total of daily defined doses of pMDIs and NPIs including DPIs and soft mist inhalers, as well as the number of dispensed spacers per patient (2020). Third, we estimated the potential emission reduction in CO₂ equivalents if 70% of patients would switch from using pMDIs to using NPIs. Fourth, we performed a budget impact analysis.

SETTING

Dutch respiratory healthcare.

PRIMARY AND SECONDARY OUTCOME MEASURES

The carbon footprint of current inhalation medication and the environmental and financial impact of replacing pMDIs with NPIs.

RESULTS

In 2020, 1.4 million patients used inhalers for COPD or asthma treatment. A total of 364 million defined daily doses from inhalers were dispensed of which 49.6% were dispensed through pMDIs. We estimated that this could be reduced by 70% which would lead to an annual reduction in greenhouse gas emission of 63 million kg.CO2 equivalents saving at best EUR 49.1 million per year.

CONCLUSIONS

In the Netherlands, substitution of pMDIs to NPIs for eligible patients is theoretically safe and in accordance with medical guidelines, while reducing greenhouse gas emission by 63 million kg.CO2 equivalents on average and saving at best EUR 49.1 million per year. This study confirms the potential climate and economic benefit of delivering a more eco-friendly respiratory care.

Carbon Footprints and Life Cycle Assessments of Inhalers: A Review of Published Evidence

Respiratory inhalers have a substantial impact on the carbon footprint of the healthcare sector. Environmental factors, including carbon footprints, are gaining importance in choosing inhalers once medical considerations have been addressed. This paper provides a review of the carbon footprint (CFP) and life cycle assessment (LCA) environmental profile of dry powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs). Despite methodological challenges, our analysis reveals that the CFP varies between DPIs ranging from 359 gCO2e per inhaler (Enerzair Breezhaler® DPI without digital companion 30-day pack) to 1250 gCO2e per inhaler (Seretide Accuhaler® 50/500) and from 6.13 gCO2e per dose (Enerzair Breezhaler® without digital companion 90-day pack) to 27 gCO2e per dose (Relvar Elipta 92/22). The breakdown of inhaler CFP by life cycle stage reveals that, although the use and end-of-life stages together contribute to most of the CFP of the MDIs, the largest contributions to the CFP of the DPI/SMI are made by the API and manufacturing stages of the life cycle. Although from a climate perspective our review aligns with the findings of Jeswani and Azapagic that DPIs have a lower CFP than pMDIs, we conclude that the performance against other environment impact categories depends on the design, choice of material and manufacturing process of the DPIs. The challenge of comparing the CFP of different inhalers can be made easier by the standardization of study boundaries and methods.

Addressing the environmental sustainability of eye health-care delivery: a scoping review

The demand for eye care-the most common medical speciality in some countries-is increasing globally due to both demographic change and the development of eye health-care services in low-income and middle-income countries. This expansion of service provision needs to be environmentally sustainable. We conducted a scoping review to establish the nature and extent of the literature describing the environmental costs of delivering eye-care services, identify interventions to diminish the environmental impact of eye care, and identify key sustainability themes that are not yet being addressed. We identified 16 peer-reviewed articles for analysis, all published since 2009. Despite a paucity of research evidence, there is a need for the measurement of environmental impacts associated with eye care to be standardised along with the methodological tools to assess these impacts. The vastly different environmental costs of delivering clinical services with similar clinical outcomes in different regulatory settings is striking; in one example, a phacoemulsification cataract extraction in a UK hospital produced more than 20 times the greenhouse gas emission of the same procedure in an Indian hospital. The environmental costs must be systematically included when evaluating the risks and benefits of new interventions or policies aimed at promoting safety in high-income countries.

Patents And Regulatory Exclusivities On Inhalers For Asthma And COPD, 1986-2020

Inhalers are the mainstay of treatment for asthma and chronic obstructive pulmonary disease (COPD). These products face limited generic competition in the US and remain expensive. To better understand the strategies that brand-name inhaler manufacturers have employed to preserve their market dominance, we analyzed all patents and regulatory exclusivities granted to inhalers approved by the Food and Drug Administration between 1986 and 2020. Of the sixty-two inhalers approved, fifty-three were brand-name products, and these brand-name products had a median of sixteen years of protection from generic competition. Only one inhaler contained an ingredient with a new mechanism of action. More than half of all patents were on the inhaler devices, not the active ingredients or other aspects of these drug-device combinations. Manufacturers augmented periods of brand-name market exclusivity by moving active ingredients from one inhaler device into another ("device hops"). The median time from approval of an originator product to the last-to-expire patent or regulatory exclusivity of branded follow-ons was twenty-eight years (across device hops on fourteen originator products). Regulatory and patent reform is critical to ensure that the rewards bestowed on brand-name inhaler manufacturers better reflect the added clinical benefit of new products.

Environmental Sustainability in Respiratory Care: An Overview of the healthCARe-Based envirONmental Cost of Treatment (CARBON) Programme

Introduction

Faced with the challenges of climate change, countries are seeking to decarbonise their economies. A greater understanding of what comprises the carbon footprint of care in healthcare systems will identify potential strategies for reduction of greenhouse gas (GHG) emissions. In respiratory care, the focus has been on preventer inhalers, thereby omitting contributions from other aspects such as healthcare resource utilisation (HCRU) and reliever inhaler use. The healthCARe-Based envirONmental cost of treatment (CARBON) programme aims to provide a broader understanding of the carbon footprint associated with respiratory care.

Methods

CARBON will quantify the carbon footprint of medications and HCRU among approximately 2.5 million patients with respiratory diseases from seven ongoing studies spanning more than 40 countries. Across studies, to obtain the carbon footprint of all inhaled, oral, and injectable medications, SimaPro life cycle assessment software modelling resource and energy consumption data, in addition to Ecoinvent^® data sets and certified published studies, will be used. The carbon footprint of HCRU in the United Kingdom will be estimated by applying the methodology and data obtained from the Sustainable Healthcare Coalition Care Pathway Guidance.

Planned Outcomes

In asthma, CARBON studies will quantify GHG emissions associated with well-controlled versus not well-controlled asthma, the contribution of short-acting β₂-agonist (SABA) reliever inhalers (and their potential overuse) to the carbon footprint of care, and how implementation of treatment guidelines can drive improved outcomes and footprint reduction. In chronic obstructive pulmonary disease (COPD), CARBON studies will assess the impact of exacerbation history on GHG emissions associated with HCRU and SABA use in subsequent years and estimate the carbon footprint associated with all aspects of COPD care.

Conclusion

CARBON aims to show that the principle of evidence-led care focused on improvement of clinical outcomes has the potential to benefit patients and the environment.

[Reduction of greenhouse gas emissions by inhaler choice in the therapy of asthma and COPD patients]

BACKGROUND

The global warming potential of inhaled medication depends on the applied inhaler. Pressurised metered dose inhalers (pMDI) contain green-house gases (GHG) and are associated with a 10 to 40 times higher CO₂-footprint than GHG-free dry-powder inhalers (DPI).

AIM

Feasibility and relevance of prescription conversion from pMDI to DPI were investigated in a pulmonology outpatient clinic regarding the CO₂-footprint and the economic costs under real-world conditions.

METHODS

Based on exemplary therapy regimens of different intensity for three patients, the annual CO₂-footprint and daily therapy costs were investigated. The effect of converting from pMDI to DPI on CO₂-footprint and economic costs were calculated on the basis of prescriptions during the first quarter of 2020 compared to the first quarter of 2021.

RESULTS

Conversion of a pMDI-based inhalative therapy of exemplary asthma and COPD patients to a DPI-based therapy saved between 115 and 480 kg CO₂ equivalents (CO₂e) per year and patient depending on intensity of therapy and GHG used. A total of 184,297 and 164,165 defined daily doses (DDD) were prescribed by the clinic for 2,610 (January-March 2020) and 2,693 (January-March 2021) patients, respectively. The proportion of DPI prescribed increased from 49 to 78% of total inhaler prescriptions. The increase in prescriptions for single-agent inhaled corticosteroids from 19.8 to 74.1% of total inhaler prescriptions was particularly striking. Due to the conversion, emissions were reduced by 35,000 to 40,000 kg CO₂e between January-March 2020 and January-March 2021 in our clinic. During the same period, there was no increase in costs compared to nationwide costs. The relation of prescribed DPI and pMDI in the same period did not change among the pulmonologists in Saxony nor nationwide in Germany. If all ambulant pulmonologists in Germany would prescribe 75% DPI, CO₂-emissions could be reduced by 11,650 tonnes CO₂e per quarter and 46,600 tonnes CO₂e per year, respectively.

CONCLUSION

The type of inhalers can be converted from pMDI to DPI in a real-world setting. Thereby, a significant reduction of GHG emissions is possible without increased costs.