Case Study Highlighting How Eastern Health faces Drug shortage challenges Dharam Singh Procurement Manager Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre Turning Point Alcohol & Drug Centre Wantirna Health Yarra Ranges Health and Yarra Valley Community Health
Overview • Analysing drug outages: a pain in the chain? • Achieving better procurement outcomes from a proactive approach • Streamlining procurement processes in a continuously changing environment
Sorry, “that cure is out of stock”
Definition • Shortage-inability to supply medicines to where and when they are needed. • A supply issue requiring a change .It impacts patient care and requires the use of an alternative agent (ASHP) • An important principle of Australia’s national medicines policy is to provide timely access of essential medicines to all Australians • Medicine Shortages have become a complex global problem –with local impact in Australia
Global Concern • In light of growing concerns- the first ever gathering in Toronto in June 2013 ‘‘ International Summit on Medicine Shortages ’ hosted by international Pharmaceutical federation’ and co-hosted by Canadian Pharmacist Association” • The purpose was to provide a forum to discuss causes, impacts and solutions to global issues • One of the major recommendation of this summit was that each country should establish a publicly accessible means of providing information on medicine shortages • Therapeutic Goods Adminstration (TGA) website-in Australia • There is evidence that these shortages are worsening with time, severity and no sign of slowing down
What do we know in Australian Hospitals • Often advised at short notice, most shortages were due to manufacture’s inability to supply • Identifying additional manufacturer’s who have capacity to initiate or increase production of the drug in shortage • It was identified majority of shortages were critical products, either life saving agents or products with no therapeutic equivalence, single source
Financial and other reasons • Drug outages are happening more regularly since 2007 and during and after the global financial crisis (GFC) and no sign of slowing down • Manufactures are conservative with their production forecast due to the fear of losses due to expiry of products and capital investment • According to data from Food and Drug Administration(FDA) the number of shortages have risen steadily to all time high of 251 products in 2011 • The therapeutic classes of drugs in shortage included oncology drugs (28%)antibiotics (13%) and electrolyte /nutrition drugs (11%)
Pristinamycin Story....(Case 1) Indications-MRSA infections unresponsive or resistant to other agents-ref RMH 2013 This drug is not marketed in Australia but may be available under the SAS scheme- Last line therapy-Gram positive infections Start date –notification by distributor May 2014 End date- September 2014 Usage across EH- 180 packs of 16 tabs per month Action -Communicated to infection control physicians , tried all sources to secure stock but none available Impact – Cost increased $45.00 to $89.00 but was able to secure 100 packs before stock ran out EH response- No patients supply was affected though patients were inconvenienced interms of coming into hospital more regularly- weekly to receive rations
Consequences if product not available • EH would need to admit 30 patients to administer iv medication –at a substantial cost • Impact.... Cost, inconvenience for patients and relatives, risk if patient refused to come to hospital and nursing staff would encounter - patient aggressive behaviour • Options- not really viable • Patient care- optimal therapy not available
Strategies to manage • Achieve better procurement outcomes from a proactive approach in engaging manufacturer's and enquiring if emergency supply available • Medical information pharmacist may suggest options- alternative treatments and engaging key stake holders- physicians, oncologists, clinical pharmacist, wholesalers, SAS suppliers, other key hospitals ie Austin, Peter MacCallum, Alfred , Cabrini, St Vincent's Public • For oncology products –prioritise ie allocate stock to existing patients to complete treatment cycle, do not start new patients
Strategies to manage (continued) • Obtain substitutes in advance- obtain usage data from across all 5 eastern health sites ,approximate ETA, SOH , product criticality - used for critical& emergency care assessed by formulary pharmacist • Communication to all stakeholder’ s- expected duration of shortage and resolution of shortage
Strategies to manage (continued) • Second line strategy to borrow from other hospitals-or in advance arrangements- example Novoseven-used for major bleeding episodes SOH may not be enough • Acquire unregistered products-(Special Access Scheme ) SAS – may be in different languages-German, Japanese • Safety risk- translation can be wrong or no translation at all • Cost implications on pharmacy budget
Issues • Shortages have created uncertainties and have major consequences for pharmaceutical care-stockpiling • Managing variability-supply versus demand • Forecast errors • Lack of communication –supply chain partners • Lack of collaboration- manufacturer’s, wholesaler’s and hospitals
Eastern Health Response
Message for the pharmaceutical Industry • The major focus of most supply chain members is inventory cost and inventory minimisation as well as improving efficiency • However, inventory may not be the ultimate measure of performance when dealing with people’s lives. For this reason, the pharmaceutical industry may need to focus more on minimizing the disruption of the supply of medicines than inventory minimisation
Shortage Case 2 “There are the melphalan based transplants planned for February. And probably a couple more in March.. There are no alternatives to melphalan, and no alternative options for these patients. This could be a disaster for the patients.” Head of Hematology EH response-Acquired some emergency stock and borrowed some stock from PMCI It was enough for one patient . All patients were booked so this information was relayed to the manufacturer to reserve some stock If above fails than obtain SAS stock which is 7x the current price
Strategies to mitigate risks & concerns Supply Assessment Supplier Relationship & Development Risk Assessment Inter-departmental communication – create Relationship with other hospitals awareness Hospital network collaboration Clinician engagement
What I have gained from the various experiences • A proactive approach-working closely with all stakeholders- greater sense of urgency • Assessment of duration of shortage, identifying alternatives and acquiring supplies –organizing early • Contract agreements with manufacturers of critical products – served better • Adaptation of processes such as database to record shortages- and creating a sense of urgency • The tight hospital budgets pose challenges and Just in time (JIT) order management limited safety stock
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