Hidden Costs of Drug Shortages Go Beyond Patient Harm

Ken Terry

June 28, 2019

A new study shows that drug shortages are increasing in US hospitals and are having a negative impact on patient care and on hospitals' bottom lines — all while posing significant challenges for frontline physicians and nurses who have to do the best they can for patients without some of the drugs they depend on.

According to a new survey by Vizient Inc, a group purchasing organization and data analytics and consulting firm, all 365 of the responding hospitals and healthcare facilities had experienced drug shortages in the previous 6 months. Over half of the facilities had experienced at least 20 such shortages.

Across the country, Vizient said, there were shortages of 186 drugs in 2018, the highest number since 2012. The drug categories for which shortages had the most impact on patient care were controlled substances, local anesthetics, crash cart drugs, antibiotics, and electrolytes.

"The drugs that go short are typically low-priced generic drugs that have been around for decades and that don't have redundant manufacturing sources," Dan Kistner, PharmD, senior vice president of pharmacy solutions for Vizient, told Medscape Medical News.

Generic drug manufacturers usually don't have redundant facilities, he explained, so generic medications are more likely to be in short supply than branded drugs. The hurricane that devastated Puerto Rico in 2017 illuminated this contrast, he noted.

A number of branded drug makers had facilities on the island. The only locally manufactured drugs that were in short supply after the hurricane were generic IV solutions from a company that made them only in Puerto Rico.

The opioid shortages in 2018 largely resulted from a misguided policy of the Drug Enforcement Administration (DEA), Kistner said. The intention behind the policy was good — to curtail the opioid crisis by limiting the amount of controlled substances available to consumers.

But the DEA imposed quotas on individual manufacturers that included both oral opioids and injectable opioids. Injectable opioids are used mostly by hospitals, so when a large manufacturer of injectable opioids reduced production, the DEA quotas prevented other drug makers from manufacturing the injectable products. The DEA modified its policy last year, but shortages still exist.

Hidden Costs

The direct and indirect costs of drug shortages, the Vizient report shows, include the following:

  • Increases in a hospital's drug budget

  • Lost revenue from canceled infusions and procedures

  • An increase in the numbers of full-time pharmacy and technician employees

  • Reallocation of pharmacy resources, which leads to lost productivity

  • Documented medication errors, potentially resulting in patient harm

Overall, Vizient estimates that managing drug shortages costs US hospitals about $360 million a year in additional labor alone. These include costs of hiring additional staff, paying staff overtime, and the redistribution of workload.

According to the survey, the average number of hours spent managing drug shortages was 12 hours per week for buyers and purchasing agents, 9.3 hours for pharmacists, 1.7 hours for nurses, and 1.4 hours for physicians, totaling about 8.6 million additional labor hours per year. The amount of time clinicians devote to this problem is actually greater than it seems, Kistner said.

"That's an underestimation of the true impact of drug shortages on clinicians," he said. "For example, they're seeing a patient and suddenly they have to completely change the protocol [because of the shortage]. They've got to change therapy, they've got to review the EMR [electronic medical record] differently. The doctor looks at the EMR and says, 'I always treat this infection this way in the ER — why am I seeing two different drugs now?' And the nurse says, 'Now I've got to give the drug differently, and I have to monitor this side effect.' So the real impact on their time is how it affects best practices and protocols that have to change."

Many of these changes are generated by hospital drug shortage task forces that include clinicians. Among the steps designed to address drug shortages, the Vizient report states, are guidelines for adjusting electrolyte replacements; increasing the stock of medications anticipated to be in limited supply; utilizing unit dosing to prevent waste; restricting the use of drugs in short supply to approved indications and to the drugs for which patients are most in need; increasing "hang time" for continuous IV fluids; and transitioning IV medications from intermittent/continuous infusion to IV push.

In the latter scenario, Kistner noted, clinicians may switch from hanging IV bags of antibiotic solutions to administering vials of the same drug via IV injection after the bags run out. Outcomes for patients will be the same, he said, but it's not the simplest solution for the nurse, and eventually the vials become depleted, too.

Thirty-eight percent of the survey respondents said they were aware of one or more medication errors related to a drug shortage. Often the error occurred because of overdosing or underdosing with a replacement drug.

"As you know, any time a drug is short, it results in change in protocol," Kistner said. "Our members [hospitals] do a great job in mitigating that. But any time you introduce a change in the supply chain, you're increasing the risk [to patients]."

The US Food and Drug Administration has formed a task force to deal with drug shortages, and Kistner said he's "encouraged" by the progress it has made so far. Some in Congress are also interested in addressing this issue, he noted. But he emphasized that drug shortages are a multifaceted problem with no easy solution.

The survey was conducted between March 6 and April 4, 2019. Respondents from the Vizient Pharmacy Program represented both acute and nonacute facilities, including health systems; academic medical centers; self-governed children's hospitals; small-, medium-, and large-sized hospitals; critical access hospitals; behavioral facilities; long-term care facilities; specialty hospitals; and ambulatory care facilities.

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