The nation’s health care system is regularly experiencing shortages of antibiotics, nutritional fluids and other kinds of commonly used prescription medications, forcing pharmacists, doctors and other health care workers to rethink treatment regimens or juggle inventory.
“Some of the most common antibiotics are the ones that are short, and that can result in people using a much stronger antibiotic than they need,” said pharmacist Erin Fox, the senior director of drug information and support services at University of Utah Health.
The shortages likely will come as a surprise to many patients, Fox said, and that’s because their health care team is doing their job, putting a plan in place to prevent any impact to their care. Yet the ongoing supply problems have so concerned Fox and other members of the American Society of Health-System Pharmacists that the organization recently issued new guidelines on how to minimize the impact on daily health system operations.
As the list of unavailable drugs has grown, Fox said, pharmacists have been spending a bigger portion of their day on managing shortages. The ASHP guidelines suggest that, rather than relying solely on a pharmacy unit, hospital leaders assemble an interdisciplinary team to make decisions on how to handle supply problems.
Fox said that the Utah Health team does a 15- to 30-minute huddle where a diverse group of medical professionals share information and problem solve. That huddle, she said, came in handy when hospitals faced a shortage of small-volume saline bags in the aftermath of Hurricane Maria in Puerto Rico.
That hurricane shut down a critical plant that supplied the bags and also crippled the U.S. territory’s transportation infrastructure. The storm damage actually exacerbated saline shortages that health care systems had been experiencing since 2014, according to a July report in the Journal of the American Medical Association Internal Medicine.
To solve the saline crisis at Utah Health, Fox said, the medical team switched to syringes of saline solution to help deliver chemotherapy treatments. Locally, Kaiser Permanente was able to find a similar workaround for its patients, said Sacramento-based spokeswoman Chyresse Hill.
“Constant vigilance and cooperation among physicians and other providers, as well as among professional organizations, help address these ongoing challenges, minimizing impact on patient care,” Hill said.
A big reason for issuing the recommendations, Fox said, is that society members felt it would provoke discussion about practices to manage shortages, especially when it includes representatives from nursing and technician teams. A drug product shortage team, as outlined by the group, should be able to help the pharmacist quickly:
- Gather information
- Determine alternatives to purchase
- Change storage, preparation, or dispensing procedures
- Make decisions on conserving or rationing products
- Implement technology and packaging changes
- Communicate more broadly about what is happening.
Establishing a standard ethics framework can also help make decisions on the best priorities for patients, the ASHP guidelines said, which added that the framework should allow for feedback and amendments.
“Drug shortages have become a barrier to clinicians providing the most appropriate and evidence-based care to patients and may create mistrust between patients and providers,” the guidelines noted.
Reasons for shortages include manufacturing problems and recalls, Fox said.
“The majority of drug shortages occur because of poor-quality manufacturing or problems at the factory,” Fox said. “It’s not upgrading your factory. It’s not making sure that you have the highest-quality manufacturing equipment. You’ve got (a factory) that passes, but it’s not up to the highest quality, and machinery breaks down frequently and that results in shortages.”
And while a shortage doesn’t typically mean that prices increase, Fox said, the products remain scarce until repairs can be made. The number of active ongoing drug shortages hovered right around 225 in the second quarter of 2018.
Fox said that many pharmacists would like to see a rating system for manufacturers that grades on reliability and quality, much as doctors and hospitals receive ratings for their performance.
“Today, hospitals buy mostly on price because there’s not really another differentiating characteristic for manufacturers,” Fox said. “But ASHP has said they feel like there are differentiating characteristics between manufacturers. Some do a much better job than others. Some have higher quality than others, and that’s important to the folks trying to buy that product.”
If there was a high-quality manufacturer selling its prescription drug products for tiny bit more money, Fox said, many hospitals would pay that small premium to ensure a reliable supply. The ASHP said U.S. health care companies spent an estimated $209 million to purchase more expensive drug substitutes in 2013, the latest year for which data are available.