Author(s)

Piter Oosterhof, Jelmer Hein Faber, Lieke van Kerkhoven, Rob Haenen

Why was it done?

PharmaSwap is a response to the significant issue of medication waste in the healthcare sector. The problem of medication waste was well-documented, with scientific research indicating that annually, a minimum of €100 million worth of prescribed medications was being discarded in the Netherlands. These medications were being wasted when they reached their expiration dates, resulting in both financial losses and environmental pollution. PharmaSwap was introduced to tackle the problem of medication waste by creating an online platform that enables pharmacists and pharmaceutical wholesalers to list and sell medications with approaching expiration dates at discounted rates. Our initiative sought to improve the situation by not only reducing the financial losses associated with medication waste but also by addressing the environmental concerns linked to the disposal of medications. By promoting the reuse of medications and encouraging a shift toward sustainability in the pharmaceutical sector, PharmaSwap aimed to make a positive impact on healthcare and the environment.

What was done?

The initiative that has been developed and implemented is https://www.PharmaSwap.com. PharmaSwap is an online marketplace established in 2018 by pharmacists Piter Oosterhof and Jelmer Faber. This platform facilitates the exchange and sale of medications among (hospital) pharmacies and pharmaceutical wholesalers that are nearing their expiration dates at discounted rates.

How was it done?

The introduction of PharmaSwap faced several obstacles:

1) Regulatory barriers: initially, regulations didn’t allow medication redistribution. We collaborated with regulatory bodies to find a legal solution.
2) Legal adjustments: we worked with authorities to amend regulations, creating a legal framework for PharmaSwap.
3) Building trust: gaining trust from pharmacists and wholesalers required transparent communication and showcasing benefits.
4) Technical development: developing the platform required the right tech partners and resources.
5) Awareness and adoption: we conducted awareness campaigns and partnered with (inter)national associations to promote PharmaSwap.

Through these efforts, we successfully overcame obstacles and implemented PharmaSwap, reducing medication waste and promoting sustainability.

What has been achieved?

1) Medication waste reduction: PharmaSwap has significantly reduced medication waste, preventing the disposal of medications, while pioneering a unique and innovative approach.
2) Environmental impact: PharmaSwap has saved 9,719 packaging units, leading to a substantial reduction in environmental pollution from medication disposal.
3) Cost Savings: healthcare systems have saved €1,165,115 by recovering the value of otherwise discarded medications.
4) Network growth: PharmaSwap connects 836 out of 2,000 Dutch pharmacies and collaborates with 8 pharmaceutical wholesalers, including one partner compliant with Good Distribution Practice (GDP).

These outcomes highlight PharmaSwap’s impactful contributions to waste reduction, cost savings, and sustainability in healthcare, supported by its expanding network of participants.

What next?

PharmaSwap’s success in reducing medication waste, saving costs, and promoting sustainability makes it a compelling example of good practice in healthcare. Its transferability to other healthcare settings involves replication, regulatory adaptation, education, partnerships, technology integration, data management, and a commitment to continuous improvement. Moreover, we are currently in advanced meetings with several other European countries, exploring the potential for international expansion and collaboration to further extend the positive impact of PharmaSwap.

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Author(s)

Moisés Couñago-Fernández, Marisol Samartín-Ucha, Ana María Regueira-Arcay, Sonia González-Costas, María Alfonsín-Lara, Paula Prado-Montes, Iván Agra-Blanco, Elena Cerdeira-Regueira, Noemí Martínez-López de Castro

Why was it done?

When a new pharmaceutical product should be introduced in a hospital, a multitude of factors must be considered in order to choose a specific brand. A lack of uniformity in the criteria for the selection of new medicines has been detected. To avoid selection errors or arbitrary decisions, a selection structured algorithm was developed using quality tools according to management quality system ISO 9001-2015.

What was done?

To ensure that the process of selecting from several pharmaceutical companies fulfil the requirements of quality and lower cost, a decision-making process for these purchases was designed, through a structured method for the evaluation of new pharmaceutical products based on standardised evaluation criteria.

How was it done?

A multidisciplinary group was created focused on making decisions about criteria. All stakeholders were represented (management pharmacist, quality experts, management assistant and pharmacy director). Also, a survey was given to different specialist pharmacists to complete the criteria. Second, criteria were categorised according to their importance or potential impact in pharmacy practice or patient.

What has been achieved?

The algorithm took into account aspects related to: a)pharmaceutical company and b)aspects related to the pharmaceutical product. Each of these aspects is valued as a percentage.

a)Pharmaceutical company: 40% of the score was based on not having a repeated history of stock-outs, 45% on the evaluation of the provider according to an internal file based on incidences registered, and 15% if the provider was already a known supplier.

b)Pharmaceutical product: 50% was based on the cost of the medicine, 15% unit dose presentation (if applicable), 10% expiry conditions of the medicine, 5% allergens, 5% if it was presented in a pre-filled pen (if applicable), 5% if it could be stored at room temperature, 5% if the drug is supplied in diluted vials (in the case of parenteral medicines) and 5% if it had all the possible indications in the technical data sheet.

This methodology has been used successfully in recent months with the pharmaceutical supplier changes of abiraterone and sugammadex.

What next?

This tool will be used for all changes of medicine brands and new drugs purchased in the hospital, enabling uniformity in the purchasing process for all new drugs.

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Author(s)

Irene Ruiz-Jarabo Gómez, Marcos Gómez Bermejo, Rocío Vázquez Sánchez, Antonio Illescas Bermudez, Elena Martín Suarez, Teresa Molina García

Why was it done?

Digitization was considered essential in reducing costs related to inventory management and improving responsiveness in critical situations, such as supply shortages. Traditional manual inventory checks and order verifications were time-consuming and error-prone, prompting the need for a digital transformation.

What was done?

In our quest for enhanced medication procurement efficiency within our Hospital Pharmacy Service, we have developed an integrated database.

How was it done?

We have developed a database by consolidating data from two primary sources: our automated medication storage system, Smart Ulises®, and the Economic Management software, Farmatools®. This database encompassed information related to medications falling below predefined minimum stock levels, historical acquisition records, pending medication orders, and warehouse capacities for each medication. Additionally, it seamlessly integrated data obtained from the Spanish Agency of Medicines and Medical Devices (AEMPS) regarding medication shortages.
This database enabled several essential functionalities:
It generates reports suggesting orders for medications below the minimum stock levels, recommending quantities based on historical acquisitions and available storage space.
By considering the suppliers for medications at minimum stock levels, it also identifies medications in alert status (1/3 above the minimum stock) for these suppliers.
Cross-referencing with AEMPS’ medication supply problem database swiftly detects critical medications during shortages
It permits agile identification of pending medication orders.
It identifies locations with incomplete medication inventories and propose medication grouping within our automated medication storage system.

What has been achieved?

The outcomes of our project were transformative:
  We streamlined medication procurement significantly and maximized each medication supply request while promoting sustainability by reducing laboratory-specific medication orders.
  We optimized storage space within our automated medication storage system, aligning medication orders precisely with storage capacities for each medication, leading to more efficient space utilization and reduced storage costs.
  Early detection of medication shortages enabled proactive preparation of alternative solutions to effectively mitigate shortages.
  Simplification of tracking pending medication orders enhanced operational efficiency in claim processing or supplier changes.

What next?

Our next phase focuses on continuous system improvement. This involves incorporating additional data sources to refine medication supply predictions and exploring the potential for complete automation of the medication ordering process. We will also enhance performance measurement to evaluate the effectiveness of our improvements.

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Author(s)

Samantha HUYNH, Olivia MAZZASCHI, Valérie TALON, Emilie MOREAU

Why was it done?

Healthcare systems face a growing need to balance patient care with environmental responsibility. This approach was initiated at the request of surgeons and was proposed during institutional committees addressing environmental issues.

What was done?

Our aim was to perform a comprehensive analysis of the potential benefits and challenges associated with the substitution of single-use medical devices (SUDs) with reprocessable medical devices (RMDs) within a hospital setting.

How was it done?

We evaluated environmental, economic and organizational impact of this transition by comparing the carbon footprints and costs associated with the substitution of SUDs (suture and antiseptic trays) with RMDs as well as their acceptance by healthcare professionals.
Environmental impact was evaluated by considering manufacturing origin, transportation, and material composition, calculating carbon equivalence based on weight. The energy and water consumption during the sterilization process of RMDs was also included in the carbon footprint quantification.
Economic considerations included SUDs purchasing and management costs as well as acquisition and sterilization costs for RMDs.
Observational audits (n=30) and user satisfaction surveys (n=7) were conducted to evaluate the acceptance of RMDs.

What has been achieved?

RMDs led to a significant reduction in the carbon footprint for both devices. The carbon equivalence for suture trays was reduced from 7.1 kg eqCO2 for SUDs to 4.0 kg eqCO2 for RMDs; for antiseptic trays, SUDs generated 2.2 kg eqCO2 while RMDs 1.1 kg eqCO2. The potential annual reduction of CO2 emissions is 5.2 tonnes per year.
The economic analysis showed that the initial investment in RMDs could be recovered within a remarkably short timeframe (10 months for antiseptic trays, 5 years for suture trays) making it a viable long-term cost-saving strategy.
User feedback showed a preference for RMDs despite slight inconveniences, with 71% of respondents supporting the reduction of SUDs and 83% perceiving RMDs as of superior quality.

What next?

Our findings underscore the feasibility and benefits of transitioning to RMDs, with a significant reduction in carbon footprint and economic viability. While complete elimination of SUDs presents challenges, a balanced approach prioritizing sustainability without compromising quality of care is possible. We believe that this approach can be replicated in diverse healthcare settings, contributing to a more sustainable future management.

Author(s)

Bitten Abildtrup, Lone Deleuran, Mira Dysgård, Nina Müller, Sofie Pedersen, Trine Schnor, Ulrik Wøldike

Why was it done?

It is estimated that medicine contribute 20% of the Danish regions total CO2e emissions. Amgros and the Hospital Pharmacies of Denmark are committed to develop carbon reduction initiatives to assist the regions CO2e reduction strategy. It is essential to identify the main contributors of CO2e emissions in the lifecycle of a drug to support CO2e reduction.

What was done?

The Danish procurement organization Amgros I/S is responsible for buying medicine for Danish public hospitals. As part of the ambition for sustainability, The Capital Region Pharmacy (RAP) in collaboration with Amgros has made a bottom-up hotspot life cycle analysis (hLCA) of the carbon-footprint of morphine in tablets and solution for injection. The hLCA identified the main CO2e emission factors from API/excipient production to administration of the drug.

How was it done?

The energy consumption of the production processes was mapped at RAP. Five reference flows were modulated (tablets in three types of primary packaging and solution for injection in two types) and reported. The hLCA data for the API was extracted from literature while data for the excipients and packaging material were calculated using Ecoinvent. Ecoinvent is a life cycle inventory database used to support environmental assessments of products and processes.

What has been achieved?

The preliminary conclusion of the analysis shows the largest CO2e emissions per DDD originates from administering the drug due to the use of single-use materials.
Leaving out administration of the drug, the main CO2e emissions from tablets are API production and packaging materials. Packaging materials are the main CO2e contributor for the solution for injection.
The end report of the LCA was available, end of autumn 2023.

What next?

The hLCA’s are being used internally in Amgros to develop criteria for tenders. The hospital pharmacies can use the hLCA calculations to identify key subprocesses where reduction of the CO2e footprint is greatest.
The results contribute to:
• Danish hospital pharmacies better understand the CO2e emissions when prescribing and administering medicines
• Dialogue with the pharmaceutical industry about their CO2e emissions hotspots
Finally, the results will hopefully encourage other countries to incorporate environmental criteria in future medicinal tendering process for medicines.

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Author(s)

ERMINIA CACCESE

Why was it done?

The aim is to hold a value-based tender by incorporating the clinical benefit into the competition score for the procurement of Hyaluronic Acid (AI) for intra-articular use.
The main purpose of this tender is to purchase the product with the best cost-effectiveness profile according to the Net Monetary Benefit (NMB) and putting drugs and medical devices in competition.

What was done?

In Italy as well as in Europe medical devices (MDs) procurement is based on construction features and on price. The price of MDs is not negotiated by regulatory authorities, but it’s defined by industry. Today, in a limited resources scenario, it is necessary to implement value-based procurement.

How was it done?

We used the NMB method (1) as an award criterion, a parameter that evaluates the cost-effectiveness of the therapeutic intervention.
A bibliographic search was carried out to support the chosen endpoints and the tender lots. The utility and cost values linked to therapeutic failure were sought and the minimum accepted quality was defined. The starting price was calculated per therapy cycle/patient.
Finally, a software was designed to calculate the value-based competition score.

What has been achieved?

The tender consisting of 3 lots was announced with resolution n.209/2023 (2). The technical evaluation focuses on the enhancement of the clinical benefit based on the following scores: price (30)/clinical benefit (70). The endpoints chosen for the evaluation of clinical benefit are deltaVAS and deltaEQ-5D. Both drugs and MDs can be offered for each therapeutic indication.

What next?

This tender is an example of value-based procurement that uses the evaluation of clinical effectiveness as a quality evaluation criterion.
The aim is to quantitatively link the purchase price of a therapeutic intervention to the extent of the benefit observed in clinical studies, rewarding the interventions that produce the greatest benefits. The innovative nature of our tender lies in putting drugs and MDs in competition in the same tender lot and for the same therapeutic indication, thus purchasing the product with the best cost-effectiveness profile based on scientific evidence. We are awaiting the award of the tender, the results of which we will publish shortly.

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Author(s)

Elisabeth CESAR, Ludivine LECHEVRETEL, Adrien NIERENBERGER, Laurent DIETRICH, Anne FEGER-FALK

Why was it done?

We decided to experiment this new solution on coronarography-packs, which presents the biggest rotation among surgery-packs (5,392 units estimated for 2,023), in order to improve working conditions of logistic workers, decrease musculoskeletal disorders (MSD) and optimise storage.

What was done?

Pallet box have been implemented as a new logistic solution for surgery-packs in our hospital pharmacy on a proposal from one of our biggest suppliers. The aim of this comparative study between 52-pack pallet boxes and the previous storage solution by 4-pack boxes was to assess the potential benefit on handling work, storage, waste and its economic impact.

How was it done?

In order to compare these two solutions, we clocked the time and evaluated the cost of transport from delivery gate to storage room and healthcare-unit order-picking step (from picking up the first pack to cardboard flattening). We also estimated the amount of waste associated.

What has been achieved?

Pallet-boxes enable a 24% room saving (52 pallet-spots yearly (2 pallet-boxes piled on one spot) instead of 68) and a 31% global time saving (22 hours yearly (13h transport + 9h order picking) instead of 32 hours (17h transport + 15h order picking)). Time saving on order picking was 40%: picking step of one pack from a pallet box requires on average 6 seconds whereas 10 seconds were needed from 4-packs-boxes. Yearly 104 pallet-boxes (603 kg of empty cardboards) will be manipulated whereas 1,348 4-pack-boxes (1,213 kg) used to be handled resulting in a 2-fold decrease. Even though pallet-boxes halve cardboard-waste, they represent 1.5 times more wooden-pallets’ waste (104 versus 68). Furthermore the price of coronarography-packs are impacted by a 2% increase representing around 4,100€ yearly which is not balanced by savings on transport or order picking (10h ≈ 150€).

What next?

Logistic workers are unanimously satisfied in implementing pallet-boxes as it facilitates their work on many aspects: pallet transport, order picking, waste disposal. Despite being costlier, a decision has been made to implement pallet-boxes in the long-term in order to improve waste management and working conditions of logistic workers. Our hospital pharmacy is already thinking about extending pallet-boxes to other references in order to assess more precisely their impact on MSD in logistic workers.

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Author(s)

Outi Lapatto-Reiniluoto, Suvi Sivula, Elina Ahomäki

Why was it done?

Price has been the most prominent criteria in procurement quality being the second. Environmental aspects haven’t been assessed earlier. Differences between the pharmaceuticals’ environmental burden can be considerable and by choosing wisely we would be more sustainable.

What was done?

Environmental criteria have not been used in Finland in hospital procurements earlier. We created the criteria which would be acceptable to all parties (hospitals, suppliers), would be reliably assessed, and easily copied to other hospitals.

How was it done?

Our tender had six questions for everyone and two more questions for antibiotics or hormones. The common questions were answered by yes / no / we do not know. Points given were 0, 1, 2. An example of the common question is: Does the company have a plan how to reduce CO2 emissions caused by itself?
Questions for antibiotics and estrogen hormones were: Company has told in which country and in which plant the API is produced and the formulation happens.

What has been achieved?

132 providers answered so far. Quality of answers varied considerably, from 0 to 12 points, mean 7 points. Questions for antibiotics created the most discrepancies: 41 providers; 15 were not able to answer these questions acceptably. The answers showed that the questions were not too difficult, these questions could be answered, and the answers can be analysed.

What next?

The criteria were very simple and assessing the answers was not difficult. Only one question was widely misunderstood. Questions were universal and can be used in other hospitals, too, which is the wish from the industry (same questions everywhere). Wide range of results showed differences between the companies. During this round we did not give any credit for the best products but in the future more responsible products should be rewarded. Antimicrobial resistance e.g., is a global problem but if the company does not know where its products are manufactured how can they look after wastewater treatment of their products.

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Author(s)

Margaux DUFOSSE, Claire ANDREJAK, Abir PETIT

Why was it done?

By May 2022, we learned about the sale discontinuation of oxygen humidifiers from one of the two manufacturers in our country, due to the constraints of MDR 2017/745. The second manufacturer restricts its products to hospitals with marketing partnerships. In our hospital, oxygen humidifiers are used regardless of the oxygenation medical device (nasal cannulas, masks, tubes or tracheotomy tube) or oxygen flow rate. We had to define indications and prescriptions to control consumption in our hospital.

What was done?

To promote good use of oxygen humidifiers and control our consumption in a context of shortage we have drawn up a scientific explanatory document, a procedure and a prescription support.

How was it done?

We suppressed services’ allocations for humidifiers, to encourage prescription via the Electronic Patient Record. We set up a working group, including pharmacists, resuscitators, pulmonologists and nurses, to write a good use sheet, underlining high-priority medical indications taking account of scientific literature and respiratory medicine learned societies’ recommendations. To assess its effectiveness, we compared humidifiers’ consumption before and after we set it up and evaluate prescriptions’ number and conformity for the first 4 months, from May to September 2022.

What has been achieved?

The group restricted indications to paediatric patients, patients with tracheotomy and patients with oxygen flow rates above 5L/min and upper respiratory tract lesions such as nose bleeding, nasal discharge congestion, or nasal mucosa’s irritation or lesions. We wrote the good use sheet, mentioning the circuit’s montage and conditions for dispensing humidifiers. Before the new procedure, the mean consumption was 1,415 units per month, versus 39 per month from June. Regarding prescriptions’ conformity, 12 (8.7%) out of 138 were denied: six patients on ambient air, four with nasal cannula, one without any severity criteria, a not nominative prescription.

What next?

This collaborative and multidisciplinary work enabled a change in practices. Supply difficulties, initially seen as challenging, are a great opportunity to promote good use, and secure patient care. Although they have now been resolved, with a new supplier, we maintain our measures to ensure patients’ security and well-being.

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Author(s)

Lone Møller Deleuran, Bitten Abildtrup, Sofie Pedersen, Ulrik Wøldike, Nina Winther Müller

Why was it done?

Amgros is committed to make its mark on the sustainability agenda regarding medicine – both nationally and internationally. Thereby improving access to medicines for patients in a more sustainable way – this project serves as a first step in this direction.

What was done?

In 2021, the Danish procurement organisation Amgros I/S issued the first national pilot tender for hospital medicines in which environment was an important award criterion along with price. Amgros procures 99% of the pharmaceuticals used at public hospitals. The pilot project was conducted to gain knowledge and experience about planning and executing future tenders with environmental criteria. The pilot tender was limited to the hormonal therapeutic area.

How was it done?

The chosen environmental criteria were environmental management, packaging (plastics and paper/cardboard), transportation and social responsibility.
It was a long process, including external help from consultants (The Technical University of Denmark), legal consultation, market dialogue with feedback, developing and adjusting the criteria to comply with national procurement legislation. Hence assuring the evaluation of the offers could be conducted in a meaningful, simple, and structured manner during the subsequent evaluation phase.
As a part of the final tender, a questionnaire was attached consisting of multiple choice questions concerning the environmental criteria. In the evaluation, the price weighed 80%, whereas the environmental criteria weighed 20%.

What has been achieved?

Amgros received 85 offers from 19 suppliers of which 76 offers contained the questionnaire about environment. Sixteen (84%) of the bidding suppliers completed the questionnaire. Three suppliers won the tender solely due to their environmental capability.
The tender with environmental criteria did not seem to discourage suppliers from bidding nor resulted in increasing price levels.
The pilot tender has created a great deal of awareness among the suppliers about the importance of environment and sustainability in production, distribution, and sales of medicine.

What next?

The experience obtained from this pilot tender is paving the way for the future broader implementation of more sustainable medicines in all tenders. Furthermore, the results will be shared nationally and internationally. Hopefully, the results will encourage other countries to incorporate environmental criteria in future medicinal tendering processes.