Tuesday, January 10, 2012

Eliminating Waste in Health Care

It's the new rage: eliminating waste in health care:
Nine medical specialty societies are joining with the American Board of Internal Medicine Foundation and Consumer Reports to curtail waste in health care and improve patient outcomes.

As much as 30% of U.S. health care is squandered on unnecessary tests, procedures, hospital stays and other services, according to the Congressional Budget Office. Such services don't benefit patients, and in some cases may harm them.
Specialty societies are joining forces to stamp out medical waste in all its forms, even resorting to petitioning their members to come up with ideas to save money.

Honestly, this should have been done long ago and should remain an ongoing priority.

But I'm going to stick my neck out and mention an area that no one ever discusses. It's an area of waste so vast that it would dwarf all of the recommendations that are likely to come any or all of these surveys. It's an area of waste that plagues every hospital, long-term care facility, rehab facility, or nursing home in our country, yet benefits every device manufacturer and supplier to our health care system.

What is it?

Medical supply planned obsolescence.

What do I mean by this? I mean the waste generated every day in our health care system by expired medical goods.

A Sampling of Expired Medical Supplies (click to enlarge)
Every day, week and month in our health care system, thousands of pieces of perfectly good medical equipment "expire." That is, their expiration date - similar to the expiration date noted on foods you eat in the grocery store - comes past due. At that instant, they can no longer be used by patients and become worthless items that must be removed from shelves, discarded, or donated. Companies will not take them back or exchange them. Re-use in America is banned. Thanks to the World Health Organization, even donations of expired goods to developing countries are banned because of their core principles regarding guidelines of medical supplies that states "there should be no double standard in quality: if the quality of an item is unacceptable in the donor country, it is also unacceptable as a donation." Such donations are even frowned upon by many veterinary clinics.

Never mind if they are non-sterilized plastic jars. If they have an expiration date that is past due, they are discarded. If they are expired shiny, new metal or plastic medical instruments that could easily be re-sterilized (think laparoscopic staplers, attachments and the like), they are discarded. Double-wrapped IV fluids? Sutures? Drape kits? Gloves? These too are discarded. You see, you can never be too safe.

In fact, expired medical equipment fills many landfills (a must-see video) both here and overseas.

Certainly there are concerns about sterility and the decomposition of medications and materials that occurs with time. No one wants to accept the liability that expired medical goods could have been the cause of illness or infection. This is certainly appropriate.

But how many thousands of pounds of medical goods are discarded each quarter from our nation's hospitals that could be re-purposed, re-sterilized, re-packaged to give us HUGE cost savings to our health care system? Could expiration dates be extended safely without compromising quality?

No. One. Knows.


Because there's no incentive to do so and it's not in the economic interest of the suppliers to find out.

But given the millions (and probably billions) of dollars wasted on expired medical equipment each year, isn't it about time we do? Even if we can only extend the purposeful shelf life of supplies from five years to six, we likely could save hundreds of millions of dollars (or more) for our health care system.

And who knows, maybe we'll do something good for our planet along the way.



Tim Hulsey, MD said...

Efudex cream is a wonderful topical drug for treating pre-cancerous and early non-melanoma cancerous lesion of the skin. Frequently, its use obviates the need for surgical treatment. I use it so frequently that I keep pre-printed 'script pads in my exam rooms. It is about $200 a tube! Most of the patients who need it are in the Medicare age group. I always remind them that the expiration date was written by lawyers, not scientists, and suggest they not throw it away on that date. Unfortunately, in the current medicolegal environment, practicality is not allowed in the hospital.
I have spent a great deal of time in Guatemala, operating on children. I have watched hospital personal wash disposable latex gloves to be re-sterilized for use in the operating room. The need for supplies is desperate there and, I'm sure, most of the third world. The need for basics– gloves, sutures, dressings, etc.– begs for a way to turn our artificial waste into a gold mine for these people. Where the situation is bad enough, being out of date is of little concern. If you were marooned on a desert island would you refuse items that were out-of-date? In truth, the people in third world countries are marooned and without supplies. It behooves us to come up with a solution. Perhaps we should use some "practical wisdom" (read- common sense, lack of legal BS)!
Someone with a progressive mind-set is going to say, "Well, you can't give them what you yourself can't use!" Balderdash! When you've got nothing, that which is less than ideal may be just what the doctor ordered!

DrWes said...


While third world county donations make complete sense, most countries will not accept ANY expired medical equipment through customs due to WHO regulations.

There are other real concerns for these countries as well. Wholesale dumping of supplies on countries as tax write-offs has lead to landfill garbage concerns. Secondly, free items placed in circulation in those countries competes with existing medical equipment suppliers whose livelihoods are adversely affected by these shipments. Finally, single shipments help once, but rarely satisfy long-term needs.

It's a complicated problem - one that I came face-to-face with earlier this year when I tried to donate a garage-full of supplies overseas.

If it can pack some supplies in your own personal luggage, you might be able to donate these items, but beyond that, it isn't so easy for all the reasons I mentioned.

Tim Hulsey, MD said...

Wes said, "...most countries will not accept ANY expired medical equipment through customs due to WHO regulations... Wholesale dumping of supplies... competes with existing medical equipment suppliers... single shipments help once, but rarely satisfy long-term needs... you might be able to donate these items..."
Wes, you're thinking like an MPH. No, donations won't solve the problem FOR THE MASSES, but I don't see THE MASSES. I see one patient at a time. Do you think the mother of a Guatemalan child with a cleft lip cares that some supplies might be recently out of date. No. She, like any other mother, would like to see her child's lip repaired. He/she would then be socially acceptable and, possibly, marriageable. In many of these countries, there are NO alternatives without donation. Cost for a ventriculoperitoneal shunt prevent their use, therefore sale, and the patient goes untreated. We had to BEG airlines to take the crates of supplies we took, because NOTHING was available there. What we took helped every child upon whom we operated. It helped THEM for a lifetime! That's pretty long term. We and the parents of the children who needed care were BEGGING for those supplies. I have even carried vials of Morphine in my suitcase for post-op pain control. How politically incorrect was that?
You are correct in that this has to be carefully and selectively done by medical personnel to maintain safety. Primum, non nocere! WHO mainly likes to control the situation. Like most bureaucracies, it has little thought for the individual patient. It is a Public Health agency. Most physicians aren't trained in and don't do public health. We do individual health. If I see a child in Guatemala with burns that have gone ungrafted and will die shortly without surgical treatment, do you really think that I'll let a dermatome blade that is 6 months out of date go unused? 100% chance of death not using it vs a THEORETICALLY slight increase in the possibility of infection because the companies lawyers decided to date it on the safe side? It's an easy answer in my mind. Just like you, as a physician, I try to err on the side of the individual patient. Public Health is population medicine. AN MPH would say, "Of course, you would never do anything medically in less than ideal circumstances.
Sorry! I can't do that! I guess that's just due to my lack of education.

Anonymous said...

The army study from early 200's was a perfect example of how much waste there is from 'automatic xpirations'.. near 90% of drugs were fine for years after the wexpiration date. And most bottles filled at pharmacies here have labeling that intimates they are no good after a year.

Tim Hulsey, MD said...

Wes is correct that there arebig hurdles to jump trying to get supplies to third world countries. We also have to be safe about it. When you've been there and seen the need, it is difficult to watch supplies going in the dumpster that could improve the lot of many around the world. It is also maddening to think that bureaucrats who get cadillac health care are making decisions impeding things.

Hal Dall, MD said...

I have a part-time employee who also works at a clinic recently purchased by a large organization. To meet Joint Commission standards, all out-of-date supplies are being tossed. She brought me a small box of "outdated" microscope slides!

Tim Hulsey, MD said...

Hal Dall, MD said... "... She brought me a small box of "outdated" microscope slides!"
Now, Hal, you know those microscope slides can be deadly if given to a patient when they're out of date!

Anonymous said...

Please, do not bring up drug expiration dates. The date is NOT a lawyer's work of art; but is based in science. If there is a bone to pick about expired drugs, one might consider petitioning that drugs are available in smaller unit-of-use packaging, as well as more fair drug pricing? Since when does it really cost a chemist to manufacture topical fluorouracil, a product that has been around AT LEAST 30 years if not longer, $200 per 30 gram tube?

Cathy Lane RPh