Prevalence and Severity of Rationing During Drug Shortages

Abstract

This study examines national survey results from hospital pharmacy managers to investigate current drug allocation and rationing practices of US hospitals during drug shortages.

Hospital medication shortages in the United States are associated with decreased quality and/or quantity of life.^1,2 In severe cases, shortages require clinicians to decide which patients receive needed medications and which do not (ie, rationing drugs between patients).³ Previous studies have proposed ethical allocation frameworks and assessed the associations of specific shortages.^2,4,5 We conducted a national survey of hospital pharmacy managers to investigate current drug allocation and rationing practices of US hospitals during shortages.

Methods

We conducted semistructured interviews with a convenience sample of 9 health-system pharmacists regarding their experiences with drug shortages. We created survey items based on a framework analysis⁶ of these qualitative interviews and tested questions for clarity and consistency. We sent this 19-item survey over a 6-week period (February 6, 2018, to March 20, 2018) via email to a listserv of self-identified pharmacy practice managers and/or pharmacy leaders (PPM) who were members of the American Society of Health-System Pharmacists. We used χ² tests to compare response differences by hospital characteristics. Respondents who completed the demographic portion and had unique metadata and characteristics were included in the analysis. The University of Chicago institutional review board approved the study and participants were not compensated and provided written consent.

Results

The study’s 719 respondents (response rate, 65.0%, based on unique listserv activity during the time of survey availability) comprised 5.7% of total PPM membership. The question completion rate was 95.4%. Respondents were demographically similar to the overall American Society of Health-System Pharmacists PPM membership. The median age was 44 years (interquartile range, 35-57 years), with 311 (43.2%) self-reporting as women and 381 (53.0%) as men; the median years in practice was 10 (interquartile range, 10-32 years). A total of 453 (63.0%) reported practicing in community hospitals, whereas 143 (19.9%) and 123 (17.1%) reported practicing in academic or academically affiliated hospitals, respectively. Respondents were from hospitals with fewer than 100 (109 [15.2%]), 100 to 199 (139 [19.3%]), 200 to 299 (111 [15.4%]), 300 to 399 (115 [15.9%]), or more than 400 beds (245 [34.0%]).

All respondents reported experiencing drug shortages in the preceding year and 498 respondents (69.2%) reported more than 50 shortages. Most respondents (664 [92.4%]) reported an average of less than 1 month from notification to active shortage, 250 (34.9%) described having no administrative mechanism to respond to shortages, 96 (13.3%) reported a standing committee that included physicians, and 20 (2.8%) included an ethicist. The Table describes the frequency of medication shortages and the strategies used to mitigate and manage them. Notably, medication hoarding was reported by 584 respondents (81.3%).

Table. Respondents’ Experiences With Shortages of Medication Types That Were Scarce in More than 50% of Respondents’ Hospitals.

Medication Category	Reporting Shortage, No. (%)
Analgesics (including opioids)	705 (98.0)
Nonopioid anesthetics or sedatives	627 (87.2)
Antibiotics	651 (90.6)
Chemotherapeuticsa	452 (62.9)
Intravenous fluids	375 (52.2)
Cardiac medications	610 (84.9)
Mitigation Strategies	Using Strategy, No. (%)
Maintain a shortage list	664 (92.4)
Substitute with similar drugs	606 (84.3)
Hoard available supply	585 (81.3)
Use central pharmacy-controlled distribution	572 (79.6)
Create lists of medications not to be shared with other hospitals	398 (55.4)
Dedicate a pharmacist to shortage management	241 (33.5)
Create a standing shortage committeeb	259 (36.0)
Allocation Strategies
Pharmacy directed an indication-specific distribution	580 (80.7)
Buying from alternative suppliers	482 (67.1)
Requesting supply from nearby hospitals	411 (57.2)
Transferring patients to other hospitals because of unresolvable shortages	37 (5.1)

^aRespondents in community hospital practice and from hospitals with fewer than 400 beds were less likely to report chemotherapy shortages (χ², 6.84; P = .03; χ², 12.85; P = .02, respectively).

^bMore respondents from hospitals with more than 400 beds and from academic hospitals reported using a shortage committee than comparator groups (χ², 6.84; P = .03; χ², 12.85; P = .02; respectively).

More than one-third of respondents (247 [34.4%]) reported an episode of rationing within the past year. Rationing occurred more frequently at academic hospitals (47.7% vs 25.5%; P = .01) and academically affiliated hospitals (45.4% vs 25.5%; P = .02) compared with community hospitals and in hospitals with more than 300 beds compared with those with fewer beds (46.1% vs 19.7%; P < .01). During rationing, 128 respondents (51.8%) reported that the treating team alone decided on allocation methods, whereas 119 (48.2%) used committees, 12 (4.9%) of which included an ethicist. Only 89 patients (36.0%) were informed that their care included rationing.

Discussion

Pharmacy practice managers reported frequent medication shortages with variation in allocation and rationing methods during shortages. Many respondents described little forewarning of upcoming shortages and a lack of administrative mechanisms with which to guide medication conservation, and although discouraged, hoarding was widespread.^3,4 Rationing was prevalent, particularly in large hospitals and academic or academically affiliated hospitals. Most respondents noted that rationing decisions were generally made by the care team without the involvement of hospital committees or ethicists. Disclosing rationing to patients was not common. This survey of PPMs suggests that more systematic approaches are needed to address the common problem of drug shortages and consequent drug rationing. Progress in this area would be furthered by research to better understand patient and physician preferences for disclosure and the association of different management strategies with the outcomes of high-risk groups.