A Cost Minimization Analysis of Ready-to-Administer Prefilled Sterilized Syringes in a Dutch Hospital.

PURPOSE: Preparation errors occur frequently during conventional preparation of parenteral medication in the clinical environment, causing patient harm and costs for the national health care system. The use of ready-to-administer prefilled sterilized syringes (PFSSs) produced by the hospital pharmacy can reduce preparation errors and the risk of bacteremia from contamination of the intravenous medication. The aim of this research is to compare the total costs of the conventional preparation method (CPM) with the PFSS method. METHODS: In this cost-minimization analysis, costs related to the preparation of the medication, bacteremia from contamination, adverse drug events as a result of preparation medication errors, and wastage of syringes were taken into account. Annual costs in a general Dutch hospital were consistently calculated. Three scenarios were analyzed: (1) all preparations as CPM (864,246 administrations per year), (2) all preparations as PFSSs, and (3) 50% as PFSSs and 50% as CPM. Deterministic and probabilistic sensitivity analyses were performed. FINDINGS: The first scenario found higher annual costs at €14.0 million (US$16.0 million) compared with the second scenario (€4.1 million, US$4.7 million). The most realistic situation (third scenario) found savings of €4.9 million (US$5.6 million) compared with the first scenario. Sensitivity analyses revealed that cost savings of PFSSs were strongly influenced by decreased risk of medication errors and contamination of intravenous medication. Extrapolating these results nationwide indicated potential savings of >€300 million (US$342 million) if only PFSSs were used. IMPLICATIONS: The use of PFSSs prepared in the hospital pharmacy yielded cost savings compared with the CPM on the ward in the Dutch hospital.

Syringe Port: A Convenient, Safe, and Cost-Effective Tubular Retractor for Transportal Removal of Deep-Seated Lesions of the Brain.

OBJECTIVE: Minimally invasive transportal resection of deep intracranial lesions has become a widely accepted surgical technique. Many disposable, mountable port systems are available in the market for this purpose, like the ViewSite Brain Access System. The objective of this study was to find a cost-effective substitute for these systems. METHODS: Deep-seated brain lesions were treated with a port system made from disposable syringes. The syringe port could be inserted through minicraniotomies placed and planned with navigation. All deep-seated lesions like ventricular tumours, colloid cysts, deep-seated gliomas, and basal ganglia hemorrhages were treated with this syringe port system and evaluated for safety, operative site hematomas, and blood loss. RESULTS: 62 patients were operated on during the study period from January 2015 to July 2017, using this innovative syringe port system for deep-seated lesions of the brain. No operative site hematoma or contusions were seen along the port entry site and tract. CONCLUSIONS: Syringe port is a cost-effective and safe alternative to the costly disposable brain port systems, especially for neurosurgical setups in developing countries for minimally invasive transportal resection of deep brain lesions.

Dump the pump: manual aspiration thrombectomy (MAT) with a syringe is technically effective, expeditious, and cost-efficient.

INTRODUCTION: Syringe aspiration for manual aspiration thrombectomy (MAT) is a cost- and time-efficient alternative to an aspiration pump with likely similar efficacy. It is counterintuitive to expect the pump to perform better than direct vacuum with a syringe, as the pump must deliver vacuum additionally through a canister and meters of tubing. OBJECTIVE: To present in vitro and clinical results of MAT with a syringe. METHODS: An in vitro analysis was performed comparing vacuum pressures generated by syringe aspiration and with pump aspiration. This was then complemented with prospective clinical data providing details of angiographic and clinical outcomes for syringe MAT. RESULTS: The in vitro analysis demonstrated that equal to slightly greater vacuum pressures were generated by a 60 cc syringe as compared with the pump in both static and partial flow conditions. In our clinical series, 106/113 acute stroke thrombectomies over a 6-month period were performed with syringe MAT on the first pass. Syringe usage instead of pump tubing and a canister led to a total savings of $58 300. The rate of Thrombolysis in Cerebral Infarction 2b/3 recanalization was 93%. Adjunctive stentriever usage was performed in 23% of cases. Median puncture to reperfusion time was 25 min; mean change in National Institute of Health Stroke Scale score at 24 hours was an improvement of 5.1 (median 6). The in-hospital mortality rate was 10%. Seventy percent of patients were discharged to home (modified Rankin Scale (mRS) score 0-2) or a rehabilitation facility (mRS score 2-4). CONCLUSION: MAT using a syringe is a safe, fast, and more cost-effective approach than using an aspiration pump.

Food-Allergic Adolescents at Risk for Anaphylaxis: A Randomized Controlled Study of Supervised Injection to Improve Comfort with Epinephrine Self-Injection.

BACKGROUND: Epinephrine self-injection is a key element in the management of food allergy, yet many adolescents report that they may not be able to use the autoinjector when needed. We hypothesized that supervised self-injection with an empty syringe would increase adolescents' comfort with self-injection. OBJECTIVE: The objective of this study was to examine the effect of supervised self-injection on self- and parent-reported comfort and anxiety during and after clinic visits in a food allergy center. METHODS: Sixty adolescent/parent pairs were randomized to self-injection versus control (education only). The predefined primary outcome was a self-reported comfort level with the injection before versus after the intervention on a Likert scale with scores of 1 (Not at all comfortable) to 10 (Extremely comfortable). The primary outcome was evaluated via within-group and between-group analyses. Secondary outcomes included adolescent and parent reports before versus after the injection, and changes in quality of life (QoL) and anxiety a month later. RESULTS: Self-injection was associated with a significant immediate increase in comfort levels (primary outcome; within-group comparison: mean scores: 6.93 preintervention vs 8.37 postintervention, P < .01; between-group ANOVA: 8.37 vs 6.69, P < .01) and with significant improvements in all other predefined (secondary) measures. On follow-up, QoL improved in 52% of intervention patients as compared with 25% of controls; similar differences were observed for anxiety. Those differences were not statistically significant. CONCLUSIONS: A self-injection (with an empty syringe) procedure in a clinic setting improves adolescents' and parents' comfort level with self-injecting. It may translate into substantial clinical benefits should self-injection be needed.

Evolution of the global use of unsafe medical injections, 2000-2010.

OBJECTIVE: Since 1999, substantial efforts have been made by the international community to reduce the risks associated with unsafe injections, through ministries of health, international donors, the World Health Organization and the Safe Injection Global Network. The present study attempted to measure the progress, or lack thereof, made over the 2000-2010 decade in reducing unsafe injections in ten regions of the world corresponding to developing and transitional economies. METHODS: Data about the number of injections per person per year and the proportion of re-use of syringes and needles were obtained for 2010, mainly from population surveys, and compared with previous estimates for 2000 which had used various sources of information including injection safety assessments, population surveys and published studies on injection practices. RESULTS: From 2000 to 2010, in developing countries and transitional economies, the average number of injections per person per year decreased from 3.40 to 2.88, while the proportion of re-use of injection devices dropped from 39.8% to 5.5%. Combining both factors the number of unsafe injections per person per year decreased from 1.35 to 0.16. Even if substantial progress has been made, the Eastern Mediterranean region remains problematic, with 0.57 unsafe injections per person per year. In sub-Saharan Africa and Latin America, people now receive on average only 0.04-0.05 unsafe injections per year. CONCLUSION: Substantial progress has been made in reducing the number of unsafe injections in developing countries and transitional economies, essentially through a reduction in the re-use of injection devices. In some regions, elimination of unsafe injections might become a reasonable goal.

Real-world rates, predictors, and associated costs of hypoglycemia among patients with type 2 diabetes mellitus treated with insulin glargine: results of a pooled analysis of six retrospective observational studies.

OBJECTIVE: To evaluate the real-world rates of hypoglycemia and related costs among patients with type 2 diabetes mellitus (T2DM) who initiated insulin glargine with either a disposable pen or vial-and-syringe. METHODS: Pooled data were evaluated from six previously published, retrospective, observational studies using US health plan insurance claims databases to investigate adults with T2DM who initiated insulin glargine. The current study evaluated baseline characteristics, hypoglycemic events, and costs during the 6 months prior to and 12 months following insulin glargine initiation. Comparisons were made between patients initiating treatment with a disposable pen (GLA-P) and vial-and-syringe (GLA-V). Multivariate analyses using baseline characteristics as covariates determined predictors of hypoglycemia after initiating insulin glargine. RESULTS: This study included 23,098 patients (GLA-P: 14,911; GLA-V: 8187). Overall annual prevalence of hypoglycemia was low (6.3% overall, 2.2% related to hospital admission or emergency department visit). Prevalence was significantly lower with GLA-P (5.5% vs 7.7%; p < 0.0001). Furthermore, average glycated hemoglobin HbA1c reduction was higher with GLA-P (-1.22% vs -0.86%; p = 0.0012). The average annual hypoglycemia-related cost associated with initiating insulin glargine was $293, with GLA-P being 46% lower than GLA-V ($225 vs $417; p = 0.001). Patients who had already developed microvascular complications at the time of initiating insulin therapy were at higher risk for developing hypoglycemia. LIMITATIONS: This study is limited by the use of retrospective data and ICD-9-CM codes, which are subject to coding error. In addition, this pooled analysis used unmatched cohorts, with multivariate regression analyses employed to adjust for between-group differences. Finally, results describe a managed care sample and cannot be generalized to all patients with T2DM. CONCLUSIONS: Patients with T2DM initiating insulin glargine treatment showed low rates of hypoglycemia, especially when using a disposable pen device. Hypoglycemia-related costs were low, contributing a very small proportion to overall diabetes-related healthcare costs.

Healthcare professional and patient assessment of a new prefilled insulin pen versus two widely available prefilled insulin pens for ease of use, teaching and learning.

OBJECTIVE: FlexTouch * (FT) is a new prefilled insulin pen with no push-button extension at any set dose and a low activation force that is designed to improve ease of use and insulin administration. This paper reports the results of two usability studies assessing perceptions of FT compared with KwikPen † (KP)and SoloStar ‡ (SS) among healthcare professionals (HCPs; both physicians and nurses) and people with diabetes (both insulin pen-experienced and insulin pen-naïve). RESEARCH DESIGN AND METHODS: Participants were randomly assigned to start with FT or KP in one study and FT or SS in the other. Participants performed injections at different doses (20, 40 and 60 International Units [IU] in the FT vs. KP study or 20, 40 and 80 IU in the FT vs. SS study) into a foam cushion before answering questions on ease of use, teaching and learning, confidence and preference. RESULTS: A total of 59 people with diabetes and 61 HCPs took part in the FT vs. SS study, and 79 people with diabetes and 81 HCPs took part in the FT vs. KP study. Considerably more patients and HCPs rated FT as very/fairly easy to inject with than KP or SS, particularly at the maximum dose (≥80% vs. ≤38% and ≤23%, respectively), and more were very/rather confident in the ability to manage daily insulin injections with FT than KP or SS. Overall, FT was rated significantly higher for ease of teaching and learning to use than KP or SS (all p < 0.001 vs. FT), and was preferred for teaching and learning compared with KP or SS (≥39% vs. ≤4% and ≤6%, respectively). More patients and HCPs would recommend FT (≥95%) than KP (≤72%) or SS (≤71%). The same pattern was generally seen across physicians, nurses, insulin pen-experienced and pen-naïve participants. CONCLUSIONS: The findings suggest that devices such as FT are easy to use and can be prescribed with relatively few training needs, which may improve ease of insulin initiation, increase pen use, and ultimately improve treatment adherence. A limitation of the usability questionnaire used in this study is that it did not assess the factors that influence preference. Further analyses could be conducted to determine the factors that appeal to different users.

Randomized trial of bulb syringes for earwax: impact on health service utilization.

PURPOSE: Bulb syringes can be used for the self-clearance of earwax and, in the short term, appear effective. We compared the long-term effectiveness of self-irrigation using a bulb syringe with routine care in United Kingdom (UK) family practice clinics where irrigating ears to remove wax is a common procedure. METHODS: We assessed the impact on health service utilization as a follow-up to a single-blind, randomized, controlled trial of 237 patients attending 7 UK family practice clinics with symptomatic, occluding earwax who were randomized to an intervention group (ear drops, bulb syringe, instructions on its use and reuse) or a control group (ear drops, then clinic irrigation). After 2 years, a retrospective notes search for earwax-related consultations was carried out. We used an intention-to-treat analysis to assess differences in dichotomous outcomes between groups. RESULTS: In the 2-year trial follow-up, more control group patients returned with episodes of earwax: 85 of 117 (73%) control vs 70 of 117 (60%) intervention, χ(2)=4.30; P = .038; risk ratio 1.21 (95% CI, 1.01-1.37). The numbers of consultations amounted to 1.15 (control) vs 0.64 (intervention) (incidence rate ratio 1.79; 95% CI, 1.05-3.04, P = .032), ie, a difference of 0.50 consultations, thus saving a consultation on average for every 2 people. CONCLUSION: For patients who have not already tried bulb syringes, self-irrigation using a bulb syringe significantly reduces subsequent demand for ear irrigation by health professionals. Advocating the initial use of bulb syringes could reduce demand for ear irrigation in family practice clinics.

Is Vancouver Canada's supervised injection facility cost-saving?

OBJECTIVE: To determine whether Vancouver's Insite supervised injection facility and syringe exchange programs are cost-saving--that is, are the savings due to averted HIV-related medical care costs sufficient to offset Insite's operating costs? METHODS: The analyses examined the impact of Insite's programs for a single year. Mathematical models were used to calculate the number of additional HIV infections that would be expected if Insite were closed. The life-time HIV-related medical costs associated with these additional infections were compared to the annual operating costs of the Insite facility. RESULTS: If Insite were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in life-time HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year. CONCLUSIONS: Insite's safe injection facility and syringe exchange program substantially reduce the incidence of HIV infection within Vancouver's IDU community. The associated savings in averted HIV-related medical care costs are more than sufficient to offset Insite's operating costs.

Correlates of receptive and distributive needle sharing among injection drug users in Kabul, Afghanistan.

We describe receptive and distributive needle/syringe sharing among injection drug users (IDUs) in Kabul, Afghanistan. In this cross-sectional study, IDUs completed an interviewer-administered questionnaire. Logistic regression identified correlates of needle sharing in the last six months. Receptive and distributive sharing in the last six months were reported by 28.2% and 28.7% of participants, respectively, and were both independently associated with reported difficulty obtaining new syringes (Receptive sharing: AOR = 2.60, 95% CI: 1.66-4.06; Distributive: AOR = 1.56, 95% CI: 1.02-2.39). Receptive and distributive sharing are common among IDU in Kabul; scaling up availability of sterile, no-cost injecting equipment is urgently needed.

Health care costs and medication adherence associated with initiation of insulin pen therapy in medicaid-enrolled patients with type 2 diabetes: a retrospective database analysis.

BACKGROUND: Clinical, health, and economic outcomes in patients with type 2 diabetes may be influenced by self-management behaviors and type of pharmacotherapy. OBJECTIVE: This study examined differences in medication adherence and total health care costs among patients with type 2 diabetes who initiated or converted to insulin administration with a pen device in comparison with a vial/syringe as add-on therapy to oral antidiabetic drugs. METHODS: This study evaluated patients with type 2 diabetes who were enrolled in the North Carolina Medicaid program from September 24, 2001, to July 18, 2006. Patients receiving insulin with a vial/syringe who converted to pen therapy were compared with those who remained on vial/syringe in both unmatched comparisons (n = 560 and n = 9988, respectively) and after pair-matching (both cohorts, n = 560) with the use of propensity scores. In a second analysis, patients who initiated insulin with vial/syringe (n = 1162) were compared with a cohort that initiated insulin pen therapy (n = 168) after controlling for covariates in a multivariate regression model. All included patients had complete enrollment for at least 24 months of followup. Multiple linear regression models were used to predict the comparative impact on total health care costs and medication adherence for each cohort. Adjusted means were calculated to determine the group differences for each outcome. RESULTS: Diabetes-related and overall medication adherence was comparable for patients initiating insulin with a pen versus a syringe (53% vs 50% and 94% vs 94%, respectively). However, total annualized health care costs were significantly lower for patients using pen therapy than for those using a syringe ($14,857.42 vs $31,764.78, respectively; P < 0.05). Cost reductions with pen therapy were reflected in hospital costs ($1195.93 vs $4965.31, respectively; P < 0.05), diabetes-related costs ($7324.37 vs $13,762.21, respectively; P < 0.05), and outpatient costs ($7795.98 vs $13,103.51, respectively; P < 0.05). However, prescription costs of syringe were significantly lower ($535.70 vs $670.52; P < 0.05) and costs of pen were higher ($840.33 vs $0; P < 0.05) in patients who were switched from syringe to pen versus those who remained on syringe therapy. CONCLUSIONS: In a state Medicaid setting among patients with type 2 diabetes, initiating insulin therapy with a pen device was associated with comparable medication adherence and significant reductions in health care resource utilization and associated costs compared with vial/syringe insulin. Health care professionals and policy makers should consider the potential economic benefits of pen therapy when initiating insulin among Medicaid beneficiaries who fail to respond to oral antidiabetic drugs.

Lack of autodisable syringe use and health care indicators are associated with high HIV prevalence: an international ecologic analysis.

PURPOSE: A growing body of evidence strongly suggests that unsafe health care is an important factor driving the human immunodeficiency virus (HIV) epidemic in sub-Saharan Africa. We investigate whether nonuse of autodisable syringes and other health care indicators predict national HIV prevalence. METHODS: These ecologic analyses use countries as study units in descriptive analyses and regression analyses. Two sets of observations are used: (i) all low- and lower-middle-income countries, and (ii) all sub-Saharan African countries with available data. RESULTS: In the descriptive analysis, health care indicators (health expenditures, vaccination coverage, and use of autodisable syringes) have a U-shaped relationship with HIV prevalence in the larger sample. Greater density of physicians is associated with lower HIV prevalence. In sub-Saharan Africa, antenatal care coverage is associated with increasing HIV prevalence. In regression analyses, nonuse of autodisable syringes is associated robustly with greater HIV prevalence in all models. For the larger sample, greater HIV prevalence also is associated with higher Gini Index, less female economic activity, less urbanization, and less percentage of Muslims. In sub-Saharan Africa, tetanus vaccination coverage has a U-shaped association with HIV prevalence. Low physician density and percentage of Muslims are associated with HIV prevalence. Other economic and health care indicators and epidemic age are not significant correlates of HIV prevalence. CONCLUSIONS: This analysis adds to the other sources of evidence for health care transmission of HIV (in sub-Saharan Africa and regions with similar epidemiologic characteristics) by showing that health care indicators (failure to use autodisable syringes and greater tetanus coverage) are associated robustly with greater HIV prevalence. We recommend that resources be reallocated to address health care transmission of HIV/acquired immunodeficiency syndrome.

[Drug addiction: harm reduction policies in France and Spain]. / Toxicomanies: la politique de réduction des risques en France et en Espagne.

INTRODUCTION: Harm reduction policies, such as needle exchange programs, injection centers, and substitution treatments, attempt to reduce the health and social damage associated with illegal drug use. Such policies were introduced in France and Spain in response to the urgent health threat that AIDS posed to injecting drug users. METHOD: This analysis of harm reduction policies as of 2003, in France and Spain, includes a review of the literature and relevant legal and administrative provisions; collection of indicators likely to illustrate the health effects of these policies; analysis of available information and information systems, to examine comparability; and finally, comparison of these indicators. RESULTS: Differences between France and Spain led to easier integration of harm reduction into global drug policy in Spain, while there was some resistance to its acceptance in France. Nonetheless, impact indicators follow the same trends in both cases. Implementation of harm reduction policies has been followed by a reduction in injection practices, HIV prevalence, and deaths from overdoses among injecting drug users. The prevalence of HIV among this population has fallen substantially more in France than in Spain. DISCUSSION: The impact of harm reduction policies in France and Spain appears very positive, although any effect on Hepatitis C virus remains unclear, probably because of the virus's inherent characteristics of resistance and infectiousness. The reasons for the more marked difference in HIV prevalence in France may be that sharing practices are more widespread in Spain than in France, that the proportion of injecting drug users with HIV at the beginning of the epidemic was higher in Spain, or that the impact of substitution treatments has been stronger in France because of different modes of management.

[Reutilization of disposable syringes: frequency and costs for the administration of insulin at home]. / Reutilização de seringas descartáveis: freqüência e custos para administração de insulina no domicílio.

The present survey has the purpose to analyze the frequency and costs of the re-utilization of disposable syringes for insulin administration at home. One hundred and thirteen patients with diabetes assisted by a public hospital in a city in the interior São Paulo State, Brazil, were interviewed. The findings showed that regarding the studied population, the frequency of needles re-utilization varied from 1 to 20 times, and syringes re-utilization from 1 to 60 times. The greatest frequencies in the use of the same syringe or needle were of four times followed by three times. Re-utilizing the same syringe four times resulted in a cost reduction of 74.68%. The results pointed out the need for a legislation review as well as for new studies on the risks and benefits arising from this practice.

[Perfusion instruments: analysis of product surveillance in 1998 and its on-the-job training. Subcommittee 4b for Product Surveillance]. / Matériels de perfusion: le bilan de la matériovigilance en 1998 et ses enseignements pour la pratique. Sous-commission 4b de matériovigilance.

OBJECTIVES: To analyze retrospectively the data base of the French national vigilance reporting system concerning infusion devices during the year 1998. METHODS: Each report has been reviewed and classified, except implantable catheter ports. RESULTS: The study included 309 reports. Among them, 28% concerned infusion pumps and 72% single use devices, i.e. catheters, infusion lines, taps, connectors, etc. We observed six deaths and 23 severe incidents. Only 25% of devices could be formally investigated by manufacturers. The origins of incidents were very different between infusion pumps and single use devices. The first showed simple failures, software errors, maintenance omissions or errors, and problems related to obsolescence of the device. The second revealed manufacturer quality insurance failures, design and utilization errors, and problems related to the technique itself rather than device. DISCUSSION: Our findings are similar to the few data available in international literature. They address the need to obtain an adequacy between the performances of devices which vary with generations of devices and the clinical risks: newest and safest devices should be preferred for the infusion of the most critical drugs.

Do protective devices prevent needlestick injuries among health care workers?

OBJECTIVES: To determine the effectiveness and direct of two protective devices-a shielded 3 ml safety syringe (Safety-Lok; Becton Dickinson and Co., Becton Dickinson Division, Franklin Lakes, N.J.) and the components of a needleless IV system (InterLink; Baxter Healthcare Corp., Deerfield, Ill.)--in preventing needlestick injuries to health care workers. DESIGN: Twelve-month prospective, controlled, before-and-after trial with a standardized questionnaire to monitor needlestick injury rates. SETTING: Six hospital inpatient units, consisting of three medical units, two surgical units (all of which were similar in patient census, acuity, and frequency of needlesticks), and a surgical-trauma intensive care unit, at a 900-bed urban university medical center. PARTICIPANTS: All nursing personnel, including registered nurses, licensed practical nurses, nursing aides, and students, as well as medical teams consisting of an attending physician, resident physician, interns, and medical students on the study units. INTERVENTION: After a 6-month prospective surveillance period, the protective devices were randomly introduced to four of the chosen study units and to the surgical-trauma intensive care unit. RESULTS: Forty-seven needlesticks were reported throughout the entire study period, 33 in the 6 months before and 14 in the 6 months after the introduction of the protective devices. Nursing staff members who were using hollow-bore needles and manipulating intravenous lines accounted for the greatest number of needlestick injuries in the pre-intervention period. The overall rate of needlestick injury was reduced by 61%, from 0.785 to 0.303 needlestick injuries per 1000 health care worker-days after the introduction of the protective devices (relative risk = 1.958; 95% confidence interval, 1.012 to 3.790; p = 0.046). Needlestick injury rates associated with intravenous line manipulation, procedures with 3 ml syringes, and sharps disposal were reduced by 50%; however, reductions in these subcategories were not statistically significant. No seroconversions to HIV-1 or hepatitis B virus seropositivity occurred among those with needlestick injuries. The direct cost for each needlestick prevented was $789. CONCLUSIONS: Despite an overall reduction in needlestick injury rates, no statistically significant reductions could be directly attributed to the protective devices. These devices are associated with a significant increase in cost compared with conventional devices. Further studies must be concurrently controlled to establish the effectiveness of these devices.