Healthcare supply chain risk management in Rio de Janeiro, Brazil: What is the current situation?

BACKGROUND: Public hospital managers in Rio de Janeiro must deal with severe budget costs, which is the only source of income of public hospitals. In this sense, systematic supply chain risk management can contribute to identifying such risks, assessing their severity, and developing mitigating plans, or even revealing the lack of such plans. Private hospital networks must also map their risks since they are facing a diminishing of demand given that unemployment in Brazil, which is growing in the past years, generates an impossibility of affording private healthcare. OBJECTIVE: The purpose of this paper is to investigate how supply chain risk management is being applied in healthcare supply chains from Rio de Janeiro - Brazil. This study considers supply chains located in the state of Rio de Janeiro. To accomplish this objective, we provide answers to two Research Questions: RQ1 - Is SCRM known as a concept among Rio de Janeiro healthcare supply chains? RQ2 - How are risk identification, risk assessment, and risk mitigation being implemented by companies from the healthcare supply chains in Rio de Janeiro - Brazil? METHOD: Our research design is based on four steps: i) Research design; ii) Case selection: iii) Data collection (11 cases selected); iv) Data analysis. RESULTS: The interviews revealed that SCRM is an entirely unknown concept among healthcare supply chains from Rio de Janeiro - Brazil. Managers have empirical knowledge of the risks, and they can identify the most hazardous risks and can come up with solutions to mitigate them, nevertheless, in many situations they do not have the authority or the manpower to implement the solutions, at most, managers implement local risk mitigation initiatives that do not consider the supply chains broader context. CONCLUSION: The healthcare organizations studied by this paper do not apply SCRM. They only apply local isolated solutions not considering a supply chain scope. This can become hazardous since isolated risk mitigation initiatives are often innocuous and have the potential to generate other risks.

Principles of supply chain management in the time of crisis.

Hospitals face catastrophic financial challenges in light of the coronavirus disease 2019 (COVID-19) pandemic. Acute shortages in materials such as masks, ventilators, intensive care unit capacity, and personal protective equipment (PPE) are a significant concern. The future success of supply chain management involves increasing the transparency of where our raw materials are sourced, diversifying of our product resources, and improving our technology that is able to predict potential shortages. It is also important to develop a proactive budgeting strategy to meet supply demands through early designation of dependable roles to support organizations and through the education of healthcare staff. In this paper, we discuss supply chain management, governance and financing, emergency protocols, including emergency procurement and supply chain, supply chain gaps and how to address them, and the importance of communication in the times of crisis.

Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya.

BACKGROUND: Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya. METHODOLOGY/PRINCIPAL FINDINGS: This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible. CONCLUSIONS: Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures.

OBJECTIVE: The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. SUMMARY BACKGROUND DATA: Reducing surgical costs is paramount to the viability of hospitals. METHODS: Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons. RESULTS: The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy. CONCLUSIONS: Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

The Crosscutting Benefits of Hospital Emergency Preparedness Investments to Daily Operations: A Hospital Senior Leadership Perspective.

Hospitals are an integral part of community resiliency during and after a disaster or emergency event. In addition to community-level planning through healthcare coalitions, hospitals are required to test and update emergency plans to comply with accreditation standards at their own expense. Justifying costs related to investments in emergency preparedness can be a barrier, as these events are relatively rare. Little is known about the crosscutting benefits of investments in daily operations including patient care. This study investigated whether hospital investments in emergency preparedness had a perceived impact on daily operations from a senior leadership perspective. Using a cross-sectional study design, a 39-item survey was emailed and mailed to chief executive officers of all 105 Nebraska hospitals. Most respondents indicated that drills and exercises, staff training, and updating emergency plans had a positive impact on daily operations. A relatively small proportion (≤11%) of respondents indicated that costs of buying decontamination equipment, personal protective equipment, and costs associated with staff training and drills/exercises had a negative impact on daily operations. No differences were noted between rural and urban locations or between hospitals that allocate funds in the budget versus those that do not. The majority of hospitals in our study are likely to continue to invest over the next 3 years, inferring a sincere commitment by hospital senior leadership to continue to invest in emergency preparedness. Future research using longitudinal design and objective measures of investments and daily benefits is needed to support a business case for hospital preparedness.

COVID-19: Implications for Supply Chain Management.

The COVID-19 pandemic has created global health and economic disruption. Hospitals and other healthcare providers have been hit particularly hard. While efforts to effectively treat and eradicate the coronavirus continue, so do the efforts of supply chains to support the provision of patient care in the event of a resurgence or future pandemic. Supply chain leaders must continuously evaluate their strategic and tactical positions to address critical supply needs. Whether the supply chain can meet expectations remains uncertain, given rolling supply shortages of personal protective equipment (PPE) and other medical-surgical supplies as healthcare providers resume prepandemic levels of operations. The ability to ensure a reliable, sustainable supply of critical PPE in the near term will remain a challenge. Longer-term substantive changes to the function and performance of healthcare supply chains will be necessary across multiple areas to meet demand more effectively during a crisis.

Achieving Surgical Supply Savings through Preference Card Standardization.

Among high volume procedures considerable variation exists in the average cost per case (ACPC) of surgical supplies used between surgeons. A contributing factor to these cost differences are divergences in surgeons' preference cards, which act as a guide to hospital staff for the supplies a surgeon requires to successfully perform a procedure. This article documents efforts and results of an initiative to standardize preference cards for Laparoscopic Cholecystectomies. Data collected for this project outlined differences between surgeon's preference card composition, utilization of selected supplies and associated procedure costs. Reports were developed that grouped surgical supplies based on United Nations Standard Products and Services Code (UNSPC) product classes and highlighted classes with the highest per case standard deviations. Based on these findings and feedback from clinical partners, a composite set of supplies for use across all preference cards was developed in conjunction with the Chief of General Surgery. The net result of moving to a standardized set of supplies was an estimated $21,650 in annual supply expenses associated with Laparoscopic Cholecystectomies. Results suggest that standard deviation-based reports organized by product class facilitate effective surgeon-to-surgeon comparisons and make apparent readily available supply substitutes that are less expensive.

Cost Analysis of Vaginal Anti-incontinence Procedures at a Tertiary Care Center.

OBJECTIVE: To compare the cost of 3 vaginal procedures used in the surgical management of stress urinary incontinence (SUI) at 1 tertiary institution. METHODS: The costs of autologous fascial sling (AFS), synthetic mid-urethral sling (MUS), and anterior vaginal wall suspension (AVWS) were analyzed from a prospective long-term database, with follow-up to 5 years after these procedures. Original costing data were obtained for operating room, medical and surgical supplies, pharmacy, anesthesia supplies, and room and bed over 2 consecutive years. Included were complete cost data provided by our institution from Medicare (2012) and private payer insurance. RESULTS: For the year 2013, the AVWS, AFS, and MUS had total median costs of $4513, $5721, and $3311, respectively. Total cost and all subcosts except for pharmacy costs were significantly different for each procedure. AVWS and MUS placement differed from each other regarding the cost of anesthesia and hospital stay, which was higher for AVWS. Compared to AFS, AVWS had significantly lower total costs due to decreased costs associated with operating time, hospital stay, and surgical supplies (P <.0001). At 5 years after these procedures, synthetic slings had less frequent follow-up visits. The most common revision for SUI failure was a bulking agent injection. CONCLUSION: Initial costs of vaginal SUI procedures at our institution fared favorably compared to SUI procedures reported in the contemporary US literature. Long-term costs can vary based on physician preference in follow-up routine and etiology of SUI.

Cost analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and the risk factors for their increased cost in a public insurance health care system - Single centre study.

INTRODUCTION: This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC. MATERIALS AND METHODS: We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services. RESULTS: The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I-V Clavien-Dindo complications (p < 0.001) were independently associated with increased costs. CONCLUSION: The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

Is "free" really free? Ethical implications of short-term discounts and giveaways to hospitals.

Canadian hospitals participate in provincial and national procurement processes to help reduce healthcare costs. This allows for redirection of funds to direct patient care, along with creating networks, integrating services, and improving innovative solutions. To be competitive, vendors offer creative solutions and provide free or low-cost supplies to hospitals with the hope that patients will continue to purchase those items when discharged. What is not always factored into the procurement decision-making processes is the potential financial impact of the supplies required for patients when discharged from hospital services and other ethical implications of accepting free/reduced-cost supplies. This column provides some guidance for health leaders in this respect.

Cost-Effectiveness of Exploratory Laparotomy in a Regional Referral Hospital in Eastern Uganda.

BACKGROUND: Surgical disease increasingly contributes to global mortality and morbidity. The Lancet Commission on Global Surgery found that global cost-effectiveness data are lacking for a wide range of essential surgical procedures. This study helps to address this gap by defining the cost-effectiveness of exploratory laparotomies in a regional referral hospital in Uganda. MATERIALS AND METHODS: A time-and-motion analysis was utilized to calculate operating theater personnel costs per case. Ward personnel, administrative, medication, and supply costs were recorded and calculated using a microcosting approach. The cost in 2018 US Dollars (USD, $) per disability-adjusted life year (DALY) averted was calculated based on age-specific life expectancies for otherwise fatal cases. RESULTS: Data for 103 surgical patients requiring exploratory laparotomy at the Soroti Regional Referral Hospital were collected over 8 mo. The most common cause for laparotomy was small bowel obstruction (32% of total cases). The average cost per patient was $75.50. The postoperative mortality was 11.7%, and 7.8% of patients had complications. The average number of DALYs averted per patient was 18.51. The cost in USD per DALY averted was $4.08. CONCLUSIONS: This investigation provides evidence that exploratory laparotomy is cost-effective compared with other public health interventions. Relative cost-effectiveness includes a comparison with bed nets for malaria prevention ($6.48-22.04/DALY averted), tuberculosis, tetanus, measles, and polio vaccines ($12.96-25.93/DALY averted), and HIV treatment with multidrug antiretroviral therapy ($453.74-648.20/DALY averted). Given that the total burden of surgically treatable conditions in DALYs is more than that of malaria, tuberculosis, and HIV combined, our findings strengthen the argument for greater investment in primary surgical capacity in low- and middle-income countries.

A simulation model to evaluate pharmaceutical supply chain costs in hospitals: the case of a Colombian hospital.

BACKGROUND: Healthcare costs is one of the most studied issue in our days because of increasing demand and the aging of population. Final costs of medicines is one of the most important issue in patient treatment and determine its real value is an important task within hospitals. Simulation models and in this case system dynamics allows to build representations of reality considering the interaction of the whole variables that affect the system where first a causal loop diagram allows to represent and identify the interaction between variables for develop a stock flow diagram to determine the final results. OBJECTIVE: Develop a simulation model that allows decision makers in Hospitals and Governments to identify the variables that affect the final cost of medicines and to determine the legal reimbursement allowed by national agencies. METHODS: This paper presents a conceptual modeling framework using a causal loop diagram and a dynamic simulation model in the real case of a hospital in Colombia to explore how different internal charges for medicines affect the behavior of the final unit-dose cost of medicines, considering the complexity of the pharmaceutical system. We developed a simulation model to represent and characterize the pharmaceutical supply chain in a hospital and by using real data we validate the results of the model and conclude about the supply chain of medicines in Colombia using the legal regulations as a main factor of analysis. RESULTS AND CONCLUSIONS: We found that in some cases the maximum reimbursement value is less than the final cost of medicines within the hospital, which means that hospitals lose money on the administration of medicines to patients. The benefit of this model is that with the result the hospital can determine the real final monetary value of medicines, including the different processes starting from the reception of the medicines, ending with the administration to patients.

Innovation Procurement in Health Systems: Exploring Practice and Lessons Learned.

As rising healthcare costs continue to challenge the sustainability of global health systems, there has been a strategic shift toward a focus on value, which considers the outcomes and value of healthcare delivery relative to the costs of care delivery. A unique feature of this focus on value has influenced a shift in procurement whereby health organizations are advancing the procurement of innovative solutions to achieve defined outcomes that overcome challenges such as the quality, safety and cost of care delivery. In this paper, we report on the implementation of three innovation procurement models in four Ontario healthcare organizations. These case studies provide evidence of the value and impact of innovation procurement approaches emerging from the four healthcare organizations. Three models of innovation procurement are described in the four cases, along with qualitative analysis of experiences and outcomes for both the organizations and the participating vendors. Evidence of the value and impact of procuring innovative solutions to address health organization challenges offers insights and new approaches to leveraging public procurement methodologies to achieve value and impact for health systems.

Development of a screening eye clinic for Ebola virus disease survivors: Lessons learned and rapid implementation at ELWA Hospital in Monrovia, Liberia 2015.

BACKGROUND: In the wake of the West African Ebola virus disease (EVD) outbreak of 2014-2016, thousands of EVD survivors began to manifest a constellation of systemic and ophthalmic sequelae. Besides systemic arthralgias, myalgias, and abdominal pain, patients were developing uveitis, a spectrum of inflammatory eye disease leading to eye pain, redness, and vision loss. To investigate this emerging eye disease, resources and equipment were needed to promptly evaluate this sight-threatening condition, particularly given our identification of Ebola virus in the ocular fluid of an EVD survivor during disease convalescence. METHODOLOGY/PRINCIPAL FINDINGS: A collaborative effort involving ophthalmologists, infectious disease specialists, eye care nurses, and physician leadership at Eternal Love Winning Africa (ELWA) Hospital in Liberia led to the development of a unique screening eye clinic for EVD survivors to screen, treat, and refer patients for more definitive care. Medications, resources, and equipment were procured from a variety of sources including discount websites, donations, purchasing with humanitarian discounts, and limited retail to develop a screening eye clinic and rapidly perform detailed ophthalmologic exams. Findings were documented in 96 EVD survivors to inform public health officials and eye care providers of the emerging disease process. Personal protective equipment was tailored to the environment and implications of EBOV persistence within intraocular fluid. CONCLUSIONS/SIGNIFICANCE: A screening eye clinic was feasible and effective for the rapid screening, care, and referral of EVD survivors with uveitis and retinal disease. Patients were screened promptly for an initial assessment of the disease process, which has informed other efforts within West Africa related to immediate patient care needs and our collective understanding of EVD sequelae. Further attention is needed to understand the pathogensis and treatment of ophthalmic sequelae given recent EVD outbreaks in West Africa and ongoing outbreak within Democratic Republic of Congo.

Effects of a Surgical Receipt Program on the Supply Costs of Five General Surgery Procedures.

BACKGROUND: Surgical supplies occupy a large portion of health care expenditures but is often under the surgeon's control. We sought to assess whether an automated, surgeon-directed, cost feedback system can decrease supply expenditures for five common general surgery procedures. MATERIALS AND METHODS: An automated "surgical receipt" detailing intraoperative supply costs was generated and emailed to surgeons after each case. We compared the median cost per case for 18 mo before and after implementation of the surgical receipt. We controlled for price fluctuations by applying common per-unit prices in both periods. We also compared the incision time, case length booking accuracy, length of stay, and postoperative occurrences. RESULTS: Median costs decreased significantly for open inguinal hernia ($433.45 to $385.49, P < 0.001), laparoscopic cholecystectomy ($886.77 to $816.13, P = 0.002), and thyroidectomy ($861.21 to $825.90, P = 0.034). Median costs were unchanged for laparoscopic appendectomy and increased significantly for lumpectomy ($325.67 to $420.53, P < 0.001). There was an increase in incision-to-closure minutes for open inguinal hernia (71 to 75 min, P < 0.001) and laparoscopic cholecystectomy (75 to 96 min, P < 0.001), but a decrease in thyroidectomy (79 to 73 min, P < 0.001). There was an increase in booking accuracy for laparoscopic appendectomy (38.6% to 55.0%, P = 0.001) and thyroidectomy (32.5% to 48.1%, P = 0.001). There were no differences in postoperative occurrence rates and length of stay duration. CONCLUSIONS: An automated surgeon-directed surgical receipt may be a useful tool to decrease supply costs for certain procedures. However, curtailing surgical supply costs with surgeon-directed cost feedback alone is challenging and a multimodal approach may be necessary.

Impact of Medicaid Restrictions on Availability of Buprenorphine in Addiction Treatment Programs.

OBJECTIVES: To examine how utilization restrictions on state Medicaid benefits for buprenorphine are related to addiction treatment programs' decision to offer the drug. METHODS: We used data from 2 waves of the National Drug Abuse Treatment System Survey conducted in 2014 and 2017 in the United States to assess the relationship of utilization restrictions to buprenorphine availability. RESULTS: The proportion of programs offering buprenorphine was 43.2% in states that did not impose any utilization restrictions, 25.5% in states that imposed only annual limits, 17.3% in states that imposed only prior authorization, and 12.8% in states that imposed both. Programs in states requiring prior authorization from Medicaid had substantially lower odds of offering buprenorphine (odds ratio = 0.50; 95% confidence interval = 0.29, 0.87). CONCLUSIONS: Medicaid prior authorization was linked to lower odds of buprenorphine provision among addiction treatment programs. Public Health Implications. State Medicaid prior authorization requirements are linked to reduced odds of buprenorphine provision among addiction treatment programs and may discourage prescribing.

A Surgeon Scorecard Is Associated with Improved Value in Elective Primary Hip and Knee Arthroplasty.

BACKGROUND: Despite increasing interest in total joint arthroplasty registries, evidence of the impact of physician-level performance on the value of care provided to patients undergoing hip and knee arthroplasty is lacking. The purpose of this study was to examine the effectiveness of an unblinded orthopaedic surgeon-specific value scorecard in improving patient outcomes and reducing hospital costs. METHODS: We retrospectively analyzed patient outcomes and hospital costs associated with total joint arthroplasties before and 9 months after the introduction of a Surgeon Value Scorecard at an urban tertiary care center. From August 2016 to May 2017, orthopaedic surgeons received an unblinded monthly Surgeon Value Scorecard summarizing a rolling 6-month view of results by surgeon for patients attributed to Diagnosis Related Group 470 (major lower-extremity arthroplasty without comorbidity or complication). Prior to implementation, surgeons were educated on the scorecard and participated in the development of a document outlining the definition and calculation of included metrics. Scorecard metrics were grouped into 5 categories: patient demographic characteristics, patient outcomes (for example, length of stay, discharge disposition, readmissions), patient experience, financial, and operational (for example, operative times). Financial (cost) measures and patient outcomes were selected as the key performance indicators analyzed in this study. Continuous variables were analyzed using the t test when a normal distribution was assumed and using Mann-Whitney tests when a non-normal distribution was assumed. Categorical variables were compared using chi-square tests. Significance was defined as p < 0.05. RESULTS: After 9 months of unblinded Surgeon Value Scorecard distribution, the mean total costs for total joint arthroplasties decreased by 8.7%, from $17,996 to $16,426 (p < 0.001). The mean total direct variable costs decreased by 17.1% from $10,945 to $9,070 (p < 0.001), and implant costs decreased by 5.3% (p < 0.001). Length of stay also decreased by 0.2 day to 1.7 days (p < 0.001), and, although there was improvement in the home-discharge rate, 30-day readmission rate, and 90-day readmission rate, the differences were not significant (p > 0.05). CONCLUSIONS: The implementation of a surgeon-specific value scorecard for lower-extremity joint arthroplasties was associated with reduced total and direct variable hospital costs, reduced implant costs, decreased variation in costs, and reduced postoperative length of stay, without compromising clinical outcomes. CLINICAL RELEVANCE: Sharing unblinded clinical and financial outcomes with surgeons may promote a culture of shared accountability and may empower surgeons to improve value-based decision-making in care delivery.