Design of shared unit-dose drug distribution network using multi-level particle swarm optimization.

Unit-dose drug distribution systems provide optimal choices in terms of medication security and efficiency for organizing the drug-use process in large hospitals. As small hospitals have to share such automatic systems for economic reasons, the structure of their logistic organization becomes a very sensitive issue. In the research reported here, we develop a generalized multi-level optimization method - multi-level particle swarm optimization (MLPSO) - to design a shared unit-dose drug distribution network. Structurally, the problem studied can be considered as a type of capacitated location-routing problem (CLRP) with new constraints related to specific production planning. This kind of problem implies that a multi-level optimization should be performed in order to minimize logistic operating costs. Our results show that with the proposed algorithm, a more suitable modeling framework, as well as computational time savings and better optimization performance are obtained than that reported in the literature on this subject.

Impact of drug storage systems: a quasi-experimental study with and without an automated-drug dispensing cabinet.

OBJECTIVE: To compare the costs and benefits of an automated-drug dispensing cabinet (ADC) versus traditional floor stock storage (TFSS). DESIGN: A quasi-experimental multicenter study conducted during 2015. SETTING: A teaching hospital (814 beds) equipped with 43 ADCs and a not-for-profit teaching hospital (643 beds) equipped with 38 TFSS systems, in Paris, France. PARTICIPANTS: All the wards of the two hospitals were included in the study. INTERVENTION(S): ADC versus TFSS. MAIN OUTCOME MEASURE(S): A composite outcome composed of cost and benefits. RESULTS: The total cost with payback period was substantially higher for the ADCs (574 006€ for 41 ADCs) than TFSS (190 305€ for 30 TFSS systems). The mean number of costly drugs and units were significantly higher for ADCs (P < 0.001). There was no significant difference in the mean number of overall drugs and units. There were significantly fewer urgent global deliveries with ADCs than TFSS units. Nurses' satisfaction with ADCs was high and the prevalence of medication process errors related to ADCs was low. No event due to storage errors was reported for ADCs and nine events were reported for TFSS units. On the contrary, informatic-related events increased with the use of ADCs, as expected. CONCLUSIONS: Overall, ADCs are well-established in wards and are particularly appreciated by nurses. A significant difference in the initial investment cost was confirmed, but it must be adjusted over time. This difference is offset in the long-term by gains in preparation time and fewer medication process errors, securing the medication process.

A centralized automated-dispensing system in a French teaching hospital: return on investment and quality improvement.

OBJECTIVES: To evaluate the return on investment (ROI) and quality improvement after implementation of a centralized automated-dispensing system after 8 years of use. DESIGN: Prospective evaluation of ROI; before and after study to evaluate dispensing errors; user satisfaction questionnaire after 8 years of use. SETTING: The study was conducted at a French teaching hospital in the pharmacy department, which is equipped with decentralized automated medication cabinets in the wards. PARTICIPANTS: Pharmacy staff (technicians and residents). INTERVENTION(S): Implementation of a centralized automated-dispensing robot. MAIN OUTCOME MEASURE(S): The true ROI was prospectively and annually compared to estimated returns calculated after implementation and upgrade of the robot; dispensing errors determined by observation of global deliveries and the satisfaction of users based on a validated questionnaire were evaluated. RESULTS: Following the upgrade, we found little difference for the ROI (+1.86%). The payback period increased by almost 3 years. There was a significant reduction of dispensing errors, from 2.9% to 1.7% (P < 0.001). User satisfaction of the robot by the pharmacy staff was reported (score of 5.52 ± 1.20 out of 7). CONCLUSIONS: These systems are worthwhile investments and largely contribute to improving the quality and safety of the medication process.

[Retrocession, a profitable but risky activity]. / La rétrocession, une activité rentable mais à risques.

The retrocession (out-patient dispensing of hospital-reserved drugs)is a pharmaceutical critical activity requiring a care security with a territorial approach. In this drug supply chain, the pharmacist is the last step before the drug administration and the economic profitability is questionable. In this context, a risk mapping and an economic evaluation seem necessary. METHODS: The risk analysis was conducted with the adverse events collected. The economic study was realised with the point of view of the hospital and with the microcosting method. RESULTS: Six never events were observed with the risk analysis. The economic study showed that the retrocession was profitable in usual situations with a net margin from 7 to 14€. But, when an exceptional situation occurred as a troubleshooting or the creation of a public deal, the added costs became so important (76 and 85€) that the retrocession was an unbeneficial activity. CONCLUSION: The retrocession is an activity with a health, legal and economic high risk. In order to improve the healthcare quality and safety, the retrocession must be considered as a coordinated process. It means that the different health professionals must communicate with each other and that the connection between the ambulatory and the hospital care must be efficient.

Cost-Effectiveness Analysis of an Automated Medication System Implemented in a Danish Hospital Setting.

OBJECTIVES: To evaluate the cost-effectiveness of an automated medication system (AMS) implemented in a Danish hospital setting. METHODS: An economic evaluation was performed alongside a controlled before-and-after effectiveness study with one control ward and one intervention ward. The primary outcome measure was the number of errors in the medication administration process observed prospectively before and after implementation. To determine the difference in proportion of errors after implementation of the AMS, logistic regression was applied with the presence of error(s) as the dependent variable. Time, group, and interaction between time and group were the independent variables. The cost analysis used the hospital perspective with a short-term incremental costing approach. The total 6-month costs with and without the AMS were calculated as well as the incremental costs. The number of avoided administration errors was related to the incremental costs to obtain the cost-effectiveness ratio expressed as the cost per avoided administration error. RESULTS: The AMS resulted in a statistically significant reduction in the proportion of errors in the intervention ward compared with the control ward. The cost analysis showed that the AMS increased the ward's 6-month cost by €16,843. The cost-effectiveness ratio was estimated at €2.01 per avoided administration error, €2.91 per avoided procedural error, and €19.38 per avoided clinical error. CONCLUSIONS: The AMS was effective in reducing errors in the medication administration process at a higher overall cost. The cost-effectiveness analysis showed that the AMS was associated with affordable cost-effectiveness rates.

Automated drug dispensing systems in the intensive care unit: a financial analysis.

INTRODUCTION: To evaluate the economic impact of automated-drug dispensing systems (ADS) in surgical intensive care units (ICUs). A financial analysis was conducted in three adult ICUs of one university hospital, where ADS were implemented, one in each unit, to replace the traditional floor stock system. METHOD: Costs were estimated before and after implementation of the ADS on the basis of floor stock inventories, expired drugs, and time spent by nurses and pharmacy technicians on medication-related work activities. A financial analysis was conducted that included operating cash flows, investment cash flows, global cash flow and net present value. RESULTS: After ADS implementation, nurses spent less time on medication-related activities with an average of 14.7 hours saved per day/33 beds. Pharmacy technicians spent more time on floor-stock activities with an average of 3.5 additional hours per day across the three ICUs. The cost of drug storage was reduced by €44,298 and the cost of expired drugs was reduced by €14,772 per year across the three ICUs. Five years after the initial investment, the global cash flow was €148,229 and the net present value of the project was positive by €510,404. CONCLUSION: The financial modeling of the ADS implementation in three ICUs showed a high return on investment for the hospital. Medication-related costs and nursing time dedicated to medications are reduced with ADS.

Comprehensive Legislative Reform to Protect the Integrity of the 340B Drug Discount Program.

The 40B Drug Discount Program (340B Program) is a federally facilitated program that requires drug manufacturers to provide steep discounts on outpatient prescription drugs to qualifying safety net health care providers. The federal program is intended as a safeguard to ensure access to affordable drugs to the indigeut. However, over the last two decades safety net health care providers have exploited financial incentives under the 340B Program at the expense of drug manufacturers and patients, including the most needy and vulnerable populations-they are committed to serve. Although the federal government has been applauded for increasing effortsto combat health care fraud and abuse including recovering $3.3 billion in 2014, federal officials and the general public have paid markedly less attention to pervasive abuse of the 340B Program. In 2014, drug purchases of 340B-designated drugs totaled $7 billion and are expected to increase to $12 billion: by 2016 as a result of the expansion of the program under the Affordable Care Act. The 340B Program has completely lost its way, and comprehensive legislation is necessary to realign the program with its intent.

[Economic benefits of using a dose dispensing system at hospital units of the Mexican Institute of Social Security]. / Beneficios económicos del uso de un sistema de dispensación en dosis unitarias en hospitales del Instituto Mexicano del Seguro Social.

OBJECTIVE: To estimate the potential economic benefits at The Mexican Institute of Social Security (IMSS per its abbreviation in spanish) according to the drug expenditure of using drug dispensing system, based on literature information. MATERIALS AND METHODS: A systematic review was performed to identify savings from drugs and reduction of medication errors. The total and mean health expenditure by level of medical attention was calculated using the dispensed collective prescriptions at IMSS during 2009. Three savings scenarios were applied. RESULTS: The total drug savings were in a range of 870.49 Mexican million pesos to 4050.05 Mexican million pesos. Reductions of medication errors can contribute with additional savings up to 3455.56 Mexican million pesos. CONCLUSION: The drug dispensing system unit generates savings opportunities at the second and third level of attention. The maximum economic benefit was observed in the last level.

Analysis of the medication-use process in North American hospital systems: underlining key points for adoption to improve patient safety in French hospitals.

This project was designed to underline any actions relative to medication error prevention and patient safety improvement setting up in North American hospitals which could be implemented in French Parisian hospitals. A literature research and analysis of medication-use process in the North American hospitals and a validation survey of hospital pharmacist managers in the San Diego area was performed to assess main points of hospital medication-use process. Literature analysis, survey analysis of respondents highlighted main differences between the two countries at three levels: nationwide, hospital level and pharmaceutical service level. According to this, proposal development to optimize medication-use process in the French system includes the following topics: implementation of an expanded use of information technology and robotics; increase pharmaceutical human resources allowing expansion of clinical pharmacy activities; focus on high-risk medications and high-risk patient populations; develop a collective sense of responsibility for medication error prevention in hospital settings, involving medical, pharmaceutical and administrative teams. Along with a strong emphasis that should be put on the identified topics to improve the quality and safety of hospital care in France, consideration of patient safety as a priority at a nationwide level needs to be reinforced.

Using pharmacogenetics knowledge to increase accuracy of alerts for adverse drug events.

Adverse drug event (ADE) has significant implications on patient safety and is recognized as a major cause of fatalities and hospital expenses. Although some medical systems today can help reduce the number of ADE occurrences, these primarily take into account clinical factors-even though recent studies show the significance of genetic profiles in ADE detection. Incorporating pharmacogenetics knowledge and data from genetic test results into these systems can improve the accuracy of preliminary alerts about potential ADEs. However, pharmacogenetics knowledge is unstructured, making it inappropriate for use in a system that involves automatic processing. We propose a methodology that can help incorporate the pharmacogenetics knowledge. Specifically, we show how pharmacogenetics knowledge can be expressed in a medical system and used together with the patient genetic data to provide alerts about ADEs at the point of care.

Implementation of guidelines for sequential therapy with fluoroquinolones in a Belgian hospital.

OBJECTIVE: This study measured the impact of three interventions for physicians, in order to implement guidelines for sequential therapy (intravenous to oral conversion) with fluoroquinolones. SETTING: A Belgian university hospital with 1,065 beds. Method The first intervention consisted of the hospital-wide publication of guidelines in the local drug letter towards all prescribers. The consumption of fluoroquinolones was measured by means of an interrupted time-series (ITS) analysis 21 months before (period A) and 24 months after publication (period B). The second intervention was an educational interactive session, by infectious disease specialists, to the medical staff of orthopaedics and endocrinology. The third intervention comprised a proactive conversion programme on the abdominal surgery, gastro-enterology and plastic surgery wards, where pharmacists attached a pre-printed note with a suggestion to switch to an oral treatment every time a patient met the criteria for switching. The second and third intervention took place 6 months after the first intervention. Fluoroquinolone treatments were evaluated during a 2 month period before (group 1) and after the introduction of the second (group 2) and third (group 3) intervention. MAIN OUTCOME MEASURE: The monthly ratio of intravenous versus total fluoroquinolone consumption (daily defined doses per 1,000 bed days) was measured to assess the impact of the first intervention. The impact of the second and third intervention was measured in relation to the number of days that intravenous therapy continued beyond the day that the patient fulfilled the criteria for sequential therapy and the antibiotic cost. RESULTS: The ITS demonstrated a reduction of 3.3% in the ratio of intravenous versus total consumption after the publication of the guidelines (P = 0.011). In group 1, patients were treated intravenously for 4.1 days longer than necessary. This parameter decreased in group 2 to 3.5 days and in group 3 to 1.0 day (P = 0.006). The mean additional cost for longer intravenous treatment decreased from 188.0 euro in group 1, to 103.0 euro in group 2 and 44.0 euro in group 3 (P = 0.037). CONCLUSION: This study demonstrated that active implementation of guidelines is necessary. A proactive conversion programme by a pharmacist resulted in a reduction in the duration of the intravenous treatment, and the treatment cost.

Return on investment: a practical calculation tool to convince your institution.

Introduction: The significant investments necessary to integrate a new technology or service often create a financial barrier. To convince a hospital board to invest, it is important to demonstrate a return on investment (ROI). As many pharmacists are not used to estimating an ROI, this short report proposes a simple methodology and a free practical tool to download. Methods: Determining an ROI requires a calculation of all the expenses linked to the initial investments and the annual running costs of the equipment or service. When possible, real costs must be used in this calculation, but the costs of some parameters can only be estimated. The methodology involves three steps: (A) calculation of the initial balance (on shot costs and savings), (B) calculation of the annual balance (valid in the years after the investment) and (C) final calculation of time to recovery (duration until the initial investments are reimbursed by the annual savings) and ROI (the net benefit in euros at the end of the amortisation period). Results: This methodology was applied to the installation of automated dispensing cabinets in our hospital. The initial balance (€32 500±€4200) included equipment acquisition costs, installation costs and initial savings (stock-value reduction and non-investment in traditional ward pharmacy). The annual balance (€8622±3564) included amortisation and maintenance costs as well as human resources, medication, logistics and safety savings. We estimated a 3.8-year (min 2.7-max 6.4) time to recovery and an ROI of €36 476 (min €7964-max €64 988) after 8 years. Conclusions: Large investments for innovative equipment or service will be harder and harder to obtain if no economic evaluation is provided. The method proposed here is simple and provides useful input for discussions with a hospital board. The case study highlights a positive ROI related to automated dispensing cabinets.

Safety, time and cost evaluation of automated and semi-automated drug distribution systems in hospitals: a systematic review.

OBJECTIVES: To systematically review automated and semi-automated drug distribution systems (DDSs) in hospitals and to evaluate their effectiveness on medication safety, time and costs of medication care. METHODS: A systematic literature search was conducted in MEDLINE Ovid, Scopus, CINAHL and EMB Reviews covering the period 2005 to May 2016. Studies were included if they (1) concerned technologies used in the drug distribution and administration process in acute care hospitals and (2) reported medication safety, time and cost-related outcomes. RESULTS: Key outcomes, conclusions and recommendations of the included studies (n=30) were categorised according to the dispensing method: decentralised (n=19 studies), centralised (n=6) or hybrid system (n=5). Patient safety improved (n=27) with automation, and reduction in medication errors was found in all three systems. Centralised and decentralised systems were reported to support clinical pharmacy practice in hospitals. The impact of the medication distribution system on time allocation such as labour time, staffing workload or changes in work process was explored in the majority of studies (n=24). Six studies explored economic outcomes. CONCLUSIONS: No medication distribution system was found to be better than another in terms of outcomes assessed in the studies included in the systematic review. All DDSs improved medication safety and quality of care, mainly by decreasing medication errors. However, many error types still remained-for example, prescribing errors. Centralised and hybrid systems saved more time than a decentralised system. Costs of medication care were reduced in decentralised systems mainly in high-expense units. However, no evidence was shown that implementation of decentralised systems in small units would save costs. More comparable evidence on the benefits and costs of decentralised and hybrid systems should be available. Changes in processes due to a new DDS may create new medication safety risks; to minimise these risks, training and reallocation of staff resources are needed.

Implementation of a pharmacy automation system (robotics) to ensure medication safety at Norwalk hospital.

This article reports an intervention to improve the quality and safety of hospital patient care by introducing the use of pharmacy robotics into the medication distribution process. Medication safety is vitally important. The integration of pharmacy robotics with computerized practitioner order entry and bedside medication bar coding produces a significant reduction in medication errors. The creation of a safe medication-from initial ordering to bedside administration-provides enormous benefits to patients, to health care providers, and to the organization as well.

[Drug supply chain safety in hospitals: current data and experience of the Grenoble university hospital]. / La sécurisation du circuit du médicament dans les établissements de santé : données actuelles et expérience du centre hospitalier universitaire de Grenoble.

Drug supply chain safety has become a priority for public health which implies a collective process. This process associates all health professionals including the pharmacist who plays a major role. The objective of this present paper is to describe the several approaches proven effective in the reduction of drug-related problem in hospital, illustrated by the Grenoble University Hospital experience. The pharmacist gets involved first in the general strategy of hospital drug supply chain, second by his direct implication in clinical activities. The general strategy of drug supply chain combines risk management, coordination of the Pharmacy and Therapeutics Committee, selection and purchase of drugs and organisation of drug supply chain. Computer management of drug supply chain is a major evolution. Nominative drug delivering has to be a prior objective and its implementation modalities have to be defined: centralized or decentralized in wards, manual or automated. Also, new technologies allow the automation of overall drug distribution from central pharmacy and the implementation of automated drug dispensing systems into wards. The development of centralised drug preparation allows a safe compounding of high risk drugs, like cytotoxic drugs. The pharmacist should develop his clinical activities with patients and other health care professionals in order to optimise clinical decisions (medication review, drug order analysis) and patients follow-up (therapeutic monitoring, patient education, discharge consultation).

Implementing technologies to prevent medication errors at a high-complexity hospital: analysis of cost and results.

OBJECTIVE: To calculate the cost and assess the results on implementing technological resources that can prevent medication errors. METHODS: A retrospective, descriptive-exploratory, quantitative study (2007-2015), in the model of case study at a hospital in the Brazilian Southeastern Region. The direct cost of each technology was calculated in the drug chain. Technological efficacy was observed from the reported series of the indicator incidence of medication errors. RESULTS: Thirteen technologies were identified to prevent medication errors. The average cost of these technologies per year in the prescription stage was R$ 3.251.757,00; in dispensing, R$ 2.979.397,10; and in administration, R$ 4.028.351,00. The indicator of medication error incidence decreased by 97.5%, gradually between 2007 to 2015, ranging from 2.4% to 0.06%. CONCLUSION: The average cost per year of the organization to implement preventive technologies in the drug chain totaled up R$ 10.259.505,10. There was an average investment/year of R$ 55,72 per patient and its association with smaller indicator of incidence of medication errors confirms a satisfactory result in this reported series regarding such investment.

Cost-benefit analysis of a hospital pharmacy bar code solution.

BACKGROUND: Bar coding can reduce hospital pharmacy dispensing errors, but it is unclear if the benefits of this technology justify its costs. The purpose of this study was to assess the costs and benefits and determine the return on investment at the institutional level for implementing a pharmacy bar code system. METHODS: We performed a cost-benefit analysis of a bar code-assisted medication-dispensing system within a large, academic, nonprofit tertiary care hospital pharmacy. We took the implementing hospital's perspective for a 5-year horizon. The primary outcome was the net financial cost and benefit after 5 years. The secondary outcome was the time until total benefits equaled total costs. Single-variable, 2-variable, and multiple-variable Monte Carlo sensitivity analyses were performed to test the stability of the outcomes. RESULTS: In inflation- and time value-adjusted 2005 dollars, total costs during 5 years were $2.24 million ($1.31 million in 1-time costs during the initial 3.5 years and $342 000 per year in recurring costs starting in year 3). The primary benefit was a decrease in adverse drug events from dispensing errors (517 events annually), resulting in an annual savings of $2.20 million. The net benefit after 5 years was $3.49 million. The break-even point for the hospital's investment occurred within 1 year after becoming fully operational. A net benefit was achieved within 10 years under almost all sensitivity scenarios. In the Monte Carlo simulation, the net benefit during 5 years was $3.2 million (95% confidence interval, -$1.2 million to $12.1 million), and the break-even point for return on investment occurred after 51 months (95% confidence interval, 30 to 180 months). CONCLUSION: Implementation of a bar code-assisted medication-dispensing system in hospital pharmacies can result in a positive financial return on investment for the health care organization.

Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting.

INTRODUCTION: Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice. METHODS: The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period. RESULTS: With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation. CONCLUSION: The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.

Hospital protocols for targeted glycemic control: Development, implementation, and models for cost justification.

PURPOSE: Evolving elements of best practices for providing targeted glycemic control in the hospital setting, clinical performance measurement, basal-bolus plus correction-dose insulin regimens, components of standardized subcutaneous (s.c.) insulin order sets, and strategies for implementation and cost justification of glycemic control initiatives are discussed. SUMMARY: Best practices for targeted glycemic control should address accurate documentation of hyperglycemia, initial patient assessment, management plan, target blood glucose range, blood glucose monitoring frequency, maintenance of glycemic control, criteria for glucose management consultations, and standardized insulin order sets and protocols. Establishing clinical performance measures, including desirable processes and outcomes, can help ensure the success of targeted hospital glycemic control initiatives. The basal-bolus plus correction-dose regimen for insulin administration will be used to mimic the normal physiologic pattern of endogenous insulin secretion. Standardized insulin order sets and protocols are being used to minimize the risk of error in insulin therapy. Components of standardized s.c. insulin order sets include specification of the hyperglycemia diagnosis, finger stick blood glucose monitoring frequency and timing, target blood glucose concentration range, cutoff values for excessively high or low blood glucose concentrations that warrant alerting the physician, basal and prandial or nutritional (i.e., bolus) insulin, correction doses, hypoglycemia treatment, and perioperative or procedural dosage adjustments. The endorsement of hospital administrators and key physician and nursing leaders is needed for glycemic control initiatives. Initiatives may be cost justified on the basis of the billings for clinical diabetes management services and/or the return- on-investment accrued to reductions in hospital length of stay, readmissions, and accurate documentation and coding of unrecognized or uncontrolled diabetes, and diabetes complications. CONCLUSION: Standardized insulin order sets and protocols may minimize risk of insulin errors. The endorsement of these protocols by administrators, physicians, nurses, and pharmacists is also needed for success.