Cost Savings and Waste Reduction Through Redispensing Unused Oral Anticancer Drugs: The ROAD Study.

Importance: New strategies targeting waste are required to improve financial and ecologic sustainability of expensive therapies, such as oral anticancer drugs, that frequently remain unused by patients. Redispensing unused oral anticancer drugs seems to be a promising strategy when drug quality is guaranteed. Objectives: To determine the waste reduction and net cost savings attained by redispensing oral anticancer drugs that go unused by patients compared with the standard practice of disposal. Design, Settings, and Participants: The ROAD study was a prospective single-group intervention conducted in the outpatient pharmacies of 4 hospitals in the Netherlands from February 1, 2021, to February 1, 2023, with 12-month follow-up of each patient. Patients with cancer and who had a prescription for an oral anticancer drug that could be stored at room temperature were included. Of 2426 eligible patients, 602 did not consent and 601 did not respond. Data analyses were performed from August 25, 2022, to April 19, 2023. Intervention: Participants received oral anticancer drugs for use at home in special packaging (ie, sealed packaging with time-temperature indicator), to be returned to the pharmacy should these remain unused. The pharmacy ensured quality of returned drugs based on authenticity, appearance, remaining shelf life and adequate storage temperature. Drugs fulfilling quality requirements were redispensed to other patients. Main Outcome and Measure: Total waste reduction and mean net annual cost savings per patient compared with the standard practice of disposal. Optimization of cost savings was explored by introducing variations in the quality assurance procedure and patient population. All analyses used the average exchange rate for 2021 €1 = US $1.18. Results: Of 1223 patients with cancer who consented, 1071 participated (median [IQR] age, 70 [62-75] years; 622 [58.1%] were male). In all, 171 patients (16.0%; 95% CI, 13.8%-18.3%) returned 335 unused oral anticancer drug packages. Of the returned drugs, 228 packages were redispensed, which reduced waste by 68.1% (95% CI, 67.7%-68.5%) compared with the standard practice (disposal). Redispensing unused oral anticancer drugs comprised 2.4% (95% CI, 2.2%-2.5%) of total drug costs, providing mean net annual cost savings of US $680 (95% CI, $524-$837) up to $1591 (95% CI, $1226-$2002) per participant. Conclusions and Relevance: The findings of this multicenter intervention study indicate that redispensing unused oral anticancer drugs is associated with waste reduction and cost savings, which in turn may improve the affordability and sustainability of cancer treatment. Trial Registration: World Health Organization International Clinical Trials Registry Platform Identifier: NL9208.

Barriers and facilitators to implement the redispensing of unused oral anticancer drugs in clinical care: A hybrid-effectiveness type I study.

Background: Minimizing medication waste through the redispensing of oral anticancer drugs (OADs) that were unused by patients provides economic and environmental benefits, but this is not yet universally implemented in clinical care. ObjectiveS: To identify barriers and facilitators to the implementation of redispensing unused OADs in clinical care. Methods: A multicentre intervention study following a hybrid effectiveness-implementation type I design was conducted, consisting of semi-structured interviews with key stakeholders involved in the redispensing program: pharmacy employees, prescribing clinicians in oncology and haematology, patients who participated in redispensing and patients who declined trial participation. Questions encompassed experiences and suggestions for future implementation. The Consolidated Framework for Implementation Research (CFIR) guided data collection and categorisation of identified barriers and facilitators through thematic analysis. Results: In total, 35 interviews were conducted, identifying 15 themes encompassing barriers and facilitators, reflecting all CFIR domains. Facilitators encompassed: 1) convenient process requiring an acceptable time-investment; 2) support from project leaders and implementation champions; 3) being well-motivated by personal values and societal impact; 4) feeling ensured of medication quality upon redispensing; 5) endorsement by healthcare providers for patient participation; 6) clear and personal patient communication; 7) good visibility of intervention successes; and 8) implementation well supported through a collaborative network. Barriers encompassed: 1) unclear target population; 2) redispensing legally prohibited; 3) absence of financial compensation for pharmacies; 4) complexity arising from two parallel work processes; 5) widespread communication on adjustments within local teams challenging; 6) patient's low receptiveness due to burden of oncology treatment; and 7) lack of familiarization among pharmacy technicians. Conclusions: Facilitators for implementation of redispensing unused drugs mainly related to people's values, motivation, and societal demand, whereas barriers mainly encompassed practical issues, including knowledge, time, financial resources, and legal conditions. Strategies emphasizing the benefits of redispensing and further streamlining process compatibility could support implementation.

Environmental Outcomes of Reducing Medication Waste by Redispensing Unused Oral Anticancer Drugs.

Importance: Medications are associated with substantial environmental outcomes, yet frequently end up being unused by patients. Waste-minimizing interventions, such as redispensing of quality-approved oral anticancer drugs remaining unused by patients at home, could reduce the environmental footprint of cancer treatment. Objectives: To assess the environmental outcomes of redispensing quality-assured oral anticancer drugs and to explore how redispensing could be environmentally optimized. Design, Setting, and Participants: In this quality improvement study, a cradle-to-grave life cycle assessment was performed in the outpatient pharmacy of 4 Dutch hospitals, based on a prospective multicenter trial comprising 1071 patients with a clinical diagnosis of cancer and an active prescription for an oral anticancer drug stored at room temperature from February 1, 2021, to February 1, 2023, with a follow-up of 12 months per patient. Intervention: Participants received prescribed oral anticancer drugs with additional quality-assurance materials (ie, seal bags and time-temperature indicators), so the pharmacy could redispense quality-assured drugs based on authenticity, appearance, remaining shelf life, and/or adequate storage. Main Outcomes and Measures: The estimated environmental outcomes avoided due to waste reduction (ie, production and transport and incineration of redispensed oral anticancer drugs) corrected for outcomes of process burdens (ie, quality assurance materials), quantified in 3 outcome measures: human health damage (disability-adjusted life-years), ecosystems damage (species × year), and climate change (kg of carbon dioxide equivalent [CO2-eq]) per patient per year. Results: A volunteer sample of 1071 patients (median age, 70 years [IQR, 62-75 years]; 622 men [58.1%]) participated in the intervention. Redispensing oral anticancer drugs was initially associated with an environmental burden, mainly because of the high impact of time-temperature indicators. However, when quality-assurance materials were selectively used for temperature-sensitive oral anticancer drugs (ie, maximum storage temperature of 25 °C), redispensing was environmentally beneficial to human health and ecosystems, providing estimated climate benefits of 1.9 kg (95% CI, 1.4-2.6 kg) of CO2-eq per patient per year. Conclusions and Relevance: In this quality improvement study, redispensing unused oral anticancer drugs was found to be a suitable strategy to reduce waste and improve environmental sustainability of cancer treatment after process optimization. Redispensing unused oral anticancer drugs could contribute to sustainability of cancer treatment through reduced costs and environmental outcomes.

Drug-related problems reported by patients with rheumatic diseases: an observational study.

BACKGROUND: Drug-related problems can negatively influence treatment outcome and well-being for patients with rheumatic diseases. Thus, it is important to support patients in preventing or resolving drug-related problems as quickly as possible. To effectively develop interventions for this purpose, knowledge on the frequency and character of drug-related problems is needed. Therefore, this study aims to quantify and characterize drug-related problems reported by patients with inflammatory rheumatic diseases along their treatment process. METHODS: A prospective observational study was conducted in a Dutch outpatient pharmacy. Adult patients with rheumatic diseases that were prescribed medication by a rheumatologist were questioned about experienced DRPs by telephone 4 times in 8 weeks using a structured interview-guide. Patient-reported DRPs were scored on uniqueness (i.e., if a specific DRP was reported in multiple interviews by one individual, this was counted as one unique DRP) and were categorized using a classification for patient-reported DRPs and analysed descriptively. RESULTS: In total, 52 participants (median age 68 years (interquartile range (IQR) 62-74), 52% male) completed 192 interviews with 45 (87%) participants completing all 4 interviews. The majority of patients (65%) were diagnosed with rheumatoid arthritis. Patients reported a median number of 3 (IQR 2-5) unique DRPs during interview 1. In subsequent interviews, patients reported median numbers of 1 (IQR 0-2), 1 (IQR 0-2) and 0 (IQR 0-1) unique DRPs for interviews 2-4 respectively. Participants reported a median number of 5 (IQR 3-9) unique DRPs over all completed interviews. Unique patient-reported DRPs were most frequently categorized into (suspected) side effects (28%), medication management (e.g., medication administering or adherence) (26%), medication concerns (e.g., concerns regarding long-term side-effects or effectiveness) (19%) and medication effectiveness (17%). CONCLUSIONS: Patients with rheumatic diseases report various unique DRPs with intervals as short as two weeks. These patients might therefore benefit from more continuous support in-between contact moments with their healthcare provider.

Feasibility of an Individualized Dispensing Program for Patients Prescribed Oral Anticancer Drugs to Prevent Waste.

PURPOSE: Waste of oral anticancer drugs (OACDs) causes financial and environmental burdens. This study evaluates the feasibility of an individualized dispensing program to prevent waste of OACDs. METHODS: Adult patients were dispensed individualized quantities of niraparib, abiraterone, enzalutamide, ruxolitinib, osimertinib, or imatinib as standard care, during the first 6 months of treatment. The first 50 patients participated in an feasibility evaluation conform five domains of Bowen's Framework. (1) implementation: reach (eligible patients included) and protocol fidelity (executions following protocol) assessed from pharmacy data, (2) acceptability: rated from 1 to 10 and agreement with theoretical framework acceptability domains via a survey among patients and pharmacy technicians, (3) practicality: program's costs, (4) effect: compared with previous practice (full package supply per month), defined as difference in unused OACD unit doses and net cost-savings, and (5) demand: potential scale-up of the program by including more OACDs. RESULTS: Participants' median age was 67 (interquartile range [IQR], 58-71) years, and 76% was male. (1) Implementation: reach and protocol fidelity were 89% and 90%, respectively. (2) Acceptability was high among patients (median, 9; IQR, 8-9) and pharmacy technicians (median, 7; IQR, 6-8). All acceptability domains were agreed on. (3) Practicality: program costs were €4,289. (4) Effect: unused OACD unit doses were reduced by 34%, causing net cost-savings of €693 per discontinued patient. (5) Demand: the program could be scaled up to seven times by including all OACDs. CONCLUSION: Individualized dispensing for patients prescribed OACDs is feasible for preventing waste in terms of implementation, acceptability, practicality, effect, and demand.