| Medication Destruction and Waste Measurement and Management in Long-term Care Facilities | Robert P. Paone F. Randy Vogenberg Edward Caporello Janice Rutkowski Roger Parent Francis Fachetti |
Objective: To evaluate the scope and costs of medication waste in Massachusetts long-term care facilities.
Design: Prospective study.
Setting: 17 nursing homes located in the Commonwealth of Massachusetts.
Patients: 2,360 nursing home residents in 17 facilities.
Interventions: Collection of medications to be wasted and entry of reason for discontinuation by nursing personnel in 1992-94. Data were collected by pharmacists, sorted by therapeutic code, and analyzed using both drug units and economic measures.
Main outcome measures: Quantity of medications wasted, expense of medications wasted, and reasons for medication waste.
Results: Collectively, 198 months of data representing 852,300 patient-days were obtained. The cost of medication waste in LTCFs was $0.15 per patient day; the average ingredient cost of medication per patient day in Massachusetts during the study period was $2.27, excluding the standard dispensing fee; the rate or percentage of drug waste in LTCFs was 6.7% of the cost of medications dispensed. As represented by the number of facilities participating in this study, the potential savings through implementation of selected interventions can reduce both the expense and incidence of medication waste in LTCFs cost-effectively.
Conclusion: The cost of medication waste was $0.15 per patient day, and percentage of drug waste was 6.7% of the cost of medications dispensed in Massachusetts LTCFs. Pharmacists can make an important impact on drug waste prevention by identifying various opportunities for intervention directed at medication prescribing, dispensing, monitoring, and destruction.
Key Words: Medication waste; Elderly; Drug wastage; Drug waste prevention.
Abbreviations used: LTCF = Long-term care facility; AWP = Average wholesale price.
Consult Pharm 1996; 11:32-40.
In January 1992, a study was initiated to evaluate the scope and
costs associated with medication waste in long-term care facilities
(LTCFs) in the Commonwealth of Massachusetts. The study was developed
out of concern for the potential costs associated with the destruction
of medication in LTCFs. These costs, as reported in the literature,
have been determined to be as high as $5.67 per patient per month.1
Once the scope of the problem was delineated, appropriate informed
decisions could be made so as to minimize the medication waste
problem, if needed.
Facility Demographics
Approximately 400 LTCFs are in the Commonwealth of Massachusetts;
17 LTCFs (approximately 4%) were recruited for study in this protocol.
Collectively the 17 homes represent 2,360 LTCF beds in the Commonwealth.
The mean number of beds/study facility was 139 and the range in
size of beds/LTCF was from 49 beds to 250 beds (Figure 1). Recruitment
for participation of LTCFs in this study was staggered, with the
first facility collecting analyzable data in January 1992 and
the final LTCF entering in October 1992. By the time of study
completion in January 1994, a total of 198 months of data was
collected from the 17 facilities.
Objectives
The objectives of this prospective study on medication waste in LTCFs were as follows:
Methods
Directors of nursing at LTCFs served by consultant pharmacist members of the Massachusetts Society of Consultant Pharmacists (MSCP) were contacted and asked to participate in this study. An available sample from all Massachusetts LTCFs was derived from nurse directors of 17 participating facilities who consented to allow data to be collected from their facilities.
Data were to be collected for 12 months from each participating LTCF to minimize the potential impact that seasonal variation might have on the study.
TABLE 1. Information Collected in study
A data-collection tool was developed and used by all facilities to capture the information listed in Table 1 in addition to the prescription number and name and strength of the medication at the end of each month. The data-collection tool was completed by nurses at each facility and collected by the consultant pharmacists at monthly intervals.
TABLE 2. Codes for Reasons for Medication Destruction
TABLE 3. Reasons for Alteration in Medication Order
In addition, nurses completing the data-collection form identified the specific reason for a change or discontinuation of medication where applicable (Table 3).
Costs of medications destroyed were estimated as the ingredient
costs. Ingredient costs for purposes of this report were based
upon the published average wholesale price (AWP) less 16% to reflect
actual Medicaid cost. Published AWP costs were obtained from the
1992 and 1993 Blue Book. For purposes of this report, AWP less
16% will be referred to simply as AWP.
| Table 4. Drug Wastage in 17 Massachusetts Long-term Care Facilities | ||||||||
|---|---|---|---|---|---|---|---|---|
| Center | No. | No. Study | Total No. | Avg. Rx Cost | Est. Dispensing | Total Destroy | Est. Destoy Cost | Destroy |
| No. | Beds | Days | Patient Days | per Day ($) | Cost ($) | Cost ($) | per Day($) | Cost (%) |
| 1 | 200 | 390 | 78,000 | 2.27 | 177,060.00 | 8,205.48 | 0.11 | 4.63 |
| 2 | 250 | 480 | 120,000 | 2.27 | 272,400.00 | 16,039.25 | 0.13 | 5.89 |
| 3 | 142 | 300 | 42,600 | 2.27 | 96,702.00 | 7,830.11 | 0.18 | 8.10 |
| 4 | 140 | 330 | 46,200 | 2.27 | 104,874.00 | 6,537.71 | 0.14 | 6.23 |
| 5 | 120 | 300 | 36,000 | 2.27 | 81,720.00 | 7,707.66 | 0.21 | 9.43 |
| 6 | 150 | 390 | 58,500 | 2.27 | 132,795.00 | 13,580.33 | 0.23 | 10.23 |
| 7 | 120 | 510 | 61,200 | 2.27 | 138,924.00 | 14,325.63 | 0.23 | 10.31 |
| 8 | 79 | 300 | 23,700 | 2.27 | 53,799.00 | 951.62 | 0.04 | 1.77 |
| 9 | 123 | 330 | 40,590 | 2.27 | 92,139.30 | 10,491.00 | 0.26 | 11.39 |
| 10 | 143 | 450 | 64,350 | 2.27 | 146,074.50 | 4,970.37 | 0.08 | 3.36 |
| 11 | 120 | 420 | 50,400 | 2.27 | 114,408.00 | 11,202.91 | 0.22 | 9.79 |
| 12 | 140 | 120 | 16,800 | 2.27 | 38,136.00 | 2,027.69 | 0.12 | 5.32 |
| 13 | 217 | 330 | 71,610 | 2.27 | 162,554.70 | 5,154.51 | 0.07 | 3.17 |
| 14 | 124 | 300 | 37,200 | 2.27 | 84,444.00 | 6,568.22 | 0.18 | 7.78 |
| 15 | 123 | 420 | 51,660 | 2.27 | 117,268.20 | 6,715.93 | 0.13 | 5.73 |
| 16 | 120 | 360 | 43,200 | 2.27 | 98,064.00 | 6,986.62 | 0.16 | 7.12 |
| 17 | 49 | 210 | 10,290 | 2.27 | 23,358.30 | 622.18 | 0.06 | 2.66 |
| Total | 2,360 | 5,940 | 852,300 | 2.27 | 1,934,721.00 | 129,854.23 | 0.15 | 6.71 |
Results
Collectively, 198 months of data representing 852,300 patient days were obtained from 17 LTCFs in Massachusetts (Table 4). Not all facilities provided complete data for 12 months, and some facilities collected data for more than 12 months (Figure 2).
The total cost of destroyed medication, as indicated in Table 4, was $129,854.23. Costs of medications destroyed were estimated as the ingredient costs. Therefore, using an average daily prescription cost of $2.27/patient and usual 100% occupancy of beds at participating facilities, the total Estimated Dispensing Costs were $1,934,721 (Table 4). The average daily prescription cost was generated by employing the following formula:
Avg. Rx Cost = [(Avg. Rx Price - Dispensing Fee) X Avg. No. Rx/day]/30 days where the dispensing fee of $4.06 was deducted from the cost of the medication and where the average number of prescriptions per patient per day equals 4.5.
The destroyed cost of medication per patient day, obtained by
dividing the Estimated Dispensing Cost divided by Total Patient
Days, was $0.15 per patient per day. The cost of medication destroyed
as a percentage of medication dispensed was approximately 6.7%
(% Destroyed Cost; Table 4).
| Table 5. Drug Wastage in 17 Massachusetts Long-term Care Facilities by Therapeutic Category, 1992-94 |
||||
|---|---|---|---|---|
| AHFS Code | AHFS Category | Destroyed Cost ($) | % Total Dispensing cost |
|
| 04:00 | Antihistamine | 916.88 | 0.05 | |
| 08:00 | Anti-infective | 15,851.74 | 0.82 | |
| 10:00 | Antineoplastic agents | 3,089.28 | 0.16 | |
| 12:00 | Autonomic | 4,271.55 | 0.22 | |
| 20:00 | Blood formation and coagulation | 4,689.98 | 0.24 | |
| 24:00 | Cardiovascular | 18,618.67 | 0.96 | |
| 28:00 | Central nervous system | 33,325.61 | 0.18 | |
| 34:00 | Dental agents | 5.34 | 0 | |
| 40:00 | Electrolytes | 5,784.18 | 0.30 | |
| 48:00 | Antitussives, expectorants, mucolytics | 766.23 | 0.04 | |
| 52:00 | Eye, ear, nose, throat preparations | 3,520.78 | 0.18 | |
| 56:00 | Gastrointestinal drugs | 22,129.41 | 1.14 | |
| 60:00 | Gold compounds | 0.00 | 0 | |
| 68:00 | Hormones | 3,713.58 | 0.19 | |
| 72:00 | Local anesthetics | 45.31 | 0 | |
| 80:00 | Serums, toxoids, vaccines | 33.01 | 0 | |
| 84:00 | Skin/mucous membrane agents | 4,387.16 | 0.23 | |
| 86:00 | Smooth muscle relaxants | 1,389.89 | 0.07 | |
| 88:00 | Vitamins | 443.06 | 0.02 | |
| 92:00 | Unclassified | 4,011.54 | 0.21 | |
| 96:00 | Pharmaceutical aids | 23.02 | 0 | |
| 99:99 | (Not listed) | 2,837.82 | 0.15 | |
| Grand total | 129,854.23 | 6.71 | ||
Costs of Destroyed Medication by AHFS Category
Table 5 summarizes the costs of destroyed medication by American
Hospital Formulary Service (AHFS) category. As can be seen from
this table, four categories-central nervous system, gastrointestinal,
cardiovascular, and anti-infective agents-collectively represent
approximately 70% of the costs of medications destroyed. Further
inspection of the raw data reveal the following types of medications
from each of the four classes above to be relevant with regard
to destroyed medication: antidepressants, tranquilizers, nonsteroidal
anti-inflammatory agents, anti-ulcer drugs, antihypertensive medications,
and cephalosporin and quinolone antibiotics.
| Table 6. % Medication Destroyed by Reason | |
|---|---|
| Medication changed | 6.3% |
| Medication discontinued | 34.2% |
| Medication decreased | 3.4% |
| Medication increased | 2.0% |
| Medication expired | 1.9% |
| Patient died | 35.5% |
| Patient hospitalized | 6.8% |
| Patient transferred | 7.3% |
| Other | 2.6% |
Reasons identified for Medication Destruction
Table 6 summarizes the reasons listed by nurses as to why medications were destroyed. Of particular interest were the following reasons: patient died, medication discontinued, medication changed, and patient hospitalized, transferred, or discharged. Collectively, these categories represent 90.1% of the reasons LTCFs destroy medications. The importance of these study data lies in the opportunity for pharmacy to work with physicians and nurses to minimize medication waste in selected populations or drug categories within LTCFs. Some medication waste may not be reduced, such as in the case of an unexpected patient death.
The categories medication discontinued and medication changed
were subcategorized during data collection to enable a better
understanding of why these actions were necessary (Table 3). Medication
was discontinued approximately 27% of the time because the medication
was no longer needed. The most common reason for changing a medication
to another product, when identified, was lack of efficacy of the
medication changed. However, lack of efficacy was only identified
in 1% of responses when the medication was changed.
Implications of Study Results in Massachusetts
One of the key study results was a determination of the cost of medication waste in LTCFs to be $0.15 per patient-day. To put that into perspective, the average ingredient cost of medication per patient day in Massachusetts during the study period was $2.27, excluding the standard dispensing fee.
A second key study result was a determination of the rate or percentage of drug waste in LTCFs, which was found to be 6.7% of the cost of medications dispensed. This figure is within the 4-10% range reported in the pharmacy literature over a 10-year period.1,2
Based upon an analysis of reasons for waste and category of medications wasted as determined in this study, we identified 10 concepts for reducing waste. The dollar amounts listed below refer to costs only in the 17 study LTCFs.
1. Hold medications in the LTCF during patients' acute hospitalization period, currently up to 10 days, then resume use of those medications reordered by the physician. This would result in decreased prescription volume for readmitted patients, require some policy or procedure changes in LTCFs, and somewhat affect storage space requirements for medications. The impact of this change would result in an approximately 3.5% reduction in destroyed drug costs, or approximately $4,545.
2. At time of discharge to home or transfer to another facility, release remaining medications to patient or new facility to use. This would result in decreased prescription volume for nursing facility discharged patients in a community pharmacy, require some policy or procedure changes in LTCFs including an additional waiver form, and require minimal additional administrative time to implement. The impact of this change would result in approximately a 5.5% reduction in destroyed drug costs, or approximately $7,142.
3. Use consultant pharmacists to determine avoidable adverse events and appropriate monitoring of patients susceptible to adverse drug events. Some 134 prescriptions related to various patient problems with medications, resulting in those prescriptions being taken out of service. Some examples of patient problems would include sensitivity or cross-sensitivity to a medication; lack of documentation or nurse-pharmacist communication of a sensitivity; and absence of concomitant medication to treat the mild adverse event. This would require a focused monitoring of the prescribing, nursing and pharmacy documentation, and dispensing of medications more closely through a multidisciplinary quality improvement process. This intervention is consistent with contemporary standards to improve overall quality of health care services in LTCFs. The impact of this change would result in less than a 1% reduction in destroyed drug costs, or approximately $1,000.
4. Use consultant pharmacists to assess the documentation and reporting of patient drug allergy information to avoid potential wasteful prescribing of medications. A total of 40 of the 134 adverse event prescriptions noted an allergy. These were presumably unpredictable and/or unavoidable allergic responses. This would require a focused assessment as well as monitoring of the prescribing, nursing and pharmacy documentation, and dispensing of medications more closely through a multidisciplinary quality improvement process. This intervention is consistent with contemporary standards to improve overall quality of health care services in LTCFs. The impact of this change would result in less than a 0.5% reduction in destroyed drug costs or approximately $500.
5. Moderate prescribing and dispensing patterns of p.r.n. (use as needed) medications to limited quantities. Only inferential data from this study suggest any impact of p.r.n. medication-use interventions. Therefore, this would require further study to determine the potential benefits of intervening on this aspect of the medication waste issue. Alternatively, a study looking at the promotion of nonprescription stock versus prescription p.r.n. medication use could be completed.
6. Limit quantity of medication dispensed on new orders to a 10-day supply before dispensing a full 30-day quantity. This intervention would require pharmacy and LTCF procedural changes, potential increased dispensing time and adverse effect on pharmacy cash flow, and more frequent ordering by nurses in LTCFs. The impact of this change would result in approximately a 5.5% reduction in destroyed drug costs, or approximately $7,142.
7. Allow return for credit of medication dispensed in original manufacturer packaging with intact seal(s) that may then be redispensed (e.g., ampuls, vials). There are no data from this study to suggest any impact, both financial and public health, of this change in policy. Therefore, this would require further study to determine the potential benefits of intervening on this aspect of the medication waste issue.
8. Use remaining medication quantities for change of dose situations before sending a new supply of the new strength, (e.g. warfarin 2.5 mg versus 5 mg). This would require increased pharmacy label changes to the LTCFs, decreased prescription volume, tablet splitting or dose combining by nurses in the LTCF, and potentially increase medication errors to the patient. The impact of this change would result in approximately a 1.5% reduction in destroyed drug costs, or approximately $2,000.
9. Implement a long-term care drug-use management system to promote (a) increased generic drug utilization and (b) therapeutic interchange on a facility-by-facility basis. This would require changes in pharmacy and LTCF policies or procedures, pharmacy administrative time, medical and nursing staff time, and potential for increased change in medications. Already, pharmacy providers promote the optimum use for generics. No detailed data from this study suggest any impact of this change in policy. Anecdotal information suggests there could be a 5% reduction in destroyed drug costs. Therefore, this requires further study to determine the potential benefits of intervening on this aspect of the medication waste issue.
10. The two reasons for the greatest amount of medication waste were when the medication was no longer needed (discontinued), or the patient died. These reasons can be affected by monitoring the prescribing and dispensing quantities more closely through a multidisciplinary quality improvement process. Minimizing quantities dispensed in patients at risk for a terminal episode or assuring that only appropriate quantities are provided should a medication not be needed in the near term can have a tremendous impact on the medication waste issue. These interventions are consistent with contemporary standards to improve overall quality of health care services in LTCFs.
By implementing interventions 1, 2, 6, and 8, medication waste could decrease by 16%. That would mean a savings in the facilities studied of $20,830. The cost of implementing and maintaining these interventions would be minimal. Additional interventions would contribute to additional direct cost savings on the medication waste issue.
A different approach to this problem is to use alternative packaging systems, including unit dose, which may allow for greater reuse of medications. To do so, however, one must consider the substantial capitalization and management costs to all pharmacy providers and nursing homes (conservatively estimated at several million dollars), and start-up costs in contrast to the offsetting savings in medication waste. Particularly if additional waste reduction measures are implemented, the short-term costs versus any potential long-term medication cost savings may be unacceptable to payers. Unit dose packaging was not being used in any of the study facilities, and reuse of medications in Massachusetts LTCFs at the time of this study was not allowed in any circumstance.
Implementation of various no- or low-cost options identified
through this research study may offer substantial medication cost
savings in the short term while potentially improving the general
quality of care delivered to LTCF patients. If other options are
to be seriously considered, specific research needs to be conducted
to determine the recommended options and their cost-benefit to
patients or payers in LTCFs.
Recommendations
Based on the study results, we recommended the following:
We suggested that the following interventions would require further study:
Study Limitations
Limitations to this study, which must be considered in any outcomes analysis and when implementing recommendations resulting from the study, include the following.
No audit was conducted or quality assurance system implemented regarding (a) the collection of medications by nursing staff at the LTCFs and (b) for reporting methods actually used by nursing personnel in the facilities.
No audit was conducted or quality assurance system implemented regarding (a) the reliability of reporting the reasons for waste by nursing personnel and (b) scatter of raw data as reported by the facilities over the study period, and (c) the possibility of too many choices for nursing to pick from when reporting potential reasons for waste.
We did not control or address a lack of consistency in data collection resulting from both potential interfacility and intrafacility variation. These data variations may result from lack of control over levels of patient care, and nursing and medical staff practice variables in the LTCFs.
The average drug cost formula calculation assumes a 30-day supply of medication in all cases when there may be less than a 30-day supply dispensed in several cases (e.g., pain killers).
Discussion
Samuel Kidder1 in his review of drug waste in LTCFs found an average of $3.12/patient/month. Data from studies reviewed by Kidder spanned the period of 1976 to 1983. In his review of 13 studies of drug waste, Kidder found the range of monthly drug waste costs/patient to fall between a low of $1.52 and a high of $5.67.
This study places the average of drug waste in LTCFs in the Commonwealth of Massachusetts at $4.50/patient/month. Allowing for an average of 8% inflation in the cost of medication over the 10-year period from 1983, the last year data were collected in the Kidder review, to 1993, the average cost of waste would increase in the Kidder study from $3.12 (1983 dollars) to $6.74 (1993 dollars).
In addition, many of the medications that contributed to the majority of the drug waste cost issues identified in this study (e.g., H2 antagonists, cardiovascular agents, antibiotics) were not available to contribute to the medication waste problem of the 1970s and early 1980s. Further, single-source products wasted in this study generally tend to be substantially more expensive per unit than other multisource products. However, this study does identify areas in which medication waste may be minimized and/or worthwhile areas identified for further investigation.
Holding medications in LTCFs for patients during acute hospitalization periods, currently up to 10 days, and resuming the medications should the patient return to the LTCF, should have a positive impact in reducing the almost 7% of medication waste. Further costs of medication would be saved by this measure in that a new prescription for the same medication would not have to be issued to the patient upon return to the LTCF. Additional study would be required to estimate the cost impact of this measure.
Similarly, allowing patients to take their medications with them from the LTCF when they are transferred would allow for an additional 7% decrease in medication waste and, as noted previously, cost savings associated with not issuing a new prescription.
As noted, medications were discontinued 27% of the time because
it was no longer needed and the dose of medication was increased
or decreased in 5% of patients. By limiting the quantity of medication
dispensed on new orders form the current 30-day supply to a 10-day
supply, savings would be realized by not having large quantities
of ineffective, not needed, or wrong dose of medication on hand.
Conclusion
Medication waste in the LTCFs of the Commonwealth of Massachusetts
is a concern to all who provide services to this patient population
and to those who must pay for those services. When adjusted for
inflation to 1993 dollars, medication waste in the LTCFs of Massachusetts
falls below the average cost/patient/month identified in the 1987
review article by Kidder.1 The medication waste in
LTCFs is approximately 6.7% of the cost of medications dispensed.
As represented by the number of facilities participating in this
study, the potential savings through implementation of selected
interventions can reduce both the expense and incidence of medication
waste in LTCF cost-effectively. Additional interventions, after
appropriate study, may also be used to reduce further the incidence
of medication waste in Massachusetts LTCFs. Selected interventions,
such as holding medications during acute hospitalization and facility
transfer of medications offer substantial, immediate opportunities
to affect the medication waste issue while maintaining an acceptable
level of quality care for the patient.
REFERENCES
1. Kidder SW. Review of drug waste in long term care facilities. J Geriatr Drug Ther 1987; 1(3): 35-47.
2. Shinavier BD, Kirk KW. Medication waste in selected central Texas long-term care facilities under the same corporate ownership. Consult Pharm 1992; 7:415-22.
Robert P. Paone, R.Ph., Pharm.D., is Research Associate,
Institute for Contemporary Pharmacy Research, Inc.; and Assistant
Professor of Clinical Pharmacy, Massachusetts College of Pharmacy
& Allied Health Sciences, Boston; F. Randy Vogenberg, R.Ph.,
M.Ed., FASCP, is President, Institute for Contemporary Pharmacy
Research, Inc.; and Assistant Professor of Pharmacy Administration,
Massachusetts College of Pharmacy & Allied Health Sciences,
Boston; Edward Caporello, R.Ph., M.B.A., is Pharmacy Director,
Matthew Thornton Health Plan, Bedford, New Hampshire; Janice
Rutkowski, R.Ph., is Regional Operations Director; Roger
Parent, R.Ph., FASCP, is Pharmacy Consultant; and Francis
Fachetti, R.Ph., FASCP, is Marketing Director, Pharmacy Corporation
of America, Brockton, Massachussetts.
Address for reprints: F. Randy Vogenberg, Institute for
Contemporary Pharmacy Research, Inc., 255 Bear Hill Road, Waltham,
MA 02154.
Acknowledgments: Before completion of this study, Ms. Rutkowski
worked for Dunnington Health Care Services; Mr. Caporello, Parent,
and Facchetti worked for InstaCare Pharmacy Services. Sponsorship
and funding for this study was provided by a research grant from
the Massachusetts Society of Consultant Pharmacists, now the Massachusetts
Chapter of ASCP.
Copyright © 1996, American Society of Consultant Pharmacists,
Inc. All rights reserved.