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Figure 1.
Cost of 1-Month Supply of Medication, by Syringe Classification
Cost of 1-Month Supply of Medication, by Syringe Classification

The median cost of a 1-month supply of medication for those administered using high dead-space syringes (HDSS) compared with those administered using low dead-space syringes (LDSS). The box plot indicates median and interquartile. The error bars indicate range.

Figure 2.
Median Cost of Medication Waste Attributable to Dead Space, by Duration and Syringe Classification
Median Cost of Medication Waste Attributable to Dead Space, by Duration and Syringe Classification

The median cost of medication waste attributable to dead space for medications administered using high dead-space syringes (HDSS) compared with medications administered using low dead-space syringes (LDSS). The error bars indicate interquartile ranges.

1.
Bach  PB, Conti  RM, Muller  RJ, Schnorr  GC, Saltz  LB.  Overspending driven by oversized single dose vials of cancer drugs.  BMJ. 2016;352:i788.PubMedGoogle ScholarCrossref
2.
Zule  WA, Ticknor-Stellato  KM, Desmond  DP, Vogtsberger  KN.  Evaluation of needle and syringe combinations.  J Acquir Immune Defic Syndr Hum Retrovirol. 1997;14(3):294-295.PubMedGoogle ScholarCrossref
3.
Strauss  K, van Zundert  A, Frid  A, Costigliola  V.  Pandemic influenza preparedness: the critical role of the syringe.  Vaccine. 2006;24(22):4874-4882.PubMedGoogle ScholarCrossref
4.
Berne  C, Agenäs  I, Eriksson  G, Wibell  L.  Insulin wastage in ambulant practice.  Diabetes Care. 1984;7(4):343-346.PubMedGoogle ScholarCrossref
5.
Shainfeld  FJ.  Errors in insulin doses due to the design of insulin syringes.  Pediatrics. 1975;56(2):302-303.PubMedGoogle Scholar
6.
Oramasionwu  CU, Bailey  SC, Moore  HN, Oramasionwu  CO, Russell  AL, Zule  WA.  Dead space in over-the-counter syringes: the implications for HIV and HCV transmission.  Int J Drug Policy. 2015;26(12):1282-1284.PubMedGoogle ScholarCrossref
Research Letter
July 2016

Estimated Cost of Injectable Medication Waste Attributable to Syringe Dead Space

Author Affiliations
  • 1Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill
  • 2RTI International, Research Triangle Park, North Carolina
 

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2016;176(7):1025-1027. doi:10.1001/jamainternmed.2016.2301

Excess waste is a well-known known driver of inefficiency in the US health care system. Medication waste contributes to this inefficiency and has recently been described among cancer medications,1 but it may also be attributable to the syringes used to deliver injectable medications. Syringe dead space is the volume of residual fluid that remains within the syringe after the plunger is fully depressed during medication injection.2,3 High dead-space syringes (HDSS), compared with low dead-space syringes (LDSS), are associated with increased risk for medication waste.2-5 If costly injectable medications are administered using HDSS, syringe dead space may contribute to excess medication waste in the US health care system. We estimated differences in the cost of injectable medication waste attributable to HDSS and LDSS.

Methods

Self-administered medications were identified from BlueCross BlueShield of North Carolina. Medications that were not injectable via a syringe or needle or were not on the US market during data collection in August 2015 were excluded. Medication prescribing information and syringe/needle characteristics were collected from drug monographs, medication package inserts, and medication injection guides. The HDSS and LDSS classifications were assigned based on the following characteristics: a detachable needle (HDSS), a permanently attached or integrated needle (LDSS), and/or a conical plunger to reduce dead space in the needle hub (LDSS).3 The study did not constitute human subjects research; therefore, institutional review board approval was not sought.

Average wholesale prices were retrieved from 2015 Red Book (Truven Health Analytics). Pricing data were used to estimate the cost of a single dose of each medication, based on the recommended initial dose. Median estimates for dead-space capacity of HDSS (3.03%) and LDSS (0.30%) were factored into these calculations to account for variations in dead space for different volume syringes.6 The costs of wasted medication were then calculated per month and year by multiplying the cost of dead-space medication per dose times the number of doses in a 30-day period and 365-day period, respectively. Medications taken for a finite period of time were extrapolated only for the period indicated. Descriptive statistics were used to characterize the cost of medication waste.

Results

We identified 24 self-injectable medications; 17 (71%) were administered using HDSS and 7 (29%) using LDSS. The initial volume of injection ranged from 0.25 to 5.0 mL for HDSS medications and 0.08 to 1.0 mL for LDSS medications. The median (interquartile range [IQR]) monthly medication supply cost was $4443.00 ($1540.20-$6316.80) for HDSS medications and $3411.64 ($1850.40-$5617.35) for LDSS medications (Figure 1).

When extrapolating accumulated waste, the median (IQR) cost of wastage for a single dose was $5.43 ($4.01-$17.19) for HDSS medications and $0.54 ($0.28-$1.49) for LDSS medications, and for 1 year was $1637.91 ($557.68-$2328.69) for HDSS medications and $124.52 ($67.54-$205.03) for LDSS medications (Figure 2). Waste exceeding $100.00 per month was solely due to HDSS medications.

Discussion

This study reveals that HDSS contribute to excess cost of injectable medication waste compared with LDSS, despite similar 1-month supply costs of LDSS and HDSS medications. Dead space from HDSS is likely to be of greatest concern for patients who self-inject medications with greater frequency and over an extended period of time. Replacing HDSS with LDSS is a practical approach to reduce the cost of medication waste. Moreover, LDSS replacement would enhance medication delivery for patients who self-inject medications, because more of the prescribed medication dose is delivered with each injection. There is an unmet need of LDSS for patients who self-inject medications.

This study has limitations. Medications were from one formulary. Average wholesale prices may not reflect the actual cost to patients. Dose calculations were based on prescribing information. In clinical practice, patient response can influence dosing, frequency, and duration of therapy.

Given that HDSS have the potential to cost the health care system a substantial amount in medication waste, efforts are warranted to endorse LDSS as the industry standard for all syringes to reduce preventable medication waste.

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Article Information

Corresponding Author: Christine U. Oramasionwu, PharmD, PhD, Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 2215 Kerr Hall, CB No. 7573, Chapel Hill, NC 27599-7573 (oramsc@unc.edu).

Published Online: June 6, 2016. doi:10.1001/jamainternmed.2016.2301.

Author Contributions: Dr Oramasionwu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Oramasionwu, Cole, Dunlap, Zule.

Acquisition, analysis, or interpretation of data: Oramasionwu, Cole, Dixon, Blalock, Zarkin.

Drafting of the manuscript: Oramasionwu, Cole.

Critical revision of the manuscript for important intellectual content: Oramasionwu, Cole, Dixon, Blalock, Zarkin, Dunlap, Zule.

Statistical analysis: Oramasionwu, Cole, Dixon, Blalock.

Obtained funding: Oramasionwu.

Administrative, technical, or material support: Oramasionwu, Zarkin.

Study supervision: Oramasionwu.

Review of analytic output/results: Dunlap.

Conflict of Interest Disclosures: Ashley Cole is a paid employee of Truven Health Analytics. No other disclosures are reported.

Funding/Support: This work was supported through startup funds granted to Dr Oramasionwu from the UNC Eshelman School of Pharmacy, University of North Carolina.

Role of the Funder/Sponsor: The funding institution had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Heather N. Moore, PharmD, and Brittany R. Cox, BS (both from UNC Eshelman School of Pharmacy), provided paid assistance in collecting medication data.

References
1.
Bach  PB, Conti  RM, Muller  RJ, Schnorr  GC, Saltz  LB.  Overspending driven by oversized single dose vials of cancer drugs.  BMJ. 2016;352:i788.PubMedGoogle ScholarCrossref
2.
Zule  WA, Ticknor-Stellato  KM, Desmond  DP, Vogtsberger  KN.  Evaluation of needle and syringe combinations.  J Acquir Immune Defic Syndr Hum Retrovirol. 1997;14(3):294-295.PubMedGoogle ScholarCrossref
3.
Strauss  K, van Zundert  A, Frid  A, Costigliola  V.  Pandemic influenza preparedness: the critical role of the syringe.  Vaccine. 2006;24(22):4874-4882.PubMedGoogle ScholarCrossref
4.
Berne  C, Agenäs  I, Eriksson  G, Wibell  L.  Insulin wastage in ambulant practice.  Diabetes Care. 1984;7(4):343-346.PubMedGoogle ScholarCrossref
5.
Shainfeld  FJ.  Errors in insulin doses due to the design of insulin syringes.  Pediatrics. 1975;56(2):302-303.PubMedGoogle Scholar
6.
Oramasionwu  CU, Bailey  SC, Moore  HN, Oramasionwu  CO, Russell  AL, Zule  WA.  Dead space in over-the-counter syringes: the implications for HIV and HCV transmission.  Int J Drug Policy. 2015;26(12):1282-1284.PubMedGoogle ScholarCrossref
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