Prevalence and Severity of Rationing During Drug Shortages: A National Survey of Health System Pharmacists | Clinical Pharmacy and Pharmacology | JAMA Internal Medicine | JAMA Network
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Table.  Respondents’ Experiences With Shortages of Medication Types That Were Scarce in More than 50% of Respondents’ Hospitals
Respondents’ Experiences With Shortages of Medication Types That Were Scarce in More than 50% of Respondents’ Hospitals
1.
 Drug shortages roundtable: Minimizing the impact on patient care.  Am J Health Syst Pharm. 2018;75(11):816-820. doi:10.2146/ajhp180048PubMedGoogle ScholarCrossref
2.
Vail  E, Gershengorn  HB, Hua  M, Walkey  AJ, Rubenfeld  G, Wunsch  H.  Association between US norepinephrine shortage and mortality among patients with septic shock.  JAMA. 2017;317(14):1433-1442. doi:10.1001/jama.2017.2841PubMedGoogle ScholarCrossref
3.
Hantel  A.  A protocol and ethical framework for the distribution of rationed chemotherapy.  J Clin Ethics. 2014;25(2):102-115.PubMedGoogle Scholar
4.
Rosoff  PM.  Unpredictable drug shortages: an ethical framework for short-term rationing in hospitals.  Am J Bioeth. 2012;12(1):1-9. doi:10.1080/15265161.2011.634483PubMedGoogle ScholarCrossref
5.
Mazer-Amirshahi  M, Fox  ER.  Saline shortages—many causes, no simple solution.  N Engl J Med. 2018;378(16):1472-1474. doi:10.1056/NEJMp1800347PubMedGoogle ScholarCrossref
6.
Ritchie  JL.  J. Qualitative Research Practice: a Guide for Social Science Students and Researchers. London, England: Sage; 2003.
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    Research Letter
    Health Care Policy and Law
    March 25, 2019

    Prevalence and Severity of Rationing During Drug Shortages: A National Survey of Health System Pharmacists

    Author Affiliations
    • 1The Maclean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois
    • 2Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, Illinois
    • 3Department of Pharmacy, The University of Chicago Hospital, Chicago, Illinois
    JAMA Intern Med. 2019;179(5):710-711. doi:10.1001/jamainternmed.2018.8251

    Hospital medication shortages in the United States are associated with decreased quality and/or quantity of life.1,2 In severe cases, shortages require clinicians to decide which patients receive needed medications and which do not (ie, rationing drugs between patients).3 Previous studies have proposed ethical allocation frameworks and assessed the associations of specific shortages.2,4,5 We conducted a national survey of hospital pharmacy managers to investigate current drug allocation and rationing practices of US hospitals during shortages.

    Methods

    We conducted semistructured interviews with a convenience sample of 9 health-system pharmacists regarding their experiences with drug shortages. We created survey items based on a framework analysis6 of these qualitative interviews and tested questions for clarity and consistency. We sent this 19-item survey over a 6-week period (February 6, 2018, to March 20, 2018) via email to a listserv of self-identified pharmacy practice managers and/or pharmacy leaders (PPM) who were members of the American Society of Health-System Pharmacists. We used χ2 tests to compare response differences by hospital characteristics. Respondents who completed the demographic portion and had unique metadata and characteristics were included in the analysis. The University of Chicago institutional review board approved the study and participants were not compensated and provided written consent.

    Results

    The study’s 719 respondents (response rate, 65.0%, based on unique listserv activity during the time of survey availability) comprised 5.7% of total PPM membership. The question completion rate was 95.4%. Respondents were demographically similar to the overall American Society of Health-System Pharmacists PPM membership. The median age was 44 years (interquartile range, 35-57 years), with 311 (43.2%) self-reporting as women and 381 (53.0%) as men; the median years in practice was 10 (interquartile range, 10-32 years). A total of 453 (63.0%) reported practicing in community hospitals, whereas 143 (19.9%) and 123 (17.1%) reported practicing in academic or academically affiliated hospitals, respectively. Respondents were from hospitals with fewer than 100 (109 [15.2%]), 100 to 199 (139 [19.3%]), 200 to 299 (111 [15.4%]), 300 to 399 (115 [15.9%]), or more than 400 beds (245 [34.0%]).

    All respondents reported experiencing drug shortages in the preceding year and 498 respondents (69.2%) reported more than 50 shortages. Most respondents (664 [92.4%]) reported an average of less than 1 month from notification to active shortage, 250 (34.9%) described having no administrative mechanism to respond to shortages, 96 (13.3%) reported a standing committee that included physicians, and 20 (2.8%) included an ethicist. The Table describes the frequency of medication shortages and the strategies used to mitigate and manage them. Notably, medication hoarding was reported by 584 respondents (81.3%).

    More than one-third of respondents (247 [34.4%]) reported an episode of rationing within the past year. Rationing occurred more frequently at academic hospitals (47.7% vs 25.5%; P = .01) and academically affiliated hospitals (45.4% vs 25.5%; P = .02) compared with community hospitals and in hospitals with more than 300 beds compared with those with fewer beds (46.1% vs 19.7%; P < .01). During rationing, 128 respondents (51.8%) reported that the treating team alone decided on allocation methods, whereas 119 (48.2%) used committees, 12 (4.9%) of which included an ethicist. Only 89 patients (36.0%) were informed that their care included rationing.

    Discussion

    Pharmacy practice managers reported frequent medication shortages with variation in allocation and rationing methods during shortages. Many respondents described little forewarning of upcoming shortages and a lack of administrative mechanisms with which to guide medication conservation, and although discouraged, hoarding was widespread.3,4 Rationing was prevalent, particularly in large hospitals and academic or academically affiliated hospitals. Most respondents noted that rationing decisions were generally made by the care team without the involvement of hospital committees or ethicists. Disclosing rationing to patients was not common. This survey of PPMs suggests that more systematic approaches are needed to address the common problem of drug shortages and consequent drug rationing. Progress in this area would be furthered by research to better understand patient and physician preferences for disclosure and the association of different management strategies with the outcomes of high-risk groups.

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    Article Information

    Accepted for Publication: December 5, 2018.

    Corresponding Author: Andrew Hantel, MD, Section of Hematology/Oncology, Department of Medicine, The University of Chicago, 5841 S Maryland Ave, MC #2115, Chicago, IL 60637 (ahantel@medicine.bsd.uchicago.edu).

    Published Online: March 25, 2019. doi:10.1001/jamainternmed.2018.8251

    Author Contributions: Drs Hantel and Daugherty had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Hantel, Siegler, Hlubocky, Daugherty.

    Acquisition, analysis, or interpretation of data: Hantel, Siegler, Hlubocky, Colgan.

    Drafting of the manuscript: Hantel, Siegler, Hlubocky.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Hantel, Hlubocky.

    Administrative, technical, or material support: Hlubocky, Colgan.

    Supervision: Siegler, Hlubocky, Daugherty.

    Conflict of Interest Disclosures: Dr Siegler reports receiving personal fees as a member of the board of directors for the Ross University School of Veterinary Medicine. No other disclosures were reported.

    References
    1.
     Drug shortages roundtable: Minimizing the impact on patient care.  Am J Health Syst Pharm. 2018;75(11):816-820. doi:10.2146/ajhp180048PubMedGoogle ScholarCrossref
    2.
    Vail  E, Gershengorn  HB, Hua  M, Walkey  AJ, Rubenfeld  G, Wunsch  H.  Association between US norepinephrine shortage and mortality among patients with septic shock.  JAMA. 2017;317(14):1433-1442. doi:10.1001/jama.2017.2841PubMedGoogle ScholarCrossref
    3.
    Hantel  A.  A protocol and ethical framework for the distribution of rationed chemotherapy.  J Clin Ethics. 2014;25(2):102-115.PubMedGoogle Scholar
    4.
    Rosoff  PM.  Unpredictable drug shortages: an ethical framework for short-term rationing in hospitals.  Am J Bioeth. 2012;12(1):1-9. doi:10.1080/15265161.2011.634483PubMedGoogle ScholarCrossref
    5.
    Mazer-Amirshahi  M, Fox  ER.  Saline shortages—many causes, no simple solution.  N Engl J Med. 2018;378(16):1472-1474. doi:10.1056/NEJMp1800347PubMedGoogle ScholarCrossref
    6.
    Ritchie  JL.  J. Qualitative Research Practice: a Guide for Social Science Students and Researchers. London, England: Sage; 2003.
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