Trend in revenue loss due to expired medication at a large urban hospital in Johannesburg, South Africa

Abstract

ntroduction Limited research has been conducted on the causes and economic impacts of expired medicine, yet medicine costs comprise a significant proportion of healthcare expenditure. Medicines and their management are an important health system function, necessary for improving and maintaining health. However the lack and wastage of essential medicine is still one of the most serious public health problems globally, including South Africa. The high rate of medicine expiry highlights a problem throughout the supply chain and this wastage reduces the quantity of medicines available to patients and therefore the quality of healthcare they receive. This study aimed to estimate the revenue loss due to expired medicines within a hospital setting from January 2011 to June 2014 and explore reasons for this. Methods This mixed methods study is a retrospective analysis review of forty-two months of expired medicine reports extracted at a public sector hospital coupled with a qualitative exploration (through semi-structured in-depth interviews) with key stakeholders about possible reasons for the expiration of medicines. In addition, informal observations were conducted across the duration of the fieldwork and recorded in a researcher diary. Ethics and research approvals for the study were obtained from the University of Witwatersrand Human Ethics Committee and the hospital. Results 32,368 medicines had expired over the study period. These data were drawn from the wards, outpatient departments and pharmacy and consisted of 68 different Anatomical Therapeutic Chemical (ATC) classes. More than 80% of the expired medicines were on the essential medicine list (EML) with antibacterial for systemic use (16%, n=5067) and antivirals for systemic use (15%, n=4970) among the highest classes that expired. The estimated total value of expired medicine for the study period was R838 029; an estimated annual revenue loss of 0.6% of the hospital’s total pharmaceutical expenditure; and an average increase in percentage revenue loss of 72% for the study period. Two main themes emerged from the in-depth interviews conducted with key stakeholders; i) Knowledge, understanding and practical application of policies and procedures related to expired medicines, and ii) Diversion from Ideal: procedures and constraints which may impact implementation. A closer examination to explore the reasons for these diversions - the ‘whys’- revealed three thematic areas: mistrust among employees and in the system, fear of being ‘caught’ yet lack of accountability and, ineffective communication and coordination. Discussion Expiry of medicines was highest among essential medicine on the supply-side. Medicines management is not restricted to pharmacists and although adequate tools for quantification and demand planning exist, none of these are focused on the health worker who has no formal training in medicine supply management. The study highlighted the need to identify effective strategies for phasing in and out of pharmaceutical policies and tenders to minimize waste. There is a lack of standard treatment guideline knowledge among prescribers. The extent of expired medicines at patients’ homes, patient returns or cost of disposing off expired medicine were not analysed. The relationship between governing documents and daily practices are not well understood by those responsible for managing medicines and accountability is not clearly assigned. Recommendations and Conclusion Creating awareness about the risk of medicines expiring and cost impact on service delivery should be communicated to healthcare workers and policy makers. Medicine supply management should be included as part of job descriptions of employees who manage medicines at this hospital to enhance accountability. Employing clinical pharmacists in the wards at tertiary hospitals may improve medicine management. Continuous monitoring and periodic evaluations to identify and address challenges related to medicine wastage is paramount to reduce financial loss and improve health outcomes. Sound coordination and communication is needed between the pharmacy and other departments in the hospital. Additionally, Pharmaceutical and Therapeutics Committees should emphasise the use of Standard Treatment Guidelines.