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Sterile Compounding
The Cost Equation for CSTDs
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Pharmacy Practice News • May 2021
an a hospital make a sound economic evaluation when it comes to purchasing a closed system drugtransfer device (CSTD)? A group of Canadian researchers say no. They claim the literature addressing the economic impact of CSTDs is sparse, and the evidence in the handful of studies that do tackle the issue lacks robustness (Eur J Hosp Pharm 2020;27[6]:361-366). But is there a potential for a comprehensive cost-effectiveness analysis of a disposable device that’s essential for preparing and administering hazardous drugs? Such data could be a major benefit to hospitals making the case to their C-suites for investing in the devices, which can cost hundreds of thousands of dollars per year for a high-volume cancer treatment center. Patricia C. Kienle, RPh, MPA, BCSCP, the director of accreditation and medication safety at Cardinal Health, told Pharmacy Practice News that the answer is yes. Furthermore, it is imperative to do so, she said, because “cost is the biggest barrier to adopting CSTDs.” But cost, Kienle said, should only be one piece of an equation that she termed the “big triad” of decision-making factors, which also include safety and efficacy. It’s the same trio that pharmacists use to assess formulary drugs, she noted. Safety may be the easiest aspect to evaluate. Despite what the Canadian researchers found in their review, Kienle said, “there are plenty of studies in the literature that say these devices absolutely work to protect personnel against contamination of chemotherapy when used correctly” (J Oncol Pharm Pract 2019;25[5]:1160-1166). Setting standards for assessing efficacy may be more challenging. After nearly four years of waiting, the National Institute for Occupational Safety and Health (NIOSH) still has not published the final unified testing protocol that could help hospitals decide which of the CSTDs they have under consideration—either the mechanical barrier types or the air-cleaning models—are most effective in preventing hazardous drug escape and personnel exposure. Then there’s the economics portion of decision making. Kienle ticked off three key determinants in weighing whether a purchase makes sense financially: the
price of the device itself; the available reimbursement; and the cost of antineoplastic drugs—a big-budget item that some health systems have tried to moderate by using CSTDs to optimize the value of single-dose drug vials through beyond-use dating (BUD). Unlike Europe and Canada, she said, in the United States device cost “is largely driven by which group purchasing organization the hospital uses. And sadly,” she added, “the decision is often made solely by materials management looking at which one is cheapest, without involving pharmacy and nursing to see which one works best in their organization. That’s a problem from a cost perspective.” As for reimbursement, Kienle noted that the CSTD economic study mentioned above was done by Canadian researchers and published in a European journal, but the way health systems get paid in this country is far different from Europe or Canada. Moreover, most health systems do rate safety and efficacy above cost when assessing CSTDs.
‘Safety, Quality and Accuracy’ At Cone Health, in Winston-Salem, N.C . , f o r exa m p l e, A n d re Ha r v i n , PharmD, the director of Pharmacy, Oncology Services, told Pharmacy Practice News that although cost was a consideration in deciding on a CSTD upgrade, “it was never from a ‘hey, this is going to save us money’ perspective.” “It’s a big pill to swallow,” Harvin conceded, referring to the cost of CSTDs, “but what we look at is the potential for preventing exposure to our technicians and nursing staff and reducing spills around the hood.” Last year in the midst of the COVID-19 pandemic, Harvin said, “we did look at the relative cost per component to find ways we could save money.” But the savings, he added, were “nothing earthshattering.” He drew a parallel between the benefits of CSTDs and Cone Health’s automated robotic compounding technology. The latter, he said, “is a multimilliondollar system that is not only a robot, but also provides gravimetrics for anything drawn up by hand.” He added: “That’s a hard return on investment to talk about. We justify it by safety and reducing low-level exposure for technicians.
