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The Cost Equation for CSTDs
Can a hospital make a sound economic evaluation when it comes to purchasing a closed system drug-transfer 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 Patricia C. Kienle, RPh, MPA, BCSCP, the director of accreditation and medication safety at Cardinal Health, said she has some issues with the study. First, it was done by Canadian researchers and published in a European journal. That’s a problem, she noted, because the way health systems get paid in this country is far different than payment approaches in Europe or Canada. Moreover, most health systems rate safety and efficacy above cost when assessing CSTDs.
Still, all three factors—the “big triad” of purchase decision making—need to be addressed during any evaluation of CSTDs, Ms. Kienle stressed. “It’s the same trio that pharmacists use to assess formulary drugs,” she noted.
Safety may be the easiest aspect to evaluate, Ms. 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).
On the question of cost, Ms. Kienle ticked off three key determinants in weighing whether a purchase makes sense: 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 in Europe and Canada, she said, in the United States, medical device cost “is largely driven by which group purchasing organization the hospital uses. And sadly,” Ms. Kienle added, “the decision is often made solely by materials management personnel looking at which device is cheapest, without involving pharmacy and nursing to see which one works best in their organization. That’s a problem from a cost perspective.”
However the cost calculus is conducted, it is a critical one to perform, Ms. Kienle stressed, “because cost is the biggest barrier to adopting CSTDs.”
At Cone Health, in Winston-Salem, N.C., Andre Harvin, PharmD, the director of Pharmacy, Oncology Services, said 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 is a big pill to swallow,” Dr. 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 COVID-19, he said, “we did look at the cost per component to find ways we could save money.” But the savings, he added, were “nothing earth-shattering.”
He drew a parallel between the benefits of CSTDs and Cone Health’s automated robotic compounding technology. The latter, he said, “is a multimillion-dollar system that provides gravimetrics for anything drawn up by hand. That’s a hard return on investment [ROI] to talk about. We justify it by safety and reducing low-level exposure for technicians. It’s safety, it’s quality, it’s accuracy that we’re really looking for.” The same standard applies to CSTDs, he said.
“I never get the argument of why you have to bring an ROI to the table for some of these [technologies]. Either you invest in quality and safety, or you don’t.”
Drug Vial Optimization
The use of CSTDs for drug vial optimization (DVO) could help to offset part of the devices’ acquisition costs. But the practice remains controversial. It requires elaborate safety testing to prove the drugs remain stable and uncontaminated as a result of CSTD use. The tests are complex and remain beyond the reach of most hospitals. Ms. Kienle said accrediting organizations have been citing hospitals throughout the country for using the devices to extend vial BUD unless they have performed the required tests.
