1
|
Shukar S, Shahid MH, Zhang J, Din SM, Khan FU, Fang Y, Yang C. Pharmacists' approach to oncology medicine shortages: results of a cross-sectional survey in Pakistan. BMJ Open 2023; 13:e070634. [PMID: 37723107 PMCID: PMC10510916 DOI: 10.1136/bmjopen-2022-070634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 08/30/2023] [Indexed: 09/20/2023] Open
Abstract
OBJECTIVES The study estimated the shortages of oncology medicines in Pakistan, their causes, impacts, mitigation strategies, and possible interventions. DESIGN Cross-sectional survey. SETTING Oncology pharmacists working at 43 oncology settings (out of 80) from five regions of Pakistan (four provinces (Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan) and one federal territory (Islamabad)) were approached. PARTICIPANTS Oncology pharmacists with more than 1 year of experience were selected using stratified random sampling, and data were collected using a questionnaire from September 2021 to January 2022. PRIMARY AND SECONDARY OUTCOME MEASURES To estimate the prevalence of oncology medicine shortages in Pakistan and establish recommendations to overcome them. RESULTS Of 167 responded pharmacists, 87% experienced shortages in their practice. Most respondents (50%) experienced both oncology and support agent shortages. It was a current problem in hospitals (58%) and increased with time, but the situation varied across regions (p=0.007). Mainly shortages occur half-yearly (p=0.001) and last for <3 months. Injectable (56.8%) and branded drugs (44.9%) were short. The most frequently mentioned drugs affected by shortages were etoposide, paclitaxel, dacarbazine, bleomycin and carboplatin. Usually, distributors (51.5%) notify the pharmacists about the shortages, and federal agencies (36%) are responsible for these shortages. Distributors (53.4%) were the main source of supply, and shortages were encountered by them as well. The impacts included delayed care (25%) and suboptimal outcomes (23%) on patients, extra time (32%) for staff, prioritisation issues (31%) for pharmacists, delayed clinical trials (60.5%) and increased drugs prices (52.1%). Some hospitals have reporting systems (39.5%) and recording (29.3%) drug shortages. The shortages were managed using available alternative options (21%) and redistributing (21%) the currently available stock. CONCLUSION Pakistan's healthcare system is affected by oncology medicine shortages. The government should establish a cancer registry and drug shortage platform, revise drug prescribing/pricing policies and practice penalties for breaching regulations. Oncology medicines must be widely available to avoid the grey market.
Collapse
Affiliation(s)
- Sundus Shukar
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | | | - Jinwei Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shayan Muhammad Din
- Department of Hospital Pharmacy, National Hospital and Medical Center, Lahore, Pakistan
| | - Faiz Ullah Khan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| |
Collapse
|
2
|
Wilson BE, Booth CM, Sullivan R, Aggarwal A, Sengar M, Jacob S, Bray F, Barton MB, Pearson SA. Global application of National Comprehensive Cancer Network resource-stratified guidelines for systemic treatment of colon cancer: a population-based, customisable model for cost, demand, and procurement. Lancet Oncol 2023; 24:682-690. [PMID: 37269845 DOI: 10.1016/s1470-2045(23)00183-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/06/2023] [Accepted: 04/19/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Resource-stratified guidelines (RSGs) can inform systemic treatment decisions in the face of limited resources. The objective of this study was to develop a customisable modelling tool to predict the demand, cost, and drug procurement needs of delivering National Comprehensive Cancer Network (NCCN) RSG-based systemic treatment for colon cancer. METHODS We developed decision trees for first-course systemic therapy for colon cancer based on the NCCN RSGs. Decision trees were merged with data from the Surveillance, Epidemiology, and End Results programme, the International Agency for Research on Cancer's GLOBOCAN 2020 national estimates for colon cancer incidence, country-level income data, and data on drug costs from Redbook (USA), the Pharmaceutical Benefits Scheme (Australia), and the Management Sciences for Health 2015 International Medical Products price guide to estimate global treatment needs and costs, and forecast drug procurement. Simulations and sensitivity analyses were used to explore the effect of scaling up services globally and the effect of alternative stage distributions on treatment demand and cost. We generated a customisable model, in which estimates can be tailored to local incidence, epidemiological, and costing data. FINDINGS First-course systemic therapy is indicated in 608 314 (53·6%) of 1 135 864 colon cancer diagnoses in 2020. Indications for first-course systemic therapy are projected to rise to 926 653 in 2040; the indications in 2020 might be as high as 826 123 (72·7%), depending on stage distribution assumptions. Adhering to NCCN RSGs, patients with colon cancer in low-income and middle income countries (LMICs) would constitute 329 098 (54·1%) of 608 314 global systemic therapy demands, but only 10% of global expenditure on systemic therapies. The total cost of NCCN RSG-based first-course systemic therapy for colon cancer in 2020 would be between about US$4·2 and about $4·6 billion, depending on stage distribution. If all patients with colon cancer in 2020 were treated according to maximal resources, global expenditure on systemic therapy for colon cancer would rise to around $8·3 billion. INTERPRETATION We have developed a customisable model that can be applied at global, national, and subnational levels to estimate systemic treatment needs, forecast drug procurement, and calculate expected drug costs on the basis of local data. This tool can be used to plan resource allocation for colon cancer globally. FUNDING None.
Collapse
Affiliation(s)
- Brooke E Wilson
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute and Department of Oncology, Queens University, Kingston, ON, Canada; Collaboration for Cancer Outcomes, Research and Evaluation, South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia; School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute and Department of Oncology, Queens University, Kingston, ON, Canada
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, UK; Department of Oncology, Guy's & St Thomas' National Health Service Trust, London, UK
| | - Ajay Aggarwal
- Department of Oncology, Guy's & St Thomas' National Health Service Trust, London, UK; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Susannah Jacob
- Collaboration for Cancer Outcomes, Research and Evaluation, South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia
| | - Freddie Bray
- Cancer Surveillance Branch, International Agency for Cancer Research, Lyon, France
| | - Michael B Barton
- Collaboration for Cancer Outcomes, Research and Evaluation, South-West Clinical School, University of New South Wales, Liverpool, NSW, Australia
| | - Sallie-Anne Pearson
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; NHMRC Medicines Intelligence Centre of Research Excellence, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
3
|
Habashy C, Yemeke TT, Bolous NS, Chen Y, Ozawa S, Bhakta N, Alexander TB. Variations in global prices of chemotherapy for childhood cancer: a descriptive analysis. EClinicalMedicine 2023; 60:102005. [PMID: 37251630 PMCID: PMC10209684 DOI: 10.1016/j.eclinm.2023.102005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Background The stark disparity in survival for children with cancer across the world has inspired a global call to expand chemotherapy access in low and middle income countries. Among the numerous barriers to success, a paucity of reliable information regarding chemotherapy pricing hinders the ability of governments and other key stakeholders to make informed budget decisions or negotiate lower medication prices. The aim of this study was to generate comparative price information on both individual chemotherapy agents and comprehensive treatment regimens for common childhood cancers using real-world data. Methods Chemotherapy agents were selected based on their inclusion in the World Health Organization (WHO) Essential Medicines List for Children (EMLc) and their use in frontline regimens for the tracer cancer types prioritized by the WHO's Global Initiative for Childhood Cancer (GICC). Sources included IQVIA MIDAS data, obtained under license from IQVIA, and publicly available data from Management Sciences for Health (MSH). Data on chemotherapy prices and purchase volumes spanning 2012-2019 were aggregated according to WHO region and World Bank (WB) income classification. Cumulative chemotherapy prices for treatment regimens were compared across WB income classification. Findings Data representing an estimated 1.1 billion doses of chemotherapy were obtained for 97 countries: 43 high income countries (HICs), 28 upper middle income countries (UMICs), and 26 low and lower middle income countries (LLMICs). Median drug prices in HICs were 0.9-20.4 times those of UMICs and 0.9-15.5 times those of LMICs. Regimen prices were generally higher for HICs, hematologic malignancies, non-adapted protocols, and higher risk stratification or stage, albeit with notable exceptions. Interpretation This study represents the largest price analysis to date of chemotherapy agents used globally in childhood cancer therapy. The findings of this study form a basis for future cost-effectiveness analysis in pediatric cancer and should inform efforts of governments and stakeholders to negotiate drug prices and develop pooled purchasing strategies. Funding NB received funding support from the American Lebanese Syrian Associated Charities and Cancer Center Support grant (CA21765) from the National Cancer Institute through the National Institutes of Health. TA received funding through the University of North Carolina Oncology K12 (K12CA120780) and the University Cancer Research Fund from the UNC Lineberger Comprehensive Cancer Center.
Collapse
Affiliation(s)
- Catherine Habashy
- Division of Pediatric Hematology-Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Tatenda T. Yemeke
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Nancy S. Bolous
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sachiko Ozawa
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Thomas B. Alexander
- Division of Pediatric Hematology-Oncology, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
4
|
Petricca K, Kambugu J, Githang'a J, Macharia WM, Njuguna F, McLigeyo A, Nyangasi M, Orem J, Kanyamuhunga A, Laiti R, Katabalo D, Schroeder K, Rogo K, Maguire B, Wambui L, Nkurunziza JN, Wong B, Neposlan J, Kilawe L, Gupta S, Denburg AE. Access to essential cancer medicines for children: a comparative mixed-methods analysis of availability, price, and health-system determinants in east Africa. Lancet Oncol 2023; 24:563-576. [PMID: 37023781 DOI: 10.1016/s1470-2045(23)00072-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Access to essential childhood cancer medicines is a core determinant of childhood cancer outcomes. Available evidence, although scarce, suggests that access to these medicines is highly variable across countries, particularly in low-income and middle-income countries, where the burden of childhood cancer is greatest. To support evidence-informed national and regional policies for improved childhood cancer outcomes, we aimed to analyse access to essential childhood cancer medicines in four east African countries-Kenya, Rwanda, Tanzania, and Uganda-by determining the availability and price of these medicines and the health system determinants of access. METHODS In this comparative analysis, we used prospective mixed-method analyses to track and analyse the availability and price of essential childhood cancer medicines, investigate contextual determinants of access to childhood cancer medicines within and across included countries, and assess the potential effects of medicine stockouts on treatment. Eight tertiary care hospitals were included, seven were public sites (Kenyatta National Hospital [KNH; Nairobi, Kenya], Jaramogi Oginga Odinga Referral and Teaching Hospital [JOORTH; Kisumu, Kenya], Moi University Teaching and Referral Hospital [MTRH; Eldoret, Kenya], Bugando Medical Centre [BMC; Mwanza, Tanzania], Muhimbili National Hospital [MNH; Dar es Salaam, Tanzania], Butaro Cancer Centre of Excellence [BCCE; Butaro Sector, Rwanda], and Uganda Cancer Institute [UCI; Kampala, Uganda]) and one was a private site (Aga Khan University Hospital [AKU; Nairobi, Kenya]). We catalogued prices and stockouts for 37 essential drugs from each of the eight study siteson the basis of 52 weeks of prospective data that was collected across sites from May 1, 2020, to Jan 31, 2022. We analysed determinants of medicine access using thematic analysis of academic literature, policy documents, and semi-structured interviews from a purposive sample of health system stakeholders. FINDINGS Recurrent stockouts of a wide range of cytotoxic and supportive care medicines were observed across sites, with highest mean unavailability in Kenya (JOORTH; 48·5%), Rwanda (BCCE; 39·0%), and Tanzania (BMC; 32·2%). Drugs that had frequent stockouts across at least four sites included methotrexate, bleomycin, etoposide, ifosfamide, oral morphine, and allopurinol. Average median price ratio of medicines at each site was within WHO's internationally accepted threshold for efficient procurement (median price ratio ≤1·5). The effect of stockouts on treatment was noted across most sites, with the greatest potential for treatment interruptions in patients with Hodgkin lymphoma, retinoblastoma, and acute lymphocytic leukaemia. Policy prioritisation of childhood cancers, health financing and coverage, medicine procurement and supply chain management, and health system infrastructure emerged as four prominent determinants of access when the stratified purposive sample of key informants (n=64) across all four countries (Kenya n=19, Rwanda n=15, Tanzania n=13, and Uganda n=17) was interviewed. INTERPRETATION Access to childhood cancer medicines across east Africa is marked by gaps in availability that have implications for effective treatment delivery for a range of childhood cancers. Our findings provide detailed evidence of barriers to access to childhood cancer medicine at multiple points in the pharmaceutical value chain. These data could inform national and regional policy makers to optimise cancer medicine availability and affordability as part of efforts to improve childhood cancer outcomes specific regions and internationally. FUNDING American Childhood Cancer Organization, Childhood Cancer International, and the Friends of Cancer Patients Ameera Fund.
Collapse
|