The decision to repackage bulk, oral-solid medications in-house or purchase these drugs in unit-dose form is a central consideration when ensuring patients receive high-quality, cost-effective medications. Both methods offer advantages and disadvantages depending on the size of the hospital and its individualized needs; while hospitals that require a limited amount of packaging may do well repackaging bulk products in-house, facilities that utilize higher volumes may benefit from purchasing pre-packaged, bar coded, unit-dose medications from an outsourcer. Carefully determining which method (or combination of methods) best supports your facility’s needs is critical.
Indiana University Health Bloomington (IUHB) is a 335-bed hospital serving south central Indiana. The hospital currently relies on a decentralized drug distribution model, utilizing medication carousels, an automated narcotic management system, automated anesthesia carts in the operating rooms, and ADCs on the units. Approximately 90% of total doses administered are dispensed from ADCs.
Outdated Approach to Distribution
Previously, our hospital’s distribution strategy was based on a centralized model, which included purchasing bulk, oral-solid tablets and capsules and repackaging them in-house. At that time, we utilized an older-model machine to repackage medications on a per-patient basis. Medications were packaged and dispensed by patient in a single strip, and then stocked by patient in secure carts located in each nursing unit. Unfortunately, the repackaging machine did not include bar-coding capabilities, nor did it interface with the other pharmacy information systems. As a result, our ability to monitor inventory and improve efficiency was severely limited.
Eight years ago, in a quest to create a more holistic, automated system, we switched to decentralized distribution supported by ADCs stocked by drug, rather than by patient. With this change, we can now rely on the in-depth reporting capabilities of our ADCs to drive increased efficiencies in inventory and usage. To support this approach, we decided to focus on purchasing the majority of our medications in bar-coded, unit-dose form, rather than make the investment in upgrading our repackaging operation. Approximately 75% to 80% of total oral-solid medications are purchased in bar-coded, unit-dose form. Those medications that are not available in unit dose from the manufacturer are repackaged in-house using a small, tabletop packaging machine.
Maximizing the Use of Pre-Packaged Unit-Dose Products
The primary benefits we have realized as a result of maximizing use of outsourced, pre-packaged, unit-dose products include the safety benefits afforded by purchasing medications in bar-coded format with compliant labeling and tall-man lettering, the extended shelf-life of these products due to the outsourcers’ stability testing, and the increase in operational efficiency resulting from avoiding the majority of in-house repackaging.
- Medication Safety. Given the primacy of patient safety, outsourced, pre-packaged, unit-dose medications have significantly improved our ability to protect patients. For example, all of the unit-dose medications purchased arrive bar-coded to ensure patients receive the correct drug. Because our unit-dose vendors are regulated by the FDA and operate cGMP facilities, we are very confident in the quality and sterility of their products. Regardless of how excellent our internal policies and procedures are, it would be impossible to replicate cGMP production standards in our facility.
- Enhanced Labeling and Packaging Options. Another significant benefit of purchasing medications in unit-dose form is the wide variety of compliant options for labeling and packaging drugs that is available. The unit-dose medication labeling and packaging options from our vendors include tall-man lettering; color-coded and light-sensitive packaging; and multiple sizes and types of blister packs. In addition, 2D bar codes are widely available from many vendors.
When repackaging medications in-house there are significantly fewer packaging and labeling options. In addition, with in-house production a list of light-sensitive drugs must be maintained and updated, and packaging material must be changed when a drug requiring protection from light needs repackaging. With outsourced products, the color-coded packaging supports patient safety and is particularly effective at increasing efficiency for restocking. The multiple types of blister packages allow for further visual differentiation of product. And with 2D bar codes, the additional space on the bar code allows for the inclusion of more safety data. In addition to the NDC code, lot numbers and expiration dates are easily accommodated, which simplifies recall tracking and the management of out-of-date products. Another benefit from the vendor’s packaging materials is the fact that they can provide smaller blister packs than are available for in-house packaging—the resultant space savings allows for less frequent restocking of ADCs. The smaller packages mean more products fit into the cabinet pockets, and thus more medication can be made available for patient needs.
- Reduced Infrastructure. Choosing to outsource unit-dose packaging eliminates the need for a robust packaging infrastructure within the pharmacy. As a result, equipment needs are reduced, and less packaging material is required. Not only does this free up an expense line in the budget, but it also frees up floor space within the pharmacy.
- Increased Efficiency. Improving operational efficiency is a continual concern in today’s busy pharmacy environment. Purchasing as many medications as possible in pre-packaged, bar-coded, unit-of-use form allows staff to be redeployed to tasks other than packaging medications. In addition, because these medications arrive in the hospital already packaged and bar coded, fewer steps are required in the drug procurement and dispensing process, which saves significant time as a technician does not need to package the drugs and a pharmacist does not need to verify that the medications are correct prior to adding them to stock. Rather, the receiving technician simply scans the package upon receipt and adds it to the inventory, saving time and resources.
- Extended Shelf Life. When repackaging bulk medications in-house, many states require they be used within 12 months or by the manufacturer’s expiration date, whichever is sooner; unit-dose medications that have undergone stability testing often support beyond-use dating of up to 24 months.
When evaluating the costs of in-house repackaging of bulk product versus purchasing medication pre-packaged in unit dose, it is important to carefully consider accurate cost estimates for each strategy. While in many cases it may initially appear more cost-effective to purchase bulk product and repackage it in-house, the total cost of this approach must be considered, including labor, equipment, packaging materials, and the time required for the technician to repackage medication and for the pharmacist to verify it is correct.
Estimates on how much it costs to repackage in-house vary, with some as little as $0.08 per dose and others as much as $0.20 per dose.1 To calculate the cost of re-packaging bulk medications in-house, we considered the costs of packaging materials, maintenance and depreciation of packaging machines, and labor costs; our estimate was approximately $0.14 to $0.15 per dose. It is important to note that some products, such as controlled substances and chemotherapy, will have a much higher associated cost, and this must be factored into the analysis. After evaluating the cost, of purchasing unit-dose medications, we estimated that approximately 80% of the time it is more economical to purchase pre-packaged, unit-dose medications rather than repackage the bulk product in-house.
While it is not possible to completely eliminate in-house repackaging—not all drugs are available in unit dose, and the price point of certain unit-dose medications may be cost-prohibitive—reducing the volume of medications that must be repackaged in-house has been an effective strategy at IUHB. However, because procurement decisions must be based on multiple factors, it is vital to continually re-evaluate the available options to secure the highest quality medications for patients.
- Unit Dose vs. Bulk Oral Solid Medication Purchasing Patterns and Repackaging: Sampling and Analysis (White Paper). McKesson Corporation; Cranberry Township, PA, USA: 2010.http://www.mckesson.com/uploadedfiles/mckessoncom/content/pharmacies/_body_components/_right_rails/whitepaper-unitdose-vs-bulkoralsolidmedpurchasing.pdf Accessed April 25, 2014.
Bledar Doraci is the pharmacy-purchasing specialist at Indiana University Health Bloomington. He has worked in the health care setting for 18 years and has been in charge of pharmacy procurement for the last eight years.
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