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Reducing Pollution From the Health Care Industry

Sherman, Jodi D; MacNeill, Andrea; Thiel, Cassandra
PMID: 31373600
ISSN: 1538-3598
CID: 4015472

Quantification of the Cost and Potential Environmental Effects of Unused Pharmaceutical Products in Cataract Surgery

Tauber, Jenna; Chinwuba, Ijeoma; Kleyn, David; Rothschild, Michael; Kahn, Jonathan; Thiel, Cassandra L
Importance/UNASSIGNED:Pharmaceutical products, including unused portions, may contribute to financial and environmental costs in the United States. Because cataract surgery is performed millions of times each year in the United States and throughout the rest of the world, understanding these financial and environmental costs associated with cataract surgery is warranted. Objective/UNASSIGNED:To investigate the financial and environmental costs of unused pharmaceutical products after phacoemulsification surgery. Design, Setting, and Participants/UNASSIGNED:This descriptive qualitative study included 4 surgical sites in the northeastern United States (a private ambulatory care center, private tertiary care center, private outpatient center, and federally run medical center for veterans). Prices and data for use of services and pharmaceuticals were obtained for the tertiary care and outpatient centers from January 1 through April 30, 2016; for the ambulatory care center from June 1, 2017, through March 31, 2018; and the federal medical center from November 1, 2017, through February 28, 2018. Data were collected from routine phacoemulsification surgical procedures without vitreous loss or other complications. Volume or weight of medications remaining after surgery was measured. Total and mean costs of medications per case and month were calculated. Environmental effects were estimated using economic input-output life cycle assessment methods. Data were analyzed from December 1, 2017, through June 30, 2018. Main Outcomes and Measures/UNASSIGNED:Cost of unused pharmaceutical products (in US dollars) and kilogram equivalents of carbon emissions (carbon dioxide [CO2-e]), air pollution (fine particulate matter emissions of ≤10 μm in diameter [PM10-e]), and eutrophication potential (nitrogen [N-e]). Results/UNASSIGNED:A total of 116 unique drugs were surveyed among the 4 centers. Assuming unmeasured medications had no materials left unused, a cumulative mean 83 070 of 183 304 mL per month (45.3%) of pharmaceuticals were unused by weight or volume across all sites. Annual unused product cost estimates reached approximately $195 200 per site. A larger percentage of eyedrops (65.7% by volume) were unused compared with injections (24.8%) or systemic medications (59.9%). Monthly unused quantities at the ambulatory care center (65.9% by volume [54 971 of 83 440 mL]), tertiary care center (21.3% [17 143 of 80 344 mL]), federal medical center (38.5% [265 of 689 mL]), and outpatient center (56.8% [10 691 of 18 832 mL]) resulted in unnecessary potential emissions at each center of 2135, 2498, 418, and 711 kg CO2-e/mo, respectively. Unnecessary potential air pollution between sites varied from 0.8 to 4.5 kg PM10-e/mo, and unnecessary eutrophication potential between sites varied from 0.07 to 0.42 kg N-e/mo. Conclusions and Relevance/UNASSIGNED:This study suggests that unused pharmaceutical products during phacoemulsification result in relatively high financial and environmental costs. If these findings can be substantiated and shown to be generalizable in the United States or elsewhere, reducing these costs may be of value.
PMID: 31369052
ISSN: 2168-6173
CID: 4015382

Potential for industrial ecology to support healthcare sustainability: Scoping review of a fragmented literature and conceptual framework for future research

Cimprich, Alexander; Santillán-Saldivar, Jair; Thiel, Cassandra L.; Sonnemann, Guido; Young, Steven B.
Healthcare is a critical service sector with a sizable environmental footprint from both direct activities and the indirect emissions of related products and infrastructure. As in all other sectors, the "inside-out" environmental impacts of healthcare (e.g., from greenhouse gas emissions, smog-forming emissions, and acidifying emissions) are harmful to public health. The environmental footprint of healthcare is subject to upward pressure from several factors, including the expansion of healthcare services in developing economies, global population growth, and aging demographics. These factors are compounded by the deployment of increasingly sophisticated medical procedures, equipment, and technologies that are energy- and resource-intensive. From an "outside-in" perspective, on the other hand, healthcare systems are increasingly susceptible to the effects of climate change, limited resource access, and other external influences. We conducted a comprehensive scoping review of the existing literature on environmental issues and other sustainability aspects in healthcare, based on a representative sample from over 1,700 articles published between 1987 and 2017. To guide our review of this fragmented literature, and to build a conceptual foundation for future research, we developed an industrial ecology framework for healthcare sustainability. Our framework conceptualizes the healthcare sector as comprising "foreground systems" of healthcare service delivery that are dependent on "background product systems." By mapping the existing literature onto our framework, we highlight largely untapped opportunities for the industrial ecology community to use "top-down" and "bottom-up" approaches to build an evidence base for healthcare sustainability.
ISSN: 1088-1980
CID: 3998872

Strategies to Reduce Greenhouse Gas Emissions from Laparoscopic Surgery

Thiel, Cassandra L; Woods, Noe C; Bilec, Melissa M
OBJECTIVES/OBJECTIVE:To determine the carbon footprint of various sustainability interventions used for laparoscopic hysterectomy. METHODS:We designed interventions for laparoscopic hysterectomy from approaches that sustainable health care organizations advocate. We used a hybrid environmental life cycle assessment framework to estimate greenhouse gas emissions from the proposed interventions. We conducted the study from September 2015 to December 2016 at the University of Pittsburgh (Pittsburgh, Pennsylvania). RESULTS:The largest carbon footprint savings came from selecting specific anesthetic gases and minimizing the materials used in surgery. Energy-related interventions resulted in a 10% reduction in carbon footprint per case but would result in larger savings for the whole facility. Commonly implemented approaches, such as recycling surgical waste, resulted in less than a 5% reduction in greenhouse gases. CONCLUSIONS:To reduce the environmental emissions of surgeries, health care providers need to implement a combination of approaches, including minimizing materials, moving away from certain heat-trapping anesthetic gases, maximizing instrument reuse or single-use device reprocessing, and reducing off-hour energy use in the operating room. These strategies can reduce the carbon footprint of an average laparoscopic hysterectomy by up to 80%. Recycling alone does very little to reduce environmental footprint. Public Health Implications. Health care services are a major source of environmental emissions and reducing their carbon footprint would improve environmental and human health. Facilities seeking to reduce environmental footprint should take a comprehensive systems approach to find safe and effective interventions and should identify and address policy barriers to implementing more sustainable practices.
PMID: 29698098
ISSN: 1541-0048
CID: 3052812

Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility

Thiel, Cassandra L; Schehlein, Emily; Ravilla, Thulasiraj; Ravindran, R D; Robin, Alan L; Saeedi, Osamah J; Schuman, Joel S; Venkatesh, Rengaraj
PURPOSE/OBJECTIVE:To measure the waste generation and lifecycle environmental emissions from cataract surgery via phacoemulsification in a recognized resource-efficient setting. SETTING/METHODS:Two tertiary care centers of the Aravind Eye Care System in southern India. DESIGN/METHODS:Observational case series. METHODS:Manual waste audits, purchasing data, and interviews with Aravind staff were used in a hybrid environmental lifecycle assessment framework to quantify the environmental emissions associated with cataract surgery. Kilograms of solid waste generated and midpoint emissions in a variety of impact categories (eg, kilograms of carbon dioxide equivalents). RESULTS:Aravind generates 250 grams of waste per phacoemulsification and nearly 6 kilograms of carbon dioxide-equivalents in greenhouse gases. This is approximately 5% of the United Kingdom's phaco carbon footprint with comparable outcomes. A majority of Aravind's lifecycle environmental emissions occur in the sterilization process of reusable instruments because their surgical system uses largely reusable instruments and materials. Electricity use in the operating room and the Central Sterile Services Department (CSSD) accounts for 10% to 25% of most environmental emissions. CONCLUSIONS:Surgical systems in most developed countries and, in particular their use of materials, are unsustainable. Results show that ophthalmologists and other medical specialists can reduce material use and emissions in medical procedures using the system described here.
PMID: 29223227
ISSN: 1873-4502
CID: 2837732

Addressing the climate impacts of healthcare

Silva, Genevieve S; Schimek, Cassandra A; Lighter, Jennifer L; Thiel, Cassandra L
PMID: 35527513
ISSN: 1553-5606
CID: 5212882

Climate change and global health: A call to more research and more action

Agache, Ioana; Sampath, Vanitha; Aguilera, Juan; Akdis, Cezmi; Akdis, Mubeccel; Barry, Michele; Bouagnon, Aude; Chinthrajah, Sharon; Collins, William; Dulitzki, Coby; Erny, Barbara; Gomez, Jason; Goshua, Anna; Jutel, Marek; Kizer, Kenneth W; Kline, Olivia; LaBeaud, A Desiree; Pali-Schöll, Isabella; Perrett, Kirsten P; Peters, Rachel L; Plaza, Maria Pilar; Prunicki, Mary; Sack, Todd; Salas, Renee N; Sindher, Sayantani B; Sokolow, Susanne H; Thiel, Cassandra; Veidis, Erika; Wray, Brittany Delmoro; Traidl-Hoffmann, Claudia; Witt, Christian; Nadeau, Kari C
There is increasing understanding, globally, that climate change and increased pollution will have a profound and mostly harmful effect on human health. This review brings together international experts to describe both the direct (such as heat waves) and indirect (such as vector-borne disease incidence) health impacts of climate change. These impacts vary depending on vulnerability (i.e., existing diseases) and the international, economic, political, and environmental context. This unique review also expands on these issues to address a third category of potential longer-term impacts on global health: famine, population dislocation, and environmental justice and education. This scholarly resource explores these issues fully, linking them to global health in urban and rural settings in developed and developing countries. The review finishes with a practical discussion of action that health professionals around the world in our field can yet take.
PMID: 35073410
ISSN: 1398-9995
CID: 5154312

What a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve

Bravo, Dalibel; Thiel, Cassandra; Bello, Ricardo; Moses, Akini; Paksima, Nader; Melamed, Eitan
BACKGROUND/UNASSIGNED:The US health care system is the second largest contributor of trash. Approximately 20% to 70% of waste is produced by operating rooms, and very few of this waste is recycled. The purpose of this study is to quantify the opened but unused disposable supplies and generate strategies to reduce disposable waste. METHODS/UNASSIGNED:-e), a measure of greenhouse gas emissions. RESULTS/UNASSIGNED:-e during the study period. CONCLUSIONS/UNASSIGNED:This study highlights the excessive waste of unused disposable products during hand surgery cases and identifies ways of improvement.
PMID: 35485263
ISSN: 1558-9455
CID: 5217682

Differences in reuse of cataract surgical supplies and pharmaceuticals based on type of surgical facility

Thiel, Cassandra L; Zhang, Jinchun; Chang, David F
PMID: 35383659
ISSN: 1873-4502
CID: 5204902

Identifying high-value care for Medicare beneficiaries: a cross-sectional study of acute care hospitals in the USA

Herrin, Jeph; Yu, Huihui; Venkatesh, Arjun K; Desai, Sunita M; Thiel, Cassandra L; Lin, Zhenqiu; Bernheim, Susannah M; Horwitz, Leora I
OBJECTIVES/OBJECTIVE:High-value care is providing high quality care at low cost; we sought to define hospital value and identify the characteristics of hospitals which provide high-value care. DESIGN/METHODS:Retrospective observational study. SETTING/METHODS:Acute care hospitals in the USA. PARTICIPANTS/METHODS:All Medicare beneficiaries with claims included in Center for Medicare & Medicaid Services Overall Star Ratings or in publicly available Medicare spending per beneficiary data. PRIMARY AND SECONDARY OUTCOME MEASURES/METHODS:Our primary outcome was value defined as the difference between Star Ratings quality score and Medicare spending; the secondary outcome was classification as a 4 or 5 star hospital with lowest quintile Medicare spending ('high value') or 1 or 2 star hospital with highest quintile spending ('low value'). RESULTS:Two thousand nine hundred and fourteen hospitals had both quality and spending data, and were included. The value score had a mean (SD) of 0.58 (1.79). A total of 286 hospitals were classified as high value; these represented 28.6% of 999 4 and 5 star hospitals and 46.8% of 611 low cost hospitals. A total of 258 hospitals were classified as low value; these represented 26.6% of 970 1 and 2 star hospitals and 49.3% of 523 high cost hospitals. In regression models ownership, non-teaching status, beds, urbanity, nurse to bed ratio, percentage of dual eligible Medicare patients and percentage of disproportionate share hospital payments were associated with the primary value score. CONCLUSIONS:There are high quality hospitals that are not high value, and a number of factors are strongly associated with being low or high value. These findings can inform efforts of policymakers and hospitals to increase the value of care.
PMID: 35361641
ISSN: 2044-6055
CID: 5201362