Faculty Bibliography

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.

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.

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.

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.

In LA County, contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus require 7.3 million gowns annually generating 506 tons of plastic waste and 1.73 million kilograms of carbon dioxide equivalents, which cause the loss of 4.07 disability-adjusted life-years. Unintended consequences of gown use necessitates exploration of infection prevention alternatives.

OBJECTIVE:To assess the environmental impact of magnetic resonance (MR) and computed tomography (CT) imaging using life cycle assessment (LCA), focusing on energy use, resource consumption, and emissions. METHODS:This ISO 14040-guided LCA-based study focused on MRI and CT services, including the production and use of three MRI and four CT scanners, at a quaternary care 800-bed academic medical center in the Southeastern USA over a one-year period. Data were collected through direct observation, record review, staff interviews, and energy metering. Environmental impacts were assessed using SimaPro 9.3.0.2 and the Ecoinvent v3.8 database. RESULTS:MRI and CT services at this site generate an estimated 221 and 108 tons of CO2e per year, respectively. This is equivalent to the emissions of 52 (MRI) and 25 (CT) cars driven annually. Energy consumption accounted for the largest portion of emissions (58% for MRI, 33% for CT), followed by disposable supplies (26% for MRI, 16% for CT), capital equipment production (7% for MRI, 13% for CT), and linens (4% for MRI, 11% for CT). Switching to solar photovoltaic electricity could reduce total MRI emissions by 70% and CT emissions by 40%, increasing the relative impacts of scanner production, disposable supplies, and linens. DISCUSSION/CONCLUSIONS:This study highlights the significant environmental impact of MRI and CT services, particularly energy consumption. Renewable energy sources, such as solar photovoltaics, offer the greatest potential for mitigating the environmental footprint. Additional strategies include optimizing scanner utilization, adopting reusable or reprocessable supplies, and embracing circular business practices such as circular manufacturing and extending the lifespan of capital equipment.

OBJECTIVE:To assess the environmental impact of radiography and fluoroscopy, using life cycle assessment (LCA), focusing on energy use and emissions. METHODS:This ISO 14040-guided LCA-based study focused on radiography and fluoroscopy services, including the production and use of two radiography and two fluoroscopy machines, at a quaternary care 800-bed academic medical center in the Southeastern United States over a 1-year period. Data were collected through direct observation, record review, staff interviews, and energy metering. Environmental impacts were assessed using SimaPro 9.3.0.2 and the Ecoinvent v3.8 database. RESULTS:e per scan). Medical linens or textiles accounted for 24% of total emissions. Other significant environmental impacts included ozone depletion, smog, acidification, and eutrophication. DISCUSSION/CONCLUSIONS:Reducing energy consumption by decarbonizing electricity sources and optimizing equipment use can significantly decrease greenhouse gas emissions. Implementing sustainable practices in linen use, procurement, and end-of-life management is also crucial. Reducing low-value imaging can further mitigate environmental impact.

BACKGROUND AND OBJECTIVE/OBJECTIVE:The health care sector is a significant contributor to greenhouse gas (GHG) emissions, and assessments of the environmental impacts of health services are essential. We aimed to evaluate the environmental impact of a highly common but controversial urology-specific blood test: the prostate-specific antigen (PSA) test. METHODS:e). The secondary outcome was the health impact attributed to the environmental harm of the test. KEY FINDINGS AND LIMITATIONS/UNASSIGNED:e, equivalent to driving 14.5 million miles, with a resulting human health impact of 6.6 disability-adjusted life years annually. This study focused on the PSA test itself, and not on emissions from staff, patient, or sample transportation; building infrastructure; or cleaning. CONCLUSIONS AND CLINICAL IMPLICATIONS/CONCLUSIONS:Although the carbon footprint of a single PSA test is small, the cumulative impact of the estimated total of 30 million PSA tests performed annually in the USA is substantial, especially when considering that a notable proportion of these tests may be performed on men who are unlikely to benefit.