During the last few years, there have been reports of shortages of anesthesiology supplies and drugs. These shortages have been caused by a combination of factors, including increased demand, manufacturing issues, and disruptions in the supply chain. For example, the use of propofol, commonly utilized during anesthesia and intensive care, has increased because of the number of COVID-19 patients on ventilators. Some manufacturers of anesthesia drugs have experienced production delays due to quality control problems or difficulties obtaining raw materials. Transportation issues, climate change and natural disasters, pandemics, and geopolitical tensions (e.g., U.S.-China) have also contributed to shortages of anesthesiology supplies and drugs (asamonitor.pub/3GQZPlS; ASA Monitor 2022;86:1-5; Am J Health Syst Pharm 2020;77:1778-85). Such shortages cause significant implications for patients and health care providers. Hence, there is a need for a renewed focus on applying supply chain principles for improving resilience and mitigating future problems.
According to the Council of Supply Chain Management Professionals, supply chain management “encompasses the planning and management of all activities involved in sourcing and procurement, conversion and logistics” (asamonitor.pub/3AaMn8M). Its goal is “the management of upstream and downstream relationships with suppliers and customers in order to deliver superior customer value at less cost to the supply chain as a whole” (Logistics and Supply Chain Management. 5th ed, 2016). The goal of health care supply chain management is to ensure uninterrupted, high-quality clinical outcomes and positive patient experiences without undue burden from the cost of services offered (Manuf Serv Oper Manag 2021;23:1333-53).
The health care supply chain consists of several stakeholders (see Table) (The HealthcareValue Chain: Demystifying the Role of GPOs and PBMs. 2022). Based on the understanding of the health care supply chain, we explore how key principles that include coordination/integration, standardization/mass-customization, pooling, and responsiveness help to ensure achievable high-quality clinical outcomes. Anesthesiology is a critical service essential for health care and is central to 24/7/365 continuous care delivery. Overlooking support for anesthesiology service provision can result in a bottleneck for needed patient care. Close attention needs to be paid to the stocking and immediate availability of essential drugs, medical supplies, parenteral fluids, monitoring equipment, and other items specific to the procedures and the different patient populations requiring care. Prior to launching any patient-related surgical or diagnostic procedure, anesthesiologists routinely perform safety checks, including ensuring the availability of these items. The anesthesiology department is an integral part of the holistic health care supply chain management, and the same principles we introduce below apply to its service as well as other clinical care areas.
Coordination and integration
Coordination refers to the alignment and synchronization of the contributions of supply chain stakeholder members to the entire interorganizational business process (J Purch Supply Manag 2004;10:165-77). Integration is the connectivity among these members to eliminate silos (Manuf Serv Oper Manag 2021;23:1333-53). Information sharing can facilitate both coordination and integration. In the integrated health care delivery pathway, anesthesiologists are in the front end of patient operating procedures, and their services should be seamlessly coordinated. The demand predictions for operating procedures should account for planning all resources, including number of anesthesiologists and needed drugs/supplies/devices. However, in the current health care delivery system, the anesthesiologist's role is frequently overlooked in the planning process in which other physicians and surgeons are the key players (Anesth Analg 1996;83:1314-21; J Clin Anesth 2016;18:504-9). Administrators should better value the role of anesthesiologist leaders in the coordination of anesthesia drugs/supplies and medical devices for clinical procedures and care services. During the COVID-19 pandemic, health care supply chain management experienced shortages in epidural kits, syringes, needles, and I.V. and A-Line catheters. In this situation, coordination efforts for demand-supply synchronization led anesthesiologists to find substitutes, procure from different vendors, or prioritize, repurpose, and ration equipment where necessary (ASA Monitor 2023;87:18-9).
Standardization and mass customization
Standardization is a process that ensures consistency. Anesthesia drugs, supplies, equipment, and procedures can be subject to standardization to remove variability and increase productivity and safety through mass production and economies of scale. For instance, suppliers may provide clinics with anesthesia kits (carts) that typically contain the equipment and supplies needed for safely administering anesthesia. Their contents can vary depending on the type of procedures to be used and the preferences of health care facilities and practitioners. As an example, in remote areas with limited tools and technology, anesthesia-configured medic bags have been used that contain the most common anesthesia supply material in a portable way for treatment in emergency situations (Avicenna J Med 2012;2:40-4). Mass customization through postponement strategy is another supply chain principle that can successfully be applied to anesthesia kits. The concept refers to delaying differentiation of the product to the time-of-service delivery depending on patients' physical characteristics and disease type/status that indicate care requirements. Using the 80/20 rule of the Pareto principle, standard anesthesia kits could be of two types: 80% of them could follow the standardization process for typical patients with no special requirements, and 20% should follow mass customization through postponement strategy for patients with special requirements. This grouping would allow anesthesiologists and surgeons to quickly prep patients and increase OR throughput, thereby relieving the overwhelming demand of elective surgeries and enhancing physicians' productivity. Hospitals/clinics can cater to a variety of patients while achieving high utilization of their delivery services. Standard anesthesia kits should also include generic drugs/supplies. Suppliers could assemble anesthesia kits from generic or branded drugs/supplies following the Pareto principle based on available budget and input from anesthesiologists and pharmacies. Moreover, efficiency can be enhanced by repurposing different existing drugs for anesthesia (if applicable) to treat rare patient cases not amenable to drugs typically used for anesthesia.
Pooling refers to the action of redesigning areas of the supply chain (by aggregating demand, resources, products, and capacity) to reduce uncertainty (Matching supply with demand: an introduction to operations management. 4th ed, 2018). For example, the procurement department within a hospital could pool purchasing of drugs/supplies/devices among all specialties, including anesthesiology. Furthermore, several hospitals can engage in pooled procurement, using group purchasing organizations, to consolidate purchases for multiple hospitals and obtain better prices. Pooling can also be used for managing resources, such as shared medical appointments for surgeries scheduled the next day or the same week, in which anesthesiologists provide consultations to a group of patients who will undergo similar or different procedures requiring varying levels and types of anesthesia/sedation depending on the patients' health condition. This pooled consultation improves outcomes and patient satisfaction while reducing waiting times and costs (N Engl J Med 2017;376:1105-7).
Shortages of anesthesiologists and anesthesiology drugs/supplies/devices can lead to delays in surgeries and changes in treatment plans that may not be as effective or that have more side effects (Can J Anesth 2013;60:539-51). Shortages may also lead to amplification of various problems in health care supply chain management (bullwhip effect), such as demand distortion (e.g., creating artificial demand by ordering more supplies than needed in anticipation of potential pricing increase, production disruption, etc.). These problems can be addressed with a responsive and resilient health care supply chain team. Important measures that can be taken include alternative suppliers for sourcing anesthesia drugs/supplies/equipment, alternative transportation depots and modes for delivery, better demand forecasting, and better coordination among the supply chain echelons with the use of information-sharing and decision synchronization by deploying supply chain management software and implementing joint relationship efforts to share supplies and increase manufacturing capacity (Ann Oper Res 2021;319:965-1002). Measures to address anesthesiologist shortages, in the short term, may include increasing the output of anesthesiologist assistants. In the long term, there must be increased recognition of the important role of anesthesiologists, e.g., through promoting the specialty in medical schools and raising awareness of both financial and nonfinancial incentives.
In conclusion, the application of supply chain principles is paramount for greater success of clinical service performance and resilience. Anesthesiologists are in the forefront of clinical interventions, and their role is critical in controlling pain and consciousness during surgical procedures, followed by satisfactory recovery from the intervention and to the overall success of the treatment outcome. Therefore, the anesthesiology supply chain is a critical component of health care supply chain management. The integration principle would enable coordination and collaboration through demand-supply synchronization of resources and would require information-sharing among various stakeholders. The standardization and mass customization principle would increase the number of patients treated and the utilization of resources, which can lead to delivery of efficient clinical care. Pooling would also lower costs in patient care. Responsiveness/flexibility in service delivery might improve resource allocation among health care providers, shorten lead times, and enable creative solutions in case of shortages or other challenges in supply chain management.
Disclosure: Dr. Belani is a grant recipient of Acacia Pharmaceuticals, Medtronic USA, Inc., and Pfizer.