HealthLawProf Blog

Editor: Katharine Van Tassel
Case Western Reserve University School of Law

Wednesday, March 12, 2014

Guest Blogger Associate Professor Ann Marie Marciarille: Who Is Wasting What?

MarciarilleA purchasing alliance among hospitals interested in quality improvement is reported [1] to have developed a “waste index” for participating facilities, designed to give them information to eliminate waste while maintaining a high level of care.  Articles that sound a little like press releases do not usually get that much of my attention, but I read on because the lead example of savings from the application of the “waste index” nearly took my breath away.

At four Adventist Midwest Health hospitals, for instance, patients with asthma and other respiratory conditions were often treated with prepackaged metered-dose inhalers. By switching some to equivalent generic drugs delivered via a nebulizer that turns medications into a fine mist for inhalation, Adventist shaved $100,000 in costs last year. [2]

What’s not to like? Opposing the elimination of waste – at least in theory -- seems almost un-American. What gives me pause, however, is considering the relationship of this “waste” example and the two fold goal of hospital-based asthma treatment: symptom relief and training the patient in better disease-management. Symptom relief, in an emergent or urgent situation, quite reasonably takes first place. But once symptom relief is underway, health care providers should be reverse engineering the circumstances that brought an individual to a hospital emergency department with an asthma attack, for example, because emergency department visits for asthma attacks ought to be but are not the low-hanging fruit of preventable emergency department use.


Asthmatics typically use maintenance inhalers on long-term predictable daily dosage/utilization rates. Rescue inhalers, by contrast, represent a study in contrasts where utilization rates vary widely from multiple times a week to single times a month for each user.  Rescue inhalers are not predictably scheduled prescription refills. Their efficient use requires an element of self-care by the user and requires a level of pharmaceutical savvy, for rescue inhalers appear to be working when they are not [3] and do not, typically, have built-in dose counters. [4] One study  [5] reportedly surveyed identified asthmatics where nearly half reported having an empty rescue inhaler in hand during an asthma attack.

Here we have the two-sided problem of less expensive, generic rescue inhalers lacking built-in dose counters that are favored by most health insurers prevailing in formulary design over the more expensive branded rescue inhalers with built-in dose counters. This is a problem long in search of a solution. [6] The FDA, in fact, requires new rescue inhalers to have dose counters but grandfathers in existing products while asthma deaths continue to rise and astonishing data emerges about the percentage of asthmatics using empty rescue inhalers in an emergency. Here we also have the problems of sophisticated consumers responding through organized waste by discarding half empty inhalers. Our problem, in search of a nudge or series of nudges, is one both of underuse of rescue inhalers   by certain segments of the population and of overuse or waste by others.

And all of this is now, apparently, to be complicated by emergency departments that focus on cheaper symptom relief supplies at the cost of failing to stock the best, most effective, and arguably cheaper to the entire health care system metered dose with built-in dose counter rescue inhalers. The former are cheaper to the hospitals in their symptom relief function but more expensive to the patient as an inadequate device to use to train better asthma management.

I have written elsewhere about the almost irresistible compulsion to cost-shift within our badly integrated health care system. [7] I do have to wonder whose waste we are monitoring here.

-Guest Blogger Associate Professor Ann Marie Marciarille



[3] Daniel More, MD, How Do I Know That My Asthma Inhaler is Empty?

[4] Wasserman RL et al.,  Real-World Assessment of a Metered-Dose Inhaler With Integrated Dose Counter, Allergy Asthma Proc. 2006 Nov-Dec; 27(6): 486-92.

[5] Kate Johnson, Asthma Inhalers Often Empty When Needed,, Nov. 20, 2013.

[6] See Conner & Buck, Improving Asthma Management: The Case for Mandatory Inclusion of Dose Counters On All Rescue Bronchodilators, J Asthma 2013 Aug:50(6); 658-653; Sander et al., Dose Counting and the Use of Pressurized Metered-Dose Inhalers: Running on Empty, Annals of Allergy, Asthma & Immunology, Vol. 97 July, 2006.


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