In May, clinicians and patients at the University of Arizona Health Network had to delay non-urgent CT scans that required contrast media, a type of dye injected into the body to make organs and blood vessels more visible. It’s used to aid in the diagnosis of a variety of conditions, including some serious ones, such as cancer and blood clots.
A strict COVID-19 lockdown in Shanghai, China, had shut down a plant that manufactures the contrast and the 30-hospital medical center, like many others, suddenly found itself in short supply of the important diagnostic agent.
“The shortage has hit us fairly acutely,” says Geoffrey Rubin, MD, chair of the Department of Medical Imaging at the University of Arizona College of Medicine – Tucson and clinical service chief of medical imaging at Banner University Medicine – Tucson.
In response, Rubin and his colleagues quickly rallied to create a tiered protocol that prioritized the most critical medical procedures. Some tests were done using alternative tools, such as CT scans without contrast or MRIs, if it made sense for the patient.
Also, because the health system sources its contrast media from two companies, only one of which was impacted by the Shanghai lockdown, their supply wasn’t completely cut off.
But this was not the case everywhere.
Contrast media is used in about 50 million exams per year in the United States, and about half of the market procures its contrast from GE Healthcare, which sources most of its product from Shanghai, says Matthew Davenport, MD, vice chair of the American College of Radiology (ACR) Commission on Quality and Safety and a professor of radiology and urology at Michigan Medicine in Ann Arbor.
“Health systems that used GE Healthcare as their preferred vendor for iodinated contrast media had an immediate crisis,” Davenport says.
According to a GE Healthcare spokesperson, the company is currently working on restabilizing its supply and continues to evaluate its global footprint to maximize resilience.
Contrast media is just one item on a growing list of medical supplies that are becoming harder to come by due to world events impacting the supply chain, from COVID-19 lockdowns in China and manufacturing errors in the United States to the rising cost of fuel and the war in Ukraine.
The Food and Drug Administration lists more than two dozen medical items currently in short supply, including personal protective equipment (PPE) such as surgical gloves and gowns, reagents for laboratory testing, and several dialysis-related products.
“[Health systems are experiencing] 8-10 times higher shortages than they were pre-pandemic,” says Kyle MacKinnon, senior director of operational excellence for Premier, a group purchasing company. “We are seeing more frequent short-term shortages than we ever have in the past.”
A history of shortages
Shortages of important medical supplies in the United States due to supply chain issues date back as far as World War II, when supply of a common malaria drug that was sourced in the Japanese-occupied East Indies was cut off. Since then, the United States has faced both consistent and acute shortages, according to a 2021 study by researchers from Baylor College of Medicine in Houston, Texas.
In 2017, Hurricane Maria wiped out a main supplier of saline solution in Puerto Rico, creating a grave shortage. At the beginning of the COVID-19 pandemic, health care workers resorted to reusing PPE and crafting gowns out of trash bags as deliveries of Chinese-made materials slowed to a trickle.
The country has also faced shortages of a variety of drugs, such as anesthetics, antibiotics, and chemotherapy agents, for decades. Often, the shortages are exacerbated by regional disasters that disrupt the supply chain.
Currently, in addition to the shortages caused by COVID-19 lockdowns and disruptions, the war in Ukraine has the potential to worsen shortages of helium, which is used in MRIs and CT scans, and neon, which is essential for making semiconductors used in MRIs, pacemakers, blood pressure monitors, and other common medical devices.
Since Russia is no longer exporting as much natural gas to some European countries, other countries have begun filling in that supply via pipeline, reducing the need to convert the gases to liquid form. Because liquification facilitates extraction of helium from natural gas, this shift has also halted some helium production processes. This is on top of several helium plants shutting down in recent months for safety reasons.
“What a convoluted way to have medical supplies disrupted by the Ukraine war,” says Wally Hopp, PhD, a professor at the University of Michigan Ross School of Business in Ann Arbor who chaired the National Academies of Sciences, Engineering, and Medicine task force to study medical supply chain resilience. “These supply chains are so complicated, so long, so interconnected, you can get crazy side effects like that.”
Also, Ukraine is a major global supplier of neon, which may exacerbate further shortages as the war stretches on.
“At this time, we haven’t seen direct shortages of semiconductors yet,” MacKinnon says, But “access to that is becoming a problem.”
While the contrast media plant in Shanghai is now fully operational and hospitals across the country are gradually getting back to a regular supply of its product, it’s likely that supply chain disruptions for this and other medical supplies will continue to be affected by world events, says Tinglong Dai, PhD, a professor of operations management and business analytics at Johns Hopkins University Carey Business School.
This means that people in the medical industry, from medical students to administrators, should be prepared to both adjust to disruptions that occur and work to prevent them from happening.
“This crisis provided us with an opportunity to think through protocol when we have contrast restrictions and shortages,” Rubin says. “We had never experienced that before. Now we have a set of guidelines.”
For affected health systems, this required a variety of interventions, including lower dosing, performing CT scans without contrast and using alternative imaging strategies when appropriate, and triaging so that the most urgent exams were performed first. Although there is no longer an acute shortage, Davenport suspects that use of iodinated contrast media may go down if research shows lower-dose or unenhanced scanning is as effective as pre-shortage procedures.
“We have to be really attentive to what’s going on around the world, especially [when it comes] to health care.”
Tinglong Dai, PhD
Johns Hopkins University Carey Business School
During the shortage, Rubin held a meeting with his radiology residents to walk them through the crisis, from why it was happening to how the health system was responding to it. He believes that clinicians will have to learn to be more adaptable to whatever shortages and challenges their field faces.
“Oftentimes, there’s so much to learn in medicine [that] people in training — medical students — are focused on the domain of the specialty. The macro-level activities that allow health care to run are not really focused on,” Rubin says. “I think it is increasingly recognized [that] medical students, residents, and fellows [should] have their focus turned more toward these macro-level issues.”
Dai says that hospital administrators, and especially procurement officers, will also need to be more aware of geopolitical issues and how they might impact the supply chain.
“We have to be really attentive to what’s going on around the world,” he says. “Especially [when it comes] to health care.”
Fortifying the supply chains of the future
In response to a request from the U.S. Congress in the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act, the National Academies of Sciences, Engineering, and Medicine convened a committee to assess the security of the nation’s medical product supply chain. In its report, released in March, the committee made several recommendations to improve supply chain resilience.
“Medical supply chains are really behind other industries in terms of building supply chain resilience,” says Hopp, who led the writing of the report.
He explains that Hurricane Katrina in 2005 resulted in unexpected supply chain shortages because companies didn’t realize that the materials they were buying were sourced from the Gulf Coast. This realization prompted many in supply chain logistics to better track where various materials needed for manufacturing their products were coming from, including risk assessment and diversification of where they sourced the materials in case of a regional disaster.
But this still isn’t common in the medical industry, at least in part because there is a lack of transparency in the production of pharmaceuticals and other medical supplies, Hopp says. Procurement officers at health systems often don’t know where the companies they contract with are sourcing and manufacturing their materials.
This becomes particularly problematic when health systems contract mainly with one company to get the best price and when they use a “just in time” inventory approach, meaning they only stock enough supply for a week or two to save money on storage costs, he adds.
“Transparency has to be step one,” Hopp says, explaining the committee’s foundational recommendation to create a public database that documents where materials are sourced and manufactured so that experts can better analyze risk and make further recommendations for fortifying the supply chain.
In addition to being aware of possible natural disasters, Dai emphasizes the importance of geopolitical awareness.
“A large proportion of medical supplies come from China. Most of the generic drugs are manufactured in India,” Dai says. “We are so dependent on countries that are geopolitically incompatible [with] us.”
He says that the United States can protect its future supply chains by focusing more on sourcing and manufacturing closer to home, not only in the United States, but in Canada and Latin America, or by strengthening our supply chain relationships with countries that are part of the North Atlantic Treaty Organization (NATO) while moving away from reliance on countries where there may be more political issues.
Hopp cautions against the idea of focusing solely on “on-shoring,” the manufacturing of goods on United States territory.
“It’s difficult to make every raw material, every intermediate step inside the U.S., [and] it’s expensive to do it in some cases,” he says.
Instead, there should be a variety of responses, including potentially stockpiling raw materials, mapping out supply chain routes to assess risk, and building contracts that incentivize companies to reduce the risk of complete disruption, Hopp says.
Many of these steps would require the federal government and manufacturers to act, but health care system administrators can also drive change by demanding better transparency and reliability from manufacturers as well as reconsidering their stockpiling strategies, according to Hopp.
Another key to securing the future of the U.S. medical supply chain, according to Dai, is ensuring that the country is on the forefront of developing innovative ideas that improve supply chains.
“If we lose the ability to innovate, that [would be] devastating,” he says. “The government can take an active role [by] investing in research and development, investing in universities and national labs, and providing support for new ideas.”