The radiology and medical communities are still recovering from a shortage of GE’s Omnipaque™ that began in May, caused by COVID-19-related lockdowns at GE’s major iodinated contrast production facility in Shanghai, China. For those affected, the shortage necessitated canceling non-emergent imaging exams and procedures that required contrast and led to new ways to stretch contrast supply and reconsider potentially wasteful practices. However, this was a vendor-specific issue and some departments and practices had no interruptions to their contrast media supply. “Groups that don’t use GE Omnipaque likely did not have a problem,” says Carolyn L. Wang, MD, chair of the ACR Committee on Drugs and Contrast Media. A similar issue could occur with any vendor or product for which there is no redundancy in the system.
Production in China was only part of the issue. Even if the facility had been at 100% production — which, according to GE, was achieved in early June — the iodinated contrast still needed to be delivered to its customers around the globe.1 This process required local drivers in Shanghai to voluntarily be away from their families for the then-mandatory 14-day quarantine period each time they traveled out of the city, a tall order. A seemingly obvious option to alleviate issues once organizations receive their contrast media orders was to share with those institutions that were in dire need. However, facilities are generally not contractually permitted by vendors to transfer contrast to another institution in need, as they could be seen as a secondary supplier. “There needs to be some waiver of this prohibition against being a secondary supplier,” says Amy L. Kotsenas, MD, FACR, ACR Speaker. “There has been some discussion locally about possibly setting up some kind of exchange or process whereby those who have a really critical shortage and aren’t able to provide emergency care are able to access the contrast. That’s the greatest concern. Some practices may have been so short that they weren’t able to provide emergency care.”
In May, Wang and other members of the ACR Committee on Drugs and Contrast Media developed a statement to provide short-term options on how to handle the shortage. Long-term changes, however, may be more difficult to achieve, such as moving to multiple vendors for contrast media instead of a single vendor. “A lot of organizations have gone through group purchasing organizations, which negotiate with vendors to get the best deal, and often they go to one vendor to get best pricing,” says Alan K. Matsumoto, MD, FACR, vice chair of the ACR BOC. “This is a vulnerability.”
After demonstrating the fragility of the contrast supply chain, it’s wise to consider when, not if, the next shortage might occur, and how groups might insulate themselves from such impacts. “This crisis may cause a lot of practices to rethink whether they should have a single supplier for something that is so critical to what we do,” says Kotsenas. “Both in diagnosis and treatment, this shortage has had a huge impact on radiology groups who now may be thinking as they go forward, ‘Is this the best practice?’”
Both in diagnosis and treatment, this shortage has had a huge impact on radiology groups who now may be thinking as they go forward, 'Is this the best practice?'
One aspect of the supply chain that’s easier to control is the route from pharmacy to institution or practice, which requires an understanding of the importance of contrast in all medical specialties. “GE sent out the notice in early April, when the plant was shut down,” says Wang. “However, the notice was sent to the pharmacy purchasing group, and it didn’t circulate quickly enough; I first learned about the shortage on social media.” To support this radiologist-pharmacist relationship, the American Society of Health-System Pharmacists also released a statement guiding its members on the importance of contrast media and the various vial sizes required for imaging and interventional procedures. While organizations looked for ways to conserve contrast (e.g., using multi-dose vials, conserving and using leftover contrast, and triaging patients), Matsumoto said they were able to reduce their contrast usage by 75% (e.g. by using the vials of contrast as multi-dose vials, using leftover contrast for non-sterile GI procedures, and delaying scheduling of CT scans and procedures requiring the use of iodinated contrast on “less-emergent” patients).2 Wang also considered the bigger picture of imaging — waste. “If you have a patient who requires 125MLs of contrast, and there are no 125ML vials, you’re using a 150ML vial and wasting 25MLs,” Wang says. “Everyone is starting to question waste, and everyone was unaware of it, particularly radiologists, prior to the shortage.”
However, despite canceling non-emergent exams and procedures, Wang’s practice saw no difference in the volume of scans. “The volumes are still the same. We just sometimes have to not use contrast,” she says. In conserving contrast, Wang noted there were a few positive unintended consequences, including patient comfort. “We’ve always done weight-based dosing, and with the shortage we’ve reduced the weight class. As a result, several patients who received smaller volumes of contrast reported having fewer side effects from the contrast — they didn’t feel the typical burning or warmth that accompanies contrast injection,” she adds, pointing to an opportunity to reexamine dosage guidelines.
Given that the contrast shortage seems to have resolved, lessons learned this spring may be applied to the next major shortage, whatever it may be. “This is what COVID-19 has taught us,” says Wang. “Supply chains are very fragile, and just-in-time inventory — while it may make some business sense — for things like healthcare-related items, might not be good enough.”