Conference Agenda

The healthcare industry is crucial for promoting human well-being but also has a considerable impact on the environment, contributing to climate change, pollution, and resource depletion. To address this issue, the concept of "Planetary Health" recognizes the interdependence of human health and the health of the planet. The production and distribution of medical equipment, pharmaceuticals, and energy-intensive infrastructure of healthcare facilities all contribute to environmental impacts, highlighting the need for identification of hotspots and stakeholder collaboration.

Various studies within our panel propose solutions, such as the first study, which aims to monitor the environmental footprint of the Dutch healthcare sector through collaboration between stakeholders. The second study identified hotspots of environmental impact in care trajectories within a Dutch academic hospital using life cycle assessments, offering perspectives for future sustainability programs. The third study highlighted the environmental impact of pharmaceuticals and suggested redispensing unused drugs to reduce costs and impact. The fourth study evaluated the sustainability of e-health through life cycle assessments and identified its potential contribution to reducing the environmental impact of healthcare.

In conclusion, the healthcare sector must adopt more sustainable approaches to promote the health of both people and the planet. Collaborative efforts between healthcare providers, policymakers, and patients are essential to ensure a sustainable future of healthcare. Hotspot identification, redispensing medication, and e-health implementation are promising solutions to reduce the environmental impact of healthcare. The concept of “Planetary Health” emphasizes the need for more sustainable healthcare practices that promote the health of both people and the planet.

In the transition to more sustainable economies, monitoring countries’ footprints is important to assess whether climate or sustainability targets are met. In recent years, the Netherlands has set specific climate and sustainability objectives at a sectoral level to drive action and to improve decision-making. We established a method to measure the environmental footprint of the Dutch healthcare sector. The generic footprint was calculated using a (top-down) input-output analysis using the latest available data and key figures. The outcome was supplemented with specific (bottom-up) data, such as the impact of propellants in inhalation medication. Bottom-up analysis was then used to deepen the understanding of the product group that contributes most to the calculated environmental footprint of the healthcare sector: chemical products, which includes pharmaceuticals and medical consumables. This hybrid approach, combining the generic top-down analysis and the bottom-up analysis, lays the foundation for a baseline measurement of the environmental footprint of the Dutch healthcare sector, i.e. the current state of affairs to provide a reference point against which future changes or results can be measured and evaluated.

However, our research does not yet provide this baseline measurement by which a transition towards environmental sustainability can be monitored. To do so, it is necessary to analyse what is minimally needed for that purpose, whether all these data are available and which uncertainties arise. In addition, it is crucial to review the possibilities to keep data and key figures representative and up-to-date and what a useful monitoring frequency would be.

In The Netherlands, healthcare institutions participate in national sustainability goals by setting individual goals and implementation strategies in the Green Deal Sustainable Care 3.0 initiated by the sector and coordinated by the Ministry of Health, Welfare and Sports (VWS). Monitoring the results of this Green Deal requires intensive collaboration with stakeholders. It is important that measurable goals are set, that stakeholders interact to achieve goals, and to know what commitment is needed from all actors. Through collaboration, a baseline measurement can be achieved, alongside an action plan for the monitoring national developments of the environmental footprint of healthcare, fulfilling one of the commitments made by the Ministry of VWS at the COP26 UN climate summit. Together with healthcare institutions, government, and other stakeholders, the Dutch National Institute for Public Health and the Environment (RIVM) aims to improve data analysis and minimize uncertainties, to provide achievable recommendations to minimize the environmental footprint.

While the healthcare sector’s primary focus is on keeping individuals healthy, its footprint causes planetary systems to shift out of balance. The goal of the CATEGORISE study is to identify environmental hotspots within common healthcare trajectories. Determining the elements and/or processes that have most impact on the environment enables future sustainability programmes of the healthcare sector to be most effective.

The environmental impact is determined of four patient healthcare trajectories (n=10) of the Radboudumc hospital. Patients with sepsis and patients with high-energy trauma are included on admission to the Emergency Room (ER) and followed onwards to the Intensive Care Unit (ICU). Furthermore, patients that undergo Coronary Artery Bypass Grafting (CABG) surgery are included from the Operation Room (OR) onwards to the ICU. Lastly, the environmental impact of cataract surgery performed at the OR, worldwide the most performed type of surgery, is quantified.

Life cycle assessment (LCA) is the method used to calculate the environmental impact and identify the environmental hotspots. In this study, real-time data is acquired by direct observation. Close collaboration between environmental researchers and hospital personnel is key here. Track is kept of all processes used to treat the patients, including the use of medical equipment, performance of diagnostics, administration of medication, consumption of energy and production of waste. Subsequently, a model is built in the LCA software SimaPro. Finally, the environmental impact of the different patient trajectories is determined using the LCA impact assessment method ReCiPe2016.

As of right now, February 2022, the CATEGORISE research has been running for one year and is expected to be finished around February 2023. For the CABG and cataract surgeries at the OR it has become clear that their carbon footprints are 532 kg CO₂eq. and 72 kg CO₂eq. respectively. CABG’s main impacts are disposables (30%), energy (21%) and employee transportation (20%). The hotspots for the cataract surgery are patient transportation (46.2%), employee transportation (19.5%) and disposables (18%). Currently, an action list of measures to lower the footprint of these surgeries is being developed and the trajectories on the ER and ICU are investigated.

This study marks the first large scale attempt to determine environmental hotspots in multiple care trajectories. Interdisciplinarity makes up the core of this research, continuously bringing the field of environmental science and the healthcare sector together. The conclusions of this LCA gives hospital management and other healthcare professionals the tool to effectively lower the sector’s environmental impact.

INTRODUCTION

Waste minimalization in healthcare could contribute to economic and environmental sustainability. Particularly, when expensive therapies, such as oral anticancer drugs (OADs), are targeted. To minimize waste, OADs remaining unused by patients could be redispensed to other patients after quality verification in the pharmacy. This study aims to assess the economic and environmental impact of redispensing unused OADs and to identify hotspots in the process to optimize those impacts.

METHODS

A prospective intervention study in four Dutch hospitals was conducted with 12 months follow-up per patient. Participants received prescribed OADs in special packaging (i.e. sealbag with temperature logger) and were requested to return unused OADs to the pharmacy for quality verification on: authenticity, remaining shelf life and correct storage. OADs of verified quality were redispensed to other patients.

The economic impact from a healthcare perspective and the environmental impact were determined compared to standard practice (i.e. no special packaging and disposal of returned OADs). Economic impact was determined per patient by the balance between costs of redispensed OADs versus operational costs (€, 2021). The environmental impact on endpoint and midpoint level, using ReCiPe2016 (H), was calculated with a cradle-to-grave Life Cycle Assessment (LCA), following ISO14040 standards. Inventory data was collected for seven OADs and the quality verification procedure, based on the intervention study, EcoInvent database and literature. Scenarios on the quality verification procedure were used to identify hotspots and optimize environmental and economic impact.

RESULTS

1,071 patients participated in the study, median age 70 years (IQR: 62 – 75) and 42% female, using OADs for ≤ 6 months (32%), 7 – 24 months (32%) or >24 months (36%) at start. In total, 184 (18%) patients returned 332 OAD packages, of which 224 (67%) OAD packages were approved of quality and redispensed. This provided mean net cost-savings between €613 (CI: €345 – €881) and €652 (CI: €516 – €788) per patient per year, depending on the quality verification procedure.

Initially, the quality verification procedure had a higher environmental impact on all indicators compared to the avoided impacts of redispensed OADs. However, by changing the type and use of temperature loggers, environmental benefits of waste reduction outweighed the operational impact.

CONCLUSIONS

Redispensing unused OADs had a substantial, positive economic impact, and, with process optimization a lower environmental impact compared to standard practice could be established. Accordingly, this study provides a hands-on strategy targeting drug waste to contribute to economic and environmental sustainability of healthcare.

Background According to the WHO, climate change is the single biggest health threat in the 21^st century. Especially for a population at-risk due to chronic diseases, negative health effects of climate change are expected to increase in the next decades. Other environmental crises, such as biodiversity loss, may even compound the negative effects of climate change. Whilst chronic diseases are already the leading cause of death on a global and national level, the number of people affected will continue to rise over the following years, partially due to population ageing. Paradoxically, the healthcare sector substantially contributes to the Dutch carbon footprint – 7% annually. In line with European regulations, carbon emissions must be reduced by 50% in 2030. Two recent reviews concluded eHealth to be a promising intervention to reduce the mobility-related carbon footprint of healthcare, yet they did not consider other environmental impacts. The simultaneous benefit of eHealth for chronic disease management and reduction of environmental impact has been suggested, but was never explicitly studied. A proof of concept is necessary for the environmental argument for telemonitoring and teleconsulting – two subtypes of eHealth.

Objectives This study aims to quantify and compare the environmental impact of teleconsulting for chronic nursing care in home setting and telemonitoring for chronic disease management in primary care to a patient care trajectory ‘as usual’.

Methods A state-of-the-art life cycle assessment (LCA) will be conducted to study the relevant processes, products and inputs required for primary care teleconsulting (long-term nursing at home) and telemonitoring (post-myocardial infarction care and cardiovascular risk management). Selected eHealth interventions have been chosen based on their ongoing implementation and large volume of usage. As a comparison, the environmental impact of an average outpatient trajectory of physical and telephone contacts will be computed as ‘care as usual’. Every eHealth intervention will include a sample of at least 10 patients to account for interindividual variations. Impacts will be reported as midpoint environmental impacts using the ReCiPe method v1.6 ‘Hierarchist’ perspective. Where possible, background information will be drawn from the Ecoinvent® database and existing LCA healthcare literature.

Results/Conclusion To our knowledge, this is the first study conducting a life cycle assessment for comparison of telemonitoring and teleconsulting to a patient care trajectory ‘as usual’. Data collection is due to commence soon and first results are expected by October 2023. Obtained insights may provide an action perspective for future efforts in healthcare sustainability.