Cost Analysis of Using a Closed-System Transfer Device (CSTD) for Antineoplastic Drug preparation in a Malaysian Government-Funded Hospital

  • Published : 2016.11.01


Background: Apart from reducing occupational exposure to cytotoxic hazards, the PhaSeal(R) closed-system transfer device (CSTD) can extend the beyond-use dates (BUDs) of unfinished vials of antineoplastic drugs for up to 168 hours (seven days). In this study, the total material cost incurred by its use in a Malaysian government-funded hospital was calculated. Methods: A list of vial stability following initial needle punctures of 29 commonly-used antineoplastic drugs was compiled. The amount of the materials used, including drugs, infusion bottles, the PhaSeal(R) CSTD and other consumables, was recorded on a daily basis for three months in 2015. The total cost was calculated based on the actual acquisition costs, and was compared with that of a hypothetical scenario, whereby conventional syringe-needle sets were used for the same amounts of preparations. Results: The use of the PhaSeal(R) CSTD incurred a cost of MYR 383,634.52 (USD 92,072.28) in three months, representing an average of MYR 170.5 (USD 40.92) per preparation or an estimated annual cost of MYR 1,534,538.08 (USD 368,289.14). Compared with conventional syringe-needle approach, it is estimated to lead to an additional spending of MYR 148,627.68 (USD 35,670.64) yearly. Conclusion: Although there was a reduction of drug wastage achieved by extending BUDs of unfinished vials using the PhaSeal(R) CSTD, cost saving was not observed, likely attributable to the wide use of lower-priced generic drugs in Malaysia. Future studies should further evaluate the possibility of cost saving, especially in health settings where branded and high-cost antineoplastic drugs are more commonly used.


  1. Carey ET, Forrey RA, Haughs D, et al (2011). Second look at utilization of a closed-system transfer device (PhaSeal). Am J Pharm Benefits, 3, 311-8.
  2. Connor TH, McDiarmid MA (2006). Preventing occupational exposures to antineoplastic drugs in health care settings. CA Cancer J Clin, 56, 354-65.
  3. De Prijck K, D'Haese E, Vandenbroucke J, et al (2008). Microbiological challenge of four protective devices for the reconstitution of cytotoxic agents. Lett Appl Microbiol, 47, 543-8.
  4. Edwards MS, Solimando DA Jr, Grollman FR, et al (2013). Cost savings realized by use of the $PhaSeal^{(R)}$ closed-system transfer device for preparation of antineoplastic agents. J Oncol Pharm Pract, 19, 338-47.
  5. Elshamy K, El-Hadidi M, El-Roby M, Fouda M (2010). Health hazards among oncology nurses exposed to chemotherapy drugs. Afr J Haematol Oncol, 1, 70-8.
  6. Favier B, Labrosse H, Gilles-Afchain L, et al (2012). The PhaSeal(R) system: impact of its use on workplace contamination and duration of chemotherapy preparation. J Oncol Pharm Pract, 18, 37-45.
  7. Forrey RA, Spivey SM, Mulvaney JM, Jorgenson JA, Haughs RD (2011). Utility of the PhaSeal closed system drug transfer device. Am J Pharm Benefits, 3, 9-16.
  8. Gahart BL, Nazareno AR (2008). Intravenous medications: a handbook for nurses and other allied health professionals. Michigan, Mosby PP 300-17.
  9. Harrison BR, Peters BG, Bing MR (2006). Comparison of surface contamination with cyclophosphamide and fluorouracil using a closed-system drug transfer device versus standard preparation techniques. Am J Health Syst Pharm, 63, 1736-44.
  10. Hassali MA, Thambyappa J, Nambiar S, Shafie AA, Lofgren H (2013). TRIPS, free trade agreements and the pharmaceutical industry in Malaysia. In The new political economy of pharmaceuticals: production, innovation and TRIPS in the global south, Eds Lofgren H and Williams OD. Palgrave Macmillan, Basingstoke pp 152-66.
  11. Hedmer M, Wohlfart G (2012). Hygienic guidance values for wipe sampling of antineoplastic drugs in Swedish hospitals. J Environ Monit, 14, 1968-75.
  12. Herndon JH, Hwang R, Bozic KH (2007). Healthcare technology and technology assessment. Eur Spine J, 16, 1293-302.
  13. Hon CY, Teschke K, Chua P, Venners S, Nakashima L (2011). Occupational exposure to antineoplastic drugs: identification of job categories potentially exposed throughout the hospital medication system. Saf Health Work, 2, 273-81.
  14. Keat CH, Sooaid NS, Yun CY, Sriraman M (2013). Improving safety-related knowledge, attitude and practices of nurses handling cytotoxic anticancer drug: pharmacists' experience in a general hospital, Malaysia. Asian Pac J Cancer Prev, 14, 69-73.
  15. Ladeira C, Viegas S, Padua M, et al (2015). Genotoxic assessment in different exposure groups working with antineoplastic agents. In Occupational safety and hygiene III", Eds Arezes EM, Baptista JS, Padua M, et al. CRC Press, Boca Raton pp 177-80.
  16. Nishigaki R, Konno E, Sugiyasu M, et al (2010). The usefulness of a closed-system device for the mixing of injections to prevent occupational exposure to anticancer drugs. JAHP, 46, 113-7.
  17. Nygren O, Olofsson E, Johannson L (2009). NIOSH definition of closed-system drug-transfer devices. Ann Occup Hyg, 53, 549.
  18. Rowe EC, Savage SW, Rutala WA, et al (2012). Economic and microbiologic evaluation of single-dose vial extension for hazardous drugs. J Oncol Pract, 8, e45-9.
  19. Samaranayake H, Wirth T, Schenkwein D, Raty JK, Yla-Herttuala S (2009). Challenges in monoclonal antibodybased therapies. Ann Med, 41, 322-31.
  20. Sessink PJ, Connor TH, Jorgenson JA, Tyler TG (2011). Reduction in surface contamination with antineoplastic drugs in 22 hospital pharmacies in the US following implementation of a closed-system drug transfer device. J Oncol Pharm Pract, 17, 39-48.
  21. Sessink PJ, Trahan J, Coyne JW (2013). Reduction in surface contamination with cyclophosphamide in 30 US hospital pharmacies following implementation of a closed-system drug transfer device. Hosp Pharm, 48, 204-12.
  22. Sorenson C, Drummond M, Khan BB (2013). Medical technology as a key driver of rising health expenditure: disentangling the relationship. Clinicoecon Outcomes Res, 5, 223-34.
  23. The American Society of Health-System Pharmacists (2006). ASHP Guidelines on Handling Hazardous Drugs. Am J Health Syst Pharm, 63, 1172-91.
  24. The BC Cancer Agency (2016a). Chemotherapy preparation and stability chart (Drugs A-K). Retrieved 1 Feb 2016, from
  25. The BC Cancer Agency (2016b). Chemotherapy preparation and stability chart (Drugs L-Z). Retrieved 1 Feb 2016, from
  26. The International Society of Oncology Pharmacy Practicioners Standards Committee (2007). ISOPP standards of practice. Safe handling of cytotoxics. J Oncol Pharm Pract, 13, 1-81.
  27. The National Institute of Occupational Safety and Health (2004). Preventing occupational exposure to antineoplastic and other hazardous drugs in healthcare settings. Retrieved 1 Feb 2016, from
  28. The United States Pharmacopeial Convention (2008). <797> Pharmaceutical compounding - sterile preparations (revision bulletin). Retrieved 1 Feb 2016, from Pharmaceutical Compounding Sterile Compounding. pdf
  29. Wong S, Wickramasinghe N (2014). Applying the principles of KM to effect streamlined healthcare operations: a Malaysian case study. In Lean thinking for healthcare, Eds Wickramasinghe N, Al-Hakim L, Gonzalez C, et al. Springer, New York pp 225-38.