Ontario Drug Benefit Formulary Research Articles

A cost effectiveness analysis of two treatment strategies for trigeminal neuralgia in Ontario.

Trigeminal neuralgia (TN) is a debilitating disease with an annual incidence of approximately 4-27/100,000. In Ontario, over 2000 patients receive interventions for profound pain, including medical and surgical therapies. The global expected cost of these approaches is unknown. This study aims to analyze the cost-effectiveness of one surgical therapy, microvascular decompression (MVD), compared with the best medical therapy (carbamazepine) as first-line therapy. Costs were gathered from the Canadian Institute for Health Information, Ontario Drug Benefit Formulary, and Ontario Ministry of Health Schedule of Benefits for Physician Services. Academic literature was used to estimate unavailable items. A cost-benefit Markov model was created for each strategy with literature-based rates for annual cycles from years 1 to 5, followed by a linear recurrent cycle from years 6 to 10. Incremental cost-effectiveness ratios (ICERs) were calculated based on the incremental cost in 2022 Canadian Dollars (CAD) per pain-free year. Base case cost per patient was $10,866 at 10 years in the "MVD first" group and $10,710 in the "carbamazepine first" group. Ten-year ICER was $1,104 for "MVD first," with strict superiority beyond this time point. One-way deterministic sensitivity analysis for multiple factors suggested the highest cost variability and ICER variability were due to surgery cost, medication failure rate, and medication cost. Economic benefit is established for a "MVD first" strategy in the Ontario context with strict superiority beyond the 10-year horizon. If a cost-effectiveness threshold of $50,000 per pain-controlled year is used, the benefit is established at 4 years.

118 A Cost Effectiveness Analysis of Two Treatment Strategies for Trigeminal Neuralgia in Ontario

INTRODUCTION: Trigeminal neuralgia is a debilitating disease affecting 4-27/100000 people annually. In Ontario, over 2000 patients will be cared for through a universal government payer model. Interventions for profound pain include medical and surgical therapies, among other options. The global expected cost of these approaches is unknown. METHODS: Costs were gathered from the Canadian Institute for Health Information, Ontario Drug Benefit Formulary, and Ontario Ministry of Health Schedule of Benefits for Physician Services Under the Health Acct. Academic literature was used to estimate unavailable items. A cost-benefit Markov model was created for each strategy with literature-based event rates for annual cycles from year one to five, followed by a linear recurrent cycle from year six to ten. Incremental cost-effectiveness ratios (ICERs) were calculated based on incremental cost in $CAD in 2022 per patient with a pain free year. RESULTS: Base case cost per patient was $10866 at ten years in the “MVD first” group and $10710 in the “carbamazepine first” group. The break-even point is slightly longer than ten years. Surgical cost is significantly higher at year one, at $9733 versus $1903. Ten year ICER was $1014 for “MVD first,” with strict superiority beyond this time point. One way deterministic sensitivity analysis for multiple factors suggested the highest cost variability and ICER variability was due to surgery cost, medication failure rate, and medication cost. CONCLUSIONS: Economic beneift is established to a “MVD first” strategy in the Ontario context with strict superiority beyond the ten-year horizon. If an arbitrary ICER of $50000 is used, benefit is established at four years. MVD could be considered broadly as a cost-effective and cost-saving measure in patients expected to live beyond these horizons.

Access to Migraine Treatments in Ontario, Canada: A Review of the Ontario Drug Benefit Program.

This paper provides a critical review of the decision-making process of the Ontario Ministry of Health and Long-Term Care (MOHLTC) regarding which migraine treatment drugs will be covered under the Ontario Drug Benefit Formulary (ODB). Under MOHLTC policy, triptans and OnabotulinumtoxinA are available to patients only through the Exceptional Access Program (EAP). This policy, and justifications for it, are examined with reference to clinical guidelines, patient experiences, and health policy literature. The contexts and consequences of compromised access are outlined. Improvements in access to these treatments are suggested by highlighting how a country with similar healthcare infrastructure - Australia - employs policies that more adequately meet the needs of migraine patients as they secure treatments. Despite clinically significant gains in the discovery of safe and effective migraine-specific treatments the ODB thus far has failed to align its practice with current clinical recommendations. This forces patients to rely heavily on medication that, while still effective for some, is potentially suboptimal. This review concludes it is prudent, at minimum, to follow clinical recommendations that advocate for the removal of triptans from EAP and recategorize them as Limited Use drugs. Ideally, moving them to a general benefit would further remove the barriers experienced by patients attempting to access this treatment.

Identifying drugs with disease-modifying potential in Parkinson's disease using artificial intelligence and pharmacoepidemiology.

The aim of the study was to assess the feasibility of an approach combining computational methods and pharmacoepidemiology to identify potentially disease-modifying drugs in Parkinson's disease (PD). We used a two-step approach; (a) computational method using artificial intelligence to rank 620 drugs in the Ontario Drug Benefit formulary based on their predicted ability to inhibit alpha-synucleinaggregation, a pathogenic hallmark of PD; and (b) case-control study using administrative databases in Ontario, Canada. Persons aged 70-110 years with incident PD from April 2002-March 2013. Controls were randomly selected from persons with no previous diagnosis of PD. A total of 15 of the top 50 drugs were deemed feasible for pharmacoepidemiologic analysis, of which seven were significantly associated with incident PD after adjustment, with five of these seven associated with a decreased odds of PD. Methylxanthine drugs pentoxifylline (OR, 0.72; 95% CI, 0.59-0.89) and theophylline (OR, 0.77; 95% CI, 0.66-0.91), and the corticosteroid dexamethasone (OR, 0.72; 95% CI, 0.61-0.85) were associated with decreased odds of PD. Our findings demonstrate the feasibility of this approach to focus the search for disease-modifying drugs. Corticosteroids and methylxanthines should be further investigated as potential disease-modifyingdrugs in PD.

Canadian Medication Cost Savings Associated with Combinatorial Pharmacogenomic Guidance for Psychiatric Medications.

ObjectiveTo estimate Canadian pharmacy cost savings associated with psychiatric medication prescribing that is guided by combinatorial pharmacogenomic testing in patients switching or augmenting their psychiatric medication.MethodsPharmacy claims data from a United States (US) pharmacy benefit manager were analyzed for 1662 patients who recently augmented or switched to a different antidepressant or antipsychotic medication and underwent combinatorial pharmacogenomic testing. Costs of prescription medications were translated to the Canadian healthcare system by matching drug names and doses using the Ontario Drug Benefit Formulary. One-year costs (2017 CAD) were compared between patients whose clinician prescribed antidepressants or antipsychotics that were consistent (congruent) or inconsistent (incongruent) with the combinatorial pharmacogenomic test recommendations.ResultsPatients whose psychiatric medication treatment was congruent with the combinatorial pharmacogenomic test report saved $1061 CAD per member per year (PMPY) on prescription medication costs relative to patients whose medications were incongruent with their test report (p<0.0001). For patients ages <65 and ≥65, prescription medication costs were $979 and $1178 CAD PMPY lower, respectively, for patients who followed the report recommendations (p=0.0004 and p=0.13). Prescription drug fills from the US pharmacy claims were concordant with the Canadian Formulary; 62% of fills matched at both the drug name and dose strength, 81% matched at drug name, and >99% matched at the therapeutic chapter.ConclusionsAntidepressant and antipsychotic prescribing that was congruent with combinatorial pharmacogenomic test guidance was associated with significant cost savings on Canadian prescription medications according to the Ontario Drug Benefit Formulary.

A Canadian Cost-Utility Analysis of 2 Trabecular Microbypass Stents at Time of Cataract Surgery in Patients with Mild to Moderate Open-Angle Glaucoma

To assess, from the Canadian public payer perspective, the cost-utility of implanting iStent Inject trabecular bypass stent (TBS) devices in conjunction with cataract surgery versus cataract surgery alone in patients with open-angle glaucoma (OAG) and visually significant cataract. Cost-utility analysis using efficacy and safety results of pivotal randomized clinical trial. Modeled cohort of patients with OAG (83.1% with mild disease, 16.9% with moderate disease) and visually significant cataract. Open-angle glaucoma treatment costs and effects were projected over a 15-year time horizon using a Markov model with Hodapp-Parrish-Anderson glaucoma stages (mild, moderate, advanced, severe or blind) and death as health states. Patients in the mild or moderate OAG health states received implantation of iStent Inject during cataract surgery versus cataract surgery alone. On worsening of visual field defect and optic disc damage, patients could receive selective laser trabeculoplasty and trabeculectomy. We measured treatment effect as reduction in intraocular pressure (IOP) and mean medication use and estimated transition probabilities based on efficacy-adjusted visual field mean deviation decline per month. Healthcare resource utilization and utility scores were obtained from the literature. Cost inputs (2017 Canadian dollars [C$]) were derived using the Ontario Health Insurance Plan, expert opinion, medication claims datasets, and Ontario Drug Benefit Formulary medication consumption costs. We conducted deterministic and probabilistic sensitivity analyses to examine the impact of alternative model input values on results. Incremental cost per quality-adjusted life year (QALY) gained. Compared with cataract surgery alone, TBS plus cataract surgery showed a 99% probability of being more effective (+0.023 QALYs; 95% confidence interval [CI], 0.004 to 0.044) and a 73.7% probability of being cost-saving (net cost, -C$389.00; 95% CI, -C$1712.00 to C$850.70). In 95% of all simulations, TBS plus cataract surgery showed a cost per QALY of C$62 366 or less. Results were robust in additional sensitivity and scenario analyses. iStent Inject TBS implantation during cataract surgery seems to be cost effective for reducing IOP in patients with mild to moderate OAG versus cataract surgery alone.

PSS3 INDUCTION COST PER RESPONDER OF BRODALUMAB COMPARED WITH OTHER BIOLOGICS APPROVED FOR PATIENTS WITH MODERATE TO SEVERE PSORIASIS IN CANADA

Brodalumab is an anti-interleukin-17R antibody recently funded across several provinces in Canada for moderate-to-severe plaque psoriasis. This study estimated the cost per responder (CPR) of brodalumab at the end of induction period of therapy for adult moderate-to-severe psoriasis patients compared to currently approved biologics: adalimumab, etanercept, guselkumab, infliximab [innovator and subsequent entry biologics (SEB)], ixekizumab, secukinumab and ustekinumab. Comparative efficacy was obtained from a random effects multinomial Bayesian network meta-analysis of 43 Phase II/III clinical trials reporting Psoriasis Area Severity Index [PASI] response for biologics of interest at the end of induction period. The primary outcome was a ≥ 90 reduction in PASI (i.e., PASI 90), with PASI 75 and PASI 100 as secondary outcomes. Drug acquisition costs were sourced from the Ontario Drug Benefit Formulary and the IQVIA database DeltaPA. The CPR was calculated as the drug acquisition costs divided by the proportion of patients with PASI 90, 75, or 100, each outcome separately during the induction period. Costs were presented in Canadian dollars. The PASI 90 response was 67.2% for brodalumab and ranged from 23.7% (etanercept) to 68.2% (ixekizumab). The drug acquisition costs ranged from $5,160 (brodalumab) to $14,813 (infliximab - innovator). For PASI 90, the CPR for brodalumab was $7,679 compared with $12,346 for the infliximab-SEB, $16,967 (guselkumab), $18,502 (ixekizumab), $19,545 (ustekinumab-90), $20,710 (secukinumab), $22,136 (ustekinumab-45), $24,213 (adalimumab), $24,730 (infliximab, innovator), $41,112 (etanercept). For PASI 75 and PASI 100, the CPR for brodalumab was $5,837 and $13,797 respectively. These were followed by the infliximab SEB at $8,783 and $24,406 for PASI 75 and PASI 100. The CPR of brodalumab at the end of induction period is the lowest across the comparators for all three PASI outcomes, hence providing the best value for money for patients, prescribers and the healthcare system as a whole.

Canadian status of "drugs to avoid" in 2017: a descriptive analysis.

The independent French drug bulletin, La revue Prescrire (henceforth Prescrire), annually releases a list of drugs to avoid. The aim of this analysis was to review the status of the 2017 list of drugs in Canada to determine whether they had been approved for marketing, their therapeutic status and whether they have been recommended for listing on public drug plans. This descriptive analysis reviewed a list of drugs compiled by Prescrire. The status of each drug in Canada was assessed through the Drug Product Database. Therapeutic ratings were obtained from the Patented Medicine Prices Review Board (PMPRB) and the formulary listing recommendation came from the Common Drug Review (CDR) or the pan-Canadian Oncology Drug Review (pCODR). For drugs without a formulary recommendation the Ontario Drug Benefit (ODB) Formulary was searched to see if the product was listed. Prescrire recommended not using 92 drugs. The PMPRB evaluated 36 of these drugs; 2 were classed as substantial improvements or breakthroughs, 3 as moderate improvements and 31 as little or no therapeutic improvement. Nine of the remaining drugs that were approved in Canada were not assessed because they were approved before 1988 (the year the PMPRB was established), 4 were approved from December 2015 onward and had not yet been reviewed by the PMPRB, and for 1 the approval date was unknown. Twenty-six of the drugs were evaluated by CDR or pCODR, of which 13 were recommended for formulary listing. Sixteen additional drugs that were not evaluated were on the ODB Formulary. Many drugs that Prescrire recommended avoiding were available in Canada. The results also highlight the diversity of the conclusions that different expert panels have reached.

PSS12 - Cost-Effectivess Analysis of Brodalumab in Moderate-To-Severe Plaque Psoriasis in Canada

To assess the cost-effectiveness of brodalumab versus available biologics and best supportive care (BSC) in adult patients with moderate-to-severe plaque psoriasis from a Canadian public payer perspective. A decision tree followed by a Markov model was developed to compare brodalumab with etanercept, adalimumab, infliximab, ustekinumab 45mg, ustekinumab 90mg, secukinumab, ixekizumab, infliximab subsequent entry biologic, and BSC. Psoriasis Area Severity Index (PASI) response was assessed at the end of the induction period (10-16 weeks) for each comparator. Responders (defined as at least 75% reduction in baseline PASI score) continued initial therapy and maintained their PASI response until treatment discontinuation or death. Non-responders switched to BSC. Comparative efficacy data were informed by a network meta-analysis. EQ-5D utility values associated with each PASI health state were derived from the brodalumab AMAGINE-1 study. Drug costs were obtained from the Ontario Drug Benefit Formulary and unit costs from the Ontario Health Insurance Plan. A 10-year time horizon was employed with 1.5% annual discount rate for costs and outcomes. Probabilistic analyses were conducted for base case and all scenario analyses. The base case analysis demonstrated that brodalumab had an ICER of $118,741 per quality-adjusted life year versus BSC. The ICER for ixekizumab versus BSC is $152,703. All other comparators were either dominated or subject to extended dominance. The results were robust across a range of scenario analyses. The model concluded that brodalumab is the most cost-effective option compared with publicly funded biologics for the treatment of moderate-to-severe plaque psoriasis in Canada. As such, the reimbursement of brodalumab will benefit the Canadian public by introducing a highly effective and most likely costs-savings alternative to the public payer system.

Formulary status of drugs in Ontario after Health Canada has issued a serious safety warning: a cohort study.

Drugs are approved for formulary listing based on limited knowledge of their safety. Serious safety issues are often identified after a drug is marketed. To determine whether the listing status of drugs on the Ontario Drug Benefit (ODB) Formulary changes following the identification of safety concerns by Health Canada and whether the results of reviews by people responsible for the ODB Formulary are made public. All new active substances (NAS) approved by Health Canada from January 1, 2002 to March 31, 2012 that subsequently had a warning issued about a serious safety concern were identified. Editions of the ODB Formulary were searched to find which of these drugs were listed on the Formulary before the safety warning was issued. A total of 263 NAS were approved of which 42 subsequently acquired one or more serious safety warnings and 15 of these were listed on the ODB Formulary before the safety warning was issued. The listing status of 14 of the 15 drugs was unchanged after the release of the safety warning. No information is available about whether the listing status of these 14 drugs was reassessed. The ODB Formulary should develop a set of criteria to determine whether the listing status of drugs should be reviewed after Health Canada issues a serious safety warning. The results of any reconsiderations should made public so that prescribers and patients alike know that the ODB Formulary officials still regard the drugs as having a positive benefit to harm ratio.

Patterns of use for brand-name versus generic oral bisphosphonate drugs in Ontario over a 13-year period: a descriptive study.

Bisphosphonates are the first-line therapy for the treatment of osteoporosis. In the province of Ontario, the Ontario Drug Benefit Program funds medications for patients aged 65 years and older. The Ontario Drug Benefit Program has a generic substitution policy that requires lower-cost generic drugs to be dispensed when they are available. However, there is controversy surrounding the efficacy and tolerability of generic bisphosphonates. The objective of this study was to describe patterns in the use of brand-name versus generic formulations when dispensing oral bisphosphonate over a 13-year period. We identified all osteoporotic preparations for alendronate and risedronate that were dispensed through the Ontario Drug Benefit Program from 2001 to 2014. We stratified our sample into community-dwelling residents and residents in long-term care facilities. The number of prescriptions dispensed per month were plotted to illustrate trends over time. We found a rapid switch from brand-name to generic bisphosphonate equivalents immediately after the generic became available on the Ontario Drug Benefit formulary, with generics accounting for > 88% of dispensed drug within 2 months. We also observed a reduction in the number of generic drugs dispensed each time a new brand-name alternative (e.g., monthly risedronate, weekly alendronate plus vitamin D) was introduced to the formulary. The dispensing trends were similar in the community and long-term care settings. The Ontario Drug Benefit Program generic substitution policy resulted in rapid uptake of generic oral bisphosphonates among seniors in Ontario. However, there was a switch away from generic medications to new brand-name alternatives whenever they were introduced to the formulary. Therefore, some patients continued to use brand-name bisphosphonate despite the availability of generic options.

Adherence to Prescribing Recommendations Made on a Provincial Formulary

Guidance regarding appropriate and cost-effective use of prescription drugs is published in the Ontario Drug Benefit Formulary in the form of "therapeutic notes." We conducted a cross-sectional study of all residents of Ontario aged 66 and older who received a new prescription for one of two drugs, aliskiren or sitagliptin, between December 1, 2008 and March 31, 2012 to determine how frequently such guidance is followed. Approximately half of initial prescriptions for aliskiren and sitagliptin were prescribed in a manner that did not conform to the therapeutic note recommendations (51.4% and 49.3%, respectively). Given this high rate of non-conformance, policy makers may wish to use other mechanisms to influence prescriber behaviour to improve the quality and efficiency of healthcare.

Despite Recent Reforms, Provinces Continue to Pay Too Much for Generic Drugs, Says Study

Provincial governments seeking to cut spending on generic drugs — by reducing prices to a lower percentage of the brand-name equivalent — are still overpaying for most of these drugs, according to a study from the Centre for Health Services and Policy Research at the University of British Columbia. The research was conducted by Dr. Michael Law, assistant professor at the Centre and an expert adviser with EvidenceNetwork.ca. Dr. Law focused his analysis on generic drug expenditures in Ontario, as that province has gone the furthest by reducing generic prices to 25% of the brandname cost, and so has the lowest prices in Canada. “I was interested in evaluating the real impact of the dramatic percentage reduction in Ontario, from 65% to 25%,” says Dr. Law. “Paying one-quarter of the brand price sounds like a great deal, but the numbers say other wise, when you examine whether these new prices are internationally competitive.” The study compared the 2011 prices of generic drugs on the Ontario Drug Benefit Formulary to price listings for 2 other public drug programs — the US Department of Veterans Affairs and the New Zealand government. Out of the 100 most frequently dispensed generic products in Ontario, 82 were listed on one or both of the other programs. “Among those 82 drugs, 90% of the time, they were more expensive in Canada than in the 2 comparator countries and on average, they were twice as expensive,” says Dr. Law. The largest price discrepancy was for simvastatin (10 mg), which was more than 30 times more expensive in Ontario. If the Ontario government had paid the best comparator prices for the 82 generic products, it would have saved $129 million in 2011, according to Dr. Law's study. Extrapolating to the total Ontario market, the savings would be $245 million. The traditional and arbitrary formula of setting generic prices as a percentage of brand-name prices is not optimizing savings, according to Dr. Law. The other countries use different mechanisms to achieve better pricing, he says. “If you look at New Zealand, for example, it uses contractual agreements with firms that guarantee them a certain amount of volume for a particular price and use competition to get the best price possible.” Dr. Law is encouraged by the recent commitment of Canada's premiers to have the provinces collaborate on bulk purchasing of generics. “In the generic drug market, there is genuine competition. If we can capture some of that competition then I am hopeful that the provinces will be successful in this initiative.” Canada's potential purchasing power could provide an advantage, he adds. “If you banded all the provinces together, our public programs are bigger than both of those other insurance schemes by a wide margin.” Achieving savings in the per-unit price of generic drugs could yield multiple benefits, says Dr. Law. “Governments could not only save money, they could improve coverage for people. With estimates like the one our Centre put out earlier this year — that 1 in 10 Canadians can't afford their prescription drugs — I think there's a real opportunity here to get better prices and improve coverage at the same time.”

Economic evaluation of open vs endovascular repair of blunt traumatic thoracic aortic injuries

During the last decade, endovascular repair (EV) has replaced open surgical repair (OSR) as the preferred method of treatment of blunt traumatic thoracic aortic injuries (BTAIs) at many trauma centers. This has resulted in reductions in mortality, length of stay, and major complications, including paraplegia, with the added expense of the initial endograft, subsequent surveillance, and reinterventions. The purpose of this study was to conduct an economic evaluation comparing these two methods of repair. We performed an economic comparison of EV and OSR for the treatment of BTAI using a decision tree analysis with transition points derived from our institution's experience and through a review of the literature. Over a 15-year period (1991-2006), 28 patients with BTAI were treated at our center (15 EV, 13 OSR). Costs were obtained from our hospital's case costing center, the Ontario Case Costing Initiative, Ontario's Drug Benefit Formulary, and Ontario's Schedule of Benefits for physician costs. Our center's results were then combined with those from the literature to arrive at an economic model. These combined results revealed that EV, when compared to OSR, resulted in decreased early mortality (7.2% vs 22.5%), decreased composite outcome of mortality and paraplegia (7.7% vs 27.6%) and decreased composite outcome of mortality and major complication (42.5% vs 69.8%). Patients undergoing EV also had shorter intensive care unit stays (12.2 vs 15.3 days), total hospital length of stays (22.5 vs 28.6 days), and ventilator days (8.0 vs 9.2 days). Additionally, patients undergoing EV had decreased total 1-year costs compared with OSR ($70,442 vs $72,833). EV repair of BTAIs offers a survival advantage as well as a reduction in major morbidity, including paraplegia, compared with OSR, and results in a reduction in costs at 1 year. As a result, from the cost-effectiveness point of view, EV is the DOMINANT therapy over OSR for these injuries.

Pricing of multiple dosage prescription medications: An analysis of the Ontario Drug Benefit Formulary

This paper investigates the pricing strategy (perfect flat pricing, perfect monotonic pricing, intermediate) used for multiple dosage medications listed in the Ontario Drug Benefit Formulary. All multiple dosage solid medications containing a single active ingredient newly listed in the Ontario Drug Benefit Formulary between 1996 and 2005 were identified. The relationship between price and dosage was calculated using a previously developed method. Seventy-three multiple dosage medications were introduced. Where medications were equivalent to existing ones in most cases companies followed the pricing strategy used by therapeutically equivalent drugs already in the formulary. Where there were no equivalent products companies did not adopt any particular pricing strategy. There was no difference in the way that companies priced scored tablets versus unscored tablets and capsules or in the way that they priced drugs that had objective measurements of efficacy/effectiveness, for example blood pressure, versus those that did not have these measurements. When Monotonic pricing is used it leads to higher expenditures whereas flat pricing results in lower expenditures and offers more predictability in expenditures. Provincial governments should consider requiring flat pricing in return for formulary listing.

CA1 ECONOMIC ANALYSIS OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORS INTHE PRIMARY PREVENTION OF SUDDEN CARDIAC DEATH—A CANADIAN PERSPECTIVE

CA1 ECONOMIC ANALYSIS OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORS INTHE PRIMARY PREVENTION OF SUDDEN CARDIAC DEATH—A CANADIAN PERSPECTIVE Deniz B, Sadri H United BioSource Corporation, Concord, MA, USA, Medtronic of Canada Ltd,Toronto, ON, Canada OBJECTIVE: To conduct a cost-benefit analysis (CB) for the Implantable Cardioverter Defibrillators (ICDs) in the primary prevention of Sudden Cardiac Death (SCD) compared to amiodarone.METHODS: A discrete event simulation model was built to determine the cost-benefit ratio associated with ICDs from a societal perspective in Canada using the “value of life” approach as a measure of “benefit”. The clinical inputs were derived from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) and the Amiodarone Trial Analysis (ATMA) studies. The related costs were derived from the Ontario Health Insuranace Plans’ (OHIP) schedule of benefits and fees, Ontario Drug Benefit formulary (ODB) and published data. The value of life in Canada (CND$5.8Mil.), as determined by Health Canada, was used in the model. One hundred replicaitons of 1000 identical twin pairs over 7 years, aligned with the average life of an ICD, were run. The costs (year 2006) and outcomes ere discounted at 3%. Sensitivity Analysis (SAs) were performed for key input parameters. RESULTS: The absolute all-cause mortality was reduced by eight percent with ICD over seven years compared to amiodarone. The average costs associated with ICD and amiodarone treatments were estimated as CND$32,000 and CND$6400 per patient, respectively. The predicted cost-benefit ratio (CBR) was 0.04. This figure suggests that for every $1 spent for ICD in the primary prevention of SCD the society will gain $25 in “value” by human lives saved. SAs showed that results were robust (CBR: 0.035–0.044). CONCLUSION: IDs reduce the risk of SCD due to arrhythmia compared to amiodarone. The estimated CBR suggests that ICDs are worthwhile investment from a societal perspective in Canada. The initial investment for ICD in primary prevention of SCD in Canada is comparable and in many cases lower when compared to other societal programs for saving lives.

Impact of formulary policy on thiazolidinedione (TZD) use in the ontario drug benefit (ODB) program

Intro The ODB formulary policy is very restrictive for TZD use, limiting reimbursement for second line use that must be documented in an individualized request from the prescribing physician. This study was designed to determine if patients receiving the drug met the required reimbursement criteria and whether the policy resulted in preventing appropriate patients from receiving a TZD. Methods ODB eligible type 2 DM patients using an oral hypoglycaemic drug were recruited through community pharmacies. Patients were interviewed using computer assisted telephone interviewing software with trained interviewers. Patient chart information was obtained from their physicians via a fax-back form. Results 249 patients were recruited. Mean (sd) age was 75(5) years, with 10.5 (8) years duration of DM, BMI 27.6 (5) and HgA1c 0.07 (0.01).). Hypertension prevalence 80%, hyperlipidemia 74%, cardiovascular disease 46%. 85% of TZD users had previously tried or were still using other oral hypoglycaemic drugs. Patients using a TZD were more likely to have used a diabetic clinic, had a history of an adverse effect with a non-TZD oral hypoglycaemic drug and had a greater household income than non TZD users. Conclusions The inability to access a diabetic clinic and limited household income may prevent patients who might benefit from a TZD from receiving these drugs. While restrictive formulary policies can prevent undesirable or inappropriate drug use they may prevent appropriate access as well. Clinical Pharmacology & Therapeutics (2005) 77, P72–P72; doi: 10.1016/j.clpt.2004.12.165

The effect of generic competition on the price of brand-name drugs

Background: Literature from the US has shown that brand-name manufacturers do not compete on price once generic competitors become available. This study was undertaken to investigate if this is also true in Canada. Methods: Editions of the Ontario Drug Benefit Formulary were used to identify brand-name drugs that lacked generic competition in July 1990 but had acquired one or more generic competitors by December 1998. Prices of the brand-name drugs were compared before generic competition, at the point when generic competition started and subsequent to the initiation of competition. Results: Price changes for 81 different products in 144 separate presentations were analysed. There was no statistically significant change in brand-name prices when generic competition started. The movement of brand-name prices was not influenced by whether the generic was made by the company producing the brand-name product or price freezes imposed by the Ontario government. When generics first became available having four or more generics was associated with a rise in the price of the brand-name drugs compared to having one, two or three generic competitor(s). Interpretation: The lack of price competition may lead to increased costs in the private market. Private insurance companies generally do not require generic substitution and some provinces do not require generic substitution for cash-paying customers. Maintaining higher prices on brand-name drugs impacts on the prices of new patented medications coming onto the Canadian market under the current pricing guidelines of the Patented Medicine Prices Review Board.

Prescribing and drug costs in the province of Ontario.

The Report of the Pharmaceutical Inquiry of Ontario documented dramatic increases in the cost of the Ontario Drug Benefit (ODB) program. This article demonstrates that the rise in ODB costs for those 65 and over is due to two factors: more intensive prescribing--physicians prescribing to the elderly more often and writing more prescriptions each time they see an elderly patient--and physicians writing prescriptions for more expensive drugs. Neither of these two changes in prescribing behavior has resulted in any demonstrable improvement in the health of the elderly. Efforts to control costs through some form of copayment or by eliminating some drugs from the ODB formulary should not be undertaken since they probably will result in a reduction in the use of medically necessary drugs. Ultimately, drug costs will only be controlled by improving the appropriateness of physicians' prescribing.