Pharmacare Program Research Articles

Inter- and intraprovincial inequities in public coverage of cancer drug programs across Canada: a plea for the establishment of a pan-Canadian pharmacare program.

Prescription drug coverage is a significant problem in Canada.[...]

Medicare's Evolution: National Pharmacare and Shared Leadership.

Repeated Health Care in Canada (HCIC) surveys over the past two decades have consistently reported that the adult public and clinical and administrative health professionals consider medicare to be successful in terms of quality of care, despite a growing concern that timely access to care remains challenging. These key stakeholders have also recently signalled that major change strategies are likely necessary for continuing success. In the 2018 survey, both the public and professionals ranked highest the creation of a national comprehensive pharmacare plan, entirely funded by the federal government, or with federal funding for those not currently covered by existing pharmaceutical plans. The majority of the public and health professionals in 2018 were also remarkably concordant regarding preferred leadership for designing, instituting and managing a national pharmacare program. The public's priority, supported by 50% of the adult population, was shared leadership involving governments, medical academia and the pharmaceutical/biotech industries, followed by government leadership at 33%. Among professionals, preference for shared leadership averaged 60% and governmental leadership averaged 33%. Based on these data, restriction of pharmacare's leadership exclusively to any single stakeholder raises concern of a critical lack of support for success. A coalition of governments, research hospitals/health authorities and the pharmaceutical/biotech industry - the highest-ranked candidates as potential leaders - would likely provide the best chance to garner the majority of public support and enhance the chances of success in the short and long terms. In summary, the addition of universal pharmacare to medicare's existing healthcare portfolios is an attractive strategy to advance Canadian healthcare and outcomes. The federal government has taken the initial step. Recruitment of additional leaders sharing aspiration, inspiration and experience to optimize pharmacare's development and measure its outcomes is needed. Things can be better.

Impact of a household-level deductible on prescription drug use among lower-income adults: a quasi-experimental study.

Several Canadian public drug plans have income-based deductibles, but we have limited data on their impact, particularly for vulnerable populations. Therefore, we studied the impact of deductibles in British Columbia's Fair PharmaCare program on drug use among lower-income adults. We used a quasi-experimental regression discontinuity design to study the impact of BC rules that impose no deductible before receiving public coverage on households with incomes less than $15 000, a deductible of 2% of household income on those with incomes between $15 000 and $30 000, and a deductible of 3% of household income on those with incomes above $30 000. We studied the impact of these thresholds on public and total drug expenditures between 2003 and 2015 using 24 million person-years of data. Both thresholds decreased the proportion of beneficiaries receiving benefits, by 0.33 (95% confidence interval [CI] -0.34 to -0.30) and 0.05 (95% CI -0.064 to -0.032) respectively. There were also substantial reductions in the extent of public drug plan expenditures ($59.94 [95% CI -74.74 to -45.14] and $26.12 [95% CI -39.78 to -12.46], respectively). The change at the $15 000 threshold reduced patient drug expenditures by $26.00 (95% CI -45.48 to -6.51), or 7.2%. In contrast, we found no statistically significant change in total expenditures when households moved from a deductible of 2% to 3% at the $30 000 threshold. Income-based deductibles considerably affected the extent of public subsidy for prescription drugs. For lower-income households making around $15 000, the deductible led to a reduction of 7.2% in overall drug use and costs. Although deductibles are a useful tool to limit public expenditures, policy-makers should be cautious in their use among vulnerable populations.

Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases

PurposeDespite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization.MethodsA descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated.FindingsWe identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis.ImplicationsIn each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.

The Impact of US FDA and Health Canada Warnings Related to the Safety of High-dose Simvastatin.

IntroductionBetween 2010 and 2012, the US Food and Drug Administration and Health Canada issued warnings to healthcare professionals emphasizing the increased risk of muscle problems with high-dose simvastatin.ObjectiveTo measure the impact of the Health Canada safety warning regarding dose-dependent adverse effects of simvastatin on prescribing of low, medium, and high doses of simvastatin.MethodsAn interrupted time-series design was used to evaluate the impact of a Health Canada safety warning on 7 November 2012 regarding the safety of high-dose simvastatin. Monthly prescription records were analyzed for beneficiaries of the Nova Scotia Seniors’ Pharmacare Program aged 65 years or older who had received > 1 prescription of simvastatin between 1 January 1997 and 31 March 2015. Autoregressive Integrated Moving Average models were used to test changes in the proportion of beneficiaries dispensed a low dose (< 40 mg), medium dose (40 mg to < 80 mg), or high dose (≥ 80 mg) of simvastatin over time.ResultsThere were 219 monthly periods, of which 29 periods occurred after the Health Canada warning. On average during the pre-warning periods there were 2944 simvastatin users per month, of whom 71% were dispensed a low dose, 26% a medium dose, and 2% a high dose. The proportion of beneficiaries dispensed low-dose simvastatin increased by 0.9% (one-sided p value 0.035; 90% CI 0.07–1.65), the proportion dispensed medium-dose simvastatin decreased by 0.7% (one-sided p value 0.0496; 90% CI −1.48 to −0), and there was no significant change in the proportion dispensed high-dose simvastatin (−0.15% change, one-sided p value 0.205; 90% CI −0.45 to 0.15).ConclusionsThe Health Canada Health Care Professional warning had a small effect on increasing the proportion of beneficiaries dispensed low and medium doses of simvastatin but not high doses of simvastatin. Nevertheless, there remain seniors in Nova Scotia receiving high-dose simvastatin for whom the benefit/risk potential may need to be re-evaluated.

Has Province-Wide Symptom Screening Changed Opioid Prescribing Rates in Older Patients With Cancer?

Previous work in Ontario demonstrated that 33% of patients with cancer with severe pain did not receive opioids at the time of their pain assessment. With efforts to increase symptom screening and management since then, the objective of this study was to examine temporal trends in opioid prescribing. The cohort was comprised of Ontario residents ≥ 65 years of age with a cancer history who were eligible for the government pharmacare program and had a pain assessment using the Edmonton Symptom Assessment System. Use of the Edmonton Symptom Assessment System is part of a provincial initiative to screen ambulatory patients with cancer for symptoms. Annually between 2007 and 2013, we used the date of an individual's highest pain score as the index date to calculate annual opioid prescription rates for claims within 30 days before and up to 7 days after the index date. A logistic regression model evaluated the association between index year and odds of receiving an opioid prescription. During the study period, the number of individuals undergoing symptom assessment annually increased more than eight-fold. Opioid prescription rates were directly related to pain scores, but there was an annual 5% relative decrease in the odds of receiving an opioid prescription during the era from 2009 to 2013. We are doing better at screening for pain, but this has not led to an increase in analgesic intervention for those identified. Additional work is required to determine what opioid prescribing rate is optimal to ensure we are not missing opportunities to improve patient comfort.

List of essential medicines for Canada

The articles by Morgan and colleagues in CMAJ, [1][1] and Taglione and colleagues in CMAJ Open [2][2] are useful prompts for resolving the continuing conjoint debates about a national list of essential medicines and a national pharmacare program in Canada. Unfortunately, their contributions are

National Pharmacare in Canada: 2019 or Bust?

It is the Canadian public policy issue that rears its head with regularity, never achieving much more than discussion, and yet never going away entirely. The issue is pharmacare, and once again it is back for discussion among academics and policy-makers, and once again it looks like the discussions will not go anywhere anytime soon. The proposal for a publicly funded pharmaceuticalcoverage plan is frequently on the table in Canada, but it still is not in the cards. Canada is the only member country of the Organisation for Economic Cooperation and Development (OECD) with a public health-care system that does not include coverage for pharmaceuticals. As a result, Canada spends markedly less public money than the OECD average on pharmaceuticals (42 per cent ofdrug payments are public funds, versus the average 70 per cent), although it also spends more than the OECD average on hospitals and doctor visits. Advocates for an expansion of the publicly funded medicare system to include prescription medication note that it has become common for some lower-income Canadians who lack private drug insurance to leave prescriptions unfilled due to the cost, or will miss doses. This affordability problem for lower-income Canadians appears to be getting more serious. However, while Canadians seem to express support for the idea of pharmacare when asked about it in surveys, it remains well behind a list of other improvements to the health-care system that they consider to be of higher priority. They are more interested in improving access and wait times, and they are more concerned about the sustainability of the current system given the increased demands of the aging population. Both employers and workers, meanwhile, also support the existing model of employer-provided drug plans. Perhaps the biggest obstacle for champions of pharmacare, however, is that the term can mean so many different things to different people. There is virtually no consensus on what would even be the appropriate Canadian system, particularly in light of how significant a factor private coverage already is in Canada. A pharmacare plan might include anything from the drastic step of eliminating all private coverage and subsidizing all prescription medicine for all patients regardless of income, to a much narrower program that covers some portion of the cost of only some drugs, for some income levels. There are also countless different possible models between those two. The matter of how much each level of government, provincial/territorial or federal, would be responsible for funding drugs is a whole other, rather thorny matter. The timing of this latest discussion about pharmacare — stimulated mainly by recent proposals and fuelled by the success of the pan-Canadian Pharmaceutical Alliance in negotiating better bulk drug prices — is also particularly unfavourable. There has been a sudden shift in the dynamic between the federal government and the provinces, where before premiers stood together and collectively bargained with the federal government for health-care funding, but recently splintered and are now making individual deals (while Quebec continues to insist that it must have complete freedom from Ottawa to design its own health system). The difficult fiscal situation across Canada, with so many governments running up debts, would also seem to make it highly unlikely that there will be much enthusiasm for embarking on a new and sizeable social program costing billions of dollars a year. Lacking enough leaders to passionately champion it, and with a public generally uninterested and very unclear on what a national pharmacare program would even entail, it seems that the current discussion about implementing a pharmacare system may come to a stall, like so many discussions before it.

Adoption of the Nova Scotia (Canada) Community Pharmacy Medication Management Program, 1-Year Post-Initiation.

Pharmacists conduct medication reviews to optimize drug therapy. Each jurisdiction implements and funds these programs differently. To describe the uptake of the first year of a community pharmacy medication review program reimbursed by the publically insured seniors' drug benefit program in Nova Scotia, Canada. This retrospective analysis included 294 pharmacies and 105,000 beneficiaries enrolled in the Nova Scotia Seniors' Pharmacare Program. Prescription and service claims data from this program were analyzed to determine type and number of beneficiaries receiving a medication review, number and predictors of pharmacies completing reviews, and number of prescribed medications 6-months before and 6-months after the review. 428 medication reviews were conducted and billed by 33% of Nova Scotia pharmacies (1-50 reviews per pharmacy per year). The mean number and range of medications before the review were 10.8 (4-28) and following the review 10.4 (0-24), with an average decrease of 0.4 medications (95% CI 0.1-0.6), p=.0043). Patients receiving a review had a mean age of 75.2 years; 64.9% were female. Most pharmacies conducted reviews when patients reached their annual copayment (93%). Approximately 33% of pharmacies billed at least one medication review in the first year of the program. In spite of a $150 reimbursement per community pharmacy medication review, only 428 reviews were conducted over a 13-month period for a population of over 100,000 seniors. Results suggest financial reimbursement alone is not sufficient to implement a medication management program; health systems need to determine patient, pharmacist, pharmacy and health system level strategies to implement medication reviews more broadly.

Does the Number of Pharmacies a Patient Frequents Affect Adherence to Statins?

We hypothesized that medication adherence is affected by the number of pharmacies a patient frequents. The objective was to estimate the strength of association between the number of pharmacies a patient frequents and adherence to statins. Using administrative data from the Nova Scotia Seniors' Pharmacare program, a retrospective cohort study was conducted among subjects aged 65 years and older first dispensed statin between 1998 and 2008. The Usual Provider of Care (UPC), was defined as the number of dispensation days from the most frequented pharmacy divided by the total number of dispensation days. Estimated adherence of over 80% of the Medication Possession Ratio was defined as adherent. Data were analyzed using hierarchical linear regression. The cohort of 25,641 subjects was 59% female with a mean age of 74 years. During follow-up, subjects filled prescriptions in a median of 2 (mean = 2; standard deviation = 0.88) pharmacies and visited pharmacies a median of 28 (mean = 30) times. During that time, 61% of patients used one pharmacy exclusively. Among subjects using 1 pharmacy, 59% were adherent while 58% using more than one pharmacy were adherent. However, upon adjustment for differences in distributions of age, sex, and other confounders, subjects who used more than one pharmacy had 10% decreased odds of statin adherence (odds ratio: 0.90, 95% confidence interval: 0.86-0.96). These results were robust in sensitivity analyses. Among seniors newly starting statin therapy, using a single community pharmacy was modestly associated with adherence.

What Does the New Ontario Pharmacare Plan offer Children and Young Adults with Rare Disorders?

A publicly-funded pharmacare program (OHIP+) was announced in the 2017 Ontario budget for all children and young adults that will begin in January 2018 and cover drugs in the Ontario Public Drug Programs (OPDP) formulary. In this commentary, drugs indicated for rare disorders commonly occurring in childhood that were reviewed by the Common Drug Review (CDR) between 2004 and 2016 are examined to assess the Ontario reimbursement situation. OPDP reimburse few of these drugs and only about half of those covered are accessible with consistency and without onerous conditions. Providing reimbursement for rare disorder drugs that received a positive CDR recommendation would likely cost less than a quarter of OHIP+'s projected cost. Children who will benefit most from OHIP+ are those with common conditions whose parents do not presently have access to provincial or private insurance. Children with rare disorders deserve accessible provincial financial support for potentially life-transforming drugs.

Trends in Statin Use in Seniors 1999 to 2013: Time Series Analysis.

PurposeTo examine HMG-CoA reductase inhibitor (statin) drug dispensing patterns to Nova Scotia Seniors' Pharmacare program (NSSPP) beneficiaries over a 14-year period in response to: 1) rosuvastatin market entry in 2003, 2) JUPITER trial publication in 2008, and 3) generic atorvastatin availability in 2010.MethodsAll NSSPP beneficiaries who redeemed at least one prescription for a statin from April 1, 1999 to March 31, 2013 were included. Aggregated, anonymous monthly prescription counts were extracted by the Nova Scotia Department of Health and Wellness (Nova Scotia, Canada) and changes in dispensing patterns of statins were measured. Data were analyzed using descriptive analyses and interrupted time series methods.ResultsThe percentage of NSSPP beneficiaries dispensed any statin increased from 5.3% in April 1999 to 20.7% in March 2013. In 1999, most NSSPP beneficiaries were dispensed either simvastatin (29.5%) or atorvastatin (28.7%). When rosuvastatin was added to the NSSPP Formulary in August 2003, prescriptions dispensed for simvastatin, lovastatin, pravastatin, and fluvastatin declined significantly (slope change, -0.0027; 95% confidence interval (CI), (-0.0046, -0.0009)). This significant decline continued following the publication of JUPITER (level change, -0.1974; 95% CI, (-0.2991, -0.0957)) and the availability of generic atorvastatin (level change, -0.2436; 95% CI, (-0.3314, -0.1558)). Atorvastatin was not significantly affected by any of the three interventions, although it maintained an overall decreasing trend. Only upon the availability of generic atorvastatin did the upward trend in rosuvastatin use decrease significantly (slope change, -0.0010, 95% CI, (-0.0015, -0.0005)).ConclusionsThe type and rate of statins dispensed to NSSPP beneficiaries changed from 1999 to 2013 in response to the availability of new agents and publication of the JUPITER trial. The overall proportion of NSSPP beneficiaries dispensed a statin increased approximately 4-fold during the study period. In 2013, rosuvastatin was the most commonly dispensed statin (44.1%) followed by atorvastatin (39.1%).

Adherence to Guidelines and the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions Criteria for Colchicine Dosing for Gout Treatment in Beneficiaries of the Nova Scotia Seniors’ Pharmacare Program

PurposeColchicine is commonly used in the management of gout; however, older persons have higher risks of toxicity. Accordingly, the Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP) criteria for colchicine consider >3 months of treatment as potentially inappropriate in older persons. Recent evidence also suggests lower dosing of colchicine is as effective and results in fewer toxicities than high-dose colchicine. The objectives of this study were to determine the dose, duration, and prescribers of colchicine and to evaluate adherence to the STOPP criteria and international guidelines for colchicine in older persons. MethodsA retrospective, observational study was conducted from April 1, 2006 to March 31, 2011 to evaluate colchicine use. Nova Scotia Seniors’ Pharmacare Program beneficiaries who met inclusion criteria for an incident case of gout and who filled at least 1 prescription for colchicine during the study period were included. Colchicine dose and duration were reported descriptively. Multivariate logistic regression was used to identify predictors of the study population in making a claim for colchicine >90 and >180 days. FindingsA total of 518 persons were dispensed 1327 courses of colchicine during the study period. The mean daily dose of colchicine ranged from 1.39 to 1.50 mg. Colchicine doses >1.2 mg were prescribed in approximately one-third of the study population. Colchicine was prescribed for >90 days in 14.2% of treatment courses and for >180 days in 8.1% of treatment courses. Female sex was the only predictor of treatment duration >90 days. ImplicationsThis study is the first to report on colchicine dose and duration using STOPP criteria in a specific cohort of older persons with incident gout. Strategies to improve colchicine prescribing in older persons are needed.

Election 2015: Communicating pharmacy's priorities.

Canadians will be heading to the polls in a federal election widely expected to occur October 19, 2015. Although the pundits would argue that political parties have been campaigning for months already, most election-related activities, such as public debates and door-to-door campaigning by candidates, will begin to ramp up in late summer and fall. As the 2015 federal election campaign moves into high gear, the Canadian Pharmacists Association (CPhA) has identified key recommendations and messages for federal political candidates on 3 key national issues of importance to the profession. These 3 issues include the following: Pan-Canadian Pharmacare Program: CPhA is seeking commitment from all federal political parties to work with the provinces/territories, health care professionals and other stakeholders towards the development of a pan-Canadian pharmacare program. Such a program must address coverage gaps between public and private systems, protect Canadians from undue financial hardship and guarantee access to a stable supply of clinically and cost-effective medications. Furthermore, the inclusion of access to pharmacy services under a pharmacare model is key to achieving better health outcomes and cost savings. National Plan for e-Prescribing: CPhA is calling on all parties to work with the provinces/territories, health care professionals and other stakeholders to implement a seamless e-prescribing system in Canada. CPhA is looking for the federal government to support the development and implementation of a common national standard for e-prescribing that ensures that Canadians’ prescription information can be more easily shared and accessed between relevant health providers, while respecting patient privacy and confidentiality. Strengthened National Immunization Strategy for Canada: Given Canada’s relatively low rates of immunization compared with other industrialized countries, CPhA is calling for a revamped National Immunization Strategy. The goal of a revamped strategy would be to increase immunization rates through a comprehensive approach that would include further expanding pharmacists’ scope of practice to administer vaccines. The National Strategy would also target increased research, comparable access and enhanced education/outreach, including building a partnership with the provinces/territories and health professionals to increase public awareness of the importance of vaccinations. In the lead-up to October 19, CPhA is encouraging pharmacists and other Canadians to promote and discuss these key recommendations with political candidates from all parties. To assist you, CPhA has assembled an election website at www.pharmacists.ca/election. On this website, you will find a print-ready brochure that summarizes the key recommendations, a more detailed platform document that provides background and rationale for these recommendations and an online tool that allows you to quickly and easily contact the candidates in your riding and send them messages of support for the above-mentioned priorities. Elections provide voters with an excellent opportunity to learn about and pin down the views of candidates and political parties on specific issues. This election is no different. Go to www.pharmacists.ca/election to share your thoughts with your candidates, and help CPhA advance these core issues. ■

Reforming private drug coverage in Canada: Inefficient drug benefit design and the barriers to change in unionized settings

Prescription drugs are the highest single cost component for employees’ benefits packages in Canada. While industry literature considers cost-containment for prescription drug costs to be a priority for insurers and employers, the implementation of cost-containment measures for private drug plans in Canada remains more of a myth than a reality. Through 18 semi-structured phone interviews conducted with experts from private sector companies, unions, insurers and plan advisors, this study explores the reasons behind this incapacity to implement cost-containment measures by examining how private sector employers negotiate drug benefit design in unionized settings. Respondents were asked questions on how employee benefits are negotiated; the relationships between the players who influence drug benefit design; the role of these players’ strategies in influencing plan design; the broad system that underpins drug benefit design; and the potential for a universal pharmacare program in Canada. The study shows that there is consensus about the need to educate employees and employers, more collaboration and data-sharing between these two sets of players, and for external intervention from government to help transform established norms in terms of private drug plan design.

Health System Leadership and the Federal Role in Canada.

While provincial governments constitute the primary locus for healthcare system decision-making and provision, the federal government retains an important funding and "steering" role in directing health system performance. This commentary explores three possible redeployments of the federal spending power to elevate health system performance; improve access; increase individual, provincial and regional equity; and achieve better health outcomes for present and future Canadians. The proposals include amending the Canada Health Transfer to better support its original policy purpose, improving and expanding an informational and analytical infrastructure and the eventual implementation of single pharmacare program by the Government of Canada. These changes are aimed at accelerating evidence-based health reforms to improve access, quality and responsiveness of healthcare and, ultimately, health outcomes.

PCN70 - Cost & Resource Utilization of Cervical Cancer in British Columbia

To assess health care resource utilization and cost of cervical cancer from the perspective of British Columbia’s health care system. Retrospective observational data on women diagnosed with cervical cancer between 2004 and 2009 was utilized to calculate patient-level resource utilization from diagnosis to death or 5-year discharge. Domains of resource use included hospitalization, chemotherapy, radiotherapy, brachytherapy, medically necessary services such as laboratory, physician and diagnostics billed under B.C.’s Medical Services Plan and medication dispensed under B.C.’s Pharmacare program. Unit costs were applied to health care resources, producing per-patient costs. Relevant costs, presented in 2012 CDN dollars, were further separated by chemotherapy protocol, stage at diagnosis, screening history, progression date and age. The average cost of treating cervical cancer in B.C. was $32 023, (95% CI: $29 785 - $34 260). Hospital costs were the largest proportion of cost at a mean proportion of 37.8% (95% CI: 35.8, 39.8) of total cost. Mean length of inpatient hospital visits was 11.2 days, with 2 outpatient hospital visits per patient. Costs were also calculated by relevant clinical subgroups, including progression, age, stage, screening history and treatment protocol on cost and resource utilization. Cervical cancer resource utilization and costs are substantial in B.C.’s health care system. Such data is necessary for decision makers in designing and implementing screening and disease management policy. Results will provide inputs for the HPV FOCAL Study, a prospective investigation into the cost-effectiveness of utilizing the detection of HPV infection as a primary screening tool in B.C.

Making Evidence Matter in Canadian Health Policy

Navigating the Evidence: Communicating Canadian Health Policy in the Media is a compilation of the EvidenceNetwork commentaries published in major newspapers in 2014, written by experts in the health policy field. These Op-Eds highlight the most recent evidence on a wide range of topics, including our aging population, healthcare sustainability, costs and spending, and the impact of the social determinants of health. It also contains essays addressing key concerns around mental health, obesity and pharmaceutical policy, among other topics.This is the third volume in the annual series of eBooks produced by EvidenceNetwork, the first being Canadian Health Policy in the News (2013), followed by Making Evidence Matter in Canadian Health Policy (2014).In this volume, please find our second compendium of Op-Eds (materials published from October 2012 to October 2013). Like our first eBook, this second volume is a snapshot of a year in the health policy debates of our country. We’ve not altered the materials to reflect changes that may have taken place since the commentaries were written, but left them as they were published, to represent accurately the time in which they were written. Most Op-Eds were originally published in English, with some translated into French, where we had resources. A few were originally published in French, with English translations.The book is organized into key themes that EvidenceNetwork experts have agreed to tackle —areas where we feel the evidence is not yet being fairly represented in media, policy and/or political circles, and where we feel we can make a contribution. Sustainability documents the challenges of affording the healthcare system Canadians want and need, and explores the way our health system gives us a competitive advantage internationally, and fleshes out optimized funding formulas that work for all regions of the country. Costs and Spending looks at remuneration systems and how they may differently incentivize those who work in the health domain in Canada, the relationship between health care dollars and healthcare quality, and how our health system contributes to a more equal society. This section highlights why healthcare costs so much and what parts of the system are eating up our healthcare dollars.Pharmaceutical Policy looks at patent processes and access to affordable, quality medications, at the over-prescription of certain medications, and the relationship of pharmaceutical firms to health research, education and marketing. This section highlights the research suggesting why a national pharmacare program makes sense, and the health cost of affordable pharmaceutical drugs, as well as the variations of drug programs across the country — what’s working and what’s not. Private, For-Profit examines the evidence comparing private-for-profit delivery of healthcare with public delivery, and the problems which arise in those sectors that largely aren’t covered by our public healthcare system, such as prescription glasses or dental care.Health is More than Healthcare details the important social determinants of health, such as the relationship between poverty and good health, home and food security, income distribution, chronic stress, discrimination in the health system and healthy parenting. Aging Population looks at the impact of our aging society on our health system, and does some myth busting on the so-called “aging tsunami,” as well examining the need for pension reform in Canada, and what path that might take. Mental Health, a new topic of focus for EvidenceNetwork this year, examines the relationship of chronic stress and health status. More will be done in this area by our experts in the coming months — stay tuned to our website. Also new is the section on Obesity, which looks at why traditional methods for combating the obesity epidemic have failed, and what works for those trying to change their lifestyle to healthier habits. We examine possible policy levers to help tackle obesity and look at weight-based discrimination and what can be done about it. Finally, in our Appendix A and B, we provide more details about the EvidenceNetwork project for those who wish to know more about us in detail.

Prescribing trends of antipsychotics in youth receiving income assistance: results from a retrospective population database study.

BackgroundPrescribing of antipsychotics (AP) to young people has increased in the last decade internationally. We aimed to characterize AP prescribing in a population of low-income youth in Nova Scotia, Canada.MethodsWe conducted a population database study of AP prescription claims and health services utilization by young people aged 25 years and younger receiving drug benefits through the publicly funded Pharmacare program between October 1, 2000 to September 30, 2007.ResultsFour percent (1715/43888) of youth receiving Pharmacare benefits filled AP prescriptions. The use of second generation antipsychotics (SGAs) significantly increased (p < 0.0001) in all age groups except 0-5 year olds, whereas first generation antipsychotic use significantly decreased. Pharmacare beneficiaries aged 21-25 years represented 45.2% of AP users. The majority (66%) of youth filling AP prescriptions had 2 or more psychiatric diagnoses. Most youth (76%) filled prescriptions for only one type of AP during the study period. Psychotic disorders were the most common indication for AP use except with risperidone, in which ADHD was the most likely reason for use. Co-prescribing of psychotropics was prevalent with antidepressants and mood stabilizers prescribed in 42% and 27% of AP users, respectively. General practitioners (GPs) prescribed incident APs most often (72%) followed by psychiatrists (16%). The age- and gender-adjusted rate of death was higher in AP users as compared to the age-matched general population of Nova Scotia.ConclusionsSGA use increased significantly over seven years in a cohort of 0 to 25 years olds receiving Pharmacare benefits. Off-label use of APs was prevalent with ADHD and other non-psychotic disorders being common reasons for AP use. GPs initiated most AP prescriptions. Co-prescribing of other psychotropics, especially antidepressants and mood stabilizers, was prevalent even in younger age strata. This study raises further questions about AP prescribing in those 25 years of age and under, especially given the range of diagnoses and psychotropic co-prescribing.

Provinces and territories agree to work together to purchase generic drugs and to expand use of bulk purchasing for brand-name drugs

Canada's provincial and territorial premiers have announced plans for a national competitive bidding process to purchase generic drugs and to expand use of group pricing for brand-name drugs. The announcement was made on July 26, 2012, during a meeting of the Council of the Federation in Halifax. Bulk purchasing for generics has become a necessity, according to a report from the Council's Working Group on Health Care Innovation. “Canadian prices on 64 generic prescription drugs are 90% higher than American prices and that's the gap were going to seek to close,” Saskatchewan Premier Brad Wall said at a July 26 news conference; he co-wrote the report with Prince Edward Island Premier Robert Ghiz. The provinces and territories — with the exception of Quebec — will begin by jointly purchasing 3 to 5 generic drugs, with prices established through competitive tendering. These pharmaceuticals are to be identified in the fall and the bulk purchasing is to begin in the spring of 2013. Pharmacists support measures to ensure the financial sustainability of health care but they have concerns about bulk purchasing, says Dr. Jeff Poston, executive director of the Canadian Pharmacists Association (CPhA). “Our concern is the risks to the supply chain that get created through competitive tendering, where you can end up with a sole supplier and potential shortage issues, says Dr. Poston. Noting that governments have already significantly reduced generic drug costs through new pricing policies, he says the focus on further reductions is somewhat misplaced and short-sighted. “They need to focus more on patient care and outcomes from drug therapy. This preoccupation with price neglects the need for investment and for improving safety and quality — ultimately saving money in the broader health care system.” National bulk purchasing with a tendering process is the best approach for generic drugs, according to Marc- Andre Gagnon, assistant professor at the School of Public Policy and Administration at Carleton University in Ottawa and an expert adviser with EvidenceNetwork.ca. “Many countries are purchasing in this way and they manage to get amazing rebates,” says Dr. Gagnon. “I am skeptical, however, about the premiers' plans to accelerate and expand bulk purchasing of brand-name drugs. That's where the real money is — generic drugs are only about 25% of drug expenditures.” In September 2010, the provinces and territories announced a pan-Canadian purchasing alliance to purchase the most expensive brand-name drugs. Since that time, Dr. Gagnon points out, only 2 products have been purchased that way. Achieving significant savings on brand-name drugs will be very challenging through joint purchasing alone, he says. For the past few years, the brand-name pharmaceutical companies have employed a global pricing strategy, in which they establish an “official price” for prescription drugs and negotiate rebates for individual purchasers. They did this after the US government agreed that its Medicare plan would always pay the official price, so there is an incentive to keep that price artificially high, explains Dr. Gagnon. “In Canada, most provinces have focused on standalone agreements for costly brand-name drugs, in which they list the official price on the formulary but secure confidential rebates for the public drug plan,” he says. “As soon as it is listed in a formulary, it is listed in every private drug plan in the province — and they don't benefit from the rebates. And patients paying out of pocket also have to pay the full official price.” Patients covered by the public plans also have co-payments and deductibles based on the official price. “It also puts smaller provinces at a disadvantage because they don't have the populations to secure the same savings as the larger provinces,” he adds. “There is a huge problem in terms of equity here between provinces.” It appears that the provinces and territories seek to negotiate on the official price of the drug, says Dr. Gagnon. “With the global pricing strategy, drug companies will be very reluctant to touch the official price. I don't think this is the best way to get high rebates.” The only way to secure significant savings on brandname drugs, he says, is to implement a national pharmacare program. He points to New Zealand, where the brand-name pharmaceuticals are 51% of the cost of those in Canada. “In New Zealand, the reason it works properly is that they do have a national pharmacare program, so when they purchase drugs they do so for all New Zealanders. Under a national program, we can eliminate playing of one province against the others. And the drug cost savings would be enough to actually fund the national drug plan.”