Rx Atlas. The Canadian. Third Edition. The following pages are an excerpt from. December 2013

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1 The following pages are an excerpt from The Canadian Rx Atlas Third Edition December 2013 British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Newfoundland and Labrador Prince Edward I. Steve Morgan, PhD Kate Smolina, PhD Dawn Mooney, MPH Colette Raymond, MSc PharmD Meryn Bowen, BSc (Pharm.) PhD Chris Gorczynski, MM Kim Rutherford, MSc MD CCFP

2 T h e c a n a d i a n R x a t l a s, t h i r d e d i t i o n Introduction Figure 5.3a» Summary of sales, spending, and use, 2012/13 Figure 5.3b» Share of spending by sex, age group, and payer, 2012/13 Drugstore sales ($-million) $368 Sex Drugstore sales as percent of all sales, including hospitals <95% 26% 74% Females Males Share of spending accounted for by pharmacist fees (est.) Estimate not available Per capita spending 2007/ /2013 Per capita spending Females Males Prescriptions per 1,000 population Females 10 Males 0 $9 $11 $16 $5 Age group 3% 29% 67% Days of treatment per 1,000 population Females Males Estimates not available Estimated cost per day of treatment Females Males Estimates not available Primary payer 14% 46% 39% Provincial drug plans Private insurance Uninsured/below deductibles Federal drug plans Table 5.3a» Leading drugs, by prescription volume, 2012/13 Percent of prescriptions Percent of spending Interferon Beta 1A 43.4% 43.6% Glatiramer 33.9% 27.7% Interferon Beta 9.5% 9.5% Natalizumab 6.4% 9.8% Fingolimod 6.1% 8.6% Table 5.3b» Leading drugs, by spending, 2012/13 Percent of prescriptions Percent of spending Interferon Beta 1A 43.4% 43.6% Glatiramer 33.9% 27.7% Natalizumab 6.4% 9.8% Interferon Beta 9.5% 9.5% Fingolimod 6.1% 8.6% Table 5.3c» Spending, use, and cost, by drug source, 2012/13 Spending per capita Prescriptions per 1,000 pop. Cost per prescription Female Male Female Male Female Male Single-source brand $15.60 $ $1, n/a Multi-source brand n/a n/a Multi-source generic n/a n/a Sourced only by generics n/a n/a 2 0 6

3 U B C c e n t r e f o r h e a lt h s e r v i c e s a n d p o l i c y r e s e a r c h Introduction Drugs included Interferon beta 1a, Interferon beta 1b, natalizumab, fingolimod, and glatiramer. Examples of indicated conditions Multiple sclerosis Clinical uses and considerations These immune modulators are used to treat multiple sclerosis, a disabling disease affecting the central nervous system. Although the exact cause of multiple sclerosis is unknown, it is thought to be immunemediated. Nerve sheaths and nerve fibres in the brain and spinal cord are attacked by the body s immune system, causing a variety of symptoms, such as numbness, vision loss, and paralysis. How might usage differ across age groups? Multiple sclerosis generally develops in the 20s or 30s, and patients tend to stay on pharmacologic therapy for the rest of their lives. Life expectancy in these patients may be reduced. How might usage differ between sexes? About twice as many women as men are diagnosed with multiple sclerosis, and women experience disease onset at an earlier age. However, men with multiple sclerosis tend to have accelerated disease progression, although they do not necessarily experience poorer outcomes. Studies have reported that the incidence of multiple sclerosis is increasing in women. The reasons for these sex differences are not known. Most patients suffer from the relapsing-remitting form of disease, where symptomatic attacks are followed by symptom-free periods. The drugs in this category are mainly used in this type of multiple sclerosis to prevent relapses and slow the progression of disease. They are not typically used to treat acute attacks. These immunomodulatory drugs can be administered subcutaneously (interferons, glatiramir), intramuscularly (interferons), intravenously (natalizumab), or orally (fingolimod). Natilizumab and fingolimod are not first-line therapy because of potential adverse effects. Note: Provincial formulary coverage information was not available for this drug class

4 T h e c a n a d i a n R x a t l a s, t h i r d e d i t i o n Levels of spending across Canada by age group and sex, 2012/13 National spending by age and sex Canadians spent an average of $11 per capita on drugs for multiple sclerosis at retail pharmacies in 2012/13 ($16 for women and $5.40 for men). Average per capita spending was insignificant for children and very low ($1.30) for Canadians aged 65 and older. Average spending per capita was highest among Canadians aged (). The level of spending was approximately three times higher for women than for men in each adult age group and for all ages combined. Provincial spending by age and sex Across provinces, average spending per capita ranged from $6.90 () to $26 () for women and from $2.80 () to $8 () for men. Differences in average spending per capita by age and sex were roughly comparable across provinces. Despite similar age gradients, there was notable variation across provinces in average spending per capita in all age groups (coefficients of variation greater than 3). Nova Scotia and British Columbia had the two lowest levels of spending per capita in all age/sex groups. Nevertheless, variations in spending across other provinces remained in all age/sex groups. Figure 5.3d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13 Figure 5.3e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13 $100 $100 $75 $75 Spending per capita $50 $30 Spending per capita $50 $25 $16 $ years years years 65+ Number of people 3,584,031 4,972,509 people 6,149,631 people 2,865,177 Number of people $ years 3,779,380 people $ years 5,097,112 people $ years 6,111,006 people $ ,321,

5 U B C c e n t r e f o r h e a lt h s e r v i c e s a n d p o l i c y r e s e a r c h Levels of spending across Canada by age group and sex, 2012/13 Figure 5.3f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13 Canada Canada Females of all ages Males of all ages $40 $40 Females age 0 18 Males age 0 18 Females age Males age $40 $40 Females age Males age $60 $60 $40 $40 Females age 65+ Males age

6 T h e c a n a d i a n R x a t l a s, t h i r d e d i t i o n Variation in spending across Canada, 2012/13 Population age and provincial spending Because spending on drugs for multiple sclerosis is concentrated among persons aged 40 64, differences in provincial population ages would predict relatively modest provincial variation in spending per capita. For example, based on age differences alone, predicted spending per capita in Saskatchewan would be 6.6% below the average for the rest of Canada; in Newfoundland & Labrador, average spending per capita would be 3.6% below the average for the rest of Canada. However, even after figures were adjusted for differences in population age, this therapeutic category had among the highest levels of variation in average spending observed in this atlas. In Quebec, age-standardized average spending per capita was 74% above the average for the rest of Canada, while in Nova Scotia it was 55% below the average for the rest of Canada. Sources of age-standardized variation Volume effects were the primary driver of provincial variation in age-standardized average retail spending on drugs for multiple sclerosis. Based on age-standardized figures, residents of Nova Scotia purchased significantly fewer drugs than other Canadians, while residents of Quebec purchased significantly more. Price effects and therapeutic choice effects contributed modestly to provincial variation in age-adjusted spending per capita. Retail pharmacies accounted for a smaller share of total sales of drugs for multiple sclerosis in Nova Scotia than in the rest of Canada. This may explain the relatively low level of spending per capita captured here. Table 5.3d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13 Spending per capita in province $6.80 $12.01 $11.82 $10.26 $8.21 $15.72 $17.02 $4.91 $13.21 $14.32 Spending per capita in rest of Canada $11.12 $10.37 $10.51 $10.56 $12.03 $9.00 $10.40 $10.71 $10.54 $10.49 Unadjusted difference in spending per capita -38.9% 15.9% 12.5% -2.9% -31.8% 74.7% 63.6% -54.1% 25.4% 36.4% Difference predicted by population age 1.8% -1.2% -6.6% % 1.7% 1.9% 0.8% 3.6% Age-standardized difference % 20.4% 2.2% -31.8% 73.8% 60.9% % 31.7% Volume effects -40.9% 27.4% 33.4% 6.2% -34.3% % -71.2% 23.2% 36.7% Prescription volume % 39.2% -9.8% -32.5% % 31.8% 28.4% Prescription size 6.1% 23.9% -5.8% 16.1% -1.7% % 16.3% -8.5% 8.3% Therapeutic choice effects 1.3% -6.6% -7.9% -8.3% -2.5% 9.7% -0.8% 12.1% -4.5% -8.3% Choices of drug sub-classes 4.4% -9.6% -15.4% -7.9% -10.3% 20.3% -0.8% 27.4% -8.5% -11.5% Choices within drug sub-classes -3.1% % -0.3% 7.8% -10.6% % % Price effects -0.4% -3.5% -5.1% 4.2% % 7.7% 4.1% 5.6% 3.3% Prices paid -0.4% -3.5% -5.1% 4.2% % 7.7% 4.1% 5.6% 3.3% Generic use

7 U B C c e n t r e f o r h e a lt h s e r v i c e s a n d p o l i c y r e s e a r c h Variation in spending across Canada, 2012/13 Figure 5.3g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13 British Columbia -4 Alberta +17% Saskatchewan +2 Manitoba +2% Quebec +74% Ontario -32% New Brunswick +61% Newfoundland and Labrador +32% Prince Edward I. Nova +24% Scotia -55% > to to to to to -6 < Figure 5.3h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13 Volume effects Therapeutic choice effects Price effects

8 T h e c a n a d i a n R x a t l a s, t h i r d e d i t i o n Trends in spending across Canada, 2007/ /13 Pace of change, 2007/ /13 At the national level, inflation-adjusted spending per capita on retail purchases of drugs for multiple sclerosis increased by an average of 3.5% per year between 2007/08 and 2012/13, for a total change of 19%. Spending per capita on drugs for multiple sclerosis increased in most provinces. Spending per capita in Quebec increased by an average of 7.2% per year (41% in total). However, in Manitoba, spending per capita actually decreased by an average of 2.3% per year (11% in total). Population aging alone would have caused spending per capita in the provinces to increase by up to 2.1% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted annual rates of change in spending per capita ranged from 3.4% () to 6.4% (). Sources of age-standardized change All three categories of cost drivers contributed modestly to changes in age-standardized spending per capita on drugs for multiple sclerosis. Volumes of treatment purchased decreased in Western Canada and increased in Eastern Canada. In many provinces, there was a small shift toward more expensive drugs from within this therapeutic category. In Quebec, this shift alone would have increased age-standardized spending per capita by 2.6% per year (14% in total). Prices were slightly higher in 2012/13 than in 2007/08 in almost all provinces, driven by higher unit prices. Table 5.3e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/ /13 CAN 2007/08 $8.86 $6.40 $10.93 $12.18 $11.51 $7.27 $11.12 $13.55 $4.15 $10.34 $ /13 $10.55 $6.80 $12.01 $11.82 $10.26 $8.21 $15.72 $17.02 $4.91 $13.21 $14.32 Average annual change 3.5% 1.2% 1.9% -0.6% -2.3% 2.5% 7.2% 4.7% 3.4% % Average annual change predicted by aging 1.2% 1.5% 2.1% 1.5% 1.2% 1.3% 0.7% 0.2% 0.2% 1.4% 0. Age-standardized avg. annual change 2.3% -0.3% -0.2% -2.1% -3.4% 1.2% 6.4% 4.5% 3.2% 3.5% 3.4% Volume effects -0.2% % -3.8% -4.3% -0.4% % 1.1% 2.3% 3.3% Prescription volume -0.3% -2.9% -1.8% -3.9% -5.1% -0.4% 1.7% % 2.1% 2.1% Prescription size 0.1% -0.2% 0.5% 0.2% 0.8% % -0.1% -0.6% 0.1% 1.1% Therapeutic choice effects 1.3% 1.6% 0.5% 0.6% -1.3% 0.7% 2.6% % 0.7% -0.5% Choices of drug sub-classes -0.7% -3.3% -1.7% -1.6% -3.6% -1.1% % 4.4% 0.4% -0.7% Choices within drug sub-classes 2.1% 4.9% 2.1% 2.2% 2.3% 1.8% 1.7% 0.7% -2.2% 0.3% 0.2% Price effects 1.2% 1.1% 0.6% 1.1% 2.3% 0.9% 1.8% 1.5% % 0.7% Prices paid 1.2% 1.1% 0.6% 1.1% 2.3% 0.9% 1.8% 1.5% % 0.7% Generic use

9 U B C c e n t r e f o r h e a lt h s e r v i c e s a n d p o l i c y r e s e a r c h Trends in spending across Canada, 2007/ /13 Figure 5.3i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/ /13 British Columbia Alberta Saskatchewan -2% Manitoba -3% Quebec +6% Ontario +1% New Brunswick +4% Newfoundland and Labrador +3% Prince Edward I. Nova +4% Scotia +3% > to to +5% -2 to +2% -3 to -5% -6 to -1 < % +1 +5% -5% -1 Figure 5.3j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/ /13 Volume effects +15% +1 +5% -5% -1 Therapeutic choice effects +1 +5% -5% Price effects +5% -5%

10 T h e c a n a d i a n R x a t l a s, t h i r d e d i t i o n Public and private spending across Canada, 2012/13 Public (provincial and federal) drug plans covered an estimated 4 of spending on drugs for multiple sclerosis in Canada; private drug plans covered an estimated 46%. Table 5.3f» Share of per capita spending by primary payer, Canada and provinces, 2012/13 CAN Spending per capita, 2012/13 $10.50 $6.80 $12.00 $11.80 $10.30 $8.20 $15.70 $17.00 $4.90 $13.20 $14.30 % Provincial drug plans 39% 7 51% 86% 72% 24% 34% 46% 2% 69% 26% % Private insurance 46% 17% 38% 6% 13% 6 51% 41% 87% 25% 62% % Uninsured / below deductibles 14% 12% 1 7% 14% 16% 15% 13% 1 6% 11% % Federal drug plans 1% 1% 1% 1% 1% Note: Estimates not available for cost per day of treatment, spending on single source brands, and generic substitution rate

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