Thank you.
I would like to thank you for providing me with the opportunity to come and speak to you. I'm a pharmacy professor with the CIHR/CHSRF-funded chair in drug use management at Dalhousie, and I've been there for 25 years.
I'm going to talk about goals of pharmaceutical policy. Then I'm going to give you two cases, one of inappropriate drug use and another of drug use where you could have a more efficient system. Finally, I'm going to talk about selected medication management strategies.
Jacobzone from the OECD defined the goals of pharmaceutical policy as improving health, fostering efficiency, improving cost-effectiveness, obtaining best value for money, preserving equity, and other--industrial policy. As Canadian jurisdictions set and refine their goals related to pharmaceutical policy, we need to determine how well they are performing against the goals, and have systems to measure them.
My first case illustrates the identification of an unsafe drug in the general population. In the 1980s, evidence was generated to show that Chlorpropamide, a drug for diabetes, was less safe than alternatives for the treatment of diabetes. It could cause low blood sugar, sometimes causing coma and hospitalization.
The Drug Evaluation Alliance of Nova Scotia funded a program to decrease Chlorpropamide use, and all seniors were switched to more appropriate therapy. But look at the time it took. The evidence came out in the 1980s, but in 1995 we still had 1,500 seniors in Nova Scotia receiving the drug. We put together an intervention that took people off the drug. In 2003, eight out of ten provincial pharmacare programs still funded the drug. In 2004, the Auditor General of Canada discussed the Beers criteria, which suggested this drug should never be used in seniors, and in 2005 there was a CBC radio show on the Beers criteria.
The key message is that even once the evidence is in, it can take a very long time to change habits and ingrain practices to adopt better practices. There needs to be a systematic approach to monitoring drugs after they are marketed in Canada, especially in susceptible populations such as children and seniors. Real-time electronic clinical decision support systems need to be developed to alert physicians to drug disease, drug interaction, and other problems.
On the next slide you'll see pictures of a mask that's used for asthma, and puffers. About three million people in Canada have asthma and bronchitis, so this is an important therapeutic area. The masks, or wet nebulization, are more costly, less efficient, less portable, have more bacterial contamination, and are less convenient. The puffers, which are supported by Canadian and international guidelines, have equal efficacy and cost about one-tenth as much.
In Nova Scotia we were paying about $2 million for the masks, and then the Drug Evaluation Alliance of Nova Scotia did an intervention that decreased the use of masks considerably. In just two years the DEANS group got patients switched from masks to puffers, which saved the government about $1 million per year and gave patients a simpler, more convenient approach. It was better for the patient, easier to provide, and it saved money.
The point of these two examples is to illustrate that there's room to improve the quality of medicines used and the cost-efficiency in the pharmacare program.
I would next like to talk about strategies that could be used to improve medication use. There are many stakeholders in pharmaceutical policy, and there need to be more opportunities in Canada where stakeholders can be brought together.
In Australia there's a national strategy on the quality of use of medicines. The Australian pharmaceuticals advisory committee is a representative council with about 30 members from diverse groups. So it includes the brand-name and generic drug industries, doctors, social workers, physicians, nurses, and journalists. They look at trying to set goals for the quality use of medicines in the country and how the various players can help implement those goals.
The next slide is on strategies for government. In Canada there are 19 federal, provincial, and territorial pharmacare programs. They differ in eligibility requirements, the drugs they provide, co-payments, and methods they use to manage programs. They use a mixture of legislative, financial, and educational approaches. These plans need to continue to work together to learn from each other and other countries on what works, what doesn't work and why, and what the trade-offs are.
Strategies are also needed to provide doctors, pharmacists, and other health professionals with tools to make good choices. Close to 400 million prescriptions per year are written by Canada's 60,000 physicians, and dispensed by Canada's 29,000 pharmacists, so a strategy that comes from Ottawa can't help all of those physician, patient, and doctor interactions. We also need tools to give to those individuals.
We also need strategies that target health organizations: the health delivery sector, information technology, drug utilization, and post-marketing surveillance. There are over 22,000 drugs on the Canadian market and an estimated 7,000 drug interactions. Busy physicians cannot keep all this information in their heads. They rely on a small set of drugs they know well. Both electronic health records and clinical decision support systems can help them take care of patients, especially when they are unfamiliar with drugs or new drugs.
Finally, I couldn't be a researcher without saying that research is important, so the pharmaceutical system in Canada needs a strong research underpinning. It's critical to understand the theories related to physician prescribing behaviour. Synthesis of the best international evidence provides useful information from Canada. New knowledge about drug effects and their use is needed, and this needs to be communicated to the decision-makers and practitioners. A strong network of post-marketing surveillance is needed to determine safety and effectiveness under real-world conditions.
In summary, do not expect that one policy will have huge breakthroughs in cost containment. Continuous improvement matters, to improve outcomes for patients and cost-effectiveness. As baby boomers age, it is ever more critical to put in place systems to manage the pharmaceutical system for sustainability.
Thank you for your attention.