Poster Presentations

Antipsychotic Use in Seniors: An Analysis Focusing on Drug Claims from 2001 to 2007

• Presenting Author: Jordan Hunt, Canadian Institute for Health Information
• Co-author:  Mike Gaucher, Canadian Institute for Health Information

Antipsychotics have been used to treat schizophrenia and bipolar disorders since the 1970s. The majority of antipsychotic use in the elderly is to treat behavioural and psychological symptoms of dementia. New information on the safety of antipsychotic use in the elderly was released between 2000 and 2005, prompting regulatory warnings and updates to product monographs and practice guidelines. 

Claims level data from the National Prescription Drug Utilization Information System (NPDUIS) Database, were analyzed for seniors on public drug programs in Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, and Prince Edward Island between 2001 and 2002 and between 2006 and 2007. The analysis included calculation of the proportion of seniors using antipsychotics, and looked further at atypical antipsychotics, including comparing their use in community and nursing home settings.

The rate of antipsychotic use among seniors in all provinces grew from 4.3% in 2001 to 2002 to 5.0% in 2006 to 2007. The rate of growth of antipsychotic use slowed during the study period from an average of 5.2% per year between 2001 and 2002 to 1.0% between 2003 and 2004 and 2006 and 2007. There was a continued shift to the use of atypical agents from typical agents during the study period. In 2006 to 2007, 37.7% of senior nursing home residents in three provinces had claims for atypical antipsychotics, compared with only 2.6% of seniors living in the community.

Assessment of Transanal Endoscopic Microsurgery (TEM)

• Presenting Author: Dr. Alain Lapointe, Centre Hospitalier de l'Université de Montréal (CHUM)
• Co-authors: Maurice McGregor, McGill University Health Center (MUHC); Dr. Luigi Lepanto, Centre Hospitalier de l'Université de Montréal (CHUM)

About 40% of the Western population will be affected by benign polyps or adenomas, and more than 90% of those detected will be suitable for colonoscopic polypectomy. When possible, local excision is preferred to radical resection to preserve sphincter function and to avoid a permanent colostomy.

Objective: To assess the clinical effectiveness, safety, and cost of transanal endoscopic microsurgery (TEM) for the removal of rectal tumours.

Methods: A review of the literature was performed to assess morbidity, mortality, and recurrence rate following TEM. Hospital data were obtained to conduct a cost analysis.

Results: Because of the absence of randomized controlled trials, current data are inadequate to allow confident conclusions on the recurrence of tumour following resection by TEM. The general consensus, however, indicates that recurrence rates for T1 tumours after TEM are comparable with those following radical resection, while morbidity and mortality rates for TEM are lower. Based on costs prevailing at the Centre hospitalier de l’Université de Montréal (CHUM), TEM would cost the hospital $7,538 less per procedure. However, switching from radical surgery to TEM would not result in budget savings to the hospital, but rather an increase in efficiency.

Conclusion: The review of the literature suggests that with TEM recurrence of tumour is similar to that seen with radical resection for T1 stage tumours with lower morbidity and mortality. However, from the point of view of the hospital, management by TEM would cost less.

Atrial Fibrillation: A Real-Life Observational Study in the Quebec Population

• Presenting Author: Jason Guertin, University of Montreal
• Co-authors: Marc Dorais, Dr. Alexis Matteau, and Dr. Jacques LeLorier, University of Montreal; Luc Sauriol, sanofi-aventis

Background: Pharmacological innovations in the medical treatment of atrial fibrillation (AF) have been absent in the last 15 years. Recently, dronedarone has been added to the pharmaceutical armamentarium of this very serious condition. A real life, population based, descriptive study of AF is thus of interest for the proper positioning of this drug by clinicians and drug plan managers.

Methods: A random sample of 66,540 patients (38%) first diagnosed with AF between January 1998 and April 2009 was obtained from the Régie de l’assurance maladie du Québec (RAMQ).

Results: Patient characteristics at the time of diagnosis and during the previous year were as follows: median (Q1; Q3): age: 77.5; chronic disease score: five (3; 8); days in the hospital 1 (0; 4); emergency room visits 2 (1; 3); outpatient visits 9 (5; 15). Main comorbidity conditions: angina pectoris 15%, Heart failure 16%, valvulopathy 6.5 %, and renal failure 4%. Mortality was 14% at one year and 36% at five years. During the year following the diagnosis of FA, 14% of the patients had an attempt at electric cardioversion and 25% were started on antiarrhythmic drugs: amiodarone (11.2%), sotalol (9.8%), propafenone (4.6%), and flecainide (1.2%). Only flecainide is approved by Health Canada for the treatment of AF.

Conclusions: At the time of the diagnosis of AF, most patients are already quite old and sick, which renders them vulnerable to the significant side effects of the drugs presently available for their treatment.

Bridging Health Technology Assessment with Multi-criteria Decision Analyses: Field Testing of the EVIDEM Framework to Support Coverage Decision for Tramadol by a Public Health Plan in Canada

• Presenting Author: Dr. Donna Rindress, BioMedCom Consultants Inc.
• Co-authors: Dr. Mireille Goetghebeur, Michele Tony, Dr. Monika Wagner, and Dr. Hanane Khoury, BioMedCom Consultants Inc.;'Dr. Paul Oh, Toronto Rehabilitation Institute

Objectives: To field test the EVIDEM framework, applying multi-criteria decision analyses (MCDA) to support health care decision-making with a public health care payer in Canada.

Methods: Tramadol for chronic non-cancer pain was selected as a relevant case study for a public health care payer in Canada. The framework included an MCDA matrix comprised of 15 quantifiable components of decision, organized into six domains; and a qualitative tool including six non-quantifiable components of decision. An extensive review of the literature was performed to develop a report tailored to investigate each component of decision. Data from the public domain and from the public payer were collected, analyzed, and synthesized.

Results: The framework included synthesized data on the severity of chronic non-cancer pain and the population size affected, clinical guidelines and limitations of current interventions, improvement of efficacy, effectiveness, safety, and patient reported outcomes with tramadol, as well as the type of benefit provided. Available clinical evidence was moderately relevant and valid. Economic data on the impact of tramadol on drug and other expenditures and its cost-effectiveness were limited. The framework also included data regarding ethical considerations (utility, efficiency, and fairness), system capacity and risk of inappropriate use, potential stakeholder pressures, and political and historical contexts. Beta testing to compare this approach with the current decision-making process of the health care payer will be discussed.

Conclusions: The framework allows transparent consideration of all components of decision and underlying evidence. Further testing and validation is needed to develop MCDA approaches in health care decision-making.

Budget Allocation and the Revealed Social Rate of Time Preference for Health

• Presenting Author: Mike Paulden, Toronto Health Economics and Technology Assessment (THETA) Collaborative
• Co-author: Karl Claxton, Centre for Health Economics, University of York

Appropriate decisions based on cost-effectiveness evaluations of health care technologies depend upon the cost-effectiveness threshold and its rate of growth, as well as upon some social time preference rate for health. A social decision-making approach is developed, which demonstrates that social time preference for health is revealed through the budget allocations made by a socially legitimate higher authority. The relationship between the social time preference rate for health, the growth rate of the cost-effectiveness threshold, and the rate at which the higher authority can borrow or invest is then examined.

We establish that the social time preference rate for health is implied by the budget allocation and the health production functions in each period. As such, the social time preference rate for health depends not on the social time preference rate for consumption or growth in the consumption value of health, but on growth in the cost-effectiveness threshold and the rate at which the higher authority can save or borrow between periods. The implications for discounting, and the policies of bodies such as the National Institute for Health and Clinical Excellence are then discussed.

Buy, Replace, Decommission, or Maintain Status? How Manitoba Sorts Through Some Health Technology Decisions

• Presenting Author: Kimi Guilbert, Manitoba Oncology Drug Program; Donna Champagne, Canadian Agency for Drugs and Technologies in Health (CADTH)
• Co-authors: Teresa Mrozek, Manitoba Health and Healthy Living

With an ever-expanding catalogue of health technology potentials, replacement or change decisions can be very complex. Some of the complexity can be managed with good planning tools. Manitoba is a province with a diverse population spanning a large geographical area, with Regional Health Authorities tasked with service delivery, funded by Manitoba Health and Healthy Living located in Winnipeg, and with many of the complex services delivered for the province in Winnipeg, a city which contains half of Manitoba’s one million plus population.

In Manitoba there are specialized committees that have the job to prioritize technology purchase and replacement requests. These decisions are complex and require a delicate balance between funding those that are high priority for the province as a whole, as in urban locations, and providing safe and continued service throughout the province so the population will have access to appropriate services as close to home as is reasonable and possible.

Planned implementation and decommissioning can benefit financial planning and provide lead time for appropriate technology assessment. Knowing which technologies have had their expected benefits and should continue to be provided helps in this delicate balance between new, replacement, continuance, and discontinuance. This presentation will describe some of Manitoba’s processes for technology investment, some gaps and methods that will attempt to rectify the gaps, and it will provide a forum for open discussion for addressing these gaps.

The Café Scientifique Approach to Knowledge Exchange: Using Café Culture to Share Evidence and Engage Audiences

• Presenting Author: Kristen Chelak, Canadian Agency for Drugs and Technologies in Health (CADTH)
• Co-authors: Bill Leslie, Heidi Staples, Janet Crain, and Lisa Farrell, Canadian Agency for Drugs and Technologies in Health (CADTH)

Introduction: Based on the experience of the Canadian Agency for Drugs and Technologies in Health (CADTH), this presentation will illustrate the opportunities, challenges, and results achieved by using the Café Scientifique discussion forum as a platform for knowledge exchange. A Café Scientifique is an intimate gathering where the public participates in an informal conversation about health and science issues.

Methods: In collaboration with partnering organizations and a professional facilitator, CADTH hosted two Café Scientifique events on the role of self-monitoring of blood glucose (SMBG) in the self-management of diabetes (one for health care professionals, and one for patients and the general public). The events began with an expert panel (family physician, endocrinologist, and an expert in behaviour change) discussing the current practice of SMBG and the evidence behind it. Questions from the audience then triggered an interactive discussion on the topic. Outcomes, including the participants’ intention to change practice or behaviour following the event, were measured using evaluation forms.

Results: The Café Scientifique was a successful method of putting knowledge exchange into action. Debate was opened to a broad audience and attendees had the opportunity to engage in a meaningful dialogue. The café also placed the evidence in a larger framework that went beyond the scientific results to include the larger societal and economic issues around the management of finite health resources.

Conclusion: This presentation will explore how this approach to knowledge exchange was used to disseminate evidence and promote discussion among key audiences, including practitioners and patients.

Capacity, Capabilities, and Confusion in Canada: Fault Lines of H1N1 2009 Pandemic Policies and Practices

• Presenting Author: Dr. Janice Graham, Dalhousie University
• Co-authors: Farah Huzair and Amrita Mishra, Dalhousie University

The new 21^st century vaccines present novel technical, social, and ethical challenges. The current regulatory framework is confronted by emergent biotherapeutic products, technologies, techniques, and citizen engagement that did not exist when many of the current regulations were first developed. The evolving science of vaccine discovery, global bioethics, and the social and governance implications for individuals and societies play out in public health policy and its translation. The H1N1 2009 pandemic called for a systematic response and comprehensive policy approach to the expected crisis and the anticipated rise in casualties during the fall and winter flu season. This poster provides a preliminary assessment of the effectiveness of the policies in place, and in transition and translation during 2009. In particular, this account will provide an assessment of Canadian health care systems in terms of capacity (physical resources) and capability (human resources), and their ability to support infrastructure and policy to adapt and respond (dynamic capabilities) during a pandemic. If improvement in capacities and capabilities is brought about in two ways, by increasing available resources through prevention of disease (e.g., vaccination) and by more effective management of resources during pandemic conditions, how did Canada do? This qualitative assessment of the implementation, formation, and adaptation of policy will include a series of recommendations that will serve as a “lessons learned” analysis in preparation for future pandemics.

CARESS: The Canadian Registry of Synagis

• Presenting Author: Abby Li, Medical Outcomes and Research in Economics (MORE) Research Group
• Co-authors: Dr. Krista Lanctôt, Medical Outcomes and Research in Economics (MORE) Research Group; Dr. Bosco Paes, McMaster University; Dr. Ian Mitchell, University of Calgary

Background: To determine the usage of palivizumab prophylaxis in children at high risk of RSV infection in Canada.

Methods: A prospective, observational, registry of infants across 26 sites, who received at least one dose of palivizumab during the 2006 to 2009 RSV seasons. Data on palivizumab utilization and compliance, including outcomes related to a respiratory infection, were collected monthly until the full course of palivizumab was completed.

Results: A total of 4,926 infants were enrolled, age two days old to 47 months old (mean = 5.4 months). In total, 57.1% were male, 71.5% Caucasian, and the average gestational age was 32.2 ± 5.4 completed weeks. Of the infants, 3,480 (70.6%) received palivizumab for prematurity only (i.e., ≤ 35 completed weeks gestational age), 397 (8.1%) required oxygen, 468 (9.5%) had congenital heart disease, and 572 (11.6%) were prophylaxed for other risk factors, such as CNS disorders, airway anomalies, and cystic fibrosis. Patients received an average of 3.7 ± 1.5 injections, with 17,909 doses given overall. Only 6.2% of patients withdrew. Zero (0) serious adverse event was deemed “possibly related” to palivizumab. A total of 296 infants had 351 hospitalizations for respiratory tract infections (hospitalization rate = 6.0%), and there were significant differences between indications (chi-square = 32.7, P < 0.005). The RSV-positive hospitalization rate was 1.1%.

Conclusions: The RSV hospitalization rate observed in the 2006 to 2009 RSV seasons was lower than that found in several published reports (range 1.3% to 5.3%). The rates of RSV hospitalization may be decreasing for various reasons, such as high compliance with palivizumab prophylaxis, variability in RSV epidemiology, hospital admission criteria, and preventive education.

Challenges in Assessing Cost-Effectiveness of Therapies for Dialysis Patients: A Case Study of Sevelamer for the Treatment of Hyperphosphatemia

• Presenting Author: Daniel Grima, Cornerstone Research Group Inc.
• Co-authors: Dr. David Mendelssohn, Humber River Regional Hospital; Dr. Parisa Airia and Lisa Barnard, Cornerstone Research Group Inc.; Elizabeth Dunn, Genzyme Corporation

Objective: Therapies that extend the lives of dialysis patients can’t be cost-effective if dialysis costs are included. This study examined the cost-effectiveness of sevelamer treatment for hyperphosphatemia in dialysis patients and within this context the suitability of the inclusion of dialysis costs.

Methods: A Markov model estimated life-years, incremental cost per life-year (LY) gained and quality-adjusted life-year (QALY) gained. Treatment-specific survival was derived from the Dialysis Clinical Outcomes Revisited (DCOR) study and extrapolated using a Weibull regression model. The base-case analysis used resource use and survival data for DCOR patients ≥ 65 years, combined with Canadian unit costs and utility weights from published literature. Dialysis costs were excluded from the base case as dialysis use is unrelated to phosphate binder choice. Analyses were conducted for a 10-year time horizon using the Alberta Health Care System perspective with costs and outcomes discounted at 5% per year.

Results: Compared with calcium-based binders (CBBs), sevelamer resulted in a gain of 1.02 LYs and 0.62 QALYs per patient (discounted) producing ratios of $20,847 per LY gained and $34,175 per QALY gained. Over a lifetime horizon, the cost per LY gained and cost per QALY gained were $23,804 and $39,022 respectively. Inclusion of dialysis costs resulted in ratios above $90,000 per LY gained and $150,000 per QALY gained.

Conclusions: The study highlights the challenge with assessing funding of therapies that extend life in dialysis patients and discusses the applicability of dialysis costs in such situations. It found that sevelamer offers good value for money compared with CBBs in the management of hyperphosphatemia in patients ≥ 65 years old with end-stage renal disease.

Clinical Benefits and Economic Impact of Surgical Pharmacists at Capital Health: Preliminary Results

• Presenting Author: Heather Lummis, Capital Health
• Co-authors: Bernadette Chevalier, Dr. Kathryn Slayter, Dr. Christopher Daley, and Lisa Nodwell, Capital Health

Clinical pharmacists improve the quality of patient care by reducing adverse drug events (ADEs), length of stay, and mortality. This impact has been inadequately evaluated in specialty areas such as surgery. Two clinical pharmacist positions were added to a general surgery service in September 2008. The objectives were to evaluate the impact of pharmacists on processes of care, and clinical and economic outcomes. This was a prospective, six-month observational study of a 50-bed surgery service. All clinical activities, including patient interventions and resolution of drug-related problems were documented. Interventions were rated for severity, value, and probability of preventing an ADE. Cost savings (direct costs) and cost avoidance (indirect costs) were estimated. Cost avoidance was calculated using two methods from the literature, either by avoiding 4.6 days of additional hospital stay ($3,593 per ADE) or additional hospital costs ($8,187 per ADE). Two investigators independently categorized the interventions; disagreements were resolved by consensus. In the first four months, there were 790 interventions (mean 5.1 interventions per day) of which 64% were of moderate to high significance. It was estimated that 54% of interventions had a 40% to 60% probability of preventing an ADE. Pharmacists also performed 232 medication reconciliations, made 252 telephone calls to community pharmacies, counselled 207 patients on 847 medications, and attended 133 patient care rounds. Cost savings were calculated to be $15,425 (mean $3,856 per month). The mean cost avoidance per intervention ranged from $654 to $1,490. These preliminary results indicate that pharmacists have made a substantial clinical impact on a surgical service in the first four months.

Cost Analysis of Psychotropic Usage in Ontario Long-Term Care Residences: Effect of Memantine Therapy

• Presenting Author: Kelly Smart, Medical Outcomes and Research in Economics (MORE) Research Group
• Co-authors: Dr. Krista Lanctôt and Dr. Nathan Herrmann, Sunnybrook Health Sciences Centre; Dr. David Conn, Baycrest; Dr. Goran Eryavec, North York General Hospital

Objectives: To determine the proportion of patients on psychotropic medications and characterize the cost impact from the payer’s perspective of hypothetical memantine initiation in the Ontario long-term care population.

Methods: A retrospective chart review was conducted at three long-term care institutions in Toronto. Patients with diagnoses of dementia, Alzheimer disease (AD), or mixed dementia (AD+ vascular dementia) were included in a drug utilization review and their scheduled and as needed (PRN) psychotropic medications, doses, and frequencies were obtained. Psychotropic medication costs were obtained from the Ontario Drug Benefit (ODB) Formulary Index Edition 41 in 2009 C$. Memantine was shown by Vidal et al. (2008) to be associated with a decrease in antipsychotic medication use. Cost changes following memantine initiation were calculated assuming the same effectiveness.

Results: Of 1,082 charts screened, 417 patients (177 male and 240 female; mean age 87.6 ± 5.8) met inclusion criteria. There were 263 patients (63.1%) using the target medications (antidepressants [44.8%], antipsychotics [29.5%], benzodiazepines/anxiolytics [12.7%]). Many patients also received a cholinesterase inhibitor (47.0%), which was included in the costs. Mean medication cost for all patients was initially $2.65 per day and was expected to reach $4.21 per day under the no memantine scenario after two years. With memantine (mean dose 17.0 ± 4.7 mg, $4.11 per day), costs increased to $5.45 per day initially then decreased to $4.03 per day at two years. Cost savings associated with decreased usage of psychotropic medications offset the cost of memantine by 106.5%, resulting in a net cost savings.

Conclusion: Decreased overall use of psychotropic medications among long-term care residents may attenuate the cost increase associated with the addition of memantine.

Cost-Effectiveness of Bariatric Surgical Procedures versus No Treatment for Morbid Obesity

• Presenting Author: Anjori Pasricha, Programs for Assessment of Technology in Health (PATH) Research Institute, McMaster University
• Co-authors: Dr. Daria O’Reilly, Ron Goeree, Dr. Jean-Eric Tarride, and Gord Blackhouse, McMaster University

Background: Obesity is a global epidemic, and obesity-related comorbidities pose health risks alongside placing financial burden on the health care system. Bariatric surgery has been shown to reduce weight, improve quality of life, and reduce morbidity for morbidly obese individuals.

Objective: To assess the cost-effectiveness and cost utility of bariatric surgery (gastric bypass [GB] and laparoscopic adjustable gastric banding [LAGB] procedures) versus no treatment for morbidly obese patients (body mass index ³ 40 kg/m²).

Methods: A combined (decision tree and Markov) model was developed to compare the costs and outcomes of bariatric surgery with no treatment for morbid obesity over a 15-year time horizon. This evaluation was conducted from the perspective of the Ontario Ministry of Health and Long-Term Care. Data on body mass index reduction, post-operative complications and mortality, costs of disease management, and health-related quality of life were used based on a literature review of national and international sources. Univariate and probabilistic sensitivity analyses were conducted.

Results: In the base-case analysis, GB dominated LAGB and no treatment (cheaper and more effective in terms of life-years (LYs) gained and quality-adjusted life-years (QALYs) gained). Univariate and probabilistic sensitivity analyses varying important model parameters, such as treatment costs, probability of complications, and utility estimates did not impact this conclusion, showing that the economic model is robust in nature.

Conclusion: This evaluation showed that GB is the cheapest and most effective strategy for morbidly obese individuals in terms of cost per LY gained and cost per QALY gained.

The Cost-Effectiveness of Bevacizumab as a First- and Second-Line Treatment for Advanced Colorectal Cancer: A Post-Market Study of Eras of Treatment

• Presenting Author: Lindsay Hedden, Cancer Control Research, BC Cancer Agency
• Co-authors: Dr. Stuart Peacock, Dr. Diego Villa, and Dr. Hagen Kennecke, BC Cancer Agency

Objective: We estimated the incremental cost-effectiveness of the use bevacizumab for treating advanced colorectal cancer as part of a larger program of research examining methods for improving the integration of cost-effectiveness evidence into allocation decision-making at the BC Cancer Agency (BCCA).

Methods: We constructed a clinical Markov model for advanced colorectal cancer, populated with survival data from a cohort of patients treated before and after the introduction of bevacizumab; treatment costs from the BCCA pharmacy and radiotherapy departments, and the Ontario Case Costing Initiative; and quality of life values from the literature. Probabilistic and one-way sensitivity analyses were conducted to test the robustness of the model. The cost-effectiveness results generated by the model were used to evaluate the impact of the BCCA’s decision to fund bevacizumab.

Results: Median survival improved from 15.56 months before the introduction of bevacizumab to 19.45 months following its introduction (P value = 0.03), at a cost of $3,791 per patient. Cost-effectiveness of the era of treatment following the introduction of bevacizumab compared with the era before its introduction is $62,468 per quality-adjusted life-year (QALY) gained. Probabilistic sensitivity analyses produced an inter-quartile range of $38,900 to $85,800 per QALY. The model was sensitive to the cost of systemic therapy treatment.

Conclusion: Pre-market studies have demonstrated that treatment with bevacizumab may not be cost-effective. This work has shown, however, that when considered as one element in a suite of systemic therapy treatments, the cost-effectiveness of bevacizumab is in the same range as other treatments for metastatic cancers.

Cost-Effectiveness of Screening Immigrants to Canada for Hepatitis B

• Presenting Author: Dr. William Wong, Toronto Health Economics and Technology Assessment (THETA) Collaborative, and the University Health Network (UHN)
• Co-authors: Dr. Murray Krahn, Department of Medicine and Faculty of Pharmacy, University of Toronto; Dr. Jenny Heathcote, Faculty of Medicine, University of Toronto

Background: The prevalence of chronic hepatitis B (CHB) infection among immigrants to Canada ranges from 2% to 15%. Approximately 40% of those with CHB develop advanced liver disease, which puts them at risk of dying of the complications of cirrhosis if left untreated. Thus, both the health and economic burden of CHB in Canada is considerable. Currently, serological screening for CHB is not routinely conducted in immigrants.

Method: We developed a Markov simulation model of CHB to evaluate the economic and clinical consequences of screening immigrants for hepatitis B virus (HBV). Health states that include serology (HBsAg, HBeAg), inflammation (ALT), viral load, and clinical states (cirrhosis, HCC, etc.), were incorporated into the model. The Canadian health care costs applied in the simulation model were collected from the literature. Our utility data (n = 433) of patients across different CHB health states were used. A probabilistic sensitivity analysis was conducted.

Results: The overall estimated prevalence of CHB infection among immigrants is 4.8%. The overall estimated immunization coverage of HBV among immigrants is 3.04%. HBV screening was associated with an increase in life-years (0.3658 years) and cost ($40.37) when compared with no screening for all immigrants. Although the final cost-effectiveness results are still pending, preliminary findings suggest that screening of immigrants to Canada is cost-effective, particularly in immigrants from countries where hepatitis B is highly endemic, and screening for CHB has the potential to substantially reduce the late complications of CHB and improve the survival of chronically infected individuals.

A Cost-Minimization Analysis of Sentinel Lymph Node Biopsy (SLNB) and Axillary Lymph Node Dissection (ALND) in Ontario

• Presenting Author: Dr. Bryan Wells, Department of Surgery, University of Toronto
• Co-authors: Dr. Peter Coyte, University of Toronto; Dr. May Lynn Quan, University of Calgary

Sentinel lymph node biopsy (SLNB) has emerged as the standard of care for axillary staging in patients with early-stage breast cancer (ESBC). SLNB is less morbid, but as effective as the default procedure of axillary lymph node dissection (ALND). SLNB adoption in Ontario hospitals has lagged however, in part because of the initial costs and the higher (perceived) total costs of SLNB implementation. The research purpose was, with a view toward informing policy, to compare the in-hospital Ontario-based costs of SLNB and ALND in the setting of ESBC. A cost-minimization analysis (CMA) was completed, using a decision-analysis model of Markov states embedded within a decision tree. The results of a literature review yielded realistic SLNB and ALND-associated clinical pathways and estimates of the risk of post-operative complications. Cost data were gathered from the publicly accessible Ontario Case Costing Initiative database. SLNB proved to be the cost-minimizing option. The probabilistic sensitivity analysis revealed a mean SLNB cost of $3,321.18  (95% CI $2,266.27 to $4,723.59) versus a mean ALND cost of $3,837.86 ($2,491.62 to $5,739.36). Complication-related costs were non-contributory; whereas, the results were highly sensitive to procedure-related differences in hospital length-of-stay. The implications are that cost, at the hospital level, should not be a strict barrier to SLNB implementation in Ontario. This CMA is novel in that it uses Ontario-specific case-costing data and incorporates SLNB and ALND-related complications into the decision analysis. The results could be used within a broader resource allocation model to help formulate policy to improve the dissemination of SLNB across Ontario.

Cost Utility of Intravenous Immunoglobulin (IVIG) for the Treatment of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)

• Presenting Author: Gord Blackhouse, Programs for Assessment of Technology in Health (PATH)
• Co-authors: Kathryn Gaebel, Programs for Assessment of Technology in Health (PATH), McMaster University and St. Joseph's Healthcare; Dr. Feng Xie, Kaitryn Campbell, Diana Robertson, Ron Goeree and Dr. Nazilla Assasi, Programs for Assessment of Technology in Health (PATH), McMaster University; Dr. Colin Chalk, Montreal General Hospital; Dr. Mitchell Levine, St Joseph’s Healthcare

Objectives: Intravenous immunoglobulin (IVIG) has demonstrated improvement in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) in placebo controlled trials. However, IVIG is also much more expensive than alternative treatments such as corticosteroids. The objective of this study is to evaluate, from a Canadian perspective, the cost utility of IVIG compared with corticosteroid treatment of CIDP.

Methods: A Markov model was used to evaluate the costs and quality-adjusted life-years (QALYs) for IVIG and corticosteroids during five years of treatment for CIDP. Patients initially responding to IVIG could remain a responder or relapse every 12-week model cycle. Non-responding IVIG patients were assumed to be switched to corticosteroids. Patients on corticosteroids were at risk for a number of adverse events (fracture, diabetes, glaucoma, cataract, serious infection) each cycle. The probabilities of initial IVIG response (0.47), IVIG relapse (0.065 every three months), and steroid-related adverse events were derived from published literature. The frequency and dose of IVIG initiation and maintenance therapy was based upon those recommended in product monographs.

Results: During the five-year time horizon, the model estimated the incremental costs and QALYs of IVIG treatment compared with corticosteroid treatment to be $105,356 and $0.188 respectively. The incremental cost per QALY gained of IVIG was estimated to be $551,031. The cost per QALY of IVIG was sensitive to the assumption of frequency and dosing of maintenance IVIG.

Conclusions: Based on common willingness-to-pay thresholds, IVIG would not be perceived as a cost-effective treatment for CIDP.

The Costs Associated with a Seniors Injurious Fall

• Presenting Author: John Woolcott, Faculty of Pharmaceutical Sciences, University of British Columbia
• Co-authors: Dr. Karim Khan, Department of Family Practice, University of British Columbia; Dr. Aslalm Anis, School of Population and Public Health, University of British Columbia; Dr. Carlo Marra, Faculty of Pharmaceutical Sciences, University of British Columbia

Objectives: Falls among seniors are the primary cause of injury-related hospitalizations, with more than one third of seniors suffering a fall each year. Previous Canadian estimates of the costs of seniors’ falls were based upon administrative data, which have been shown to underestimate the incidence of falls. Our study prospectively collected information on seniors who fell who presented to an emergency department (ED) to estimate the costs of injurious falls from the health provider perspective.

Methodology: This analysis prospectively collected data from seniors (> 70 years) presenting to the Vancouver General Hospital ED due to a fall. We excluded individuals who where cognitively impaired or unable to read or write English. Data were collected on the care provided, including physician or specialist assessments and consultations, ED or hospital time, in-hospital procedures, and all radiology and laboratory tests. Unit costs of health resources were taken from a fully allocated hospital cost model.

Results: Data were collected on 100 fall-related ED presentations. The most common diagnosis was hip fracture (N = 16), followed by upper body fracture (n = 12), and laceration (n = 11). Of those who fell, 38 had injuries requiring hospital admission, with an average length of stay of 40 days (median 29 days, range two to 143 days). For those individuals discharged to the community (n = 62), the average cost was $648 (median $780, range $51 to $1,670). Individuals with injuries requiring hospital admission represented an average cost of $27,414 (median $25,755, range $2,198 to $87,220).  

Conclusion: Among the growing population of Canadian seniors, falls have substantial costs. The cost of a fall-related hospitalization exceeds $27,000, highlighting the need for increased investigation into fall prevention and reduction of fall risk.

Da Vinci robot-assisted surgery in oncological gynecology

• Presenting Author:  Dr. Luigi Lapanto, Centre hospitalier de l'Université de Montréal
• Co-author: Dr. Mouhcine Nassef, Centre hospitalier de l'Université de Montréal

Background: The da Vinci robotic surgical system is increasingly used by surgeons in various specialities, particularly in gynecology.

Objectives: To evaluate the clinical effectiveness, safety, and efficiency of the da Vinci surgical system in oncological gynecology in comparison with laparoscopy and laparotomy.

Approach: The clinical effectiveness and cost data related to the use of the da Vinci surgical system in oncological gynecology stem from a series of studies that were published on the topic.

Results:  Lacking randomized trials and economic analyses, the results of this study are based on a case series. The studies identified showed that the clinical effectiveness of robotic surgery is clearly superior to that of laparotomy for indications such as endometrial cancer and cervical cancer. Using the da Vinci surgical system reduces the average hospital stay from five days to one day, cuts the average volume of blood lost from 300 ml to 100 ml, and reduces the number of blood transfusions by half. However, there is no significant difference between robot-assisted surgery and laparoscopy. Robot-assisted surgery is more expensive than laparotomy. On average, a robot-assisted myomectomy costs US $18,000 more than a laparotomic myomectomy.

Conclusion: The da Vinci surgical system offers advantages for clinicians (in terms of visualization of the surgical site and ergonomics). Patients benefit from shorter hospital stays and fewer intra- and post-operative complications. Nevertheless, the high cost of robotic surgical systems is a substantial purchase barrier, especially lacking evidence regarding their effectiveness, safety, and efficiency.

Developing a Clinical Policy Model for Pressure Ulcer Prevention in Ontario: A Case Study

• Presenting Author: Ba’ Pham and Dr. Murray Krahn, Toronto Health Economics and Technology Assessment (THETA) Collaborative
• Co-authors: Nancy Sikich, Ontario Ministry of Health and Long-Term Care; Anita Stern, Toronto Health Economics and Technology Assessment (THETA) Collaborative

Purpose: We developed a clinical policy model for pressure ulcer (PrU) prevention in Ontario.

Methods: We conducted telephone surveys of directors of long-term care (LTC) homes and wound specialists in acute-care (AC) hospitals regarding current prevention practice. Systematic reviews of preventive interventions were conducted by the Medical Advisory Secretariat at the Ontario Ministry of Health and Long-Term Care, including grading of the evidence. We formulated a comprehensive history model of PrUs with input from an expert panel convened by the Ontario Health Technology Advisory Committee (OHTAC). Data sources included the Resident-Assessment Instrument – Minimum Data Sets for LTC and home care (HC), and annual surveys of PrU prevalence and incidence in AC hospitals. We used jurisdiction specific data for costs and utilities. The PrU history model was calibrated to reflect the PrU epidemiology in AC, LTC, and HC. The model was used to address policy concerns put forward by OHTAC. We derived expected cost-effectiveness estimates, explored sources of uncertainty, and estimated aggregated costs and quality-adjusted life-years and implementation costs to the Ontario health care system.

Results: We obtained three sets of projections regarding clinical consequences, cost-effectiveness, and health system implications of prevention strategies for AC, LTC, and HC. The evidence-based prevention strategies were endorsed for specific recommendations by OHTAC. OHTAC commissioned additional clinical studies to address uncertainties in key areas identified in the projection.

Conclusion: Published cost-effectiveness studies conducted in a milieu divorced from the complexities of health systems cannot drive policy development. Robust and jurisdiction-specific cost-effectiveness analyses facilitate policy recommendations.

Disparity in Prevalence of Hypertension among Social Districts of Different Income Levels — A Population-Based Study

• Presenting Author: Dr. Mingfu Liu, Alberta Health Services
• Co-authors: Dr. Stafford Dean and Ceris Bird, Alberta Health Services; Dr. Hude Quan and Dr. Nathalie Jetté, University of Calgary

Hypertension is a cardiac condition that can lead to coronary artery disease, cognitive heart failure, and stroke; it can therefore be considered a burden on health service utilization. The objective of this study was to investigate the disparity in prevalence of hypertension among social districts of different income levels in a large population.

The study population included Calgary Health Region residents, 35 years and older, from fiscal years 1996 to 1997 and 2002 to 2003. Patients with hypertension in Physician Claims and Inpatient Discharge Abstract databases were identified using ICD-9-CM codes (401.x, 402.x , 403x, 404.x , 405.x) and ICD-10-CA codes (I10.x, I11.x, I12.x, I13.x, I15.x). Several case definitions were used in a larger study. For this report of disparity, one year one claim rule was used for fiscal year 2002.  

There was apparent disparity in crude prevalence of hypertension among social districts with an extremal quotient of 1.65 (%33.49/%20.29). After age and gender standardization, the extremal quotient remained 1.38 (%30.82/%22.22). GIS maps showed an east to west decreasing pattern in hypertension among social districts. The disparity in median family income, based on the 2001 national census, was also significant with an extremal quotient of 2.35 ($109, 236.00/$46,518.00). At the community level, hypertension decreased as family income increased, and the relationship was close to statistical significance
(P = 0.0774).

This study showed that hypertension was more prevalent in economically disadvantaged communities. This finding will help us in planning and delivering health services to the communities to reach an economic optimization in health services.

Economic Evaluation of Rituximab in the First-Line Treatment of Chronic Lymphocytic Leukemia (CLL) in Canada

• Presenting Authors: Donna Lawrence, I3 Innovus
• Co-authors: Fakher Aissa, Hoffmann La-Roche, Canada; Rick Aultman and Dr. Emma Carr, Hoffmann La-Roche, Switzerland; Dr. Douglas Stewart, University of Calgary; Margaret Hux, I3 Innovus

Objective: Chronic lymphocytic leukemia (CLL) is the most common adult leukemia. Cost-effectiveness of rituximab combined with fludarabine and cyclophosphamide (R-FC) is compared with fludarabine and cyclophosphamide alone (FC), or with chlorambucil for first-line treatment of CLL.  

Methods: For patients with previously untreated CLL, R-FC cost-effectiveness to a Canadian health care system was compared with FC using a Markov model based on data of the CLL8 clinical trial. CLL8 reported 10.6 months additional progression-free survival (PFS) for R-FC (P <.001). Modelled analyses used trial information on chemotherapy drug use, PFS and survival, adverse events, resource utilization data for post-progression treatments, bone marrow transplants, and blood transfusions. Transitions to progression were based on a Weibull fit to PFS curves, and death post-progression was assumed equal in both arms. Health state utilities and unit prices for resources were obtained from published literature or standard Canadian sources. An evaluation of R-FC versus chlorambucil was based on an indirect comparison, using data from the CLL4 trial, in which significantly improved five-year PFS with FC compared with chlorambucil was found.

Results: During a lifetime horizon to a maximum 15 years, R-FC was associated with, on average, 8.6 additional quality-adjusted months and $20,234 in cost, resulting in $28,315 per quality-adjusted life-year (QALY) gained. An indirect comparison with chlorambucil found R-FC associated with a mean gain of 17.9 quality-adjusted months, resulting in $22,754 per QALY gained.

Conclusion: R-FC shows cost-effectiveness that is within commonly accepted cost per QALY thresholds in Canada compared with FC, and compared with chlorambucil.

The Effect of Provincial Reviews on Time to Reimbursement

• Presenting Author: George Wyatt, Wyatt Health Management

“The CDR [Common Drug Review] was set-up to reduce duplication, and provide equal access to high-level evidence and expert advice; thereby, contributing to the quality and sustainability of Canadian public drug plans.” Yet, several provinces continue to do their own reviews despite participating in the CDR. The presentation will detail the provincial reviews and show the effect of those review activities on time to reimbursement.

Emergency Physician Performed Ultrasonography

• Presenting Author: Gord Blackhouse, Programs for Assessment of Technology in Health (PATH), McMaster University
• Co-authors: Kellee Kaulback, Diana Robertson and Dr. Feng Xie, Programs for Assessment of Technology in Health (PATH), McMaster University; Kathryn Gaebel, Programs for Assessment of Technology in Health (PATH), McMaster University and St. Joseph's Healthcare

In the 2001 policy statement from the American College of Emergency Physicians, they considered a large number of conditions as primary indications for emergency ultrasonography (US). Early trials of US did not take place in emergency departments (EDs) and the US interpreter was not an emergency physician (EP).

Objective: The objective was to determine if there is evidence to evaluate whether US conducted by non-radiologists in a small ED is an effective diagnostic tool.

Methods: A systematic review was conducted to identify health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, and controlled clinical trials published in the last five years.

Results: The search identified nine trials and two systematic reviews. The primary indications in these reports were trauma, deep vein thrombosis, pain, undifferentiated hypotension, and US-guided procedures. Reports regarding US-guided procedures took place in small EDs and the success rates of US-guided cannulation were significantly larger compared with the traditional techniques. Sensitivity and specificity estimates for EP-performed US in the diagnosis of trauma, and deep vein thrombosis are high, and similar to those reported when radiologists interpreted the US scans. The addition of US in diagnosing pelvic pain increased physician confidence and was especially valuable in the evaluation of a patient who is also obese.

Conclusion: Diagnostic estimates obtained when EPs perform US are comparable with those obtained when the US was performed by a radiologist. US is an effective tool in the hands of EPs in EDs, both small and large.

Environmental Scanning: Informing Policy from the Roots Up

• Presenting Author: Andra Morrison, Canadian Agency for Drugs and Technologies in Health (CADTH)

Background: The Environmental Scanning Service keeps Canadian jurisdictions informed on the latest developments affecting health care. The service alerts decision-makers to new and emerging health technologies, and provides insight into upcoming health policy and practice issues.

Since its inception in 1997, the Environmental Scanning Service continues to evolve. Now, along with our usual array of informative products, we have launched our Environmental Scanning Briefs, which are intended to help decision-makers to anticipate, plan, and manage the introduction and diffusion of new technologies and policies.

Method: Our Environmental Scanning Briefs were developed in response to our stakeholders’ needs for timely pan-Canadian information, and/or international comparisons, on access to health services or technology, reimbursement, utilization, or current practice issues.

By proactively monitoring developments in the health care field, and cultivating relationships with an expanding network of connections (comprising clinical experts, decision-makers, health organizations, and industry), our environmental scans deliver timely information on emerging health care concerns.

Results: We have already produced four cutting-edge reports and are working on others. The four reports currently on our website include PET scanning in Canada (including the location and number of cyclotrons), future alternatives to Molybdenum-99 production for medical imaging, seasonal and H1N1 flu vaccination strategies, and carbon ion radiation therapy.

Other products under the Environmental Scanning Service umbrella include the Health Technology Update newsletter and Issues in Emerging Technologies bulletins.

Next Steps: As we continue to refine our environmental scanning process and build a strong network of key health care stakeholders, it is our aim to empower decision-makers with value-added information on real-time issues that impact the Canadian health care landscape.

Evaluation of Innovative Knowledge Translation Tools for Pharmacy Practice Research

• Presenting Author: Dr. Marie-Anik Gagné, Canadian Pharmacists Association (CPhA)
• Co-author: Kelly Hogan, Canadian Pharmacists Association (CPhA)

Background: The health and safety of populations can be improved by optimizing the use of medications and the roles played by health care providers. For this to occur, the gaps between research, policy, and practice must be reduced.

Purpose: Pharmacists are the third largest group of health care providers in Canada. Leading Canadian pharmacists have dedicated their careers to practice research that defines the most effective roles for pharmacists in improving population health outcomes. Knowledge Translation (KT) literature establishes that economic, human resource, health technology, and drug therapy decision-making processes depend on clear and concise research evidence that supports policy development.

Methods: The Canadian Pharmacists Association (CPhA) has launched two initiatives, the Translator and Live Links to support KT between pharmacy practice research and the health policy community. Each quarterly issue of the Translator selects four pharmacy practice research articles, summarizes them, and highlights the health policy implications. Live Links is a quarterly e-bulletin that summarizes current international pharmacy practice research. This tool provides access to relevant peer-reviewed research and grey literature.

Results: Evaluation of the utilization of Live Links and the Translator reveals that although reception of these knowledge tools is high, increases in the levels of utilization are desirable.

Discussion: To enhance our understanding of how we can improve utilization of these knowledge dissemination tools, we will conduct targeted interviews to determine user needs, and conduct further analysis of best practices for reaching our target audience.

Health Care Costs Associated with the Disease History of HPV Infection: Estimates from a Population-Based Study

• Presenting Authors: Orges Ormanidhi and Ba’ Pham, Toronto Health Economics and Technology Assessment (THETA) Collaborative
• Co-authors: Dr. Lawrence Paszat, Institute for Clinical Evaluative Sciences; Dr. Chris Bauch, University of Guelph; Dr. Murray Krahn, Toronto Health Economics and Technology Assessment (THETA) Collaborative

Background: Population-based cost estimates for input into disease history models of human papillomavirus (HPV) infection reflect real-world utilization of screening and treatment services. These estimates may increase the fidelity of mathematical models.

Objective: To estimate the total health care costs and costs attributable to HPV infection, cervical neoplasia, and cancer; and describe the cost of care across the disease continuum.

Methods: We estimated direct medical costs for women with stage-specific ICC, treatment for CIN2-3, and inferred HPV infection (HSIL, but no CIN2-3 treatment) in Ontario between 2000 and 2008, using linked administrative data. Attributable costs were estimated by comparing costs in cases to matched controls (identified by age, social economic status, and Charlson’s score). Observation time was divided into the following three phases: before diagnosis (six months before), biannual continuing care, and terminal care (six months before death). Specific cost estimates were derived for these three phases.

Results: Preliminary data suggest that cervical cancer is common among women who are seldom or never screened, and costs are increased over the natural history of the disease and are highest around two events, cancer diagnosis and cancer death.

Conclusion: Population-based estimates of health care costs increase the validity of our sexual network model to reliably estimate the efficiency gain between competing screening policies in the era of vaccination. They better capture the consequences related to the lack of adherence to screening and provide a better alternative to the conventional cost estimates derived through microcosting of procedures, services, and utilization, according to guideline recommendations.

Highlights from e-Therapeutics+ Delivered Via Email: What Are Their Perceived Relevance, Cognitive Impact, Use, and Benefit to Patient Care?

• Presenting Author: Barbara Jovaisas, Canadian Pharmacists Association
• Co-authors: Carol Repchinsky, Canadian Pharmacists Association; Dr. Pierre Pluye, Dr. Roland Grad, and Janique Johnson-Lafleur, McGill University

The Canadian Pharmacists Association (CPhA) publishes e-Therapeutics+, a regularly updated electronic information resource of evidence-based treatment recommendations, based on a reference text (Therapeutic Choices).

The objective of the study was to evaluate e-Therapeutics+ information delivered through email, using the Information Assessment Method (IAM). Each email delivered a succinct nugget of information called a ‘Highlight’, content selected from e-Therapeutics+.

The design was a web-based survey using a participatory approach. Participants were subscribers to
e-Therapeutics and/or CPhA members. From August to December 2008, 36 emails were delivered with a link to one highlight embedded within one related chapter in e-Therapeutics+. Participants were asked to rate highlights using IAM, a validated method for assessing four dimensions: relevance, cognitive impact, use, and expected health benefits of information. Outcome measures were IAM ratings and comments. During a 20-week period, 3,198 completed questionnaires were collected; 1,938 from community pharmacists (60.6%), 438 from hospital pharmacists (13.7%), 393 from pharmacy students (12.3%), and 429 from other health professionals (13.4%). Of the ratings, 74.4% indicated that e-Therapeutics highlights were relevant for a patient, 61% were used in a clinical context, and 51.1% could lead to perceived health benefits. IAM ratings of relevance, cognitive impact, use, and health benefit varied significantly by highlight. No single highlight rated highest on all four dimensions. Highlights with the lowest ratings also differed along these dimensions, with the exception of one highlight that scored lowest on all four dimensions. CPhA reviewed IAM-derived comments. This review led to changes to content in 15 cases. These changes consisted of adding a reference (N = 4), adding more content (N = 6), and improving the wording (N = 5). IAM-stimulated evaluation of therapeutic information delivered through email permits the identification of highlights with high versus low ratings, and leads to the improvement of content. e-Therapeutics+ was relevant and used for patient care. Readers believe the information delivered could benefit patient health.

How to Find Evidence for Decision-Making in Two Hours or Less!

• Presenting Author: Hayley Fitzsimmons, Canadian Agency for Drugs and Technologies in Health (CADTH)
• Co-authors: Emmanuel Nkansah, Carolyn Spry, Jessie Cunningham, and Ray Banks, Canadian Agency for Drugs and Technologies in Health (CADTH)

The Canadian Agency for Drugs and Technologies in Health (CADTH) has a rapid response program (Health Technology Inquiry Service [HTIS]) that supplies available evidence for informed decision-making to Canadian health care providers. Products range from a reference list to a detailed assessment of the best evidence-based information on a topic. Reference lists (bibliographies categorized by higher quality of evidence) are the HTIS product with the fastest turnaround time and can be completed in a few days. Increasingly the HTIS service is receiving ultra-urgent requests for information, often needed in a matter of hours. To meet this need, Information Specialists evaluated their current list of approximately fifty websites to determine the top twelve.

Objective(s): To evaluate which of the approximately fifty websites regularly searched for CADTH rapid response requests are most likely to produce a wide variety of good quality evidence and are therefore suitable for extremely urgent same-day requests for information.

Methods: A random sample of twenty HTIS reports from 2008 to 2009 was analyzed to determine which websites were searched in order to identify the reports or articles included in the final HTIS report. A list of the most commonly used websites was generated and ranked according to frequency of use. Information Specialists were also asked to highlight the top twelve websites that they felt to be the most valuable for finding information for rapid review requests. Websites chosen as useful by Information Specialists were given extra weight in the original ranked list of websites identified in the random sample.

Results: PubMed was used to retrieve articles included in 90% of the HTIS reports surveyed and was also ranked as the most valuable site by Information Specialists. The complete list of the top twelve websites identified are as follows: databases (PubMed, Centre for Reviews and Dissemination, The Cochrane Library, and TRIP), health technology assessment agencies (AHRQ, ANZHSN, NICE, and ICSI), and guideline repositories (NGC, CMA Infobase, Aetna, and SIGN).

Conclusions: Urgent requests for evidence supporting health technology decisions do not have the time available for comprehensive searches. Information Specialists have ranked the top 12 websites proven to be the most valuable in past rapid response reviews to help support extremely urgent same-day requests for information.

Identification and Testing of Tools for the Classification of Study Designs in Systematic Reviews of Interventions and Exposures

• Presenting Author: Kenneth Bond, Alberta Research Centre for Health Evidence
• Co-authors: Lisa Hartling, Alberta Research Centre for Health Evidence; Dr. Meera Viswanathan, UNC-RTI Evidence-Based Practice Center; Dr. Lina Santaguida, McMaster University Evidence-Based Practice Center; Dr. Donna Dryden, University of Alberta Evidence-Based Practice Center

Background: The appropriate classification of study designs is essential in systematic reviews to guide decisions around inclusion, risk of bias assessments, pooling of studies, and interpretation of the evidence. 

Objectives: To identify tools used to classify study designs, select a single tool for evaluation, develop guidelines for application of the tool, and test the tool for concurrent validity and inter-rater reliability.

Methods: A steering committee developed and applied criteria to select one classification tool from a sample of tools identified by key informants. The selected tool was modified and accompanying glossary and guidelines were developed. Three members of the steering committee classified 30 studies representing all considered designs (reference standard). Six reviewers, varying in training and experience, independently applied the tool to the same 30 studies. Inter-rater reliability and accuracy against the reference standard were measured.

Results: Initial reliability was fair among testers (κ = 0.26) and reference standard raters (κ = 0.33). Testing following revisions showed improved reliability (κ = 0.45) with improved, but still low, accuracy. The most common disagreements were whether the study design was experimental (five of 15 studies) and whether there was a comparison of any kind (four of 15 studies). Agreement was higher among testers with graduate degrees versus those without.

Conclusion: The moderate reliability and low accuracy may be due to lack of clarity and comprehensiveness of the tool, inadequate reporting of the studies, and variability in user characteristics. Application of such a tool should be accompanied by training, pilot testing, and context-specific decision rules.

Increasing Drug Costs: Comparing the Money Funding and Spending Avenues in Pharmaceutical R&D in Canada and Other Major Countries

• Presenting Author: Tenneille Loo, University of Toronto
• Co-author: Dr. Paul Grootendorst, University of Toronto

Introduction: By contrasting the exponential rise in pharmaceutical research and development (R&D) expenditures with the stagnant numbers of new chemical entities submitted to the Food and Drug Administration, studies have illuminated an alarming trend that threatens the future of health care and the pharmaceutical industry.

Objective: To evaluate the key parameters affecting spending and funding patterns through the development of a novel method by estimating the breakdown of funding sources (government and industry) and spending avenues (clinical and basic research) in pharmaceutical R&D. To investigate additional topics affecting Canada's R&D: the nature of public and private scientific partnerships, US legislation on intellectual property, and the concept of “innovation.”

Modelling Methods: The sample frame was obtained from an OECD database where the purchasing power of parity and uniform dollars were accounted for between countries (Canada, US, Europe, and Japan), for the years 1991 to 1996 and 2001 to 2006.

Results: Globally, the US overtakes Europe in overall spending; the US has more R&D funding from the industry sector than the government (unlike Europe); and overall, more money is spent in clinical research by all countries. Compared with the other countries, Canada lags significantly in all areas, has a smaller disparity between public and private funding, and has experienced a small growth.

Conclusions: Canada's technology transfer initiatives, promotion of innovation, and private and public partnerships are beginning to create a favourable environment for industrial growth. However, since Canada is similar to the US in commercialization environments and trends, Canada needs to develop clear policies on ownership and rights. Furthermore, based on Europe's success, it is theorized that increases in government funding could supplement investments by the industry. In addressing the challenges faced by Canadian policy-makers, this unique pharmacoeconomic analysis of the state of Canada's pharmaceutical R&D sector highlights the strategies that Canada needs to adopt to be more efficient and competitive.

Is Genetic Testing in Combination with Preventive Donepezil Treatment for Patients with Amnestic Mild Cognitive Impairment Cost-Effective in Canada?

• Presenting Author: Dr. Sandjar Djalalov, Centre for Research on Inner City Health (CRICH), St. Michael's Hospital
• Co-authors: Jean Yong and Dr. Gustavo Saposnik, Centre for Research on Inner City Health (CRICH); Zahra Musa, Cancer Care Ontario; Michael Mendelson, Caledon Institute of Social Policy

The presence of apolipoprotein e4 alleles (APOE e4) in patients with amnestic mild cognitive impairment (AMCI) is associated with a higher rate of progression to Alzheimer disease. Introducing genetic testing in combination with preventive treatment in these patients may prolong their time to progression of disease. This strategy is not the usual care in Canada, and understanding the cost-effectiveness of this strategy may be useful before introducing it into routine clinical practice.

The objective of this study is to compare the cost-effectiveness of APOE e4 testing in combination with donepezil preventive treatment to usual care in AMCI patients in Canada.

A decision tree was constructed to project the progression of AMCI patients to Alzheimer disease over three years, using effectiveness data from a randomized controlled trial of donepezil in AMCI patients. Resource use was based on treatment patterns in Canada, and the health state utilities were taken from published quality of life studies.

Genetic testing in combination with preventive donepezil treatment resulted in a gain of 0.003 quality-adjusted life-years at an additional cost of $700, when compared with usual care. The incremental cost-effectiveness ratio for the base case is $230,061 per quality-adjusted life-year. The results are sensitive to health state utilities, rate of progression to Alzheimer disease, effectiveness, and cost of donepezil preventive treatment.

Genetic testing in combination with donepezil preventive treatment for AMCI patients may not be cost-effective in this setting. If a more effective and less costly preventive treatment becomes available, screening with genetic tests will be more cost-effective.

Knowledge Exchange and Impact — What is the Connection?

• Presenting Author: Nancy Robertson, Canadian Agency for Drugs and Technologies in Health (CADTH)

The purpose of this presentation is three-fold:

• to demonstrate that the practice of knowledge exchange does have (positive) impact
• to showcase how integrating knowledge exchange planning early on can facilitate the generation of impact
• to communicate how having a plan with pre-set initiatives can facilitate tracking, analyzing, and reporting impact.

This presentation is geared toward audience members faced with increased requirements to demonstrate meaningful impact. This could include, for example, researchers, knowledge exchange professionals, and health system managers that have the responsibility to show the uptake and/or impact of work being produced.

This presentation will use the knowledge exchange planning for CADTH’s Liquid Based Cytology (Liquid-Based Techniques for Cervical Cancer Screening; Systematic Review and Cost-Effectiveness Analysis) report to demonstrate an approach that builds in depth and breadth over time. The momentum gained from the first planned knowledge exchange initiative lead to another — which lead to another. This chain of events showed (positive) impact on many fronts including the following:

• decision-makers were interested in the topic
• decision-makers were actively engaged in dialogue around the report information
• decision-makers were keen to use evidence to support their decisions.

Knowledge of Your Family History Could Save Your Life Using Information Technology to Link Familial and Genotype Information to Prevent Sudden Cardiac Death

• Presenting Authors: Catherine Street and Astrid Perrot-Daley,  Memorial University of Newfoundland
• Co-authors: Dr. Terry-Lynn Young, Dr. Roy West, Dr. Proton Rahman, Dr. Kathy Hodgkinson and Dr. Daryl Pullman, Memorial University of Newfoundland

Sudden cardiac death (SCD) has a significant impact on social structures and on the health and well-being of families and communities. The mutation responsible for a genetic subtype of  SCD (ARVD5) has been identified, and a test has been developed. Those individuals identified with the mutation are fitted with an implantable cardiac defibrillator. This prophylactic intervention has saved many lives.

Geneticists and cardiologists working with ARVD5 know there are more at-risk families not yet identified. Historically, building family pedigrees is a long and painstaking process that takes months or years to complete. Many affected individuals can die in the meantime. PTRG, in partnership with the Newfoundland and Labrador Statistics Agency, and the Canadian Century Research Infrastructure, has developed a state of the art heritability information technology platform that draws on Newfoundland census data and other historical records to construct family pedigrees. The proprietary matching software, KINNECT, enables PTRG to develop extended pedigrees in a matter of hours. These pedigrees are used to quickly identify individuals who may be at risk, but are not currently known to health services. The identification of these individuals raises significant ethical issues.

The presentation, which will be of interest to those with a clinical background, researchers and information technology experts, will highlight how, through the use of a heritability information technology platform, it is possible to identify individuals and families at risk of SCD, and the ethical issues associated with this identification.

Knowledge-to-Action in the Pharmacist Context: The Impact of Pharmacist Specific Clinical Practice Guidelines in Respiratory Care

• Presenting Author: Rosemary Killeen, Canadian Pharmacists Journal
• Co-authors: Dr. Elaine Chong, British Columbia Ministry of Health Services; Dr. Ross Tsuyuki, University of Alberta; Dr. Barry Power, Rideau Family Health Team; Trevor Elton, Alberta Health Services

Purpose: To evaluate the impact of pharmacist-specific respiratory practice guidelines published in a professional journal supplement.

Methods: Initial and follow-up surveys of pharmacists were conducted after the release of the supplement in December 2007. The data collection tool consisted of 22 items relating to the following: interaction with respiratory patients; awareness and application of evidence-based guidelines; disease control; utility of action plans; practice information and opinions regarding the supplement itself. The initial survey was administered from January 2008 to August 2008, in English and French, in electronic and paper-based formats. A follow-up electronic survey was sent to 56 respondents who consented to follow-up.

Results: The initial survey was completed by 160 pharmacists (n = 155 English, n = 5 French). As of November 3, 2009, 24 pharmacists had completed the follow-up survey (n = 24 English). Most respondents practised in community settings and perceived that their patients with asthma and/or chronic obstructive pulmonary disease had a disease that was either “not very well-controlled” or “somewhat well-controlled.” The utilization of action plans was low, and nearly a third of the respondents indicated no access to information about patients’ action plans. Nearly half of respondents had read the journal supplement, and 36.7% (initial) and 72.8% (follow-up) either agreed or strongly agreed that the supplement increased their awareness of the most current evidence-based respiratory guidelines.

Conclusions: This evaluation suggests that pharmacist-specific clinical practice guidelines in respiratory care have the potential to positively impact pharmacists. This study implies that specific follow-up activities should be planned for future guidelines, as preliminary evidence appears to support knowledge-to-action efforts for pharmacists.

A Multi-Level Analysis of Price Differentials for a Selected Cohort of Drugs

• Presenting Author: Zhe (Jerry) Ren, Dalhousie University

Objective: This paper empirically explores the dynamic relationship between the drug price differentials and the evolution of the drug market structure, under Canadian health care policy and legislation. It focuses on one class of antilipemic drugs (the statins), one class of antifungal drugs (the triazoles), and one class of antimigraine drugs (the triptans), as the sample cohort.

Methods: Data related to drug products, including Anatomical-Therapeutic Classification (ATC), strength, dosage form, and manufacturer list price, etc. were accessed through the National Prescription Drug Utilization Information System (NPDUIS). The dataset represented 149 drugs (drug identification numbers) in 14 drug molecules, under the three selected drug classes, during the period from April 2000 to June 2008. The longitudinal dataset contains 2,955 observations in an unbalanced manner. A multi-level (three level) random-intercept regression model was employed to examine the statistical relationship between drug price dynamics and the changes of drug market structure.

Results: The regression results suggest considerable random variations at the drug molecule level. The paper also witnessed the generic competition paradox: drug prices had an increasing trend when there were more generic competitors available within the molecule, even after controlling for inflation.

Conclusions: The lack of drug pricing regulations regarding off-patent brand name drugs at the Federal level and limited policies applying to these drugs by public drug plans have important implications on nationwide drug cost containment. The research result is relevant to the decision-makers for their endeavors of containing drug cost inflation while ensuring the availability of safe and effective drugs for their clients.

OPRM — Oncology Pharmaceutical Review Model: A proposed Reimbursement Review Process for Oncology Medications

• Presenting Author: Colin Vicente, PIVINA Consulting Inc.
• Co-authors: Dr. Walid Homsy, Novartis Pharmaceuticals Canada; Gerry Jeffcott, IOWG; Tony Kim, Celgene; Angela Thompson, Eli Lilly Canada

The IOWG is comprised of 14 manufacturers of innovative medicines with an interest in oncology. During the past few years, government has been challenged with finding an ideal process for a national review of oncology products to guide public reimbursement decisions. Recognizing the role of manufacturers in the process, the IOWG sought to propose a multi-stakeholder focused model for reviews. A dedicated subgroup of IOWG members started by creating a “zero-based approach” draft. The draft model was shared with the full IOWG membership, including advisors with multiple stakeholder experience. It was then issued to a range of external stakeholders, including the JODR leadership and evaluators. Subsequently, it was modified in response to their feedback and suggestions. The group concluded that to meet all stakeholders’ needs, the process should respect the following eight core principles: patient-focused, respectful of payers’ accountability, timely, geared to provide assessments about medications, inclusive, transparent, oriented to continuous quality improvement, and ethical. It is hoped that this proposed review process addresses unique considerations specific to oncology; however, other factors, including jurisdictional-specific criteria must also be accounted for in the overall process.

Orpheus: An Optimization Model for Allocating Chemotherapy among a Cohort of Cancer Patients When Funding and Human Resources are Limited

• Presenting Authors: Dr. Hugh Walker, Walker Economics Inc.
• Co-authors: Mark Anderson, Jamie Thornhill, Dr. Farah Farahati, Raphaelle Deraspe and Erin Hansen , Walker Economics Inc.

Purpose: Simulation and optimization of resource allocation to an annual cohort of incident cancer patients. Considering clinically relevant chemotherapy choices, the model achieves the maximum overall survival in life-years (LY) gained for patients across all cancer sites and stages.

Method: Orpheus is a software tool that uses operations research techniques (linear programming and simulation) to optimize the selection of health care resources by maximizing the total LY gained, for a cohort of new cancer patients who are candidates for chemotherapy. Data are from the Cancer Care Ontario program for evidence-based care. The model considers the number of new patients with each cancer (e.g., colon, lung, and breast), and the overall survival for each alternative chemotherapy regimen, drug costs, staff requirements for treatment delivery, and costs per patient per year. Data from the clinical trials literature provide expected survival and incremental survival benefits among drug regimens for each cancer site and stage.

Results: The total cohort is cancer patients with cancers of the following types: 7,800 colon, 7,000 lung, and 8,100 breast, in Ontario based on 2007 incidence data. The cohort includes both adjuvant and metastatic patients. The increase in costs from using new and expensive drugs is more rapid than the increase in benefits. Changes in human resources availability, such as oncologists, nurses, pharmacists, and in daily clinic capacity, affect drug selection and outcomes.

Conclusion: The results have strong implications for those policy-makers who are interested in value for money in health care delivery.

Patient Impact of Policy-Driven Statin Substitution Programs

Presenting Authors: Anna Liovas, AstraZeneca Canada Inc.; Christine Folia, Agro Health Associates

Objectives: Although cardiovascular disease remains a main cause of death and morbidity, statins are well recognized for their role in prevention. The need for cost-effective health care has led to greater use of policy-driven therapeutic substitution policies; however, their impact on patients is under-reported.

Methods: A Medline review of literature describing statin substitution programs. The search terms included Hydroxymethylglutaryl-CoA Reductase Inhibitors (MeSH); and statin, switch, interchange, substitute, substitution (all fields). The search was limited to English papers published from 1989 to 2009. Reference lists from selected papers were also reviewed.

Results: There were 23 studies identified: 17 evaluated the impact of a “switch down” to equal or less potent statins; six evaluated the impact of a “switch up” to more potent statins. With “switch down” programs, 23% to 47% of patients were not eligible or willing to switch (seven studies), 17% to 38% of patients were switched to a non-equivalent (lower) dose of the new statin (three studies), 4% to 11% of patients switched back to their original statin (five studies), and switched patients were 19% to 33% less likely to be adherent to therapy. Persistence was also reduced (two studies). No significant trend in lipid levels was noted (12 studies). Loss of target levels was reported in 7% to 20% of patients (two studies) and three studies reported an increase in vascular events or death after switching. “Switch Up” programs demonstrated improved reductions in lipid levels (six studies) and a greater proportion of patients achieving low-density lipoprotein goals (five studies).

Conclusions: Policy-driven statin substitution programs may impact the delivery of patient care and treatment outcomes.

Qualitative Evaluation of the Canadian Fabry Disease Initiative

• Presenting Author: Mark Embrett, IWK Health Centre
• Co-authors: Neil MacKinnon and Tom Rathwell, Dalhousie University; Daryl Pullman, Memorial University

Rationale:The Canadian Fabry Disease Initiative (CFDI) is a national study designed to assess the effectiveness of two treatment options for the rare Fabry disease.

Objectives: Evaluate the CFDI using input from key informants; and determine the initiative’s merit, assess its value, and provide feedback to information users and seekers.

Study Design and Methods: This study used an ideal qualitative methods strategy comprised of interview transcripts, a holistic-inductive design, and content analysis. In May to June 2009, key informants, including CFDI patients, CFDI investigators, and provincial and pharmaceutical representatives, were interviewed about their experiences with the CFDI. Content analysis was applied to identify core consistencies and meanings.

Results: Eighteen participants were interviewed. Within group analysis it was suggested that patients are concerned about the restrictions a clinical trial placed on access to therapy; CFDI investigators believe the database and monitoring are essential components to treating rare diseases, but the CFDI is not the ideal model; provincial representatives believe research should not be a foundation for drug access; and pharmaceutical representatives perceived the CFDI as a poorly designed answer to a reimbursement problem. Between group analysis revealed that the CFDI is an important initiative in Canada. However, it is not the solution to the issues related to reimbursement for expensive drugs for rare diseases.

Conclusion: The CFDI was a temporary solution to a reimbursement problem; no group was completely satisfied with the CFDI; and the CFDI can and should be redesigned to better accommodate each group’s needs.

The Relationship between Disease Severity and Cost of Caring for Patients with Alzheimer Disease in Canada

• Presenting Author: Derrick Tam, University of Toronto
• Co-authors: Dr. Nathan Herrmann, Sunnybrook Health Sciences Centre; Dr. Krista Lanctôt, Medical Outcomes and Research in Economic (MORE); Nadia Lesnikova, Robert Sambrook, and Robert Balshaw, Syreon Corporation

Background: The goal of this study was determine the relationship between costs of caring for a patient in the community in Canada with Alzheimer disease (AD) based on disease severity.

Methods: Community dwelling, mild-to-moderate AD patients were enrolled in the Canadian Outcomes Study in Dementia (COSID), a three-year, naturalistic, observational study. Patients were assessed on global severity (Global Deterioration Scale, [GDS]), cognition (Mini-Mental Status Examination), and daily function (Functional Autonomy Measurement System). Resource utilization questionnaires were used to collect direct (medical and non-medical) and indirect costs. Costs at baseline were compared with costs at follow-up and correlated with disease severity.

Results: Total monthly costs associated with treating AD were significantly higher with increasing disease severity. Mean total cost to treat very mild AD patients (GDS = 2) was $367 per month, compared with $4,063 per month for those with severe or very severe AD (GDS ≥ 6). Similarly, greatest changes in cost were observed in the most severe group of AD patients as measured by all three scales from baseline to follow-up. The greatest contributor to total cost was indirect cost when severity was greater than mild (GDS ≥ 3). Significant independent contributors to cost were being female, having more impaired activities of daily living, and exhibiting more neuropsychiatric symptoms.

Conclusion: Costs for treating a patient with AD were strongly associated with disease severity, even when patients are not institutionalized. Delaying the progression of AD may reduce indirect costs and burden to caregivers.

Short-Term Reduction in Private Insurance Claims Growth with the Listing of Some Biologics on Public Drug Plan Formularies

• Presenting Author: Lindy Forte, Valore Research
• Co-authors: Thomas Holloway, Equitus Consulting; Robert Kulik, EMD Serono Canada Inc.

Introduction: Transfer of patient claims for higher cost drugs from employer-sponsored plans to public drug programs at the time of public formulary listing is thought to occur. The purpose of this research was to determine the extent to which such a shifting of costs might exist.

Methods: Public and private claims for anti-TNF alpha agents were obtained for the four most populated provinces. Claims for each biologic were plotted with linear trend lines to highlight evidence of shifting from one type of plan to the other, and the proportion of total claims reimbursed by the public drug plans were calculated. In addition, five main private insurers were surveyed for their knowledge of cost shifting.

Results: The share of public versus private claims varied by province, where British Columbia, Alberta, Ontario, and Quebec reimbursed an average of 60%, 45%, 37%, and 44% of the claims respectively. Linear trend lines indicated a small short-term drop in private claims growth coincident with public reimbursement in the four provinces for infliximab and adalimumab, but not etanercept. In cases where a short-term growth reduction was seen, the share of privately reimbursed claims later increased to, or exceeded, the level expected based on the initial growth at product launch. Interviews with private payers suggested that a shift in cost was not apparent and no emerging trends were identified.

Conclusion: Although the possibility for preferential reimbursement of biologics by public drug payers exists, the cost does not appear to shift from private to public insurers over the long-term following public reimbursement.

Surrogate Outcomes in HTA Decision-Making

• Presenting Author:,Michael Marentette, Merck
• Co-authors: Dr. Rakhee Modha,  Maria Sedelnikova, Kevin Lock and Paul Howard, Heron Health

Objectives: Efficacy data from surrogate outcomes (SOs) can suggest beneficial treatment effects years before evidence from true clinical end points (TCEs) becomes available. Here, we present key findings from a study exploring the use and impact of SOs in decision-making by Health Technology Assessment (HTA) organizations.

Methods: A review of appraisal reports produced by seven HTA organizations (AHRQ, CADTH, HAS, IQWiG, NICE, SMC, and PBAC) between 2004 and 2009 was conducted. To control scope, diseases of a combined high global burden of illness (cardiovascular disease [CVD], diabetes mellitus, HIV, oncology, and osteoporosis), were selected for inclusion in the review. To ensure data of sufficient depth were available for comparison only those reporting sufficient information both in the number of reports and in detail were extracted for analysis.

Results: Approximately 10% of appraisals retrieved were extracted. Overall, across HTAs, consideration of SO data was stated in the recommendation section of appraisals in 52% (CVD), 70% (diabetes), 81% (HIV), 40% (oncology), and 67% (osteoporosis) of cases. Typically cost-effectiveness analyses based on SO efficacy data were accepted in HIV and diabetes, accepted with reservations in CVD and in oncology. The level of detail rationalizing recommendations varied between HTA organizations. NICE in the UK reported the greatest detail whilst the SMC provided the least.

Conclusion: Across HTA organizations, HAS generally accepted SO data, whilst the SMC, PBAC, and CADTH were more cautious in some disease areas.

Toward Evidence-Based Decision-Making for Canadian Physicians

• Presenting Author: Dr. Samuel Shortt, Canadian Medical Association (CMA)
• Co-authors: Nan Bai and Jean-Marc Guillemette, Canadian Medical Association (CMA)

Background and Purpose: Clinical practice guidelines (CPGs) are “systemically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” To help physicians access CPGs and adopt evidence-based best practice, the CMA Infobase was created by the Canadian Medical Association in 1994 and has since grown into the most comprehensive online source of Canadian CPGs, with 1,300 CPGs included. The objective of this study was to assess physicians’ information needs and identify new features that would enhance physicians’ use of the Infobase as a tool for evidence-based decision-making.

Methods: A user survey was conducted online between April 1 and April 30 2009. The questionnaire included 11 questions about user demographics, purpose and frequency of visits, satisfaction, desirable features, and experience with CPG development and implementation.

Results: A total of 512 users responded. Overall physicians were highly satisfied (83%). The top two reasons for visits were continuing education (80%) and acquiring information for managing a clinical case (63%). Clinical pearls — short, practical summaries of CPGs (90%), integrated accredited CME (81%), and email alert of new CPGs (81%) — were among the highest rated features, followed by peer review of CPGs (66%).

Discussion: Physicians’ enthusiasm about clinical pearls concurs with research findings that a lack of user-friendly format of CPGs might be one of the barriers to CPG adherence. Creating CPG summaries with clear, succinct, and actionable recommendations might help physicians adopt evidence-based decision-making in patient care delivery process. Enhanced educational material, such as online learning modules of CPGs, might help physicians assimilate research evidence. Quality rating of CPGs, based on critical appraisal, interests physicians given the growing number of CPGs of varied quality.

Toward National Evidence-Informed Practice Guidelines for Canadian EMS: Future Directions

Presenting Author: Thomas Dobson, Dalhousie University/Emergency Health Services

Co-authors: Jan Jensen, Dalhousie University/Emergency Health Services

Introduction: In emergency medical services (EMS), like other areas of health care, a substantial knowledge-to-action gap exists between the production of research results and widespread use in clinical practice. In Canada, paramedic clinical decision-making is largely directed by protocols or medical directives, which are determined by medical director expert opinion, practice trends, and other factors. The quality of EMS is evaluated by operational data, which are often neither comparable across services nor based on patient outcomes or clinical research evidence.

Methods: A workshop was held to brainstorm a process for creating National Evidence-Informed Guidelines for EMS. A group of twelve continuous quality improvement experts from across Canada met in October 2009. Drafts of three guidelines, with accompanying quality indicators, were developed, and the process was evaluated.

Results: The group determined that a set of National Evidence-Informed Guidelines would be a valuable resource for Canadian EMS. It was identified that a thorough and efficient evidence evaluation process would be necessary. The intervention recommendations in published clinical practice guidelines are not directly applicable to EMS. Several next steps were established, including collaboration with key stakeholders, including medical directors; securing funding and a dedicated coordinator; identifying areas of clinical care of highest priority; and establishing knowledge translation plans in conjunction with national EMS organizations.

Conclusion: A set of National Evidence-Informed Guidelines is needed for Canadian EMS. This substantial body of work would be a meaningful knowledge translation activity, which would help minimize the knowledge-to-action gap that currently exists.

Under Utilization of Disease Modifying Antirheumatic Drugs (DMARDs) in Early Rheumatoid Arthritis (ERA): A Population-Based Study from the Ontario Biologics Research Initiative Comparing Rheumatology Care with Primary Care

• Presenting Author: Michael Paterson, Institute for Clinical Evaluative Sciences (ICES)
• Co-authors: Dr. Sasha Bernatsky, McGill University; Dr. Claire Bombardier and Jessica Widdifield, University of Toronto; Dr. Carter Thorne, Southlake Regional Health Centre; Dr. Janet Pope, University of Western Ontario; Dr. Alfred Cividino, McMaster University

Purpose: In patients with early rheumatoid arthritis (ERA), delays in initiating therapy are associated with negative health outcomes. Primary care physicians function as gatekeepers for access to specialists and play an integral role in ensuring rheumatoid arthritis (RA) patients receive optimal care. The Ontario Biologics Research Initiative represents a collaboration of arthritis stakeholders evaluating real-world effectiveness and safety of antirheumatic therapies, and delineating practice patterns. We estimated the percentage of RA patients in Ontario exposed to disease modifying antirheumatic drugs (DMARDs) within the first year of diagnosis.

Method: We assembled an incident RA cohort from physician billing data for between 1997 and 2006. We used a standard algorithm to identify 24,326 cases aged ≥ 65 years, based on ≥ 2 RA billing codes,
≥ 60 days apart, but ≤ 5 years. Drug exposures were obtained from pharmacy claims data. We followed patients for one year, assessing drug exposure within one year of diagnosis. We assessed secular trends and differences for patients who had received rheumatology care (defined as ≥ 1 rheumatology encounter) versus those who had not.

Results: Overall 40% of seniors with ERA who were identified between 1997 and 2006 were exposed to DMARDs within one year of diagnosis. This increased from 30% in 1997 to 55% in 2006. Only 55% of patients saw a rheumatologist. In 2006, 70% of ERA patients who saw a rheumatologist were prescribed DMARDs compared with 20% who did not.

Conclusion: Improvements in RA care have occurred, but more efforts are needed, particularly in patients who were not referred to a rheumatologist where only 20% receive a DMARD in the first year. This emphasizes the key role of rheumatologists.

The Use of Modelling to Reduce Wait Times in the Emergency Department: A Systematic Literature Review

• Presenting Author: Morgan Lim, McMaster University
• Co-authors: James Bowen, Ron Goeree, and Dr. Jean-Eric Tarride, Programs for Assessment of Technology in Health (PATH) Research Institute

Objective: The complexity of the hospital emergency department (ED) process of care compounded with the multi-faceted issues associated with excessive wait times lends itself well to systems analysis. The objective of this study was to conduct a literature review to identify and compare the types of mathematical modelling techniques used to evaluate wait times in the hospital ED. The secondary objective was to describe main study findings.

Methods: Search strategies were developed for electronic databases: Medline, Embase, Compendex, Inspec, and Business Source Complete. The abstraction form was developed to extract the mathematical modelling technique, study information (country, objectives, primary performance measure, findings or conclusions) and model development.

Results: Nineteen studies met the inclusion criteria, resulting in four different mathematical modelling techniques: queuing model (n = 2), discrete event simulation (n = 14), discrete event simulation with optimization (n = 1), and system dynamics (n = 2). Compared with the other techniques, discrete event simulation may have advantages because of its ability to model complex systems, staff shifts, patient history and randomness, its transparency for decision-makers, and the wealth of software available for implementation.

These studies evaluated three main strategies: staff rescheduling, fast-tracking low acuity patients, and altering inputs to increase throughput. Overall conclusions were that the number of rooms had no effect on wait time, if added without matching staff increase; and fast-tracking patients resulted in a trade-off between low-acuity and high-acuity wait times.

Conclusion: This review has shown that mathematical modelling is a potentially powerful tool in the evaluation of wait times in the ED.

Using CADTH’s Rapid Response Program to Assist in a Coverage Decision: Customizing CADTH Products to Meet the Needs of Stakeholders

• Presenting Author: Dr. Michelle Mujoomdar, Canadian Agency for Drugs and Technologies in Health (CADTH)
• Co-authors: Carolyn Spry, Michelle Clark, and Jeannette Smith, Canadian Agency for Drugs and Technologies in Health (CADTH); Aaron Sehn, Health Canada (Non-Insured Health Benefits Program)

Objective: To describe a case in which CADTH’s Liaison and Rapid Response Programs worked with a requestor to assist the Federal Pharmacy and Therapeutics committee in making a recommendation regarding coverage of a drug by the federal drug plans.

Background: In 2008, the Canadian Expert Drug Advisory Committee recommended that acamprosate be covered by Canada’s publicly funded drug plans for patients in which naltrexone was contraindicated. At that time, naltrexone was not covered by federal drug plans. A request was made to CADTH to review the clinical effectiveness of naltrexone for the treatment of alcohol dependence.

Methods: CADTH worked with the requestor to understand the coverage decision being considered. It was decided that CADTH would produce two reports, and a follow-up presentation on the second report would be made to the committee.

Results: A report with a list of references was prepared and used to gauge the volume of literature. After reviewing the report, the scope of the research questions was further refined, a summary report with critical appraisal was prepared, and a presentation was given to the committee. Following the presentation, the committee deliberated and developed a recommendation for coverage regarding naltrexone.

Conclusions: CADTH worked with the requestor and adapted our standard approach to suit the requestor’s decision-making needs. In approximately four months, two reports and a presentation were produced, a recommendation regarding coverage was made, and knowledge gaps were identified. Since the original inquiry, CADTH’s Rapid Response Program has completed four additional reports for the requestor on topics related to naltrexone therapy.

Using Mixed Treatment Comparisons to Generate Recommendations for Optimal Use of Medications

• Presenting Author: Sumeet Singh, Canadian Agency for Drugs and Technologies in Health (CADTH)

Mixed treatment comparisons (MTC) meta-analysis is a powerful methodology for synthesizing evidence when a policy or therapeutic decision requires consideration of multiple treatment options. However, results from MTC have been used infrequently in making recommendations or policy decisions. The purpose of this presentation will be to highlight the experiences of the Canadian Agency for Drugs and Technologies in Health (CADTH) in applying MTC to make recommendations for the optimal use of second-line antidiabetes drugs for the treatment of type 2 diabetes inadequately controlled on metformin, and to identify key learnings for others who may wish to employ results from MTC in decision-making. The intended audience consists of individuals involved in developing recommendations, guidance, or policy for therapeutic areas in which multiple options are available. The presentation will cover the following: a brief introduction of Canadian Optimal Medication Prescribing and Utilization Service and the project to assess second-line antidiabetes drugs; an overview of MTC methodology; some common perceptions regarding MTC and barriers to accepting this approach; overcoming challenges in fostering understanding and acceptance of MTC methodology on the part of an expert committee; incorporating MTC results within the GRADE approach to developing recommendations; committee processes used to develop recommendations based on results from MTC; and key elements of a framework to successfully use MTC results to develop recommendations.

Utilization Patterns of Statins in Nova Scotia Seniors Pharmacare Program

• Presenting Authors: Michael Joyce and Dr. Jane Gillis, Nova Scotia Department of Health

Objectives: The study looks at the change in utilization patterns over time for the use of statins in the Nova Scotia Seniors’ Pharmacare program. The associated change in costs and factors causing costs to change are identified.

Methods: The study uses claims data residing on the Nova Scotia Seniors’ Pharmacare Decision Support System (DSS) covering the January 1, 2005 to November 30, 2008 time period. The measures of change are unique monthly beneficiary counts for utilization and annual drug ingredient costs. A measure of average defined daily doses on a per molecule basis is calculated to compare costs between molecules. The products are grouped at the molecule level. The changes related to cost are identified as demographic (population aging, growth), price, and quantity (change in the number of tablets, strength, and molecule mix).

Results: Increased use on a unique beneficiary basis is observed for atorvastatin and rosuvastatin. The other molecules indicate flat to declining patterns. Atorvastatin has the largest share of beneficiaries; however, growth in the use of rosuvastatin is at a higher rate compared with atorvastatin. Higher numbers of beneficiaries are observed over the time period; however, the rate of cost growth is slowing in each year from 10.4% in 2006 to 7.3% in 2008. Quantity change has the greatest impact on cost growth in terms of comprising the largest component of overall price change. A breakdown of the quantity variable reveals that the largest factor in the slowing cost increase is related to the impact of the change in product mix, which indicates a decline of −3.5% in 2008.

Conclusions: On a per defined daily dose basis, rosuvastatin is the least costly molecule in its chemical/therapeutic subgroup. Although a definite link cannot be firmly established, it is possible that the observed change in molecule mix and associated decreased rate of cost growth is related to the increased use of rosuvastatin.

Value of a Criteria-Based Approach for HTA Topic Prioritization: The Canadian Experience

• Presenting Author: Michel Boucher, Canadian Agency for Drugs and Technologies in Health (CADTH)
• Co-authors: Don Husereau and Hussein Noorani, Canadian Agency for Drugs and Technologies in Health (CADTH)

Health technologies are increasing both in quantity and complexity. Health technology assessment (HTA) research provides valuable information to assist with funding decisions. Given the wide range of available technologies, selecting the most relevant HTA topics is critical. A criteria-based prioritization process for selecting HTA topics has been used at the Canadian Agency for Drugs and Technologies in Health (CADTH) since 2006. Six core-prioritization criteria (disease burden, clinical impact, budget impact, economic impact, alternative interventions, and available evidence) are used to prepare briefing papers on each proposal. Information relating to each criterion is rated by two researchers independently. Ratings are then translated into a score and rank. Jurisdictional contextual information is also collected to inform deliberation among CADTH advisory committee members by further describing the pan-Canadian relevance of topic proposals. Since its implementation, advisory committee members have considered 116 proposals during 15 bi-annual in-person meetings. Of these, 26 topics were selected for HTA research. Ranking of selected topics varied from 1 to 9, depending on topic cycles. Overall 65% (n = 17) were among the three top ranking proposals (five topics [19%] ranked # 1, five other topics [19%] ranked # 2, and seven topics [27%] ranked # 3). Feedback from advisory committee members indicates this approach resulted in an increase in the level of impact of HTA reports. As CADTH is moving toward an integrated topic prioritization model for its three science directorates, additional factors such as trends in the utilization of a technology may need to be considered to inform the selection of the most relevant topics and efficiently allocate resources available for evidence-based research.