Issues in the approval of, access to, and post-marketing follow-up of new drugs in Canada: a personal viewpoint

The Influence of Socioeconomic Status on Selection of Anticoagulation for Atrial Fibrillation

IMPORTANCE

Without third-party insurance, access to marketed drugs is limited to those who can afford to pay. We examined this phenomenon in the context of anticoagulation for patients with nonvalvular atrial fibrillation (NVAF).

OBJECTIVE

To determine whether, among older Ontarians receiving anticoagulation for NVAF, patients of higher socioeconomic status (SES) were more likely to switch from warfarin to dabigatran prior to its addition to the provincial formulary.

DESIGN, SETTING AND PARTICIPANTS

Population-based retrospective cohort study of Ontarians aged 66 years and older, between 2008 and 2012.

EXPOSURE

Socioeconomic status, as approximated by median neighborhood income.

MAIN OUTCOMES AND MEASURE

We identified two groups of older adults with nonvalvular atrial fibrillation: those who appeared to switch from warfarin to dabigatran after its market approval but prior to its inclusion on the provincial formulary ("switchers"), and those with ongoing warfarin use during the same interval ("non-switchers").

RESULTS

We studied 34,797 patients, including 3183 "switchers" and 31,614 "non-switchers". We found that higher SES was associated with switching to dabigatran prior to its coverage on the provincial formulary (p<0.0001). In multivariable analysis, subjects in the highest quintile were 50% more likely to switch to dabigatran than those in the lowest income quintile (11.3% vs. 7.3%; adjusted odds ratio 1.50; 95% CI 1.32 to 1.68). Following dabigatran's addition to the formulary, the income gradient disappeared.

CONCLUSIONS AND RELEVANCE

We documented socioeconomic inequality in access to dabigatran among patients receiving warfarin for NVAF. This disparity was eliminated following the drug's addition to the provincial formulary, highlighting the importance of timely reimbursement decisions.

Lessons for a national pharmaceuticals strategy in Canada from Australia and New Zealand

BACKGROUND

The provincial formulary review processes in Canada lead to the slow and inequitable availability of new products. In 2004, the exploration of a national pharmaceuticals strategy (NPS) was announced. The pricing policies of New Zealand and Australia have been suggested as possible models for the NPS.

OBJECTIVE

To compare health care indexes and health care use information from Canada, Australia and New Zealand.

METHODS

The 2006 Organisation for Economic Co-operation and Development health data were used to compare health and health care indexes from Canada, Australia and New Zealand between 1994 and 2002 to 2004. The principal focus of the evaluation was cardiovascular and respiratory disorders.

RESULTS

Although the mortality rate from acute myocardial infarction decreased in each country from 1994, it levelled off in New Zealand in 1997, 1998 and 1999. Between 1994 and 2003, the average length of hospital stay for any cause and for cardiovascular disorders was stable in Australia and Canada, but increased in New Zealand, while the rate of hospital discharges for cardiovascular diseases decreased in Canada and Australia, but strongly increased in New Zealand. Over the same period, sales of cardiovascular drugs decreased in New Zealand, while sharply increasing in Canada and Australia.

CONCLUSIONS

Although only circumstantial, our results suggest an association between decreasing cardiovascular drug sales and markers of declining cardiovascular health in New Zealand. Careful consideration must be given to the potential consequences of any model for an NPS in Canada, as well as to opportunities provided for discussion and input from health care professionals and patients.

Availability of Hormone Replacement Therapy Products in Canada

OBJECTIVES

To determine the availability in Canada of different types of hormone replacement therapy (HRT) products, and to compare the availability of HRT products in Canada to their availability in other countries.

METHODS

A systematic review was conducted of the availability of products indicated for treatment of menopausal symptoms in Canada, the United States (US), the United Kingdom (UK), Sweden, and Australia. Products indicated for the treatment of menopausal symptoms were determined for each country by using on-line drug product databases. Products administered by injection and androgen products, unless combined with estrogens, were excluded from the analysis.

RESULTS

There were 111 different brands identified in the 5 countries examined, with Canada having the lowest number of brands and active ingredients (28 and 22, respectively) compared to the other countries (Sweden and UK at 67 and 47 brands and 39 and 40 active ingredients, respectively). Not available in Canada are 34 active ingredients (either alone or in combination products) and 5 different types of formulations of HRT. There was a significant difference between the number of combination brand products available in Canada and in the UK (5 versus 29, P <.001, respectively).

CONCLUSIONS

Canadian women have comparatively few options available to them for the management of menopausal symptoms. The wide range of HRT products available in other developed countries provides alternatives for managing side

Canadian and US drug approval times and safety considerations

BACKGROUND

Approval times of new drugs are frequently longer in Canada than in the US, but it has been argued that reducing approval times might lead to unsafe drugs receiving marketing approval.

OBJECTIVE

To compare new drug approval times in Canada and the US over a 10-year period and to relate them to safety discontinuations.

METHODS

Application and approval dates of all new drugs except diagnostic products, new salts, esters, isomers, and dosage forms of already-marketed drugs, as well as combinations containing previously approved substances approved in the US and Canada between January 1992 and December 2001 were obtained from the respective drug regulatory agencies and other sources. Information about drugs discontinued for safety reasons was obtained from the agencies' publications and Web sites and from journal articles.

RESULTS

New drug approval times were significantly longer in Canada than in the US. The difference occurs in all drug categories and by review type (priority/standard). However, the proportion of new drugs approved and later discontinued for safety reasons from the Canadian market (2.0%) was just over half that in the US (3.6%).

CONCLUSIONS

When serious drug safety problems were identified in a timely manner after US approval, the products were not subsequently approved in Canada. Canada avoided potential dangers because its longer approval times provided an opportunity to observe actual market experience in other countries. However, the trade-off is that new drugs, including those for conditions for which current therapy has limited efficacy, take significantly longer to be approved in Canada and, hence, to be available to Canadians.

Timeliness of review and approval of new drugs in Canada from 1999 through 2001: is progress being made?

BACKGROUND

The median time to approval of new drugs in Canada decreased considerably in the mid-1990s, although it continued to be longer than in such countries as Australia, Sweden, the United Kingdom, and the United States. Ongoing concern about approval times pointed to a need for a further international comparison.

OBJECTIVE

This study was designed to assess whether there have been continuing improvements in drug approval times in Canada relative to these other countries.

METHODS

Application and approval dates of new chemical or biological substances approved for marketing from 1999 through 2001 were requested from the Canadian, Australian, and Swedish regulatory agencies. Information for the United States was derived from publications of the Pharmaceutical Research and Manufacturers of America. The regulatory agency for the United Kingdom does not release application dates, although these were the same as the Swedish application dates for most drugs approved in both countries through the centralized European Union (EU) review procedure. Application dates for drugs licensed under the EU mutual-recognition arrangement or in the United Kingdom only were requested from the relevant pharmaceutical companies.

RESULTS

One hundred eighty-six new drugs were approved in >/=1 of the countries studied between January 1999 and December 2001: 17 (9.1%) in all 5 countries, 25 (13.4%) in 4, 27 (14.5%) in 3, 39 (21.0%) in 2, and 78 (41.9%) in 1. Approval times were longer in Canada than in Australia, although not significantly so (median time, 645 and 551 days, respectively). Canadian and Australian approval times were significantly longer than those in Sweden (431 days), the United Kingdom (479 days), and the United States (371 days) (P < 0.001). The annual median approval time in Canada increased in each of the 3 years. The approval times of priority-reviewed drugs in Canada were significantly longer than in the United States (median 317 vs 232 days) but significantly shorter than in Australia (509 days) (both comparisons, P < 0.001).

CONCLUSIONS

Overall approval times of new drugs in Canada were longer than those in Australia, Sweden, the United Kingdom, and the United States in the period studied. The findings warrant ongoing monitoring of Canadian drug approval times.

"Cost-effectiveness" estimates result in flawed decision-making in listing drugs for reimbursement

BACKGROUND

Facing financial pressures, the provinces and territories have chosen to use "cost-effectiveness" for making decisions about drug listings. This study examines the scientific basis for the procedures used to determine cost-effectiveness in 5 Canadian provinces.

METHODS

Questionnaires were mailed to key provincial informants asking about the respondent's expertise and role, the administrative and scientific basis for decision-making, organizational structures and other factors in the scientific evaluation and decision-making process, and the transparency of the process. There were also questions about the data required and received and their importance, the place of cost-effectiveness and other economic impact evaluations, the data sources for them, and the use of follow-up monitoring to evaluate the decisions made.

RESULTS

Information required by the provinces for decision-making about cost-effectiveness is not available to them at the time of their decisions about listing new medications. The primary sources of data on both efficacy and cost-effectiveness are pharmaceutical companies. Efficacy information is generated in a scientifically rigorous manner, whereas the effectiveness and cost data are estimates potentially subject to biases and evaluated by judgement (expert opinion) alone. Moreover, there is no collaboration in the assessment process between provinces. The outcomes are large differences between provinces in the decisions made and, hence, in the pharmaceuticals accessible to residents.

CONCLUSIONS

Current methods for making decisions about provincial drug listings are based on inadequate data, and the lack of consistency in the provinces' decisions suggest they may be scientifically flawed. We recommend establishing a single national scientific review committee, with re-evaluation of each drug's cost-effectiveness after a suitable period of monitored use.