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Guindon GE, Stone E, Trivedi R, Garasia S, Khoee K, Olaizola A. The Associations of Prescription Drug Insurance and Cost-Sharing With Drug Use, Health Services Use, and Health: A Systematic Review of Canadian Studies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1107-1129. [PMID: 36842717 DOI: 10.1016/j.jval.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 12/12/2022] [Accepted: 02/17/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES In Canada, public insurance for physician and hospital services, without cost-sharing, is provided to all residents. Outpatient prescription drug coverage, however, is provided through a patchwork system of public and private plans, often with substantial cost-sharing, which leaves many underinsured or uninsured. METHODS We conducted a systematic review to examine the association of drug insurance and cost-sharing with drug use, health services use, and health in Canada. We searched 4 electronic databases, 2 grey literature databases, 5 specialty journals, and 2 working paper repositories. At least 2 reviewers independently screened articles for inclusion, extracted characteristics, and assessed risk of bias. RESULTS The expansion of drug insurance was associated with increases in drug use, individuals who reported drug insurance generally reported higher drug use, and increases in and higher levels of drug cost-sharing were associated with lower drug use. Although a number of studies found statistically significant associations between drug insurance or cost-sharing and health services use, the magnitudes of these associations were generally fairly small. Among 5 studies that examined the association of drug insurance and cost-sharing with health outcomes, 1 found a statistically significant and clinically meaningful association. We did not find that socioeconomic status or sex were effect modifiers; there was some evidence that health modified the association between drug insurance and cost-sharing and drug use. CONCLUSIONS Increased cost-sharing is likely to reduce drug use. Universal pharmacare without cost-sharing may reduce inequities because it would likely increase drug use among lower-income populations relative to higher-income populations.
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Affiliation(s)
- G Emmanuel Guindon
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
| | - Erica Stone
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Riya Trivedi
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Sophiya Garasia
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Kimia Khoee
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Alexia Olaizola
- Department of Economics, Stanford University, Stanford, CA, USA
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Guilcher SJT, Hogan ME, Guan Q, McCormack D, Calzavara A, Patel T, Hitzig SL, Packer T, Lofters AK. Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study. Arch Phys Med Rehabil 2020; 102:35-43. [PMID: 32891422 DOI: 10.1016/j.apmr.2020.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use. DESIGN Retrospective cohort study using population-level administrative data. SETTING Ontario, Canada. PARTICIPANTS Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period). RESULTS A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity. CONCLUSIONS A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.
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Affiliation(s)
- Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Mary-Ellen Hogan
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Qi Guan
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Tejal Patel
- University of Waterloo School of Pharmacy, Waterloo, Ontario, Canada; Schlegel - University of Waterloo Research Institute of Aging, Waterloo, Ontario, Canada; Waterloo Institute for Complexity and Innovation, Waterloo, Ontario, Canada
| | - Sander L Hitzig
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tanya Packer
- Schools of Occupational Therapy and Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Rehabilitation, Radboud Medical University, Nijmegen, The Netherlands
| | - Aisha K Lofters
- ICES, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada
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Isaranuwatchai W, Fazli GS, Bierman AS, Lipscombe LL, Mitsakakis N, Shah BR, Wu CF, Johns A, Booth GL. Universal Drug Coverage and Socioeconomic Disparities in Health Care Costs Among Persons With Diabetes. Diabetes Care 2020; 43:2098-2105. [PMID: 32641377 DOI: 10.2337/dc19-1536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 05/25/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine whether neighborhood socioeconomic status (SES) is a predictor of non-drug-related health care costs among Canadian adults with diabetes and, if so, whether SES disparities in costs are reduced after age 65 years, when universal drug coverage commences as an insurable benefit. RESEARCH DESIGN AND METHODS Administrative health databases were used to examine publicly funded health care expenditures among 698,113 younger (20-64 years) and older (≥65 years) adults with diabetes in Ontario from April 2004 to March 2014. Generalized linear models were constructed to examine relative and absolute differences in health care costs (total and non-drug-related costs) across neighborhood SES quintiles, by age, with adjustment for differences in age, sex, diabetes duration, and comorbidity. RESULTS Unadjusted costs per person-year in the lowest SES quintile (Q1) versus the highest (Q5) were 39% higher among younger adults ($5,954 vs. $4,270 [Canadian dollars]) but only 9% higher among older adults ($10,917 vs. $9,993). Adjusted non-drug costs (primarily for hospitalizations and physician visits) were $1,569 per person-year higher among younger adults in Q1 vs. Q5 (modeled relative cost difference: 35.7% higher) and $139.3 million per year among all individuals in Q1. Scenarios in which these excess costs per person-year were decreased by ≥10% or matched the relative difference among seniors suggested a potential for savings in the range of $26.0-$128.2 million per year among all lower-SES adults under age 65 years (Q1-Q4). CONCLUSIONS SES is a predictor of diabetes-related health care costs in our setting, more so among adults under age 65 years, a group that lacks universal drug coverage under Ontario's health care system. Non-drug-related health care costs were more than one-third higher in younger, lower-SES adults, translating to >$1 billion more in health care expenditures over 10 years.
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Affiliation(s)
- Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Health Intervention and Technology Assessment Program, Bangkok, Thailand
| | - Ghazal S Fazli
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Arlene S Bierman
- ICES, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Lorraine L Lipscombe
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Nicholas Mitsakakis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Baiju R Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Ashley Johns
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Gillian L Booth
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada .,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Morgan SG, Weymann D. Patterns, predictors and persistence of chronic sedative use: a population-based observational study of older adults in British Columbia, Canada. Eur J Clin Pharmacol 2017; 73:1001-1008. [PMID: 28435984 DOI: 10.1007/s00228-017-2253-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/04/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Benzodiazepines and benzodiazepine-like sedatives (zopiclone, zolpidem and zaleplon) are commonly prescribed to treat anxiety and insomnia but are contraindicated for chronic use. We sought to study the persistence, over multiple years, of chronic use of benzodiazepines and benzodiazepine-like sedatives among community-dwelling adults in British Columbia, Canada. METHODS This is a retrospective analysis of linked health data for adults aged 50 to 69 in 2004 who resided in British Columbia, Canada, between 2004 and 2013. We assigned subjects to one of four groups according to the total number of days of benzodiazepines and benzodiazepine-like sedatives that they were dispensed from retail pharmacies in each observation year. We estimated logistic regression models to measure associations between the odds of chronic sedative use and explanatory variables. We computed transition probability matrices that depict likelihood of changes in sedative utilization levels across years. RESULTS Nearly one in ten (9.4%) community-dwelling older adults in British Columbia filled prescriptions with more than 90 days' worth of benzodiazepines or benzodiazepine-like sedatives in 2013. The odds of such chronic sedative use were higher for people who were older, had lower income, were sicker, or lived in rural communities; odds were lower for people with Chinese or South Asian surnames and for men who were married. Controlling for other factors, chronic users of sedatives in 2008 were 15 times more likely than non-users of sedatives in 2008 to be chronic sedative users in 2013 (OR = 14.73; 95% CI = [14.24, 15.24]). Approximately two out of every five older British Columbians who were chronic sedative users in 2013 had been chronic users of sedatives 10 years prior. Two out of every three chronic sedative users in 2004 were either chronic users (57%) or dead (16%) by 2013. INTERPRETATION Chronic use of sedatives is prevalent and persistent among older adults in British Columbia. The persistence of chronic sedative use between when patients were 50 to 59 years old and when they were 60 to 69 years old suggests that earlier interventions to curb chronic sedative use may be warranted even if patients do not experience significant risks until later ages.
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Affiliation(s)
- Steven G Morgan
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T1Z3, Canada.
| | - Deirdre Weymann
- British Columbia Cancer Agency, Canadian Centre for Applied Research in Cancer Control, 675 W 10th Ave, Vancouver, BC, V5Z 1L3, Canada
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