Cost-related nonadherence to medications (CRNA) is common in many countries and thought to be associated with adverse outcomes. The characteristics of CRNA in Canada, with its patchwork coverage of increasingly expensive medications, are unclear. Our objective in this systematic review was to summarize the literature evaluating CRNA in Canada in three domains: prevalence, predictors, and effect on clinical outcomes. We searched MEDLINE, Embase, Google Scholar, and the Cochrane Library from 1992 to December 2019 using search terms covering medication adherence, costs, and Canada. Eligible studies, without restriction on design, had to have original data on at least one of the three domains specifically for Canadian participants. Articles were identified and reviewed in duplicate. Risk of bias was assessed using design-specific tools. Twenty-six studies of varying quality (n = 483,065 Canadians) were eligible for inclusion. Sixteen studies reported on the overall prevalence of CRNA, with population-based estimates ranging from 5.1 to 10.2%. Factors predicting CRNA included high out-of-pocket spending, low income or financial flexibility, lack of drug insurance, younger age, and poorer health. A single randomized trial of free essential medications with free delivery in Ontario improved adherence but did not find any change in clinical outcomes at 1 year. CRNA affects many Canadians. The estimated percentage depends on the sampling frame, the main predictors tend to be financial, and its association with clinical outcomes in Canada remains unproven.

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Cost-related medication nonadherence in Canada: a systematic review of prevalence, predictors, and clinical impact

/pdf/a-cost-utility-analysis-of-biosimilar-infliximab-compared-to-1n9tcr0uoy.pdf

A Cost-Utility Analysis of Biosimilar Infliximab Compared to Reference Infliximab in Adult Switch Patients with Crohn’s Disease: A Canadian Analysis

Development and Implementation of a Strategy to Ensure Outpatient Access to Medications Started in the Inpatient Setting

Background: In 2007, a drug benefit plan for Seniors (SDP) was launched in Saskatchewan, Canada SDP capped out-of-pocket costs at $15 per prescription for individuals aged 65 and older
Objectives: To quantify the impact of the SDP on chronic medication adherence 
Methods: A retrospective cohort study was conducted for participants aged 65 or older who were eligible to the SPD, controlled by a younger group aged 40 to 64 who were ineligible Adherence was measured over 365 days using medication possession ratio (MPR) MPRs were compared between age groups, and between pre and post SDP-launch periods The odds ratio of optimal adherence (ie, MPR≥80%) was estimated using logistic regression models with generalized estimating equations (GEE)
Results: Between 2005 and 2009, 353,568 adherence observations were observed from 188,109 unique patients Comparing the post-SDP period vs before, the increase in the odds of optimal medication adherence was significant (OR=108, 95% CI: 104 to 111) and was stronger after excluding patients already receiving medication benefits from other government programs (OR= 121, 95% CI: 116 to 126) The SDP was associated with improved adherence among the subgroup of prevalent medication users (OR=108, 95% CI: 104 to 112), but not incident users (OR=105, 95% CI: 098 to 113)
Conclusion: Reducing out-of-pocket medication costs for seniors was associated with small improvements in medication adherence across the population

/pdf/reduced-out-of-pocket-costs-and-medication-adherence-a-cl4j6mv6l4.pdf

Reduced Out-of-Pocket Costs and Medication Adherence - A Population-Based Study.

Background 
Few details are available about the factors driving cost increases of biologic medications.
 Objectives
To describe trends in utilization and cost of biologic agents using administrative databases in Saskatchewan, Canada.
Methods
Two analyses were conducted. First, aggregate utilization of biologics based on prescriptions dispensed was measured in each calendar year between 2001 and 2013. Second, a retrospective cohort of new biologic users was created to examine trends in spending between 2001 and 2013. During the first year of biologic therapy, biologic cost was quantified for each specific biologic agent as: (a) total spending; (b) total mil - ligrams dispensed; and (c) estimated unit cost (i.e., total cost in 2013 $CAD divided by total milligrams dispensed during the year). Data analyses were descriptive and all biologic costs were adjusted to 2013 dollars (CAD).
Results
In the first year of biologic availability in Saskatchewan (2001), 133 patients were dispensed at least one biologic agent for a total cost of $0.5 million. In 2013, 2,402 biologic recipients were identified for a total cost of $51.8 million. Almost all of these biologic costs (88.9%) were paid by the provincial government. In 2013, infliximab was the most frequently used agent, accounting for 46.5% of all spending on biolog - ics. Infliximab was also the most expensive agent in 2013 (mean cost $31,340 ± 15,307) and showed the highest increase in the mean yearly cost over time due to greater quantities dispensed.
Conclusion 
Biologic utilization will require ongoing monitoring to optimize patient-level and societal-level benefits.

Shenzhen Yao

Papers

Reduced Out-of-Pocket Costs and Medication Adherence - A Population-Based Study.

Utilization of Biologics in Saskatchewan