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The Canadian Rx atlas, 3rd edition Morgan, Steve; Smolina, Kate; Mooney, Dawn; Raymond, Colette; Bowen, Meryn Louisa; Gorczynski, Chris; Basham, Kimberley A. Rutherford 2013

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Steve Morgan, PhDKate Smolina, PhDDawn Mooney, MPHColette Raymond, MSc PharmDMeryn Bowen, BSc (Pharm.) PhDChris Gorczynski, MMKim Rutherford, MSc MD CCFPThe CanadianRx AtlasThird EditionDecember 2013BritishColumbiaNewBrunswickNovaScotiaNewfoundlandand LabradorPrince Edward I.AlbertaSaskatchewanManitobaQuebecOntarioThe Canadian Rx Atlas, 3rd Edition (The Canadian Prescription Drug Atlas) was produced by: The Centre for Health Services and Policy Research University of British Columbia 201–2206 East Mall  Vancouver, BC   V6T 1Z3  Phone: 604-822-4969  Email: enquire@chspr.ubc.caYou can download this publication from our website, at www.chspr.ubc.caThis publication is protected by copyright. It may be distributed for educational and non-commercial use, provided that the UBC Centre for Health Services and Policy Research is credited.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3Contents	 4	 About	CHSPR	 4	 Acknowledgments	 5	 Introduction	 6	 Drugs	included	in	this	atlasKey	findings	 9	 Age,	sex,	and	drug	spending	 13	 Trends	in	drug	spending	 17	 Provincial	variation	in	drug	spending	 20	 Methods	 24	 How	to	read	this	atlas	Chapters	of	analysis	by	therapeutic	category	 29	 1	 Overall	(all	prescription	drugs)	 	 Cardiovascular	system	 39	 2.1	Antihypertensives	 49	 2.2	Cholesterol-lowering	drugs	 59	 2.3	Anticoagulants	 69	 2.4	Antiplatelets	 	 Nervous	system	 79	 3.1	Antidepressants	 89	 3.2	Opioids	 99	 3.3	Antipsychotics	109	 3.4	Pregabalin	and	gabapentin	119	 3.5	Drugs	for	ADHD	129	 3.6	Benzodiazepines	139	 3.7	Drugs	for	dementia	149	 3.8	Drugs	for	migraines	 	 Gastrointestinal	tract	and	metabolism	159	 4.1	Acid-reducing	drugs	169	 4.2	Drugs	for	diabetes:	Non-insulins	179	 4.3	Drugs	for	diabetes:	Insulins	 	 Antineoplastics	&	immunomodulating	agents	189	 5.1	Biologics	for	inflammatory	conditions199	 5.2	Antineoplastics	205	 5.3	Drugs	for	multiple	sclerosis	 		 	 Respiratory	system215	 6.1	Drugs	for	respiratory	conditions	 	 Anti-infectives225	 7.1	Antibiotics235	 7.2	Antiretrovirals	for	HIV	 	 Hormonal	preparations241	 8.1	Hormonal	contraceptives251	 8.2	Hormone	replacement	therapy261	 8.3	Drugs	for	hypothyroidism271	 8.4	Androgens281	 8.5	Drugs	for	female	infertility	 	 Musculo-skeletal	system291	 9.1	Non-steroidal	anti-inflammatory	drugs301	 9.2	Drugs	for	osteoporosis	 	 Genito-urinary	system311	 10.1	Drugs	for	erectile	dysfunction321	 10.2	Drugs	for	benign	prostatic	hypertrophy331	 10.3	Drugs	for	urinary	frequency	&	incontinence	 	 Sensory	organs341	 11.1	Drugs	for	glaucoma351	 10.2	Drugs	for	ocular	vascular	conditions	Appendices358	 I	 Characteristics	of	provincial	populations362	 II	 Provincial	drug	plan	comparisont h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n4About CHSPRThe Centre for Health Services and Policy Research (CHSPR) is an independent research centre based in the School of Population and Public Health of the University of British Columbia. Its mission is to stimulate scientific enquiry into health system performance, equity, and sustainability.CHSPR’s faculty members are among Canada’s leading experts in primary health care, health care funding,  variations in health services utilization, health human resources, and pharmaceutical policy. They are active in various policy-making forums and are regularly called upon to provide policy advice in British Columbia, Canada, and abroad.CHSPR promotes interdisciplinarity in its research, training, and knowledge translation activities because contem-porary problems in health care systems transcend traditional academic boundaries.The University of British Columbia provides CHSPR with core financial support. The research of CHSPR faculty, staff, and students is primarily funded through competitive, peer-reviewed grants and awards from Canadian and international funding agencies.For more information about CHSPR, please visit www.chspr.ubc.ca AcknowledgmentsThis project was made possible by a Canadian Institutes of Health Research (CIHR) operating grant entitled, “Sex, gender and equity in prescription drug access, appropriateness, and affordability.” We are grateful to the co-appli-cants and researchers working on that grant who have assisted directly and indirectly with the production of this Atlas, including Barbara Mintzes, Sean Skeldon, and Lixiang Yan.The Canadian Institute for Health Information (CIHI) supported this project with formulary data from the National Prescription Drug Utilization Information System. The information contained in this publication is derived in part from data obtained under license from IMS Health Canada Inc. We are particularly grateful for the assistance and advice provided by Allan Gillman and Josiane Gaudet at IMS.This study was not directed in any way by the CIHR, IMS, or CIHI. All results and conclusions in this report are solely those of the authors and not necessarily those of CIHR, CIHI, IMS, or any of their affiliates.Merrie-Ellen Wilcox provided professional editing that has helped to make this atlas as accessible as possible for those who will use it.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch5What	you	will	find	in	The Canadian Rx Atlas, 3rd EditionIntroductionPrescription drug spendingAs a result of increased availability and use of medi-cines to treat a wide variety of conditions, prescription drugs were one of the fastest growing components of health care spending for decades. Reflecting this, prescription drug spending in Canada grew from 6% of total health care costs in 1977 to 14% in 2007. Previous editions of the Canadian Rx Atlas docu-mented the tremendous growth in drug spending in the late 1990s through to 2007. Since then, however, the pharmaceutical sector has changed dramatically.It is still true that about three out of four Canadians fill at least one prescription this year. It is also still true the total cost of prescription drugs borne by governments, employers, unions, and patients is significant: approxi-mately $23 billion.But, after adjusting for general inflation, spending per capita on prescription drugs in Canada actually fell over the five years since 2007—despite the fact that the population was getting older. Such a decline has not occurred over any five year period since World War II.New questions arisingWith growth in prescription drugs slowing down, even dipping into the negative territory, a host of new questions arise. Which types of medicines account for the slow-down in spending? Are any drug classes  still experiencing significant growth? What is driving the changes in spending? And, if the sector is stabi-lizing, are the differences in spending levels across provinces shrinking?Despite the importance of these questions, there are surprisingly few places to turn to find answers to them. This is because very few provinces systematically collect and monitor information about the use, impact, and cost of prescription drugs. Important information can nevertheless be produced using market research data, as is done in this atlas.Illustrating first-of-kind informationThe 3rd edition of The Canadian Rx Atlas significantly enhances our understanding of medicine use by  providing the first-ever portrait of age- and sex-specific patterns of prescription drug use and costs across provinces.In the pages that follow, we quantify and illustrate dif-ferences in per capita spending by age and sex groups and across provinces as they occurred in 2012/13.For the first time, we provide estimates of the source of financing for the prescriptions filled in 2012/13 across Canada and in every province.We also illustrate the magnitude and causes of prov-ince-specific changes in per capita spending between 2007/08 and 2012/13.We present separate analyses for each of 33 clinically and economically important therapeutic categories. These are grouped by anatomical system throughout  the atlas.Evidence on popular hypothesesThis 3rd edition of The Canadian Rx Atlas provides considerable information to help readers critically assess common hypotheses about why spending is higher in some provinces than in others.The appendices also contain information about the characteristics of provincial populations that may (or may not) explain some of the findings in this atlas.We do not draw conclusions about policy or practices in this document. Instead, we hope that the data presented here will serve as a valuable guide for the policy makers, practitioners, and researchers who are best positioned to determine which areas are worthy of further investigation or potential policy intervention.t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n6Rx per 1,000 people Total (millions) Percent of totalAll drugs 14,588 508.8 100%Antihypertensives 2,503 87.3 17.2%Antidepressants 1,132 39.5 7.8%Cholesterol-lowering	drugs 1,127 39.3 7.7%Acid-reducing	drugs 861 30.0 5.9%Antibiotics 649 22.7 4.5%Drugs	for	diabetes:	non-insulins 628 21.9 4.3%Benzodiazepines 592 20.6 4.1%Drugs	for	respiratory	conditions 537 18.7 3.7%Drugs	for	hypothyroidism 505 17.6 3.5%Antipsychotics 481 16.8 3.3%Opioids 422 14.7 2.9%Non-steroidal	anti-inflammatory	drugs 327 11.4 2.2%Hormonal	contraceptives 325 11.3 2.2%Drugs	for	osteoporosis 209 7.3 1.4%Drugs	for	benign	prostatic	hypertrophy 206 7.2 1.4%Anticoagulants 196 9.0 1.3%Pregabalin	and	gabapentin 172 6.0 1.2%Hormone	replacement	therapy 164 5.7 1.1%Drugs	for	diabetes:	insulins 138 4.8 0.9%Drugs	for	glaucoma 126 4.4 0.9%Drugs	for	ADHD 120 4.2 0.8%Antiplatelets 118 4.1 0.8%Drugs	for	dementia 100 3.5 0.7%Drugs	for	urinary	frequency	and	incontinence 73 2.5 0.5%Drugs	for	erectile	dysfunction 67 2.3 0.5%Antineoplastics 47 1.6 0.3%Drugs	for	migraine 39 1.4 0.3%Antiretrovirals	for	HIV 21 0.7 0.1%Biologics	for	inflammatory	conditions 21 0.7 0.1%Androgens 15 0.5 0.1%Drugs	for	multiple	sclerosis 5 0.2 <0.1%Drugs	for	female	infertility 5 0.2 <0.1%Drugs	for	ocular	vascular	conditions 3 0.1 <0.1%Total in this atlas 11,936 $418 82%Drugs	not	assigned	to	a	chapter	in	this	atlas 2,652 $90 18%Prescription volume by therapeutic category, Canada, 2012/13Drugs included in this atlasPrescription	volumeUBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch7SpendingSpending per capita Total (millions $) Percent of totalAll drugs $656 $22,892 100%Antihypertensives $67 $2,342 10.2%Cholesterol-lowering	drugs $47 $1,643 7.2%Biologics	for	inflammatory	conditions $45 $1,554 6.8%Antidepressants $42 $1,450 6.3%Drugs	for	respiratory	conditions $39 $1,361 5.9%Acid-reducing	drugs $36 $1,253 5.5%Drugs	for	diabetes:	non-insulins $21 $748 3.3%Opioids $21 $717 3.1%Antibiotics $20 $699 3.1%Antipsychotics $20 $682 3.0%Drugs	for	diabetes:	insulins $15 $530 2.3%Hormonal	contraceptives $13 $459 2.0%Antineoplastics $13 $452 2.0%Non-steroidal	anti-inflammatory	drugs $13 $445 1.9%Antiretrovirals	for	HIV $12 $427 1.9%Pregabalin	and	gabapentin $11 $519 1.7%Drugs	for	ADHD $11 $376 1.6%Drugs	for	multiple	sclerosis $11 $368 1.6%Benzodiazepines $10 $336 1.5%Drugs	for	osteoporosis $9 $323 1.4%Anticoagulants $9 $305 1.3%Drugs	for	dementia $7 $249 1.1%Drugs	for	erectile	dysfunction $7 $238 1.0%Drugs	for	benign	prostatic	hypertrophy $6 $225 1.0%Hormone	replacement	therapy $6 $223 1.0%Drugs	for	glaucoma $6 $223 1.0%Drugs	for	hypothyroidism $6 $209 0.9%Antiplatelets $5 $185 0.8%Drugs	for	ocular	vascular	conditions $5 $181 0.8%Drugs	for	migraine $5 $164 0.7%Drugs	for	urinary	frequency	and	incontinence $4 $129 0.6%Androgens $2 $66 0.3%Drugs	for	female	infertility $1 $45 0.2%Total in this atlas $545 $19,123 83%Drugs	not	assigned	to	a	chapter	in	this	atlas $112 $3,769 17%Spending by therapeutic category, Canada, 2012/13Drugs included in this atlast h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n8Drugs included in this atlasPrescription	volume	and	spendingPrescription volume by drug type, Canada, 2012/13 Spending by drug type, Canada, 2012/13Drugs notassigned to achapter in this atlasOphthalmologicalsGenito-urinary systemMusculo-skeletal systemHormonal preparationsAnti-infectivesRespiratory systemAntineoplastics& immuno-modulatingagentsGastrointestinaltract &metabolismCardiovascularsystemNervoussystemDrugs notassigned to achapter in this atlasOphthalmologicalsGenito-urinary systemMusculo-skeletal systemHormonal preparationsAnti-infectivesRespiratory systemAntineoplastics& immuno-modulating agentsGastrointestinaltract &metabolismCardiovascularsystemNervoussystemUBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch9Age, sex, and drug spendingKey findingsSpending by drug type, Canada, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 0Age, sex, and drug spendingSex	differences	in	prescription	drug	spending	over	the	life	courseWhile average spending per capita on prescription drugs at retail pharmacies increased significantly  with age for both women and men, the level of spending and the categories of medicines on which it was spent differed considerably between sexes within each age group.Ages 0–18Among children and adolescents aged 0–18, average spending per capita on all prescription drugs was 20% higher for boys than for girls, a total difference of approximately $23 per capita. This was primarily because of higher spending per capita among boys for ADHD drugs ($29 difference). Boys also had notably higher spending per capita for asthma drugs ($4.60 difference) and antipsychotics ($3.30 difference). The only drug classes for which spending per capita was at least $1 higher for girls than boys were contraceptives ($13 difference) and antidepressants ($1.20 difference). Ages 19–39In the 19–39 age category, average spending per  capita on all prescription drugs was approximately 60% higher for women than for men, a total difference of approximately $141 per capita. A large portion of this was because only women use hormonal contraceptives ($68 difference) and drugs for female infertility ($5.90 difference). However, spending per capita was at least $5 higher among women than men for other drug categories as well, including antidepressants ($20 dif-ference), drugs for multiple sclerosis ($9.90 difference), and antibiotics ($7.90 difference), among others. Men of this age had notably higher spending per capita on antipsychotics ($11 difference) and HIV drugs  ($5.20 difference). Ages 40–64Among adults aged 40–64 years, average spending per capita on all prescription drugs was 8% higher for women than for men, a total difference of approxi-mately $64 per capita. However, this modest difference between sexes in overall spending masks significant differences in amounts spent on specific types of drug. Differences in spending per capita between women and men aged 40–64 exceeded $5 in 22 of 33 drug classes in this atlas.In the 40–64 age group, categories in which spending per capita was significantly higher for women than for men included antidepressants ($45 difference), hormone replacement therapy ($26 difference), drugs for multiple sclerosis ($20 difference), migraine treat-ments ($12 difference), and contraceptives ($11 dif-ference). Spending per capita was significantly higher for men in the categories of drugs to treat HIV ($35 difference), high cholesterol ($30 difference), erectile dysfunction ($26 difference), diabetes ($18 difference), and hypertension ($17 difference).Ages 65+Among adults aged 65+, average spending per capita on all prescription drugs was 6% higher for men than for women, a total difference of approximately $95 per capita. Differences in spending per capita between women and men aged 65+ exceeded $5 in 25 of 33 drug classes in this atlas. In 65+ age group, the categories in which spending per capita for men most significantly exceeded that for women were drugs to treat benign prostatic hyperpla-sia ($72 difference), high cholesterol ($53 difference), diabetes ($49 difference), and erectile dysfunction ($26 difference). Spending per capita was most significantly higher for women in the categories of drugs to treat osteoporosis ($71 difference), depression ($33 differ-ence), stomach acid ($23 difference), and hormone replacement therapy ($17 difference).UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 10$25$50$75$$100Age 40–640$25$50$Age 19-390$25$50$Age 0–180$25$50$125$150$75$$100$225$250$175$200Age 65+Drugs for benign prostatic hypertrophyDrugs for benign prostatic hypertrophyDrugs for osteoporosisDrugs for osteoporosisNon-steroidal anti-inflammatory drugsNon-steroidal anti-inflammatory drugsHormonal contraceptivesHormonal contraceptivesAntibioticsAntibioticsDrugs for respiratory conditionsDrugs for respiratory conditionsDrugs for multiple sclerosisDrugs for multiple sclerosisBiologics for inflammatory conditionsBiologics for inflammatory conditionsDrugs for diabetes: insulinsDrugs for diabetes: insulinsDrugs for diabetes: non-insulinsDrugs for diabetes: non-insulinsAcid-reducing drugsAcid-reducing drugsDrugs for ADHDDrugs for ADHDPregabalin and gabapentinPregabalin and gabapentinAntipsychoticsAntipsychoticsOpioidsOpioidsAntidepressantsAntidepressantsCholesterol-lowering drugsAntihypertensivesCardiovascularsystemNervoussystemGastrointestinaltract andmetabolismAnti-neoplasticand immuno-modulating agentsRespiratorysystemAnti-infectivesHormonalpreparationsMusculo-skeletalsystemGenito-urinarysystemFemales MalesPer capita spending on drugs in selected therapeutic categories, by age group and sex, Canada, 2012/13Age, sex, and drug spendingSex	differences	in	prescription	drug	spending	over	the	life	courset h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 2Biological and social influencesMany of the observed differences in prescription drug spending between women and men reflect biological differences in needs for particular treatment types. Some drug classes—such as hormone replacement therapy, contraceptives, benign prostatic hyperplasia treatments, and drugs for erectile dysfunction—are essentially sex specific. Other drug types may be used to treat conditions affecting both women and men but in different ways. For example, biological differences, including a drop in estrogen levels during menopause, predispose women to osteoporosis more than men, and thus a higher level of spending among women on drugs used to manage osteoporosis is expected. Social factors also influence sex differences in medicine use. Gender identity, relations, roles, and institutions may influence access to health care, health-seeking behaviour, the experience and perception of symptoms, the frequency of health service encounters, and interactions with healthcare professionals. For example, women are more likely to go to the doctor to seek treatment for their health conditions, which may contribute to a higher rate of diagnosis of some diseases in women. Additionally, prescribing may be influenced by the sex of the patient or the prescriber, and the parity between the two.Age, sex, and drug spendingSex	differences	in	prescription	drug	spending	over	the	life	courseUBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 3Trends in  drug spendingKey findingst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 4Trends in drug spendingCanadians spent almost $23-billion on prescription drugs at retail pharmacies in 2012/13—or over $650 per capita, according to the findings in this atlas. That is a lot of money. However, after adjusting for general inflation, spending per capita actually fell over the past five years—despite the fact that the population was getting older. The size of the fall in spending per capita was not large (about 1%) but the finding is significant. Inflation-adjusted spending per capita on prescription drugs in Canada has not declined over any five-year period since World War II. Adjusting for both inflation and the aging population gives an average change in per capita spending of -1.9% per year between 2007/08 and 2012/13.As impressive as it is, the slowdown in total spending on prescriptions in Canada masks dramatic changes in the pharmaceutical sector. Beneath the calm surface lies a rapid decline in spending on widely used medi-cines to treat relatively common conditions, and even more dramatic increases in spending on medicines used by relatively few people who suffer from  serious conditions.Five years ago, almost $9-billion—40% of all retail spending on prescription drugs—was spent on drugs to treat high blood pressure, high cholesterol, heart-burn and depression. Although these treatments only cost about a dollar per day, they are so commonly used they have been the dominant drivers of pharmaceuti-cal costs since the 1980s and 1990s.0%2%4%6%8%10%12%14%16%Share of market$500 million$3,000 millionCircle size indicates per capita spendingCircle colour indicates year2007/08 2012/13Non-steroidal anti-inflammatory drugsNon-steroidal anti-inflammatory drugsHormonal contraceptivesHormonal contraceptivesAntibioticsAntibioticsDrugs for respiratory conditionsDrugs for respiratory conditionsBiologics for inflammatory conditionsBiologics for inflammatory conditionsDrugs for diabetes: insulinsDrugs for diabetes: insulinsDrugs for diabetes: non-insulinsDrugs for diabetes: non-insulinsAcid-reducing drugsAcid-reducing drugsDrugs for ADHDDrugs for ADHDPregabalin and gabapentinPregabalin and gabapentinAntipsychoticsAntipsychoticsOpioidsOpioidsAntidepressantsAntidepressantsCholesterol-lowering drugsCholesterol-lowering drugsAntihypertensivesAntihypertensivesMarket share and spending per capita on drugs in selected therapeutic categories, Canada, 2007/08 and 2012/13Changes	in	prescription	drug	spending	between	2007/08	and	2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 5Trends in drug spendingThese drugs continue to be used frequently; however, patents on many brands of these drugs expired over the past five years and few newly-patented brands have entered the market. Thus, largely because of increased availability and use of lower-cost generics, annual spending on these previously-dominant drug classes fell by $2-billion over five years. These drugs now account for $6.7-billion in spending, or 29% of the retail prescription drug market.The most dramatic reductions in spending occurred for cholesterol-lowering drugs and antihypertensives. In these classes, age-standardized spending per capita fell by over 30% between 2007/08 and 2012/13, or greater than 9% per year.The decline in spending resulting from generic com-petition is good news if you are an uninsured patient, a company providing employees drug coverage, or a government running a public drug plan. But the budgetary relief that comes from the “genericization” of drug classes to treat common conditions won’t last long for two reasons. First, most blockbuster drugs in these classes have lost their patents. There will simply be fewer opportunities to control drug spending by switching to new generic entries on the horizon. Second, the pharmaceutical industry has already found a new revenue model. Whereas the industry’s business model was historically focused on developing drugs to be prescribed in large numbers for common condi-tions, future revenue growth in developed countries like Canada lies primarily in treatments for less common but more serious conditions.Indeed, data in this atlas show that spending on specialty drugs to treat conditions such as cancer, HIV, and multiple sclerosis has increased dramatically, mostly driven by the increased use of these drugs. The fastest growth occurred for immunosuppressants to treat inflammatory conditions such as rheumatoid arthritis and psoriasis, where spending grew by nearly $1-billion over the past five years. Rapid growth pro-pelled this class of drugs to the third largest Canada-wide, a steep climb in total market share from 2.8% in 2007/08 to 6.8% in 2012/13.Far fewer prescriptions are filled for these specialty drugs than for the blockbuster drugs of the recent  past. But the prices of the new treatments are stagger-ing. The average cost per prescription for drugs to treat inflammatory conditions was over $2,000 last year. Many new drugs now cost over $5,000  per prescription.It is worth noting that over a third of drugs currently in development by the pharmaceutical industry are specialty drugs. Thus, “niche” components of drug spending will likely be significant cost drivers for the foreseeable future. Many of the specialty drugs in the R&D pipeline, like the ones that drove recent spending in Canada, are biologics. Being the products of biological, not chemical, production processes, some of the regulatory and policy tools in place for traditional pharmaceu-ticals do not readily apply to biologic drugs. Notably, whereas policy makers have over 40 years of experi-ence encouraging the production of generic versions of chemical drugs, they have far less experience doing the same for biologics.The trend toward high-cost, specialty drugs is a global one. But it will require domestic policy responses. Pharmacare policy will need to be revisited to ensure equitable access when truly effective treatments come available. Furthermore, tough but fair drug pricing policy will need to be established to place reasonable constraints on prices charged to treat patients with serious health needs.Changes	in	prescription	drug	spending	between	2007/08	and	2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 6The scale of recent generic competitionThe figure below illustrates national savings from generic competition in drug classes wherein “block-buster” drugs recently lost patent protection. In these drug classes, Canadians saved almost $4.0-billion in 2012/13 relative to what would have been spent without increased availability and use of generic drugs and lower drug prices since 2007/08. Ontario saved the most (nearly $1.8-billion), both because of its size and aggressive generic pricing and utilization policies.Almost $3-billion of the savings in these drug classes came from increased generic availability and use. Such savings were concentrated in a few drug classes. For example, $1.1-billion was saved from generic substitutions for cholesterol-lowering drugs and nearly $1-billion for antihypertensives.Trends in drug spendingChanges	in	prescription	drug	spending	between	2007/08	and	2012/13Amount saved Canada-wide in 2012/13 from increased generic drug use and reduced drug prices relative to 2007/08 ($-millions)$0$200$400$600$800$1,000$1,200$1,400$1,600Price changesGeneric useDrugs for osteoporosisDrugs for osteoporosisAntidepressantsAntidepressantsAntipsychoticsAntipsychoticsAcid-reducing drugsAcid-reducing drugsAntihypertensivesAntihypertensivesCholesterol-lowering drugsCholesterol-lowering drugsMillions of $Price reductions generated an additional savings of roughly $1-billion for these blockbuster drug classes. Price reductions were most significant for existing antidepressants, acid reducing drugs, and antihypertensives.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 7Provincial variation in drug spendingKey findingst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 8In 2012/13, age-standardized spending per capita on prescription drugs at retail pharmacies varied greatly across provinces. Most of the provincial variation in spending was driven by differences in the volume of drugs being purchased. However, differences in spending also stemmed from differences in the choices of drugs from within therapeutic classes, differences in rates of generic drug substitution, and differences in prices paid for drug products. Across many therapeutic categories, spending per capita was lowest in British Columbia. Overall, age-standardized spending per capita in British Columbia was 27% below average spending per capita in the rest of Canada. British Columbia also had lower spending per capita in many leading drug categories, such as antihypertensives, cholesterol-lowering drugs, acid-reducing drugs, diabetes drugs, ADHD drugs, and drugs for osteoporosis. The major reason for this was that residents of British Columbia purchased lower volumes of these drugs.The level of spending was highest in Quebec, both overall as well as for the majority of drug categories included in this atlas. Compared to the rest of Canada, age-standardized spending per capita on all prescrip-tion drugs was 30% higher in Quebec. This was driven mostly by a number of factors, including the higher use of drugs in general, as well as by more expensive treatment options being prescribed by physicians, lower use of available generics, and higher unit prices for particular drug products. Generally, the highest levels of relative variation (e.g., highest coefficients of variation) were observed in age-standardized spending per capita for speciality drugs that are not commonly prescribed—such as drugs for macular degeneration or multiple sclerosis. Although there was less relative variation in spending per capita for commonly prescribed drug classes—such as cardiovascular drugs, acid-reducing drugs, and antidepressants—the total cost-impact of variations in spending on those drug types was significant.Overall cost impact of variationsThe aggregate impacts on variations in cost drivers were dramatic for some provinces. To reduce bias associated with looking at some drug classes that may be dispensed from hospitals or special clinics in some provinces but not others, the table below shows the aggregate financial impact of age-standardized differences in spending per capita in the provinces for the five largest, commonly prescribed drug classes: antihypertensives, cholesterol-lowering drugs, anti-depressants, drugs for respiratory conditions, and acid-reducing drugs.On an age-standardized basis, if the volume, choice, and price of these five high-volume drug classes were the same in Quebec as in the rest of Canada, total spending on those drugs in Quebec would be $550-million lower than was actually the case in 2012/13. Most of the difference ($255-million) was a result of higher prices paid for these drugs in Quebec, due Variation in drug spendingBC AB SK MB ON QC NB NS PE NLAntihypertensives $79.2 -$0.4 -$9.9 $0.0 $173.0 -$180.5 -$14.2 -$6.1 $0.6 -$14.5Cholesterol-lowering	drugs $97.2 $24.6 $1.9 $15.3 $18.1 -$165.0 -$3.1 -$1.7 $0.9 -$9.3Antidepressants $26.8 -$15.4 $7.2 $6.1 -$19.9 -$2.3 -$4.8 -$6.5 $0.2 -$1.9Drugs	for	respiratory	conditions $72.8 -$11.7 $5.8 $12.9 -$26.9 -$67.4 -$2.3 -$4.4 $0.4 $0.6Acid-reducing	drugs $65.4 -$0.8 $1.0 $7.4 $120.4 -$134.4 -$12.4 -$15.5 -$1.7 -$10.4Financial impact of differences in age-standardized spending per capita, Canada, 2012/13 compared to 2007/08Total	amount	more	(positive	numbers)	or	less	(negative	numbers)	that	would	have	been	spent	in	each	province	in	2012/13	if		age-standardized	spending	per	capita	on	selected	drug	classes	was	the	same	as	in	the	rest	of	Canada,	$-millionsDifferences	in	prescription	drug	spending	in	provinces	across	Canada	in	2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 9in part to higher pharmacists’ fees paid per unit of a particular drug product and lower use of available generics. Residents of Quebec also used more of these drugs and received more expensive types of drugs from within these drug classes.Conversely, if the age-standardized volume, choice, and price of these five drug classes were the same in British Columbia as in the rest of Canada, spending per capita in British Columbia would have been $341-million higher than was the case in 2012/13. Most of this difference ($291-million) was a result of British Columbia residents purchasing fewer prescription drugs on an age-standardized basis. The selection of lower cost treatment options within therapeutic cat-egories also explained a sizable amount ($73-million) of the low spending in British Columbia.Potential explanations for variationsFormulary listingsDifferences in provincial formularies do not appear  to explain provincial variation in prescription  drug spending.Ontario and Prince Edward Island listed the smallest total number of drug types across all therapeutic categories; yet age-standardized spending per capita in Ontario was slightly (4%) below the average in the rest of Canada, while in Prince Edward Island, it was on par.Overall, British Columbia listed slightly more types of prescription drugs on its formulary than did Quebec; yet, age-standardized prescription drug spending per capita was approximately 60% higher in Quebec than in British Columbia.Environment and health care systemAn examination of environmental characteristics that might explain variation in age-standardized spending per capita on prescription drugs—such as socioeco-nomic environment and health care system resources and financing—does not point to any clear causes of observed provincial variation.The two provinces that differ most in terms of age-standardized prescription drug spending per capita—British Columbia and Quebec—do not systematically differ in demographic and socioeconomic population characteristics that might explain the variation in prescription drug use and cost (see Appendix I).Demographically, these provinces differ most in immigration rates (31% for British Columbia and 14% for Quebec) and proportion of the population report-ing an Aboriginal identity (5.4% for British Columbia and 1.8% for Quebec). However, these differences alone do not explain interprovincial variations in drug spending. For example, Ontario had the same propor-tion of immigrants in 2012 as British Columbia but spent 24% per capita on prescription drugs.Health statusWhile there are some important differences, the overall health status of Quebec and British Columbia is comparable to each other, with these two provinces being some of the healthiest in Canada.According to the latest Canadian health data (see Appendix I), Quebec and BC are similar in key health status indicators, having comparable population life expectancy and mortality, both reporting good overall and mental health, and having some of the lowest rates of obesity in the country. However, health behaviours differ substantially between two provinces. British Columbia residents smoke significantly less, are more physically active, and are much more likely to get their flu shot. Regarding prevalence of specific health conditions, Quebecers have a higher disease burden of cancer and heart disease, while British Columbia residents suffer more from arthritis and mood disorders compared to Quebec residents.Variation in drug spendingDifferences	in	prescription	drug	spending	in	provinces	across	Canada	in	2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n2 0MethodsDataThe findings in this atlas are derived from data obtained under license from IMS Brogan (IMS  Health Canada Inc.), data from Statistics Canada,  and data from the Canadian Institute of Health Information (CIHI).We obtained retail sales volumes for every province from the IMS CompuScript database. These data span May 2007 to April 2013. For every province, we also obtained from IMS Rx Dynamics estimates of sales volumes stratified by age and sex and by primary payer. These stratified data span May 2012 to  April 2013.We obtained population estimates and various indica-tors of population health and health system perfor-mance from Statistics Canada and CIHI.Cost informationSales information from IMS pertains to total retail sales, including all markups and pharmacists’ fees. Our price estimates throughout this analysis therefore include the amount of pharmacists’ fees paid per unit of drugs received.In the databases used for this report, the primary payer can be government, private insurance or the patient. The primary payer is the one that made the largest contribution to the cost of a prescription, even if a par-ticular prescription was paid in part by other payers. As a result, our estimates of the source of financing are approximate. We have checked the results against financing shares reported by CIHI and have concluded that biases are small.To estimate the volume of therapy purchased in each category, we used the World Health Organization’s Defined Daily Doses (DDDs) to convert units of oral solid drugs into approximate days of therapy. We computed the average number of daily doses per prescription for drug types that had a DDD value. We then projected that number of days per prescription to all prescriptions within the relevant chapter of the atlas. We suppressed analyses of days of therapy whenever DDDs could be computed for less than 70% of relevant prescriptions.Separate from other analyses, we estimated the share of total spending in each drug class that was for pharmacists’ fees by netting out the share of spending that could reasonably be accounted for by the cost of the drugs alone. Drug costs were estimated using the maximum allowable prices listed on any provincial formulary. We excluded liquids, injectable drugs, and creams from this analysis and only report these results when our dispensing fee estimates are based on at least 70% of total sales for the respective chapter of the atlas.Therapeutic codingWe focus on therapeutic prescription-only medicines only. This excludes drugs sold over the counter, diag-nostic agents (e.g., glucose test strips), and devices.We assigned drugs into hierarchical, mutually exclu-sive groupings using the World Health Organization’s Anatomical Therapeutic Chemical (ATC) drug classification system. The ATC system groups drug products based on the anatomic system on which they act, their therapeutic properties, and their chemical characteristics.The therapeutic categories that make up the chapters of this atlas are based in part on the chemical/phar-macological sub-groups of the ATC system (e.g., ATC code A02BC = “Proton pump inhibitors”). However, we clustered some ATC groupings where they gener-ally had a common primary indication: for example, our “antihypertensives” category includes drugs from ATC groupings for thiazide diuretics, beta blockers, calcium channel blockers, angiotensin converting enzyme (ACE)-inhibitors, and angiotensin II  receptor blockers.UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 1In total, our database contained information about 10,395 drug products. IMS identified 3,472 of these as brand-name drugs, 2,429 of which were single-sourced brands. There were 6,923 generic versions of 2,123 dif-ferent drugs in the dataset; 1,086 of these were sourced only by generics. In total there were 4,559 drugs identi-fied by active ingredient and dosage. These spanned a total of 498 chemical/pharmacological sub-groups of the ATC system, which were assigned to the 34 therapeutic categories for the chapters of this atlas plus a residual category for all other drugs on the market. Determining spending levels and causesWe used economic indexes designed to separate the effect of population age on per capita spending from other determinants of spending across regions or  over time.Analyses of trends over time are based on comparisons of the 12 months from May 2007 to April 2008 to the period from May 2012 to April 2013. They apply to each province and to Canada as whole.Our analyses of variations across provinces pertain to the 12 months from May 2012 to April 2013. These analyses compare each province to the rest of Canada. This means that the comparator for Quebec (all of Canada outside Quebec) is different from the com-parator for Ontario (all of Canada outside Ontario).For analyses of trends and variations, we computed the impact of six age-standardized pharmaceutical cost drivers that fall into three broad categories: volume effects, therapeutic choice effects, and price effects.Age-standardizationThe first step in our analysis was to compare and adjust for differences in drug utilization and spending across age groups. We used direct age-standardization (based on each province’s age-specific spending profile and the rest of Canada’s age distribution) and indirect age-standardization (based on age-specific spending profile in the rest of Canada and each province’s age distribution). The geometric mean of these two measures was our final estimate of age-standardized per capita spending for each province.We did not sex-standardize the analyses because, after adjusting for population age, sex ratios do not vary significantly across provinces or over time.Age-standardized cost drivers Our methods show the impact of six factors that fall into three broad categories of pharmaceutical cost drivers: volume effects, therapeutic choice effects, and price effects. This is illustrated on the following page.Volume effectsVolume effects relate to the absolute amount of pre-scription drug therapy received by a population after adjusting for population age.These cost drivers include the “prescription volume,” which is the per capita volume of prescriptions received from the broad categories of treatment studied, and “prescription size,” which is the average amount of drug received per prescription.Differences in the age-standardized volume of therapy are not necessarily a cause for concern if driven by differences in health needs. However, differences may indicate areas of potential underuse or overuse.Therapeutic choice effectsTherapeutic choice effects relate to the average selec-tion of general and specific types of drug per course of treatment after adjusting for population age.Broad choices, referred to as “choices of drug sub-classes,” reflect the cost impact of decisions concerning the drug classes from which prescriptions are written. This includes such choices as beta blockers or ACE-inhibitors within the antihypertensives category.Methodst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n2 2Narrow choices, referred to as “choices within drug sub-classes,” reflect the selection of specific drug types within a particular drug class. This includes such choices as enalapril or ramipril within the drug class of ACE-inhibitors.Age-standardized differences in therapeutic choice effects may reflect health needs or differences in the cost-effectiveness of prescribing patterns.Price effectsPrice effects are factors that influence spending without altering the quantity or type of drug used.These cost drivers include “generic use,” which is the average savings generated by generic drug use after adjusting for population age. This will be influenced by the availability of generics, the relative price of generics versus brands, and the extent to which generics are selected when available.“Prices paid” are a cost driver that simply reflects the average price paid per unit of a given brand or generic drug product. In this study, such prices are partly determined by length of prescription written, because dispensing fees are included in our cost data.Price effects generally have no impact on the quality of health outcomes obtained per course of therapy. As such, they are common targets for policy intervention.IndexesThe results presented throughout this Canadian Rx Atlas depict the impact of age-standardized cost drivers in an additive fashion. The actual computations required to quantify the analytic framework used are based on economic indexes that interact multiplica-tively; however, for ease of reading, we have converted these indexes to an additive format using logarithms. Thus, individual cost drivers add up to the three respective sub-totals, and these sub-totals add up to the total differences observed. Provincial formulariesProvincial formularies list medicines that are eligible for public subsidy under the drug benefit programs operated by each province.Variations in the drugs listed on formularies may explain some of the interprovincial differences in prescription drug spending. We therefore determined the shares of the products within each therapeutic category that were listed on provincial formularies as of April 2013.MethodsFramework for determining the drivers of spendingAge-standardized deviation/growthDifference (across provinces or over time) in per capita spending after adjusting for population age=Volume effectsPrice effectsTherapeuticchoice effects+Prescription volumeDifference in number of prescriptions filledfrom 34 broad therapeutic categoriesPrescription sizeDifference in average number of units per prescription filled++PricesDifference in prices paid per unit of 10,395 brand and generic versions of drugsGeneric useDifference in average price paid per unit of 4,559 drugs due to use of generics++Choices of drug sub-classesDifference in average mix of 498 drug classes selected from within 34 therapeutic categoriesChoices within drug sub-classesDifference in average mix of 4,559 drugs selected from within 498 drug classesTotalUBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 3Data sourcesCIHI provided a tabulation of all provincial formulary listings from the National Prescription Drug Utiliza-tion Information System (NPDUIS). These data were current as of March 2013.Quebec does not provide data to NPDUIS. We therefore used an electronic copy of Quebec’s public formulary in August 2013 to identify which drugs were listed for public coverage in that province. For this reason, results for Quebec are simply identified as “listed” or “not listed” without details concerning possible restricted listings.The formulary data reported here pertain to all major drug plans within provinces, such as programs for social assistance recipients, senior citizens or families with high drug costs. Results do not include coverage for specific types of patients (e.g., cancer agency listings) or coverage that might be attainable through special access programs. We focus our analyses on coverage for only those medicines that might reasonably be sold across the country by excluding drugs with less than $10,000 in national sales in 2012/13.ListingsUsing the World Health Organization’s ATC therapeu-tic coding system, we grouped products according to active chemical substances (e.g., N06AB03 = fluox-etine), inclusive of all strengths and brands of a given drug. We then searched provincial formulary data to determine if any drugs within these groups were listed.A drug was deemed to have “unrestricted coverage” if at least one version of it (e.g., a generic) received unrestricted coverage under a provincial formulary. A drug was deemed to have “restricted coverage” if public subsidy was available only under certain condi-tions. For example, some provinces only cover certain medicines if a special authority request is submitted by the prescribing physician.Measures of coverageWe characterized provincial coverage with and without national expenditure weighting. The unweighted percentage of all of the drugs analyzed (in a given therapeutic category) gives the crude variety of drugs (within the therapeutic category) covered by a provin-cial formulary.To give a sense of the relative (financial) importance of drugs covered by each province, we also weighted all coverage decisions by total national sales of each drug (within the therapeutic category). While it is not always true that the economic and clinical importance of medicines are correlated, the expenditure-weighting gauges the relative importance of drugs covered, in the sense that coverage for many drugs with minimal national sales volume receives less weight than coverage of fewer drugs with greater national sales. The weighted measure is in no way intended to mean that any province in question actually does pay for the respective portions of national purchases. Estimates of the shares of drug spending covered by provincial drug plans are provided within each chapter.ReferencesThe methods used in determining spending levels and causes are based on the approach described in  the following:Morgan, S. (2005a) “Drug expenditure trends in the Canadian provinces: Magnitude and causes from 1998 to 2004.” Healthcare Policy 1(1): 85–99.Morgan, S. (2005b) “Booming prescription drug expenditure: A population-based analysis of age dynamics.” Medical Care 43(10): 996–1008.Patented Medicine Prices Review Board (2013) “The Drivers of Prescription Drug Expenditures – A Methodological Report – December 2013” Patented Medicine Prices Review Board: Ottawa.Methodst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n2 4Results by therapeutic categoryThis atlas contains 34 nine-page chapters: one chapter for all prescription drugs combined, and 33 for specific therapeutic categories, which are grouped by either how they work or what anatomical system they target. Introductory pagesThe following information is provided on the first two pages of each chapter, pictured above:1.   Summary statistics on the therapeutic category for 2012/13, including bar graphs on sales, spending, and use overall and by sex, and pie charts depicting share of total spending in this category by sex, age, and primary payer.2.   Tables listing the leading (top five) drugs by pre-scription volume and by spending, as well as spending, use, and prescription cost for single- and multi-source brand and generic drugs by sex.How to read this atlast h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales($-million)SexAge groupPrimary payerPer capita spending			2007/2008			2012/2013Per capita spending			Females			MalesPrescriptions per 1,000 population			Females			MalesDays of treatment per 1,000 population			Females			MalesEstimated cost per day of treatment			Females			MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.)Cholesterol-lowering drugs43%56%1%47%36%17%1%43%57%$1643>95%26%$77$47$40$541,0601,19041,89063,640$0.96$0.85   Percent of prescriptionsPercent of spendingAtorvastatin 43.8% 36.6%Rosuvastatin 33.3% 33.5%Simvastatin 7.2% 6.8%Ezetimibe 5.8% 12.7%Fenofi	brate 3.7% 3.2%Percent of prescriptionsPercent of spendingAtorvastatin 43.8% 36.6%Rosuvastatin 33.3% 33.5%Ezetimibe 5.8% 12.7%Simvastatin 7.2% 6.8%Fenofi	brate 3.7% 3.2%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $5.50 $8.50 70 90 $78.57 $94.44Multi-source	brand $10.40 $14.40 140 170 $74.29 $84.71Multi-source	generic $16.80 $21.20 600 630 $28.00 $33.65Sourced	only	by	generics $7.50 $10.10 260 300 $28.85 $33.67Figure	2.2b»	Share of spending by sex, age group, and payer, 2012/13Figure	2.2a»	Summary of sales, spending, and use, 2012/13Table	2.2c»	Spending, use, and cost, by drug source, 2012/13Table	2.2b»	Leading drugs, by spending, 2012/13Table	2.2a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredCholesterol-lowering drugsProvincial formulary coverageAll provinces provided restricted or unrestricted coverage for at least 10 (BC, PE) of the 14 types of cholesterol drugs that had more than $10,000 in sales in each province.Weighted by national sales, the drugs covered in all provinces accounted for 85% (BC, MB) or more of the $1.64-billion Canadian cholesterol drug market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 14 drugs covered% market value of drugsDrugs includedStatins, fi brates, bile acid sequestrants, and others.Examples of indicated conditionsHigh cholesterol and coronary artery disease.Clinical uses and considerations Cholesterol-lowering drugs are used to treat high blood cholesterol levels to help reduce the risk of acute cardiovascular events such as heart attack or stroke. Both genetic factors and diet contribute to the devel-opment of high cholesterol. Statins are the most commonly prescribed drug in this category and work to decrease the body’s endogenous cholesterol production by inhibiting a key enzyme involved in cholesterol biosynthesis. Fibrates and niacin work in several diff erent ways to alter the lipid balance in the blood. Ezetimibe and cholastyramine prevent the absorption of cholesterol and bile acids from the intestinal tract.Statins have been widely recommended and prescribed for secondary prevention aft er an initial cardiovascular event. However, the benefi t of statins in those without a history of cardiovascular events is less well established, and statin use in primary prevention remains controversial. How might usage differ across age groups?Prevalence of heart disease and elevated cholesterol increases with age, and the higher use of cholesterol-lowering drugs among older adults is expected. How might usage differ between sexes?Adult men develop heart disease on average 10 years earlier than adult women. Symptom presentation also diff ers, with women oft en experiencing atypical and less clearly cardiovascular-related symptoms. Women may therefore be less likely to be diagnosed with heart disease and to receive appropriate medication aft er an acute cardiovascular event. Historically, women have been under-represented in clinical trials for statins and studies have not shown that statin treatment reduces all-cause mortality in women.Figure	2.2c»	Percentage of drugs and their market values listed on provincial formularies, 20133.   Text summarizing key clinical information about the therapeutic category and discussing how and why use might differ by age group or by sex. Examples of drug classes or specific drugs included in the category and conditions for which these drugs may be used  are provided.4.   Stacked bar graphs illustrating information about provincial formulary coverage of drugs in the thera-peutic category. The top graph shows the percentage of all drugs in the category that were listed on each provincial formulary as of summer 2013. The bottom graph weights the same analysis by total national spending on each drug. (Note: The bottom graph gives an indication of the relative importance of drugs listed; it is not meant to suggest that provinces actually pay for those shares of drug costs.)11223344UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 5How to read this atlast h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $47 per capita on cholesterol-lowering drugs at retail pharmacies in 2012/13 ($40 for women and $54 for men). Average spending per capita was insignifi cant for children and only $2.10 for Canadians aged 19–39. Spending per capita rapidly increased with age to $58 for the 40–64 age group and $176 for the 65+ age group.Th e level of spending was higher for men than for women in all age groups. Relative to averages for women, average spending was 118% higher for men in the 19–39 age group, 72% higher for men in the 40–64 age group, and 36% higher for men in the 65+ age group. Provincial spending by age and sexAcross Canada, average spending per capita on cholesterol-lowering drugs ranged from $26 (BC) to $63 (NL) for women and from $36 (MB) to $78 (NL) for men. Diff erences in average spending per capita between women and men in each age group were roughly comparable across provinces. Age gradients were also similar across provinces, with the ratio of average spending per capita in the 65+ age group to average spending per capita overall ranging from 3.1 to 4.5.Within each age group, there was substantial variation across provinces in average spending per capita. British Columbia had the lowest average spending per capita in all age/sex groups and Newfoundland & Labrador had the highest average spending per capita in most age/sex groups. Even without those outliers, moderate provincial variation in spending remained in all age/sex groups, with lower average spending in the western provinces.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$43$152$0 $1 $0 $3$73$206Cholesterol-lowering drugsFigure	2.2e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	2.2d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch4Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada Canada$0$50NLNS PENBQCONMBSKBC AB$0$50NLNS PENBQCONMBSKBC ABFemales of all ages$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC ABFemales age 0–18$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC AB PEPEFemales age 19–39$0$50$100NLPENSNBQCONMBSKBC AB$0$50$100NLPENSNBQCONMBSKBC ABFemales age 40–640$50$100$150$200$250NLPENSNBQCONMBSKBC AB$ 0$50$100$150$200$250NLPENSNBQCONMBSKBC AB$Females age 65+Males of all agesMales age 0–18Males age 19–39Males age 40–64Males age 65+Cholesterol-lowering drugs Figure	2.2f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13Levels of spending by sex and age groupThe third and fourth pages explore levels of spending in 2012/13 by age group and sex nationally and across the provinces. The following information is provided in each chapter:5.   Text summarizing information provided in the figures on national and provincial per capita spending on drugs in the therapeutic category by age group  and sex.6.   Bar graphs illustrating national age-specific per capita spending on drugs within the therapeutic category among females and males. Bar widths are proportional to the Canadian population in each sex and age group.7.   Bar graphs illustrating provincial age-specific per capita spending on drugs within the therapeutic category among females and males. The top two graphs are for females of all ages and males of all ages; the graphs below are for specific age groups. The solid line across each set of bars indicates the value for Canada overall. 667755t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n2 6Variation in spending across CanadaThe fifth and sixth pages explore variation in per capita spending in 2012/13 across the provinces. The  following information is provided in each chapter:8.   Text discussing provincial variation in per capita spending on drugs included in the therapeutic category, the drivers of this variation, and the effect of age.9.   A table listing percent differences in per capita spending on drugs within the therapeutic category between each province and the rest of Canada (i.e., minus the province in question). The first highlighted row in the table corresponds to the map and the bar graph at the top of the following page 10. The next three highlighted rows correspond to the next three bar graphs on the following page 11 . The highlighting in the table rows utilizes the same colour classification scheme as the map and the bar graphs.The table also shows the extent to which differences in cost drivers contribute to provincial variation. Bold figures indicate subtotals of the two components for each driver. The sum of “volume effects” plus How to read this atlast h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n5Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on cholesterol-lowering drugs was driven by all three categories of cost drivers.Residents of Western Canada and Prince Edward Island purchased signifi cantly fewer drugs in this therapeutic category than other Canadians.Price eff ects signifi cantly infl uenced spending in some provinces. Residents of Saskatchewan and New-foundland & Labrador paid the highest unit prices for particular drug products in Canada, while residents of Ontario paid the lowest prices. Th erapeutic choice eff ects contributed modestly to provincial variation in age-adjusted spending per capita. Generally, the chosen mix of drugs contributed to lower levels of spending in all provinces except Quebec, where residents were prescribed a more costly mix of drugs.Population age and provincial spendingBecause spending on cholesterol-lowering drugs is so highly concentrated among older adults, diff erences in provincial population ages would predict relatively signifi cant provincial variation in spending per capita.For example, based on age diff erences alone, predicted spending per capita in Alberta would be 18% below the average for the rest of Canada; in all provinces east of Ontario, it would be 7% or more above the average for the rest of Canada.However, even aft er the fi gures were adjusted for diff erences in population age, signifi cant variation in spending per capita on cholesterol-lowering drugs remained. In Quebec and Newfoundland & Labrador, age-standardized average spending was 35% above the average for the rest of Canada, while in British Columbia it was 40% below the average for the rest of Canada.Cholesterol-lowering drugsBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $31.25 $33.61 $43.13 $32.94 $45.85 $65.13 $55.93 $54.00 $44.59 $70.29Spending	per	capita	in	rest	of	Canada $49.52 $48.79 $47.23 $47.63 $47.89 $41.69 $46.91 $46.91 $47.11 $46.75Unadjusted	difference	in	spending	per	capita -19.2% -18.2% 9.1% -5.3% -19.2% 44.1% 38.9% 21.0% 1.1% 53.5%Difference	predicted	by	population	age 5.6% -18.4% -4.6% -5.3% -1.5% 7.4% 10.6% 11.4% 7.7% 11.1%Age-standardized difference -40.2% -15.9% -4.0% -26.8% -2.8% 45.9% 7.8% 3.5% -12.3% 35.0%Volume effects -36.6% -15.2% -18.4% -20.8% 16.0% 21.4% 11.5% 11.5% -11.9% 25.6%Prescription	volume -67.5% -61.4% -5.4% -34.6% -27.0% 117.5% -34.6% -37.2% -31.8% -16.5%Prescription	size 30.9% 46.2% -13.0% 13.8% 43.0% -96.1% 46.2% 48.6% 19.9% 42.1%Therapeutic choice effects -8.8% -8.8% -2.7% -2.4% -0.4% 10.7% -11.0% -10.3% -9.3% -10.3%Choices	of	drug	sub-classes -4.4% -1.7% 4.5% -3.9% 3.8% -2.6% 0.9% 0.3% 0.6% -0.6%Choices	within	drug	sub-classes -4.4% -7.1% -7.2% 1.5% -4.2% 13.3% -11.9% -10.5% -9.9% -9.8%Price effects 5.2% 8.1% 17.2% -3.6% -18.4% 13.8% 7.2% 2.3% 9.0% 19.7%Prices	paid 5.1% 9.9% 19.3% -0.6% -19.8% 12.4% 10.1% 4.9% 11.1% 22.0%Generic	use 0.1% -1.8% -2.1% -3.0% 1.4% 1.3% -2.8% -2.6% -2.2% -2.2%Table	2.2d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch6Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Cholesterol-lowering drugsFigure	2.2h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	2.2g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-40%NewBrunswick+8%NovaScotia+3%Newfoundlandand Labrador+35%Prince Edward I.-12%Alberta-16%Saskatchewan-4%Manitoba-27% Quebec+46%Ontario-3%Volume effectsPrice effectsTherapeutic choice effects“therapeutic choice effects” plus “price effects” equals “age-standardized difference.”10. A map and a bar graph illustrating age-stan-dardized difference in per capita spending for each province when it is compared to per capita spending in the rest of Canada. The map corresponds to the first highlighted row in the table on the previous page, and the same values are also shown in the bar graph directly below the map.11. A series of bar graphs illustrating drivers of provincial variation in per capita spending, with one graph for each of the following drivers: volume effects, therapeutic choice effects, and price effects. Each bar graph depicts the extent to which age-standardized provincial differences in spending are driven by provincial differences in a specific driver.The values for each bar graph are listed and high-lighted in the table on the previous page (9) .89 111089UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 7t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n7Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $76.88 $52.50 $57.32 $60.17 $58.07 $79.74 $97.91 $85.95 $86.43 $74.69 $92.052012/13 $47.10 $31.25 $33.61 $43.13 $32.94 $45.85 $65.13 $55.93 $54.00 $44.59 $70.29Average	annual	change -9.3% -9.9% -10.1% -6.4% -10.7% -10.5% -7.8% -8.2% -9.0% -9.8% -5.3%Average	annual	change	predicted	by	aging 2.2% 2.6% 2.7% 1.1% 1.5% 2.3% 2.0% 1.7% 1.6% 2.4% 1.9%Age-standardized avg. annual change -11.3% -12.1% -12.5% -7.5% -12.0% -12.5% -9.6% -9.7% -10.4% -11.9% -7.0%Volume effects -0.6% -0.8% -0.9% 2.2% 0.8% 0.7% 0.0% 3.1% 2.1% -0.2% 3.2%Prescription	volume 1.6% -0.6% -0.7% 1.3% 0.8% 2.5% 2.1% 2.7% 1.5% -3.6% 1.2%Prescription	size -2.2% -0.2% -0.2% 0.9% 0.0% -1.8% -2.1% 0.4% 0.5% 3.4% 1.9%Therapeutic choice effects -0.8% -1.9% -2.3% -2.2% -1.3% -2.6% 0.0% -3.4% -3.5% -2.3% -3.6%Choices	of	drug	sub-classes 0.3% 0.0% 0.1% 0.3% -0.1% 0.2% 0.3% 0.2% 0.2% 0.6% 0.1%Choices	within	drug	sub-classes -1.1% -1.9% -2.4% -2.5% -1.2% -2.8% -0.3% -3.6% -3.7% -2.9% -3.7%Price effects -9.9% -9.4% -9.3% -7.6% -11.6% -10.6% -9.6% -9.4% -9.0% -9.5% -6.6%Prices	paid -0.6% -1.3% -0.8% 0.1% -0.9% -0.6% -0.7% -1.0% -1.0% -1.5% 4.1%Generic	use -9.2% -8.0% -8.5% -7.7% -10.7% -10.0% -8.9% -8.4% -8.0% -8.0% -10.7%Sources of age-standardized changeLower prices of drugs purchased was the major driver of decreased age-standardized spending per capita on cholesterol-lowering drugs across Canada. Owing mostly to savings resulting from generic substitutions, but also to lower unit prices, average prices paid for drugs decreased.Shift s in the types of drugs selected for treatment toward cheaper options contributed to a decrease in age-standardized spending per capita in all provinces except for Quebec, where there was no change in either direction.Volumes of treatment purchased either did not change or slightly increased between 2007/08 and 2012/13 in most provinces. British Columbia and Alberta were the only provinces to experience a slight decrease in volumes of purchased cholesterol-lowering drugs.Pace of change, 2007/08–2012/13At the national level, infl ation-adjusted spending per capita on retail purchases of cholesterol-lowering drugs decreased by an average of 9.3% per year between 2007/08 and 2012/13, for a total change of −39%.Spending per capita on cholesterol-lowering drugs decreased in all provinces. Th e greatest change occurred in Manitoba, where spending per capita decreased by an average of 11% per year (−43% in total). Th e smallest change, which was still consid-erable, was in Newfoundland & Labrador, where spending per capita decreased by 5.3% per year (−24% in total).Population aging alone would have caused spending per capita in the provinces to increase by 1.1% to 2.7% per year between 2007/08 and 2012/13. Th erefore, age-standardized and infl ation-adjusted spending per capita decreased by annual rates ranging from 7% (NL) to 12.5% (ON, AB).Cholesterol-lowering drugsTable	2.2e» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch8Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-12%NewBrunswick-10%NovaScotia-10%Newfoundlandand Labrador-7%Prince Edward I.-12%Alberta-12%Saskatchewan-7%Manitoba-12% Quebec-10%Ontario-13%Volume effectsPrice effectsTherapeutic choice effectsCholesterol-lowering drugsFigure	2.2j» Sources of change in age-standardized, infl ation-adjusted per capita spending, by province, 2007/08–2012/13Figure	2.2i» Age-standardized average annual rate of change in infl ation-adjusted per capita spending, by province, 2007/08–2012/13Trends in spending across CanadaThe seventh and eighth pages explore changes in per capita spending between 2007/08 and 2012/13 across the provinces. The layout of these two pages is similar to the layout of the previous two pages. The following information is provided in each chapter:12. Text discussing the changes in per capita spending on drugs included for the therapeutic category for each province between 2007/08 and 2012/13.13. A table listing percent changes in per capita spending on drugs within the therapeutic category between 2007/08 and 2012/13 for Canada and each province. The first highlighted row in the table cor-responds to the map and the bar graph at the top of the following page (14. The next three highlighted rows correspond to the next three bar graphs on the follow-ing page (15. The highlighting in the rows utilizes the same colour classification scheme as the map and the bar graphs.The table also shows the extent to which different cost drivers contributed to changes in spending over the How to read this atlasperiod. Bold figures indicate subtotals of the two com-ponents for each driver. The sum of “volume effects” plus “therapeutic choice effects” plus “price effects” equals “age-standardized average annual change.”14. A map and a bar graph illustrating average annual rate of change in per capita spending across Canada, after adjusting for inflation and changes in the popula-tion age structure in each province. The map corre-sponds to the first highlighted row in the table on the previous page, and the same values are also shown in the bar graph directly below the map.15. A series of bar graphs illustrating drivers of age-standardized rates of change in per capita spending over the period, with one graph for each of the follow-ing drivers: volume effects, therapeutic choice effects, and price effects. Each bar graph depicts the extent to which changes in spending are driven by changes in a specific driver.The values for each bar graph are listed and high-lighted in the table on the previous page (13.131513151412t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n2 8t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n9Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 86.3% 97.2% 94.8% 93.6% 88.0% 91.0% 81.3% 98.3% 95.8% 98.5% 90.1%Private	insurers 60.8% 65.3% 76.7% 77.2% 75.5% 52.4% 63.1% 86.5% 76.4% 77.9% 78.3%%-point	diff.	btw.	prov.	&	private	plans 25.6% 31.9% 18.1% 16.4% 12.5% 38.6% 18.2% 11.8% 19.4% 20.6% 11.8%Uninsured	patients	/	below	deductibles 77.7% 83.2% 80.5% 89.4% 79.7% 79.6% 70.0% 92.0% 86.5% 92.5% 83.9%%-pt.	diff.	btw.	prov.	plan	&	uninsured 8.6% 13.9% 14.3% 4.2% 8.4% 11.4% 11.3% 6.3% 9.3% 6.0% 6.2%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 16.4% 0.6% 12.5% 27.3% 10.2% 23.6% 20.1% 14.4% 12.2% 8.1% 8.4%Private	insurers 13.9% 11.3% 13.2% 17.5% 10.7% 15.4% 21.4% 18.2% 15.6% 26.5% 15.1%%-point	diff.	btw.	prov.	&	private	plans 2.5% -10.7% -0.8% 9.8% -0.5% 8.2% -1.2% -3.8% -3.4% -18.4% -6.7%Uninsured	patients	/	below	deductibles 11.8% 11.3% 14.6% 13.5% 10.7% 15.5% 13.5% 14.1% 13.6% 13.2% 13.4%%-pt.	diff.	btw.	prov.	plan	&	uninsured 4.6% -10.7% -2.1% 13.8% -0.5% 8.1% 6.6% 0.2% -1.4% -5.0% -5.0%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $0.83 $0.82 $0.89 $1.13 $0.73 $0.74 $0.77 $0.81 $0.79 $0.87 $0.87Private	insurers $0.99 $1.04 $0.95 $1.10 $0.84 $0.94 $0.86 $0.86 $0.85 $0.97 $0.97%	diff.	btw.	provincial	&	private	plans -16.0% -21.0% -6.7% 2.9% -12.9% -22.0% -10.2% -5.9% -7.0% -10.4% -9.9%Uninsured	patients	/	below	deductibles $0.88 $0.91 $0.93 $1.04 $0.83 $0.73 $0.84 $0.77 $0.79 $0.80 $0.88%	diff.	btw.	provincial	plan	&	uninsured -5.7% -10.1% -4.8% 9.2% -12.0% 0.1% -8.7% 5.5% 0.1% 7.9% -0.7%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $47.10 $31.20 $33.60 $43.10 $32.90 $45.90 $65.10 $55.90 $54.00 $44.60 $70.30%	Provincial	drug	plans 47% 30% 49% 50% 20% 47% 58% 33% 39% 40% 31%%	Private	insurance 36% 38% 36% 25% 34% 38% 28% 50% 47% 39% 51%%	Uninsured	/	below	deductibles 17% 31% 14% 22% 43% 14% 14% 15% 13% 21% 16%%	Federal	drug	plans 1% 1% 1% 3% 3% 0% 0% 1% 1% 0% 1%Public drug plans covered an estimated 48% of spending on cholesterol drugs in Canada; private drug plans covered an estimated 36%.Th e cost per day of treatment for prescriptions paid for by provincial drug plans was $0.83, 16% less than the cost per day for prescriptions paid for by private drug plans.For every 100 prescriptions for multi-sourced drugs, 26 more were fi lled with generics under public drug plans than under private drug plans.Cholesterol-lowering drugsTable	2.2i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	2.2h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	2.2g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	2.2f» Share of per capita spending by primary payer, Canada and provinces, 2012/131716Public and private spending across CanadaThe ninth page looks at the share of public and private spending in Canada and the provinces for the thera-peutic category. The following information is provided in each chapter:16. Text describing the share of per capita spending that is public (provincial and federal drug plans) and private (private insurance and uninsured/below deductible), in Canada and the provinces.17. Four tables listing share of per capita spending, average cost per day of treatment, share of spending on single-source brands, and generic substitution rate for multi-source prescriptions, each by primary payer (provincial governments, private insurers, and unin-sured or below deductible patients).How to read this atlasUBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch2 91OverallAll prescription drugst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n3 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) OverallPercent of prescriptionsPercent of spendingLevothyroxine 3.4% 0.9%Atorvastatin 3.4% 2.6%Rosuvastatin 2.6% 2.4%Metformin 2.5% 1.0%Pantoprazole 2.4% 1.7%Percent of prescriptionsPercent of spendingAtorvastatin 3.4% 2.6%Infliximab 0.0% 2.5%Rosuvastatin 2.6% 2.4%Adalimumab 0.0% 1.9%Pantoprazole 2.4% 1.7%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $346.20 $304.40 4,150 2,660 $83.42 $114.44Multi-source	brand $105.70 $94.70 2,020 1,480 $52.33 $63.99Multi-source	generic $173.60 $153.00 7,810 6,130 $22.23 $24.96Sourced	only	by	generics $71.40 $60.80 2,690 2,170 $26.54 $28.02$22,89290%$661$65616,69012,460502,240458,980$1.39$1.3443%35%20%1%54%46%14%37%4%45%$698$614Estimate not availableFigure	1b»	Share of spending by sex, age group, and payer, 2012/13Figure	1a»	Summary of sales, spending, and use, 2012/13Table	1a»	Leading drugs, by prescription volume, 2012/13Table	1c»	Spending, use, and cost, by drug source, 2012/13Table	1b»	Leading drugs, by spending, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredOverallProvincial formulary coverageProvinces provided restricted or unrestricted coverage for 65% (PE, ON) to 81% (NL) of all analyzed drugs (those with more than $10,000 in sales in each province).Weighted by national sales, the drugs covered in each province accounted for 69% (MB) to 92% (SK) of the entire $22.02-billion Canadian prescription drug market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 838 drugs covered% market value of drugsDrugs includedAll therapeutic prescription-only medicines sold at retail pharmacies across Canadian provinces are included in this chapter. This includes all drugs in the 33 chapters of this atlas that pertain to specific thera-peutic categories as well as all other drugs not assigned to a specific chapter of this report.This report excludes drugs sold over the counter, diagnostic agents (e.g., glucose test strips), and devices. It also excludes drugs received from non-retail phar-macies and other facilities, such as hospitals, cancer clinics, and many long-term care facilities.This chapter reports information about 10,395 drug products. Of these, 3,472 were identified as brand-name drugs, 2,429 of which were single-sourced brands. There were 6,923 generic versions of 2,123 dif-ferent drugs in the dataset; 1,086 of these were sourced only by generics. In total there were 4,559 drugs identi-fied by active ingredient and dosage. These spanned a total of 498 chemical/pharmacological sub-groups of the World Health Organization’s Anatomical Thera-peutic Chemical (ATC) drug classification system.How might usage differ across age groups?Although the age-specific needs for and use of medi-cines depends on the specific indications for which the drugs are prescribed, total use of and spending on medicines is expected to increase with age because of general increases in health care needs over the life-course.How might usage differ between sexes?Differences in medicine use and spending between women and men will depend, in part, on differences in the prevalence of conditions for which the drugs are prescribed. Gender identity, relations, roles, and insti-tutions may also affect spending by way of influences on access to health care, health-seeking behaviour, and interactions with healthcare professionals.Figure	1c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n3 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $656 per capita on all drugs at retail pharmacies in 2012/13 ($698 for women and $614 for men). The level of spending increased significantly with increasing age. Overall, the highest average spending per capita occurred among Canadi-ans aged 65 and older ($1,642), followed by Canadians aged 40–64 ($838).The level of spending differed for women and men depending on the age group. Average spending per capita in the 0–18 age group was 19% higher for boys than for girls. In the 19–39 age group, average spending per capita was 58% higher for women than for men. Average spending per capita in the 40–64 age group was 8% higher for women than for men. Finally, average spending in the 65+ age group was 6% higher for men than for women.Provincial spending by age and sexAcross provinces, average spending per capita ranged from $549 (BC) to $874 (NB) for women and from $473 (BC) to $769 (QC) for men. Differences in average spending per capita by age and sex were roughly comparable across provinces.British Columbia had the lowest average spending per capita in all age/sex groups, and Quebec had the highest spending in all age/sex groups except for women and men aged 19–39. Greatest variation occurred in the 0–18 age group and least variation occurred in the 40–64 age group. The level of variation across provinces within each age group was similar for women and men.Spending per capita$2,000$1,500$1,000$0 $0$500$2,000$1,500$1,000$500Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177Spending per capitaNumberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645$870$1,600$119$383$142$242$806$1,695OverallFigure	1d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13Figure	1e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0$500$1,000NLPENSNBQCONMBSKBC AB$0$500$1,000NLPENSNBQCONMBSKBC ABFemales age 40–64 Males age 40–64$0$500$1,000NLPENSNBQCONMBSKBC AB$0$500$1,000NLPENSNBQCONMBSKBC ABFemales age 19–39 Males age 19–39$0$500$1,000NLPENSNBQCONMBSKBC AB$0$500$1,000NLPENSNBQCONMBSKBC AB$0$500NLNSNBQCONMBSKBC AB PE$0$500NLNSNBQCONMBSKBC ABFemales age 0–18PEMales age 0–180$500$1,000$1,500$2,000NLPENSNBQCONMBSKBC AB$ 0$500$1,000$1,500$2,000NLPENSNBQCONMBSKBC AB$Females age 65+ Males age 65+OverallFigure	1f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n3 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationVolume effects were the most important driver of provincial variation in age-standardized spending per capita on prescription drugs. However, therapeutic choice effects and price effects also influenced provin-cial spending levels.Both of the choice-related cost drivers—the broad therapeutic mix of drug classes as well as specific drug types within a particular drug class—influenced spending, with each driver being more influential in some provinces than in others. Residents of British Columbia, who had the lowest age-standardized spending per capita, purchased fewer medicines than other Canadians and used lower cost options from within therapeutic categories. Residents of Quebec, who had the highest age-standardized spending per capita, purchased more medicines than other Canadians and paid higher unit prices for  drugs purchased, partly driven by lower use of avail-able generics.Population age and provincial spendingBecause average spending per capita on prescrip-tion drugs increases significantly with age, some of Canada’s provincial variation in retail spending on prescription drugs can be explained by differences in the ages of provincial populations.Provinces east of Ontario have older populations than the rest of Canada, and would therefore be expected to have higher spending per capita. The same is true for British Columbia. The biggest expected difference in spending due to population age alone would be for Alberta, which has the smallest share of population aged 65+.Age-standardized average per capita spending on prescription drugs in Quebec, New Brunswick, and Newfoundland & Labrador was significantly above the average in the rest of Canada, while spending in British Columbia and Manitoba was significantly below.OverallBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $511.38 $576.40 $570.81 $558.13 $631.75 $820.60 $807.30 $752.35 $651.44 $799.95Spending	per	capita	in	rest	of	Canada $678.43 $666.27 $659.02 $659.99 $671.80 $606.96 $652.95 $653.61 $656.31 $654.15Unadjusted	difference	in	spending	per	capita -24.6% -13.5% -13.4% -15.4% -6.0% 35.2% 23.6% 15.1% -0.7% 22.3%Difference	predicted	by	population	age 3.6% -10.7% -4.1% -4.3% -0.9% 4.3% 6.5% 6.8% 4.4% 7.0%Age-standardized difference -27.2% -3.1% -9.7% -11.7% -5.1% 29.6% 16.1% 7.8% -4.9% 14.2%Volume effects -23.2% -5.9% -12.0% -8.7% -0.1% 23.5% 15.4% 11.5% -1.1% 13.0%Prescription	volume -40.4% -30.6% -12.0% -19.9% -23.5% 80.3% -11.5% -22.7% -19.3% -8.2%Prescription	size 17.2% 24.7% 0.0% 11.2% 23.3% -56.8% 27.0% 34.2% 18.2% 21.2%Therapeutic choice effects -4.7% 0.7% -3.0% -7.3% 1.7% -1.6% -1.4% -2.4% -4.8% -5.9%Choices	of	drug	sub-classes -3.6% 1.3% 1.5% -2.8% 2.0% -5.4% 0.7% -0.5% -0.7% -2.5%Choices	within	drug	sub-classes -1.1% -0.6% -4.4% -4.5% -0.3% 3.9% -2.1% -1.9% -4.1% -3.4%Price effects 0.7% 2.1% 5.3% 4.4% -6.7% 7.6% 2.0% -1.3% 1.0% 7.1%Prices	paid 0.8% 3.0% 5.5% 5.4% -5.9% 5.5% 3.3% -0.4% 2.1% 8.1%Generic	use -0.1% -0.9% -0.2% -1.1% -0.7% 2.1% -1.3% -1.0% -1.1% -1.1%Table	1d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%OverallFigure	1h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	1g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-27%NewBrunswick+16%NovaScotia+8%Newfoundlandand Labrador+14%Prince Edward I.-5%Alberta-3%Saskatchewan-10%Manitoba-12% Quebec+30%Ontario-5%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n3 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $661 $514 $578 $572 $595 $671 $773 $762 $744 $709 $7092012/13 $656 $511 $576 $571 $558 $632 $821 $807 $752 $651 $800Average	annual	change -0.1% -0.1% -0.1% 0.0% -1.3% -1.2% 1.2% 1.2% 0.2% -1.7% 2.4%Average	annual	change	predicted	by	aging 1.8% 2.1% 2.4% 1.4% 1.4% 1.9% 1.6% 1.1% 1.1% 1.9% 1.2%Age-standardized avg. annual change -1.9% -2.1% -2.4% -1.4% -2.6% -3.0% -0.4% 0.0% -0.8% -3.5% 1.2%Volume effects -0.9% -1.7% -1.8% -1.6% -1.2% -1.1% 0.4% 1.3% 0.2% -1.9% 1.7%Prescription	volume 0.0% -2.2% -2.0% -1.8% -0.6% -0.2% 1.6% 1.3% -0.3% -2.3% 0.3%Prescription	size -0.9% 0.6% 0.3% 0.2% -0.6% -0.9% -1.2% 0.0% 0.6% 0.4% 1.4%Therapeutic choice effects 2.2% 2.1% 1.8% 2.1% 1.0% 1.9% 2.2% 1.9% 2.0% 1.5% 2.0%Choices	of	drug	sub-classes 1.9% 2.1% 1.7% 2.2% 1.1% 1.7% 2.1% 2.3% 2.7% 2.0% 2.5%Choices	within	drug	sub-classes 0.3% 0.1% 0.1% -0.2% -0.1% 0.2% 0.1% -0.5% -0.7% -0.5% -0.5%Price effects -3.2% -2.6% -2.5% -1.9% -2.4% -3.9% -2.9% -3.1% -3.1% -3.2% -2.5%Prices	paid -0.5% -0.5% -0.1% 0.3% -0.1% -0.9% -0.2% -1.1% -1.1% -1.3% 0.3%Generic	use -2.7% -2.1% -2.3% -2.2% -2.3% -3.0% -2.8% -2.0% -2.0% -1.9% -2.7%Sources of age-standardized changeThe major driver of the decrease in age-standardized average spending on prescription drugs in many prov-inces was lower prices of drugs purchased. Average prices paid for prescription drugs decreased across Canada, mostly as a result of generic substitutions.However, the effects of lower prices were countered by changes in the types of drugs selected for treatment, with more expensive options being chosen in 2012/13 than in 2007/08 in all provinces.Changes in the volumes of prescription drugs purchased also contributed to changes in average spending, but the volume effects were inconsistent across the country.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of prescription drugs decreased by an average of 0.1% per year between 2007/08 and 2012/13, for a total change of just −0.7%.Although spending per capita on prescription drugs was virtually unchanged at the national level, spending decreased in some provinces and increased in others. In Prince Edward Island, spending decreased by an average of 1.7% per year (−8.1% in total). In contrast, spending in Newfoundland & Labrador increased by an average of 2.4% per year (13% in total). Population aging alone would have caused per capita retail spending in the provinces to rise by 1.1% to 2.4% per year between 2007/08 and 2012/13. Therefore, age-standardized, inflation-adjusted annual rates of change in retail spending on prescription drugs ranged from −3.5% (PE) to 1.2% (NL).OverallTable	1e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-2%NewBrunswick0%NovaScotia-1%Newfoundlandand Labrador+1%Prince Edward I.-4%Alberta-2%Saskatchewan-1%Manitoba-3% Quebec0%Ontario-3%Volume effectsPrice effectsTherapeutic choice effectsOverallFigure	1j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	1i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n3 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 84.7% 88.6% 86.9% 82.4% 86.0% 87.2% 86.5% 83.7% 85.8% 79.2% 83.6%Private	insurers 71.1% 73.8% 75.2% 74.2% 78.7% 70.1% 71.0% 76.8% 75.3% 74.9% 76.6%%-point	diff.	btw.	prov.	&	private	plans 13.6% 14.7% 11.6% 8.3% 7.4% 17.1% 15.5% 6.9% 10.5% 4.4% 7.0%Uninsured	patients	/	below	deductibles 76.6% 78.6% 74.3% 79.5% 82.1% 77.7% 68.7% 82.1% 78.8% 83.9% 80.0%%-pt.	diff.	btw.	prov.	plan	&	uninsured 8.2% 10.0% 12.6% 3.0% 3.9% 9.5% 17.8% 1.6% 7.1% -4.7% 3.6%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 49.3% 48.3% 45.7% 50.9% 53.0% 53.9% 51.0% 43.4% 42.1% 47.1% 36.0%Private	insurers 52.2% 47.1% 52.5% 40.3% 37.9% 55.1% 58.9% 51.0% 52.2% 47.8% 48.1%%-point	diff.	btw.	prov.	&	private	plans -2.9% 1.2% -6.8% 10.5% 15.0% -1.2% -7.9% -7.6% -10.1% -0.7% -12.0%Uninsured	patients	/	below	deductibles 45.5% 43.4% 49.1% 37.9% 34.5% 49.3% 52.2% 43.2% 46.7% 34.4% 40.1%%-pt.	diff.	btw.	prov.	plan	&	uninsured 3.8% 4.9% -3.4% 13.0% 18.5% 4.6% -1.2% 0.2% -4.7% 12.7% -4.0%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $1.34 $1.36 $1.21 $1.46 $1.94 $1.19 $1.21 $1.24 $1.05 $1.14 $0.97Private	insurers $1.42 $1.17 $1.34 $1.18 $1.05 $1.37 $1.35 $1.29 $1.30 $1.25 $1.28%	diff.	btw.	provincial	&	private	plans -5.5% 16.1% -9.4% 23.3% 86.0% -13.7% -10.9% -4.4% -19.3% -9.1% -24.0%Uninsured	patients	/	below	deductibles $1.21 $1.04 $1.33 $1.09 $0.98 $1.16 $1.26 $1.03 $1.15 $0.86 $1.06%	diff.	btw.	provincial	plan	&	uninsured 10.8% 29.9% -9.1% 33.6% 97.6% 2.0% -4.2% 19.5% -9.0% 31.9% -8.3%Overall, public (provincial and federal) drug plans covered an estimated 44% of spending on all drugs in Canada; private drug plans covered an estimated 35%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $1.34, 5% less than the cost per day for prescriptions paid for by private drug plans.For every 100 prescriptions for multi-sourced drugs, 14 more were filled with generics under public drug plans than under private drug plans.OverallCAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $656 $511 $576 $571 $558 $632 $821 $807 $752 $651 $800%	Provincial	drug	plans 43% 36% 42% 47% 37% 42% 49% 31% 33% 32% 30%%	Private	insurance 35% 30% 37% 23% 25% 38% 33% 49% 50% 44% 51%%	Uninsured	/	below	deductibles 20% 32% 19% 25% 33% 19% 18% 18% 16% 23% 19%%	Federal	drug	plans 1% 2% 2% 5% 5% 1% 0% 1% 1% 0% 1%Table	1f» Share of per capita spending by primary payer, Canada and provinces, 2012/13Table	1h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	1g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	1i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch3 92.1Cardiovascular systemAntihypertensivest h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n4 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.)Antihypertensives$2,34239%58%2%50%29%20%1%50%50%>95%35%$99$67$67$672,7202,290121,100129,990$0.55$0.52Percent of prescriptionsPercent of spendingAmlodipine 12.2% 12.2%Ramipril 10.6% 9.2%Metoprolol 9.1% 4.7%Hydrochlorothiazide 8.3% 3.1%Bisoprolol 5.9% 2.5%Percent of prescriptionsPercent of spendingAmlodipine 12.2% 12.2%Ramipril 10.6% 9.2%Perindopril 4.6% 8.5%Nifedipine 3.7% 6.3%Diltiazem 3.5% 5.1%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $13.00 $13.90 270 250 $48.15 $55.60Multi-source	brand $12.20 $12.10 230 210 $53.04 $57.62Multi-source	generic $30.10 $30.90 1,550 1,320 $19.42 $23.41Sourced	only	by	generics $11.60 $10.40 660 500 $17.58 $20.80Figure	2.1b»	Share of spending by sex, age group, and payer, 2012/13Figure	2.1a»	Summary of sales, spending, and use, 2012/13Table	2.1c»	Spending, use, and cost, by drug source, 2012/13Table	2.1b»	Leading drugs, by spending, 2012/13Table	2.1a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch4 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredAntihypertensivesProvincial formulary coverageNearly all provinces provided restricted or unre-stricted coverage for at least 51 (QC) of the 62 types of antihypertensive drugs that had at least $10,000 in sales in each province. Only British Columbia provided restricted coverage for a significant number of antihypertensive drugs. (Note: the level of restrictions on drugs covered in Quebec is unknown.)Weighted by national sales, the drugs covered in each province accounted for 93% (QC) or more of the $2.33-billion Canadian antihypertensive market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 62 drugs covered% market value of drugsDrugs includedBeta blockers, calcium channel blockers, angiotensin converting enzyme inhibitors, and others.Examples of indicated conditionsHypertension (high blood pressure).Clinical uses and considerations Antihypertensives are primarily used to treat high blood pressure in an effort to reduce the risk of acute cardiovascular events such as heart attack or stroke. Factors contributing to high blood pressure include smoking, a high-salt diet, high alcohol intake, obesity, high cholesterol, lack of physical activity, and genetic predisposition. Hypertension may also be secondary to other medical conditions.Antihypertensives work to reduce blood pressure through a variety of mechanisms that target different organ systems, including the heart, kidneys, and blood vessels. Many of these drugs are also used to manage other conditions and associated symptoms, includ-ing peripheral vascular disease, chronic renal failure, congestive heart failure, and cardiac arrhythmias. How might usage differ across age groups?The use of antihypertensives increases with age, paralleling the increasing prevalence with age of both hypertension and many of its risk factors. How might usage differ between sexes?Men are more likely to develop hypertension at an earlier age than women, but there is a higher incidence of hypertension in the older ages among women than men. The rate of complications due to high blood pressure is significantly lower in women than men at comparable blood pressures. For example, hyper-tensive women have a lower incidence of coronary artery disease. Women are more likely than men to have contact with the health care system and therefore receive a diagnosis of hypertension through routine checkups. However, women and men are equally likely to receive and respond to treatment once the diagnosis is made.Figure	2.1c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n4 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $67 per capita on antihypertensive drugs at retail pharmacies in 2012/13. Spending was highly concentrated in the older age groups. Average spending per capita in the 65+ age group ($263) was more than three times the average for the 40–64 age group and more than 50 times the average for the 19–39 age group.Average spending per capita within age groups was higher for men than for women. Age-specific dif-ferences in spending per capita between sexes were greatest (approximately 26%) for the 19–39 and 40–64 age groups. However, because a greater  share of women lives to the high-spending  ages of 65 and older, women and men had  similar overall average levels of spending  per capita on antihypertensive drugs.Provincial spending by age and sexAcross provinces, average spending per capita on antihypertensive drugs ranged from $56 (BC) to $102 (NL). Age-related patterns of spending were similar across provinces. Moreover, in all provinces age-specific spending levels were higher for men than for women, but overall averages for women and men were approximately equal (because more women live to age 65 and older).In all age/sex groups, average spending per capita was lowest in British Columbia and highest in Newfound-land & Labrador. Greatest variation occurred in the 19–39 age group (coefficient of variation:  33%) and least variation occurred in the  65+ age group (coefficient of variation:  14%). The level of variation across provinces  within each age group was similar for  women and men.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$67$260$1$4$1$5$84$268AntihypertensivesFigure	2.1e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	2.1d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch4 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada Canada$0$100NLNS PENBQCONMBSKBC AB$0$100NLNS PENBQCONMBSKBC ABFemales of all ages Males of all ages$0$100$200NLPENSNBQCONMBSKBC AB$0$100$200NLPENSNBQCONMBSKBC ABFemales age 40–64 Males age 40–640$100$200$300$400NLPENSNBQCONMBSKBC AB$ 0$100$200$300$400NLPENSNBQCONMBSKBC AB$Females age 65+ Males age 65+$0$100NLNSNBQCONMBSKBC AB PE$0$100NLNSNBQCONMBSKBC ABFemales age 0–18PEMales age 0–18$0$100NLNSNBQCONMBSKBC AB PE$0$100NLNSNBQCONMBSKBC AB PEFemales age 19–39 Males age 19–39AntihypertensivesFigure	2.1f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n4 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationVolume effects and price effects were the most impor-tant drivers of provincial variation in age-standardized average retail spending on antihypertensives.While prices were the key cost driver of the higher level of spending in Quebec, volume effects accounted for most of the higher spending observed in New Brunswick and Newfoundland & Labrador. On the other hand, the lower level of spending in Ontario was driven largely by price effects, while in British Columbia the lower level of spending was driven largely by volume effects. Residents of Quebec were less likely than other Canadians to receive available generics.Therapeutic choice effects contributed modestly to provincial variation in age-adjusted spending per capita on antihypertensives.Population age and provincial spendingBecause of the very steep age gradient in spending on antihypertensive drugs, differences in provincial population ages would predict relatively significant provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 18% below the average for the rest of Canada; in Nova Scotia, it would be 11% above the average for the rest of Canada.However, even after the figures were adjusted for population age, spending levels in several provinces differed significantly from the average for the rest of Canada. In Quebec, New Brunswick, and Newfound-land & Labrador, age-standardized average spending was more than 25% above the average for the rest of Canada. In British Columbia and Ontario, it was  24% and 17% below the average for the rest of  Canada, respectively.AntihypertensivesBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $55.65 $56.04 $73.09 $63.69 $58.64 $87.84 $92.49 $80.79 $67.89 $102.26Spending	per	capita	in	rest	of	Canada $68.91 $68.54 $66.96 $67.28 $72.54 $60.94 $66.59 $66.77 $67.15 $66.63Unadjusted	difference	in	spending	per	capita -19.2% -18.2% 9.1% -5.3% -19.2% 44.1% 38.9% 21.0% 1.1% 53.5%Difference	predicted	by	population	age 5.6% -18.4% -4.6% -5.3% -1.5% 7.4% 10.6% 11.4% 7.7% 11.1%Age-standardized difference -23.5% 0.2% 14.4% 0.0% -17.9% 34.3% 25.6% 8.6% -6.1% 38.2%Volume effects -16.9% -1.2% -6.6% -7.1% 5.3% 3.7% 20.8% 12.5% 0.1% 30.1%Prescription	volume -52.5% -49.7% 6.4% -22.1% -28.7% 99.3% -26.7% -34.6% -47.3% -14.5%Prescription	size 35.6% 48.5% -13.0% 15.1% 33.9% -95.6% 47.4% 47.1% 47.4% 44.6%Therapeutic choice effects -6.5% 0.7% 7.9% -0.7% -2.5% 3.3% 3.1% -0.9% -4.4% 0.7%Choices	of	drug	sub-classes -3.2% 2.0% 6.1% -2.2% -1.1% 2.4% -2.2% -2.8% -3.5% -5.6%Choices	within	drug	sub-classes -3.3% -1.3% 1.8% 1.5% -1.4% 0.9% 5.3% 2.0% -0.9% 6.3%Price effects -0.2% 0.7% 13.0% 7.7% -20.7% 27.3% 1.7% -3.0% -1.8% 7.4%Prices	paid 0.0% 3.0% 16.1% 10.9% -17.5% 19.4% 4.9% 0.2% 0.4% 10.2%Generic	use -0.2% -2.3% -3.1% -3.2% -3.2% 7.8% -3.2% -3.2% -2.3% -2.8%Table	2.1d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch4 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%AntihypertensivesFigure	2.1h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	2.1g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-24%NewBrunswick+26%NovaScotia+9%Newfoundlandand Labrador+38%Prince Edward I.-6%Alberta0%Saskatchewan+14%Manitoba0% Quebec+34%Ontario-18%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n4 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $98.74 $76.99 $80.64 $106.22 $97.62 $95.61 $119.79 $111.62 $116.92 $113.00 $121.092012/13 $67.15 $55.65 $56.04 $73.09 $63.69 $58.64 $87.84 $92.49 $80.79 $67.89 $102.26Average	annual	change -7.4% -6.3% -7.0% -7.2% -8.2% -9.3% -6.0% -3.7% -7.1% -9.7% -3.3%Average	annual	change	predicted	by	aging 2.3% 2.6% 2.7% 1.2% 1.5% 2.3% 2.2% 1.7% 1.7% 2.4% 2.0%Age-standardized avg. annual change -9.5% -8.7% -9.5% -8.3% -9.5% -11.4% -8.0% -5.3% -8.7% -11.8% -5.2%Volume effects -2.4% -2.6% -2.8% -2.3% -2.1% -2.5% -1.8% -0.6% -2.1% -4.5% -0.7%Prescription	volume -1.2% -2.8% -2.8% -3.0% -2.1% -0.9% -0.3% -0.5% -2.7% -4.3% -2.6%Prescription	size -1.2% 0.2% 0.0% 0.6% -0.1% -1.6% -1.5% -0.1% 0.6% -0.2% 1.9%Therapeutic choice effects -0.2% -0.3% -0.2% -0.2% -1.4% -0.2% -0.8% 1.3% 0.0% -0.3% 0.3%Choices	of	drug	sub-classes 0.5% 0.7% 0.8% 0.7% -0.1% 0.7% 0.4% 1.1% 0.7% 0.7% 0.5%Choices	within	drug	sub-classes -0.7% -1.0% -1.0% -0.9% -1.3% -0.8% -1.2% 0.2% -0.7% -1.1% -0.2%Price effects -6.9% -5.8% -6.5% -5.7% -6.0% -8.7% -5.4% -6.1% -6.6% -7.0% -4.9%Prices	paid -1.4% -2.0% -1.1% -1.1% -0.8% -2.0% -0.6% -2.0% -1.7% -2.1% -1.6%Generic	use -5.5% -3.8% -5.4% -4.6% -5.2% -6.7% -4.8% -4.1% -4.9% -4.9% -3.3%Sources of age-standardized changeLower prices of drugs purchased was the major driver of the decrease in age-standardized spending on antihypertensive drugs across Canada, particularly in Ontario. Owing mostly to savings resulting from generic substitutions, but also to lower unit prices, average prices paid for antihypertensive drugs decreased.Decreasing volumes of treatment purchased also contributed to a decrease in average spending in all provinces, particularly in Prince Edward Island.Changes in the types of drugs selected for treatment had little influence on changes in spending.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of antihypertensive drugs decreased by an average of 7.4% per year between 2007/08 and 2012/13, for a total change of −32%.Spending per capita on antihypertensive drugs decreased in all provinces. The greatest change occurred in Prince Edward Island, with an average decrease of 9.7% per year (−40% in total). Newfound-land & Labrador experienced the smallest change, with an average decrease of 3.3% per year (−16% in total).Population aging alone would have caused spending per capita in the provinces to increase by 1.2% to 2.7% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted spending per capita decreased by annual rates ranging from 5.2% (NL) to 11.8% (PE).AntihypertensivesTable	2.1e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch4 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-9%NewBrunswick-5%NovaScotia-9%Newfoundlandand Labrador-5%Prince Edward I.-12%Alberta-9%Saskatchewan-8%Manitoba-10% Quebec-8%Ontario-11%Volume effectsPrice effectsTherapeutic choice effectsAntihypertensivesFigure	2.1j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	2.1i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n4 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 88.1% 93.8% 89.8% 85.4% 90.2% 90.4% 90.4% 89.8% 89.5% 91.2% 87.7%Private	insurers 82.0% 86.6% 84.9% 84.2% 87.2% 84.0% 84.0% 87.6% 86.0% 89.0% 86.2%%-point	diff.	btw.	prov.	&	private	plans 6.1% 7.2% 4.9% 1.2% 3.1% 6.5% 6.4% 2.2% 3.5% 2.2% 1.5%Uninsured	patients	/	below	deductibles 84.3% 87.2% 80.7% 88.0% 87.7% 88.1% 84.2% 90.6% 86.3% 94.1% 88.5%%-pt.	diff.	btw.	prov.	plan	&	uninsured 3.8% 6.6% 9.0% -2.6% 2.6% 2.3% 6.2% -0.8% 3.2% -2.9% -0.9%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 20.4% 15.3% 18.6% 21.8% 13.2% 25.0% 23.8% 19.7% 18.0% 16.6% 18.7%Private	insurers 21.7% 20.0% 22.2% 23.0% 17.0% 24.9% 26.8% 23.5% 22.3% 20.5% 22.1%%-point	diff.	btw.	prov.	&	private	plans -1.3% -4.6% -3.6% -1.2% -3.9% 0.2% -3.1% -3.7% -4.3% -3.9% -3.4%Uninsured	patients	/	below	deductibles 18.7% 18.2% 22.5% 16.6% 15.4% 22.0% 25.8% 19.7% 19.8% 12.7% 19.3%%-pt.	diff.	btw.	prov.	plan	&	uninsured 1.7% -2.8% -3.9% 5.2% -2.2% 3.0% -2.0% 0.1% -1.7% 3.9% -0.7%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $0.53 $0.44 $0.54 $0.65 $0.59 $0.44 $0.45 $0.56 $0.54 $0.52 $0.55Private	insurers $0.57 $0.47 $0.55 $0.64 $0.56 $0.48 $0.48 $0.54 $0.56 $0.50 $0.57%	diff.	btw.	provincial	&	private	plans -6.3% -6.5% -2.8% 1.5% 4.5% -7.4% -6.2% 3.2% -3.7% 5.2% -4.4%Uninsured	patients	/	below	deductibles $0.53 $0.46 $0.58 $0.60 $0.57 $0.43 $0.49 $0.48 $0.54 $0.43 $0.53%	diff.	btw.	provincial	plan	&	uninsured -0.5% -4.4% -6.5% 7.8% 4.0% 3.6% -8.0% 15.2% -0.3% 22.4% 3.4%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $67.20 $55.60 $56.00 $73.10 $63.70 $58.60 $87.80 $92.50 $80.80 $67.90 $102.30%	Provincial	drug	plans 50% 34% 53% 48% 22% 53% 61% 35% 44% 46% 37%%	Private	insurance 29% 29% 30% 22% 30% 29% 24% 45% 41% 30% 43%%	Uninsured	/	below	deductibles 20% 35% 15% 26% 45% 17% 15% 19% 15% 23% 18%%	Federal	drug	plans 1% 1% 1% 3% 3% 1% 0% 1% 1% 1% 1%Public (provincial and federal) drug plans covered  an estimated 51% of spending on antihypertensive drugs in Canada; private drug plans covered an estimated 29%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $0.53, 6% less than the cost per day for prescriptions paid for by private drug plans.AntihypertensivesTable	2.1i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	2.1h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	2.1g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	2.1f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch4 92.2Cholesterol-lowering drugsCardiovascular systemt h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n5 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.)Cholesterol-lowering drugs43%56%1%47%36%17%1%43%57%$1643>95%26%$77$47$40$541,0601,19041,89063,640$0.96$0.85   Percent of prescriptionsPercent of spendingAtorvastatin 43.8% 36.6%Rosuvastatin 33.3% 33.5%Simvastatin 7.2% 6.8%Ezetimibe 5.8% 12.7%Fenofibrate 3.7% 3.2%Percent of prescriptionsPercent of spendingAtorvastatin 43.8% 36.6%Rosuvastatin 33.3% 33.5%Ezetimibe 5.8% 12.7%Simvastatin 7.2% 6.8%Fenofibrate 3.7% 3.2%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $5.50 $8.50 70 90 $78.57 $94.44Multi-source	brand $10.40 $14.40 140 170 $74.29 $84.71Multi-source	generic $16.80 $21.20 600 630 $28.00 $33.65Sourced	only	by	generics $7.50 $10.10 260 300 $28.85 $33.67Figure	2.2b»	Share of spending by sex, age group, and payer, 2012/13Figure	2.2a»	Summary of sales, spending, and use, 2012/13Table	2.2b»	Leading drugs, by spending, 2012/13Table	2.2c»	Spending, use, and cost, by drug source, 2012/13Table	2.2a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch5 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredCholesterol-lowering drugsProvincial formulary coverageAll provinces provided restricted or unrestricted coverage for at least 10 (BC, PE) of the 14 types of cholesterol drugs that had more than $10,000 in sales in each province.Weighted by national sales, the drugs covered in all provinces accounted for 85% (BC, MB) or more of the $1.64-billion Canadian cholesterol drug market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 14 drugs covered% market value of drugsDrugs includedStatins, fibrates, bile acid sequestrants, and others.Examples of indicated conditionsHigh cholesterol and coronary artery disease.Clinical uses and considerations Cholesterol-lowering drugs are used to treat high blood cholesterol levels to help reduce the risk of acute cardiovascular events such as heart attack or stroke. Both genetic factors and diet contribute to the devel-opment of high cholesterol. Statins are the most commonly prescribed drug in this category and work to decrease the body’s endogenous cholesterol production by inhibiting a key enzyme involved in cholesterol biosynthesis. Fibrates and niacin work in several different ways to alter the lipid balance in the blood. Ezetimibe and cholastyramine prevent the absorption of cholesterol and bile acids from the intestinal tract.Statins have been widely recommended and prescribed for secondary prevention after an initial cardiovascular event. However, the benefit of statins in those  without a history of cardiovascular events is less well established, and statin use in primary prevention remains controversial. How might usage differ across age groups?Prevalence of heart disease and elevated cholesterol increases with age, and the higher use of cholesterol-lowering drugs among older adults is expected. How might usage differ between sexes?Adult men develop heart disease on average 10 years earlier than adult women. Symptom presentation also differs, with women often experiencing atypical and less clearly cardiovascular-related symptoms. Women may therefore be less likely to be diagnosed with heart disease and to receive appropriate medication after an acute cardiovascular event. Historically, women have been under-represented  in clinical trials for statins and studies have not  shown that statin treatment reduces all-cause  mortality in women.Figure	2.2c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n5 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $47 per capita on cholesterol-lowering drugs at retail pharmacies in 2012/13 ($40 for women and $54 for men). Average spending per capita was insignificant for children and only $2.10 for Canadians aged 19–39. Spending per capita rapidly increased with age to $58 for the 40–64 age group and $176 for the 65+ age group.The level of spending was higher for men than for women in all age groups. Relative to averages for women, average spending was 118% higher for men in the 19–39 age group, 72% higher for men in the  40–64 age group, and 36% higher for men in the 65+ age group. Provincial spending by age and sexAcross Canada, average spending per capita on cholesterol-lowering drugs ranged from $26 (BC) to $63 (NL) for women and from $36 (MB) to $78 (NL) for men. Differences in average spending per capita between women and men in each age group were roughly comparable across provinces. Age gradients were also similar across provinces, with the ratio of average spending per capita in the 65+ age group to average spending per capita overall ranging from 3.1 to 4.5.Within each age group, there was substantial variation across provinces in average spending per capita. British Columbia had the lowest average spending per capita in all age/sex groups and Newfoundland & Labrador had the highest average spending per capita in most age/sex groups. Even without those outliers, moderate provincial variation in spending remained  in all age/sex groups, with lower average  spending in the western provinces.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$43$152$0 $1 $0 $3$73$206Cholesterol-lowering drugsFigure	2.2e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	2.2d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch5 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada Canada$0$50NLNS PENBQCONMBSKBC AB$0$50NLNS PENBQCONMBSKBC ABFemales of all ages$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC ABFemales age 0–18$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC AB PEPEFemales age 19–39$0$50$100NLPENSNBQCONMBSKBC AB$0$50$100NLPENSNBQCONMBSKBC ABFemales age 40–640$50$100$150$200$250NLPENSNBQCONMBSKBC AB$ 0$50$100$150$200$250NLPENSNBQCONMBSKBC AB$Females age 65+Males of all agesMales age 0–18Males age 19–39Males age 40–64Males age 65+Cholesterol-lowering drugs Figure	2.2f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n5 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on cholesterol-lowering drugs was driven by all three categories of cost drivers.Residents of Western Canada and Prince Edward Island purchased significantly fewer drugs in this therapeutic category than other Canadians.Price effects significantly influenced spending in some provinces. Residents of Saskatchewan and New-foundland & Labrador paid the highest unit prices for particular drug products in Canada, while residents of Ontario paid the lowest prices. Therapeutic choice effects contributed modestly to provincial variation in age-adjusted spending per capita. Generally, the chosen mix of drugs contributed to lower levels of spending in all provinces except Quebec, where residents were prescribed a more costly mix of drugs.Population age and provincial spendingBecause spending on cholesterol-lowering drugs is so highly concentrated among older adults, differences in provincial population ages would predict relatively significant provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 18% below the average for the rest of Canada; in all provinces east of Ontario, it would be 7% or more above the average for the rest of Canada.However, even after the figures were adjusted for differences in population age, significant variation in spending per capita on cholesterol-lowering drugs remained. In Quebec and Newfoundland & Labrador, age-standardized average spending was 35% above the average for the rest of Canada, while in British Columbia it was 40% below the average for the rest  of Canada.Cholesterol-lowering drugsBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $31.25 $33.61 $43.13 $32.94 $45.85 $65.13 $55.93 $54.00 $44.59 $70.29Spending	per	capita	in	rest	of	Canada $49.52 $48.79 $47.23 $47.63 $47.89 $41.69 $46.91 $46.91 $47.11 $46.75Unadjusted	difference	in	spending	per	capita -19.2% -18.2% 9.1% -5.3% -19.2% 44.1% 38.9% 21.0% 1.1% 53.5%Difference	predicted	by	population	age 5.6% -18.4% -4.6% -5.3% -1.5% 7.4% 10.6% 11.4% 7.7% 11.1%Age-standardized difference -40.2% -15.9% -4.0% -26.8% -2.8% 45.9% 7.8% 3.5% -12.3% 35.0%Volume effects -36.6% -15.2% -18.4% -20.8% 16.0% 21.4% 11.5% 11.5% -11.9% 25.6%Prescription	volume -67.5% -61.4% -5.4% -34.6% -27.0% 117.5% -34.6% -37.2% -31.8% -16.5%Prescription	size 30.9% 46.2% -13.0% 13.8% 43.0% -96.1% 46.2% 48.6% 19.9% 42.1%Therapeutic choice effects -8.8% -8.8% -2.7% -2.4% -0.4% 10.7% -11.0% -10.3% -9.3% -10.3%Choices	of	drug	sub-classes -4.4% -1.7% 4.5% -3.9% 3.8% -2.6% 0.9% 0.3% 0.6% -0.6%Choices	within	drug	sub-classes -4.4% -7.1% -7.2% 1.5% -4.2% 13.3% -11.9% -10.5% -9.9% -9.8%Price effects 5.2% 8.1% 17.2% -3.6% -18.4% 13.8% 7.2% 2.3% 9.0% 19.7%Prices	paid 5.1% 9.9% 19.3% -0.6% -19.8% 12.4% 10.1% 4.9% 11.1% 22.0%Generic	use 0.1% -1.8% -2.1% -3.0% 1.4% 1.3% -2.8% -2.6% -2.2% -2.2%Table	2.2d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch5 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Cholesterol-lowering drugsFigure	2.2h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	2.2g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-40%NewBrunswick+8%NovaScotia+3%Newfoundlandand Labrador+35%Prince Edward I.-12%Alberta-16%Saskatchewan-4%Manitoba-27% Quebec+46%Ontario-3%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n5 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $76.88 $52.50 $57.32 $60.17 $58.07 $79.74 $97.91 $85.95 $86.43 $74.69 $92.052012/13 $47.10 $31.25 $33.61 $43.13 $32.94 $45.85 $65.13 $55.93 $54.00 $44.59 $70.29Average	annual	change -9.3% -9.9% -10.1% -6.4% -10.7% -10.5% -7.8% -8.2% -9.0% -9.8% -5.3%Average	annual	change	predicted	by	aging 2.2% 2.6% 2.7% 1.1% 1.5% 2.3% 2.0% 1.7% 1.6% 2.4% 1.9%Age-standardized avg. annual change -11.3% -12.1% -12.5% -7.5% -12.0% -12.5% -9.6% -9.7% -10.4% -11.9% -7.0%Volume effects -0.6% -0.8% -0.9% 2.2% 0.8% 0.7% 0.0% 3.1% 2.1% -0.2% 3.2%Prescription	volume 1.6% -0.6% -0.7% 1.3% 0.8% 2.5% 2.1% 2.7% 1.5% -3.6% 1.2%Prescription	size -2.2% -0.2% -0.2% 0.9% 0.0% -1.8% -2.1% 0.4% 0.5% 3.4% 1.9%Therapeutic choice effects -0.8% -1.9% -2.3% -2.2% -1.3% -2.6% 0.0% -3.4% -3.5% -2.3% -3.6%Choices	of	drug	sub-classes 0.3% 0.0% 0.1% 0.3% -0.1% 0.2% 0.3% 0.2% 0.2% 0.6% 0.1%Choices	within	drug	sub-classes -1.1% -1.9% -2.4% -2.5% -1.2% -2.8% -0.3% -3.6% -3.7% -2.9% -3.7%Price effects -9.9% -9.4% -9.3% -7.6% -11.6% -10.6% -9.6% -9.4% -9.0% -9.5% -6.6%Prices	paid -0.6% -1.3% -0.8% 0.1% -0.9% -0.6% -0.7% -1.0% -1.0% -1.5% 4.1%Generic	use -9.2% -8.0% -8.5% -7.7% -10.7% -10.0% -8.9% -8.4% -8.0% -8.0% -10.7%Sources of age-standardized changeLower prices of drugs purchased was the major driver of decreased age-standardized spending per capita on cholesterol-lowering drugs across Canada. Owing mostly to savings resulting from generic substitutions, but also to lower unit prices, average prices paid for drugs decreased.Shifts in the types of drugs selected for treatment toward cheaper options contributed to a decrease in age-standardized spending per capita in all provinces except for Quebec, where there was no change in either direction.Volumes of treatment purchased either did not change or slightly increased between 2007/08 and 2012/13 in most provinces. British Columbia and Alberta were the only provinces to experience a slight decrease in volumes of purchased cholesterol-lowering drugs.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of cholesterol-lowering drugs decreased by an average of 9.3% per year between 2007/08 and 2012/13, for a total change  of −39%.Spending per capita on cholesterol-lowering drugs decreased in all provinces. The greatest change occurred in Manitoba, where spending per capita decreased by an average of 11% per year (−43% in total). The smallest change, which was still consid-erable, was in Newfoundland & Labrador, where spending per capita decreased by 5.3% per year (−24% in total).Population aging alone would have caused spending per capita in the provinces to increase by 1.1% to 2.7% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted spending per capita decreased by annual rates ranging from 7% (NL) to 12.5% (ON, AB).Cholesterol-lowering drugsTable	2.2e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch5 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-12%NewBrunswick-10%NovaScotia-10%Newfoundlandand Labrador-7%Prince Edward I.-12%Alberta-12%Saskatchewan-7%Manitoba-12% Quebec-10%Ontario-13%Volume effectsPrice effectsTherapeutic choice effectsCholesterol-lowering drugsFigure	2.2j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	2.2i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n5 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 86.3% 97.2% 94.8% 93.6% 88.0% 91.0% 81.3% 98.3% 95.8% 98.5% 90.1%Private	insurers 60.8% 65.3% 76.7% 77.2% 75.5% 52.4% 63.1% 86.5% 76.4% 77.9% 78.3%%-point	diff.	btw.	prov.	&	private	plans 25.6% 31.9% 18.1% 16.4% 12.5% 38.6% 18.2% 11.8% 19.4% 20.6% 11.8%Uninsured	patients	/	below	deductibles 77.7% 83.2% 80.5% 89.4% 79.7% 79.6% 70.0% 92.0% 86.5% 92.5% 83.9%%-pt.	diff.	btw.	prov.	plan	&	uninsured 8.6% 13.9% 14.3% 4.2% 8.4% 11.4% 11.3% 6.3% 9.3% 6.0% 6.2%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 16.4% 0.6% 12.5% 27.3% 10.2% 23.6% 20.1% 14.4% 12.2% 8.1% 8.4%Private	insurers 13.9% 11.3% 13.2% 17.5% 10.7% 15.4% 21.4% 18.2% 15.6% 26.5% 15.1%%-point	diff.	btw.	prov.	&	private	plans 2.5% -10.7% -0.8% 9.8% -0.5% 8.2% -1.2% -3.8% -3.4% -18.4% -6.7%Uninsured	patients	/	below	deductibles 11.8% 11.3% 14.6% 13.5% 10.7% 15.5% 13.5% 14.1% 13.6% 13.2% 13.4%%-pt.	diff.	btw.	prov.	plan	&	uninsured 4.6% -10.7% -2.1% 13.8% -0.5% 8.1% 6.6% 0.2% -1.4% -5.0% -5.0%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $0.83 $0.82 $0.89 $1.13 $0.73 $0.74 $0.77 $0.81 $0.79 $0.87 $0.87Private	insurers $0.99 $1.04 $0.95 $1.10 $0.84 $0.94 $0.86 $0.86 $0.85 $0.97 $0.97%	diff.	btw.	provincial	&	private	plans -16.0% -21.0% -6.7% 2.9% -12.9% -22.0% -10.2% -5.9% -7.0% -10.4% -9.9%Uninsured	patients	/	below	deductibles $0.88 $0.91 $0.93 $1.04 $0.83 $0.73 $0.84 $0.77 $0.79 $0.80 $0.88%	diff.	btw.	provincial	plan	&	uninsured -5.7% -10.1% -4.8% 9.2% -12.0% 0.1% -8.7% 5.5% 0.1% 7.9% -0.7%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $47.10 $31.20 $33.60 $43.10 $32.90 $45.90 $65.10 $55.90 $54.00 $44.60 $70.30%	Provincial	drug	plans 47% 30% 49% 50% 20% 47% 58% 33% 39% 40% 31%%	Private	insurance 36% 38% 36% 25% 34% 38% 28% 50% 47% 39% 51%%	Uninsured	/	below	deductibles 17% 31% 14% 22% 43% 14% 14% 15% 13% 21% 16%%	Federal	drug	plans 1% 1% 1% 3% 3% 0% 0% 1% 1% 0% 1%Public (provincial and federal) drug plans covered an estimated 48% of spending on cholesterol drugs in Canada; private drug plans covered an estimated 36%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $0.83, 16% less than the cost per day for prescriptions paid for by private drug plans.For every 100 prescriptions for multi-sourced drugs, 26 more were filled with generics under public drug plans than under private drug plans.Cholesterol-lowering drugsTable	2.2i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	2.2h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	2.2g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	2.2f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch5 92.3AnticoagulantsCardiovascular systemt h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n6 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) AnticoagulantsPercent of prescriptionsPercent of spendingWarfarin 80.9% 23.3%Dabigatran	Etexilate 13.7% 35.2%Dalteparin 2.6% 23.5%Enoxaparin 1.4% 9.3%Tinzaparin 0.9% 7.7%Percent of prescriptionsPercent of spendingDabigatran	Etexilate 13.7% 35.2%Dalteparin 2.6% 23.5%Warfarin 80.9% 23.3%Enoxaparin 1.4% 9.3%Tinzaparin 0.9% 7.7%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $6.40 $7.00 40 40 $160.00 $175.00Multi-source	brand $0.40 $0.40 40 40 $10.00 $10.00Multi-source	generic $1.40 $1.80 120 110 $11.67 $16.36Sourced	only	by	generics $0.00 $0.00 0 0 n/a n/a$30570%$4.60$8.70$8$92001903,1804,480$2.58$2.07 5%66%57%25%18%47%53%1%28%Estimate not availableFigure	2.3b»	Share of spending by sex, age group, and payer, 2012/13Figure	2.3a»	Summary of sales, spending, and use, 2012/13Table	2.3c»	Spending, use, and cost, by drug source, 2012/13Table	2.3b»	Leading drugs, by spending, 2012/13Table	2.3a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch6 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredAnticoagulantsProvincial formulary coverageProvinces provided restricted or unrestricted coverage for five (PE) to nine (AB) of the 10 types of anticoagulant drugs that had more than $10,000 in sales in each province. Weighted by national sales, the drugs covered in each province accounted for 64% or more of the $300-million Canadian anticoagulant drug market. Four provinces (BC, SK, NB, NS) covered drugs that accounted for the entire market. Ontario and Quebec covered drugs that accounted for almost the entire market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 10 drugs covered% market value of drugsDrugs includedVitamin K antagonists, heparin group, direct thrombin inhibitors, and direct factor Xa inhibitors.Examples of indicated conditionsAtrial fibrillation and venous thromboembolism (blood clots).Clinical uses and considerations Anticoagulants are used to treat venous thromboem-bolism (such as pulmonary embolism or deep vein thrombosis). They are also used to prevent thrombosis formation in individuals with an elevated risk of clotting, including those diagnosed with atrial fibrilla-tion or cardiac valve disorders and those with a history of venous thromboembolism. As well, they may be used for a short time after orthopedic surgeries to prevent the formation of clots. The most common complication with anticoagulant use is bleeding. Patients taking warfarin (historically the main anticoagulant) require regular laboratory testing to ensure that their blood’s clotting ability remains in the therapeutic range. While the newer drugs in this category are more expensive, they do not require regular monitoring. Vitamin K can be admin-istered to reverse the elevated anticoagulant effect of a warfarin overdose; however, no such antidote exists for the newer drugs.How might usage differ across age groups?The use of drugs in this category is highly concentrated in the elderly. Age is a major risk factor for both atrial fibrillation and venous thromboembolism; thus, higher use in older patients is expected.How might usage differ between sexes?During the childbearing years, women use anticoagu-lants more frequently than men. This may be a result of an elevated thrombosis risk from both oral contra-ceptive use and pregnancy. Among older adults, men are prescribed anticoagulants more frequently than women are, likely related to both a higher prevalence of atrial fibrillation and a slightly higher incidence of venous thrombosis in men than women older than 45.Figure	2.3c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n6 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $8.70 per capita on anti-coagulant drugs at retail pharmacies in 2012/13 ($8.20 for women and $9.30 for men). Almost all spending on these drugs is among Canadians aged 40 and older. Average spending per capita was $7.10 in the 40–64 age group and $39 in the 65+ age group. In contrast, average spending per capita was $1.70 for Canadians aged 19–39.Though spending per capita on anticoagulant drugs was low for Canadians aged 19–39, average spending for women in this age group was more than double the spending for men. In contrast, average spending per capita in the 40–64 age group was 37% higher for men than for women and average spending per capita in the 65+ age group was 41% higher for men than for women.Provincial spending by age and sexAverage spending per capita on anticoagulant drugs ranged from $6.10 (BC and PEI) to $11 (QC) for women and from $7.30 (MB) to $11 (QC) for men. In all provinces, average spending per capita in the 19–39 age group was far higher for women than for men, whereas average spending in the two older age groups was slightly higher for men than for women. In all adult age groups, there was more variation in average spending per capita for women than for men. However, Alberta and Quebec had the two highest levels of spending per capita for women and men in all of the adult age groups. Excluding those provinces, variations were moderate (coefficients of variation less than 20%) in all age/sex groups.Spending per capita$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177Spending per capitaNumberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645$6$33$0 $2 $0 $1$8$46AnticoagulantsFigure	2.3e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	2.3d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch6 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada Canada$0NLNSNBQCONMBSKBC AB PE$0$10$10NLNSNBQCONMBSKBC AB PE$20 $20$30$30$40$50$40$50Females age 65+ Males age 65+Females of all ages Males of all ages$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 40–64 Males age 40–64$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 19–39 Males age 19–39$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20 $20$10$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 0–18 Males age 0–18AnticoagulantsFigure	2.3f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n6 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on anticoagulant drugs was driven by all three categories of cost drivers.Volume of treatment purchased was the predominant reason for British Columbia having a lower level of spending than other provinces.Therapeutic choice effects was an important factor in some provinces, with residents of Saskatchewan receiving less costly anticoagulant drugs than other Canadians.Prices paid per unit of particular anticoagulant drug products in Ontario were 6.2% lower than the average prices paid in the rest of Canada. Residents of Quebec were also less likely than other Canadians to receive available generics.Population age and provincial spendingBecause spending on anticoagulants is so highly con-centrated among older adults, differences in provincial population ages would predict relatively significant provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 19% below the average for the rest of Canada; in all provinces east of Ontario, it would be 7.5% or more above the average for the rest of Canada.However, even after the figures were adjusted for differences in population age, significant variation in spending per capita on anticoagulant drugs remained. In Manitoba, age-standardized average spending was 29% above the average for the rest of Canada, while in British Columbia it was 28% below the average for the rest of Canada.AnticoagulantsBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $6.87 $8.64 $7.65 $7.01 $8.40 $11.13 $9.15 $8.35 $6.83 $7.54Spending	per	capita	in	rest	of	Canada $9.03 $8.76 $8.78 $8.81 $8.97 $8.03 $8.74 $8.76 $8.75 $8.76Unadjusted	difference	in	spending	per	capita -23.9% -1.4% -12.9% -20.4% -6.4% 38.5% 4.7% -4.6% -22.0% -14.0%Difference	predicted	by	population	age 5.8% -18.9% -3.6% -4.9% -1.7% 7.7% 10.7% 11.5% 7.5% 10.3%Age-standardized difference -28.1% 21.5% -9.6% -16.3% -4.8% 28.6% -5.4% -14.5% -27.4% -22.0%Volume effects -25.6% 3.7% 11.8% -11.3% 0.7% 19.5% 3.6% -15.6% -21.8% -5.9%Prescription	volume -47.8% -42.3% -9.3% -27.3% -31.2% 100.4% -33.2% -50.3% -41.0% -41.3%Prescription	size 22.2% 46.0% 21.1% 16.0% 31.9% -80.9% 36.8% 34.7% 19.2% 35.4%Therapeutic choice effects -0.9% 13.0% -26.1% -15.6% 3.4% -1.6% -9.0% 3.4% -3.4% -17.3%Choices	of	drug	sub-classes -0.3% 15.5% -29.1% -17.0% 6.4% -4.0% -9.2% 1.1% 3.9% -19.5%Choices	within	drug	sub-classes -0.6% -2.5% 3.0% 1.4% -3.0% 2.4% 0.2% 2.3% -7.3% 2.1%Price effects -1.7% 4.8% 4.7% 10.6% -8.8% 10.7% 0.0% -2.3% -2.3% 1.3%Prices	paid 0.2% 6.6% 6.9% 11.8% -6.2% 7.4% 2.0% -0.4% -0.5% 3.4%Generic	use -1.8% -1.8% -2.2% -1.2% -2.7% 3.3% -2.0% -1.9% -1.8% -2.1%Table	2.3d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch6 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%AnticoagulantsFigure	2.3h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	2.3g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-28%NewBrunswick-5%NovaScotia-14%Newfoundlandand Labrador-22%Prince Edward I.-27%Alberta+22%Saskatchewan-10%Manitoba-16% Quebec+29%Ontario-5%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n6 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $4.56 $3.66 $4.41 $4.16 $4.49 $4.26 $5.85 $4.45 $3.94 $3.79 $4.442012/13 $8.75 $6.87 $8.64 $7.65 $7.01 $8.40 $11.13 $9.15 $8.35 $6.83 $7.54Average	annual	change 13.9% 13.4% 14.4% 12.9% 9.3% 14.5% 13.7% 15.5% 16.2% 12.5% 11.2%Average	annual	change	predicted	by	aging 2.4% 2.8% 2.8% 1.2% 1.6% 2.5% 2.4% 2.0% 1.9% 2.5% 2.2%Age-standardized avg. annual change 11.2% 10.3% 11.3% 11.6% 7.6% 11.7% 11.1% 13.2% 14.0% 9.7% 8.8%Volume effects -0.5% -1.4% -2.6% 0.7% -2.4% -0.3% 1.1% 1.8% 0.1% -3.0% 4.0%Prescription	volume 2.1% -2.1% -1.5% -2.3% 1.5% 2.6% 3.7% 3.6% 2.2% 1.5% 0.7%Prescription	size -2.6% 0.8% -1.1% 3.1% -3.8% -2.9% -2.6% -1.7% -2.1% -4.5% 3.3%Therapeutic choice effects 12.7% 14.3% 14.2% 13.7% 8.8% 13.4% 10.4% 12.8% 16.6% 14.8% 5.4%Choices	of	drug	sub-classes 8.8% 9.1% 9.6% 9.5% 3.4% 9.5% 7.6% 9.6% 12.4% 13.0% 4.1%Choices	within	drug	sub-classes 3.9% 5.1% 4.6% 4.2% 5.4% 3.8% 2.7% 3.2% 4.2% 1.8% 1.3%Price effects -1.0% -2.6% -0.3% -2.9% 1.1% -1.4% -0.3% -1.4% -2.6% -2.1% -0.6%Prices	paid -0.7% -2.4% -0.1% -2.7% 1.2% -1.3% -0.5% -1.3% -2.5% -1.9% -0.5%Generic	use -0.2% -0.1% -0.2% -0.1% 0.0% -0.1% 0.2% -0.1% -0.1% -0.2% -0.1%Sources of age-standardized changeIn all provinces, most of the increase in age-standard-ized spending per capita on anticoagulants between 2007/08 and 2012/13 was driven by a shift in the  types of drugs selected for treatment toward more expensive options. Volumes of treatment purchased was also an impor-tant determinant of change in age-standardized spending per capita. The change in the use of antico-agulants was not consistent across Canada, with some provinces purchasing more drugs and other provinces purchasing fewer drugs. Prices were lower in 2012/13 than in 2007/08 in many provinces; Manitoba was the only province where prices were slightly higher.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of anticoagulants increased by an average of 14% per year between 2007/08 and 2012/13, for a total change of 92%.Inflation-adjusted spending per capita on antico-agulants increased in all provinces. The most rapid increase occurred in Nova Scotia, with an average change of 16% per year (112% in total). The smallest increase occurred in Manitoba, with an average change of 9.3% per year (56% in total).Population aging alone would have caused spending per capita in the provinces to increase by 1.2% to 2.8% per year between 2007/08 and 2012/13. However, age-standardized and inflation-adjusted annual rates of growth in spending per capita remained high, ranging from 7.6% (MB) to 14% (NS).AnticoagulantsTable	2.3e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch6 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia+10%NewBrunswick+13%NovaScotia+14%Newfoundlandand Labrador+9%Prince Edward I.+10%Alberta+11%Saskatchewan+12%Manitoba+8% Quebec+11%Ontario+12%Volume effectsPrice effectsTherapeutic choice effectsAnticoagulantsFigure	2.3j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	2.3i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n6 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 81.5% 99.6% 99.3% 99.7% 99.2% 99.2% 98.2% 99.6% 99.6% 99.4% 100.0%Private	insurers 81.1% 97.8% 96.4% 99.4% 98.6% 95.8% 97.5% 97.9% 97.9% 97.8% 99.6%%-point	diff.	btw.	prov.	&	private	plans 0.4% 1.8% 2.9% 0.3% 0.7% 3.4% 0.7% 1.8% 1.7% 1.7% 0.4%Uninsured	patients	/	below	deductibles 84.7% 96.5% 87.3% 99.0% 98.7% 95.1% 97.5% 98.4% 96.0% 99.1% 99.0%%-pt.	diff.	btw.	prov.	plan	&	uninsured -3.3% 3.1% 12.0% 0.7% 0.6% 4.1% 0.7% 1.3% 3.6% 0.3% 1.0%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 76.0% 61.7% 74.4% 66.9% 67.2% 79.5% 79.5% 53.7% 53.5% 24.6% 18.4%Private	insurers 81.5% 80.6% 84.4% 65.8% 66.5% 85.4% 86.6% 82.7% 83.5% 85.4% 75.0%%-point	diff.	btw.	prov.	&	private	plans -5.5% -18.9% -10.0% 1.1% 0.8% -5.8% -7.0% -29.0% -29.9% -60.8% -56.7%Uninsured	patients	/	below	deductibles 70.4% 75.3% 82.3% 55.1% 60.6% 76.6% 73.5% 66.9% 85.0% 60.2% 76.4%%-pt.	diff.	btw.	prov.	plan	&	uninsured 5.5% -13.6% -7.9% 11.8% 6.6% 3.0% 6.1% -13.2% -31.5% -35.6% -58.1%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $2.29 $1.85 $2.38 $2.24 $2.82 $2.24 $2.18 $1.54 $1.62 $1.23 $1.13Private	insurers $2.42 $2.14 $2.88 $1.84 $2.07 $2.32 $2.39 $2.31 $2.44 $2.31 $2.30%	diff.	btw.	provincial	&	private	plans -5.2% -13.5% -17.2% 21.7% 36.3% -3.8% -8.8% -33.1% -33.4% -46.6% -50.8%Uninsured	patients	/	below	deductibles $1.93 $1.90 $2.46 $1.55 $1.94 $1.75 $1.70 $1.56 $2.35 $1.32 $2.06%	diff.	btw.	provincial	plan	&	uninsured 19.2% -2.5% -3.0% 44.4% 45.7% 27.9% 28.1% -1.2% -30.8% -6.8% -45.0%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $8.70 $6.90 $8.60 $7.70 $7.00 $8.40 $11.10 $9.10 $8.40 $6.80 $7.50%	Provincial	drug	plans 57% 34% 55% 52% 33% 64% 70% 29% 36% 16% 23%%	Private	insurance 25% 29% 28% 17% 23% 21% 19% 48% 43% 50% 53%%	Uninsured	/	below	deductibles 18% 36% 16% 29% 42% 14% 11% 22% 21% 33% 24%%	Federal	drug	plans 0% 1% 1% 2% 2% 0% 0% 0% 0% 0% 1%Public (provincial and federal) drug plans covered an estimated 57% of spending on anticoagulant drugs in Canada; private drug plans covered an estimated 25%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $2.29, 5% less than the cost per day for prescriptions paid for by private drug plans.AnticoagulantsTable	2.3i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	2.3h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	2.3g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	2.3f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch6 92.4Cardiovascular systemAntiplateletst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n7 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) AntiplateletsPercent of prescriptionsPercent of spendingClopidogrel 91.4% 86.4%Acetylsalicylic	Acid/Dipyridamole 6.3% 8.0%Prasugrel 0.9% 2.0%Ticagrelor 0.8% 2.1%Ticlopidine 0.5% 0.4%Percent of prescriptionsPercent of spendingClopidogrel 91.4% 86.4%Acetylsalicylic	Acid/Dipyridamole 6.3% 8.0%Ticagrelor 0.8% 2.1%Prasugrel 0.9% 2.0%Epoprostenol 0.0% 0.8%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $0.60 $0.80 10 10 $60.00 $80.00Multi-source	brand $1.30 $2.20 20 20 $65.00 $110.00Multi-source	generic $0.10 $0.10 0 0 n/a n/aSourced	only	by	generics $2.20 $3.40 80 90 $27.50 $37.78$18590%17%$9$5$4.15$6.491101302,8204,330$1.47$1.50   29%70%53%31%16%1%39%61%1%Figure	2.4b»	Share of spending by sex, age group, and payer, 2012/13Figure	2.4a»	Summary of sales, spending, and use, 2012/13Table	2.4b»	Leading drugs, by spending, 2012/13Table	2.4c»	Spending, use, and cost, by drug source, 2012/13Table	2.4a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch7 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredAntiplateletsProvincial formulary coverageProvinces provided restricted or unrestricted coverage for three (ON) to seven of the eight types of antiplatelet drugs that had more than $10,000 in sales in each province.Weighted by national sales, the drugs covered in each province accounted for 88% (PE) or more of the $190-million Canadian antiplatelet drug market. Manitoba and New Brunswick provided unrestricted coverage for the highest-grossing drugs in this therapeutic category.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 8 drugs covered% market value of drugsDrugs includedClopidogrel, acetylsalicylic acid/dipyridamole,  and others.Examples of indicated conditionsCoronary artery disease, cerebrovascular disease, and peripheral artery disease.Clinical uses and considerations Antiplatelets are primarily used to help reduce the risk of acute cardiovascular events such as a heart attack or stroke. These drugs prevent platelets from aggregating in the bloodstream and forming clots. Antiplatelets are used in patients who are at high risk of an acute cardiovascular event (primary prevention) and in patients after an event to prevent a subsequent event (secondary prevention). They are also used after percutaneous coronary intervention for coronary artery disease. The benefit of antiplatelets in secondary prevention has been well established, but the benefit in primary prevention is less clear and must be weighed against the potential risks, including bleeding. The most commonly used antiplatelet is aspirin, but since it is available over the counter, its use is not captured in this report. How might usage differ across age groups?Prevalence of cardiovascular disease increases with age, and the higher use of antiplatelets among older adults is expected. Age over 70 is particularly associ-ated with a high risk of peripheral artery disease.How might usage differ between sexes?Men develop heart disease on average 10 years earlier than women. Men also undergo percutaneous coronary intervention three times more often  than women.Women often experience atypical symptoms of heart disease and may therefore be less likely to be diag-nosed and receive appropriate medication after an acute cardiovascular event. The prevalence of peripheral artery disease appears to be similar for women and men at all ages.Figure	2.4c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n7 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $5.30 per capita on anti-platelet drugs at retail pharmacies in 2012/13 ($4.20 for women and $6.50 for men). Average spending per capita on these drugs was insignificant for Canadians aged 39 and younger. Average spending per capita was $4.40 for the 40–64 age group and $25 for the 65+ age group.Average spending per capita on antiplatelet drugs was more than twice as high for men than for women in the 40–64 age group. For the 65+ age group, spending per capita was approximately 60% higher for men than for women.Provincial spending by age and sexAcross provinces, average spending per capita ranged from $2.80 (AB) to $6.00 (NB) for women and from $4.50 (AB) to $9.30 (QC) for men. The main age and sex differences in spending were similar across prov-inces. Spending was highly concentrated in the 65+ age group in all provinces, and average spending per capita for men aged 40–64 was approximately double the average for women of the same age in all provinces. Within each age group, there was moderate varia-tion across provinces in average spending per capita. Excluding age groups under 40, the greatest variation occurred among women in the 40–64 age group, ranging from $1.50 in British Columbia to $3.70 in New Brunswick (coefficient of variation: 27%).$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$3$20$0 $0 $0 $0$6$31AntiplateletsFigure	2.4e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	2.4d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch7 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 40–64 Males age 40–64$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 19–39 Males age 19–39$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10$0NLNSNBQCONMBSKBC AB PE$0$10$10NLNSNBQCONMBSKBC AB PE$20 $20$30$30$40$50$40$50Females age 65+ Males age 65+$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 0–18 Males age 0–18AntiplateletsFigure	2.4f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n7 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on antiplatelet drugs was driven by all three categories of cost drivers.Volume of treatment purchased influenced age-standardized retail spending on antiplatelets in many provinces. It contributed to lower levels of spending in British Columbia, Alberta, and Manitoba, and higher levels in Manitoba and Ontario. Therapeutic choice effects contributed to lower levels of spending in all provinces except Quebec. Residents of Quebec used significantly higher cost options than all other Canadians.Prices paid per unit of particular antiplatelet drug products in Newfoundland & Labrador were 21.8% above the average for the rest of Canada. In Quebec, higher unit prices were offset by higher use of available generics. Ontario residents paid significantly lower unit drug prices than other Canadians.Population age and provincial spendingBecause spending on antiplatelets is so highly concen-trated among older adults, differences in provincial population ages would predict relatively significant provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 21% below the average for the rest of Canada; in Nova Scotia, it would be 13% above the average for the rest of Canada.However, even after the figures were adjusted for differences in population age, spending per capita on antiplatelet drugs deviated by more than 13% in four provinces. In Quebec, age-standardized average spending was 51% above the average for the rest of Canada, while in British Columbia it was 34% below the average for the rest of Canada.AntiplateletsBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $3.86 $3.63 $4.20 $5.44 $4.95 $7.60 $6.30 $5.25 $5.74 $6.55Spending	per	capita	in	rest	of	Canada $5.54 $5.52 $5.35 $5.31 $5.54 $4.63 $5.29 $5.32 $5.31 $5.30Unadjusted	difference	in	spending	per	capita -30.3% -34.3% -21.6% 2.5% -10.7% 64.3% 19.1% -1.2% 8.1% 23.7%Difference	predicted	by	population	age 6.2% -20.7% -3.7% -5.2% -1.8% 8.5% 11.1% 13.0% 8.6% 11.4%Age-standardized difference -34.3% -17.1% -18.6% 8.2% -9.1% 51.3% 7.2% -12.6% -0.5% 11.0%Volume effects -23.1% -13.0% -14.2% 28.8% 31.4% -9.6% 5.4% 1.9% 8.4% 6.1%Prescription	volume -59.6% -63.1% -27.8% 2.4% -6.8% 92.4% -43.0% -47.0% -16.6% -42.8%Prescription	size 36.5% 50.2% 13.7% 26.4% 38.2% -102.0% 48.4% 48.9% 25.1% 48.9%Therapeutic choice effects -18.5% -12.4% -20.4% -27.2% -27.8% 59.6% -12.2% -23.7% -25.2% -18.1%Choices	of	drug	sub-classes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Choices	within	drug	sub-classes -18.5% -12.4% -20.4% -27.2% -27.8% 59.6% -12.2% -23.7% -25.2% -18.1%Price effects 7.2% 8.2% 16.1% 6.5% -12.7% 1.4% 14.0% 9.2% 16.3% 22.9%Prices	paid 5.8% 7.0% 15.0% 5.0% -15.4% 6.5% 12.8% 7.9% 15.1% 21.8%Generic	use 1.4% 1.3% 1.0% 1.5% 2.7% -5.1% 1.2% 1.3% 1.2% 1.2%Table	2.4d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch7 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%AntiplateletsFigure	2.4h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	2.4g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-34%NewBrunswick+7%NovaScotia-13%Newfoundlandand Labrador+11%Prince Edward I.0%Alberta-17%Saskatchewan-19%Manitoba+8% Quebec+51%Ontario-9%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n7 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $9.04 $7.04 $6.34 $10.46 $12.05 $9.15 $10.19 $11.38 $9.78 $10.22 $11.052012/13 $5.31 $3.86 $3.63 $4.20 $5.44 $4.95 $7.60 $6.30 $5.25 $5.74 $6.55Average	annual	change -10.1% -11.3% -10.6% -16.7% -14.7% -11.6% -5.7% -11.2% -11.7% -10.9% -9.9%Average	annual	change	predicted	by	aging 2.5% 2.9% 2.9% 1.1% 1.6% 2.6% 2.5% 1.9% 2.2% 2.6% 2.5%Age-standardized avg. annual change -12.3% -13.8% -13.1% -17.6% -16.1% -13.8% -8.0% -12.8% -13.6% -13.2% -12.1%Volume effects -3.0% 4.6% 1.0% -4.4% -0.9% 4.5% 0.8% 2.5% 1.2% 1.3% -0.4%Prescription	volume 0.7% -2.9% -1.8% -5.4% -0.1% 2.0% 1.4% -1.0% 0.5% -0.2% -2.1%Prescription	size -3.7% 7.5% 2.8% 1.1% -0.8% 2.6% -0.7% 3.5% 0.7% 1.5% 1.7%Therapeutic choice effects -9.6% -19.7% -15.1% -14.3% -16.1% -19.3% -8.5% -16.3% -16.1% -15.3% -12.0%Choices	of	drug	sub-classes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Choices	within	drug	sub-classes -9.6% -19.7% -15.1% -14.3% -16.1% -19.3% -8.5% -16.3% -16.1% -15.3% -12.0%Price effects 0.4% 1.3% 1.0% 1.0% 0.9% 1.0% -0.2% 0.9% 1.3% 0.9% 0.3%Prices	paid 1.3% 1.3% 1.0% 1.0% 0.9% 1.0% 1.5% 0.9% 1.3% 0.9% 0.3%Generic	use -1.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.8% 0.0% 0.0% 0.0% 0.0%Sources of age-standardized changeIn all provinces, most of the increase in age-standard-ized spending per capita on antiplatelets between 2007/08 and 2012/13 was driven by a shift in the types of drugs selected for treatment toward less expensive options. This effect was particularly strong in British Columbia and Ontario.Volumes of treatment purchased was also an impor-tant determinant of change in age-standardized spending per capita. The change in the use of anti-platelets was not consistent across Canada, with some provinces purchasing more drugs (notably British Columbia and Ontario) and other provinces purchas-ing fewer drugs (notably Saskatchewan). Prices were slightly higher in 2012/13 than in 2007/08 in almost all provinces, but the effects on changes in age-standardized spending per capita were small.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of antiplatelets decreased by an average of 10% per year between 2007/08 and 2012/13, for a total change of −41%.Spending per capita on antiplatelets decreased in all provinces. The greatest change was observed in Saskatchewan, where spending per capita decreased by an average of 17% per year (−60% in total). Quebec experienced the smallest change, which was still considerable, with a total decrease of 5.7% per year (−25% in total).Population aging alone would have caused spending per capita in the provinces to increase by 1.1% to 2.9% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted spending per capita decreased by annual rates ranging from 8.0% (QC) to 18% (SK).AntiplateletsTable	2.4e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch7 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-14%NewBrunswick-13%NovaScotia-14%Newfoundlandand Labrador-12%Prince Edward I.-13%Alberta-13%Saskatchewan-18%Manitoba-16% Quebec-8%Ontario-14%Price effectsVolume effectsTherapeutic choice effectsAntiplateletsFigure	2.4j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	2.4i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n7 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 17.5% 30.6% 26.5% 31.8% 15.4% 34.1% 6.6% 60.6% 30.8% 76.5% 37.8%Private	insurers 4.6% 0.8% 0.3% 2.8% 2.8% 0.7% 2.9% 2.7% 2.2% 4.2% 14.2%%-point	diff.	btw.	prov.	&	private	plans 12.9% 29.8% 26.2% 29.0% 12.5% 33.4% 3.7% 57.9% 28.6% 72.3% 23.6%Uninsured	patients	/	below	deductibles 8.9% 2.7% 2.2% 6.7% 5.1% 4.8% 11.1% 5.6% 2.6% 25.5% 9.9%%-pt.	diff.	btw.	prov.	plan	&	uninsured 8.6% 27.9% 24.2% 25.2% 10.3% 29.3% -4.6% 55.0% 28.2% 51.0% 27.9%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 3.3% 6.2% 11.3% 1.0% 0.3% 0.0% 3.9% 13.5% 0.1% 0.0% 0.0%Private	insurers 9.1% 6.9% 8.4% 12.3% 1.6% 10.5% 9.9% 20.5% 1.7% 3.2% 4.8%%-point	diff.	btw.	prov.	&	private	plans -5.8% -0.7% 3.0% -11.3% -1.4% -10.4% -6.1% -7.0% -1.6% -3.2% -4.8%Uninsured	patients	/	below	deductibles 5.8% 3.2% 3.7% 4.0% 0.8% 9.9% 6.1% 29.0% 1.5% 0.1% 0.3%%-pt.	diff.	btw.	prov.	plan	&	uninsured -2.5% 3.0% 7.7% -3.0% -0.5% -9.9% -2.3% -15.5% -1.3% -0.1% -0.3%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $1.41 $1.36 $1.44 $1.41 $1.27 $0.99 $1.24 $1.55 $1.30 $1.39 $1.55Private	insurers $1.87 $1.81 $1.65 $1.73 $1.38 $1.85 $1.36 $1.74 $1.49 $1.60 $1.70%	diff.	btw.	provincial	&	private	plans -24.5% -24.7% -12.6% -18.6% -8.1% -46.2% -8.9% -10.8% -12.3% -13.0% -8.9%Uninsured	patients	/	below	deductibles $1.48 $1.43 $1.41 $1.51 $1.38 $1.24 $1.16 $1.93 $1.36 $1.45 $1.56%	diff.	btw.	provincial	plan	&	uninsured -4.2% -4.5% 2.3% -6.8% -8.5% -19.8% 6.6% -19.8% -4.3% -3.9% -0.8%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $5.30 $3.90 $3.60 $4.20 $5.40 $5.00 $7.60 $6.30 $5.30 $5.70 $6.50%	Provincial	drug	plans 53% 35% 49% 56% 34% 48% 70% 42% 48% 38% 33%%	Private	insurance 31% 35% 33% 20% 23% 39% 17% 39% 36% 41% 43%%	Uninsured	/	below	deductibles 16% 29% 17% 22% 41% 12% 12% 18% 15% 21% 23%%	Federal	drug	plans 1% 1% 1% 2% 2% 0% 0% 1% 1% 0% 1%Public (provincial and federal) drug plans covered an estimated 54% of spending on antiplatelet drugs in Canada; private drug plans covered an estimated 31%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $1.41, 24% less than the cost per day for prescriptions paid for by private drug plans.For every 100 prescriptions for multi-sourced drugs, 13 more were filled with generics under public drug plans than under private drug plans.AntiplateletsTable	2.4i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	2.4h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	2.4g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	2.4f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch7 93.1Nervous systemAntidepressantst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n8 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.)Antidepressants$1,450>95%29%$40$42$55$271,49077045,69023,200$1.21$1.1835%43%22%1%67%33%20%56%2%22%Percent of prescriptionsPercent of spendingCitalopram 18.1% 11.2%Venlafaxine 17.3% 14.9%Trazodone 10.5% 3.4%Escitalopram 8.6% 19.5%Amitriptyline 7.9% 3.5%Percent of prescriptionsPercent of spendingEscitalopram 8.6% 19.5%Venlafaxine 17.3% 14.9%Duloxetine 4.2% 14.7%Citalopram 18.1% 11.2%Bupropion 6.9% 7.0%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $24.70 $12.30 290 150 $85.17 $82.00Multi-source	brand $2.70 $1.30 40 20 $67.50 $65.00Multi-source	generic $17.40 $8.70 700 370 $24.86 $23.51Sourced	only	by	generics $10.70 $5.20 460 230 $23.26 $22.61Figure	3.1b»	Share of spending by sex, age group, and payer, 2012/13Figure	3.1a»	Summary of sales, spending, and use, 2012/13Table	3.1b»	Leading drugs, by spending, 2012/13Table	3.1c»	Spending, use, and cost, by drug source, 2012/13Table	3.1a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch8 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredProvincial formulary coverageAll provinces provided restricted or unrestricted coverage for at least 20 of the 22 antidepressant drugs that had more than $10,000 in sales in each province. Alberta was the only province to provide unrestricted coverage for all 22 drugs.Weighted by national sales, the drugs covered  in each province accounted for 65% (MB, PE)  or more of the $1.4-billion Canadian antidepres-sant market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 22 drugs covered% market value of drugsAntidepressantsDrugs includedTricyclics, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin norepineph-rine reuptake inhibitors, and others.Examples of indicated conditionsDepression, anxiety, and post-traumatic  stress disorder.Clinical uses and considerations Antidepressants are used to treat symptoms of depressive and anxiety disorders. In addition, some antidepressants may also be prescribed for smoking cessation, neuropathic pain, and insomnia. This category includes many different types of drugs; their effect on the brain and the mechanism by which they exert their effects vary greatly and for many of these drugs remain poorly understood. As the efficacy of different drugs to treat  depression is similar on average, the choice of  medication may be based on drug side effect profiles or individual preference. How might usage differ across age groups?Depressive symptoms may develop at any age and antidepressants are used throughout the lifespan. Generally, however, depression is less common among older adults than younger adults, and its prevalence declines as older adults age. How might usage differ between sexes?The reasons for higher antidepressant use among women are complex and likely involve both biological and social influences. Depression and anxiety dis-orders are twice as common in women as in men. Women may find themselves more frequently in life situations that can contribute to depression or anxiety, including poverty and abuse. Women are also more likely than men to be labelled as depressed or anxious when presenting with the same symptoms. Finally, men may be less likely to seek medical help for symptoms of depression and/or anxiety.Figure	3.1c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n8 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13AntidepressantsNational spending by age and sexCanadians spent an average of $42 per capita on antidepressant drugs at retail pharmacies in 2012/13 ($56 for women and $27 for men). Average spending per capita increased with age from a low of $3.80 in the 0–18 age group to a high of $66 in the 40–64 age group. Overall, spending per capita on antidepressants was twice as high for women as for men.The increase in spending per capita between the 0–18 and 19–39 age groups was sharper for women and men. Whereas average spending per capita on antide-pressants was 37% higher for girls aged 0–18 than for boys, average spending per capita was about twice as high for women as for men in all other age groups.Provincial spending by age and sexAcross provinces, average spending per capita  ranged from $44 (SK) to $66 (NS and NB) for women and from $22 (SK) to $33 (NS and NB) for men. The ratio of average spending per capita for women to average spending per capita for men ranged from 1.8 (PEI) to 2.3 (AB). In all provinces, average spending per capita for women and men was highest in the 40–64 age group.In most age groups, there was only modest provincial variation in average spending per capita on antidepres-sant drugs (coefficients of variation less than 15%). Greatest variation occurred in the 0–18 age group (coefficient of variation: 25%), where spending ranged from $2.40 (QC) to $6.20 (NS) for girls and from $1.80 (QC) to $5.30 (NL) for boys. The level of variation across provinces within each age group was similar for women and men.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$89$75$4$40$3$19$44 $42Figure	3.1e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.1d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch8 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0$50$100NLPENSNBQCONMBSKBC AB$0$50$100NLPENSNBQCONMBSKBC ABFemales age 40–64 Males age 40–64$0$50$100NLPENSNBQCONMBSKBC AB$0$50$100NLPENSNBQCONMBSKBC AB0$50$100NLPENSNBQCONMBSKBC AB$ 0$50$100NLPENSNBQCONMBSKBC AB$Females age 65+ Males age 65+$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC ABFemales age 0–18PEMales age 0–18$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC AB PEFemales age 19–39 Males age 19–39AntidepressantsFigure	3.1f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n8 4Variation	in	spending	across	Canada,	2012/13AntidepressantsSources of age-standardized variationProvincial variation in age-standardized average retail spending on antidepressant drugs was driven by all three categories of cost drivers.Volume of treatment purchased was the most impor-tant cost driver for provinces that had average retail spending above the average for the rest of Canada. In most provinces, therapeutic choices contributed to lower levels of spending. However, Ontario residents purchased significantly more costly drugs than the rest of Canadians.Conversely, price effects contributed to higher levels of spending in most provinces except Ontario, where residents paid significantly less per unit of particular antidepressant drugs than other Canadians.Population age and provincial spendingBecause persons aged 40–64 accounted for such a large share of spending on antidepressants, differences in provincial population ages would predict relatively modest provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita would deviate from the average for the rest of Canada by less than 5.5% in all provinces except Alberta, where it would be 6.6% less than the average for the rest of Canada.After the figures were adjusted for differences in population age, significant variation in spending per capita on antidepressant drugs remained, although this therapeutic category had some of the lowest provincial variation in this atlas. Age-standardized spending per capita in Saskatchewan was 17% below the average for the rest of Canada, while in Nova Scotia it was 16% above the average for the rest of Canada.BC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $37.56 $42.68 $33.03 $35.08 $42.35 $42.63 $49.58 $50.12 $41.32 $47.39Spending	per	capita	in	rest	of	Canada $42.17 $41.42 $41.83 $41.81 $41.07 $41.24 $41.38 $41.32 $41.56 $41.47Unadjusted	difference	in	spending	per	capita -10.9% 3.0% -21.1% -16.1% 3.1% 3.4% 19.8% 21.3% -0.6% 14.3%Difference	predicted	by	population	age 2.8% -6.6% -5.2% -4.6% -0.5% 2.7% 4.5% 4.7% 2.9% 5.5%Age-standardized difference -13.4% 10.3% -16.8% -12.0% 3.6% 0.7% 14.7% 15.9% -3.3% 8.3%Volume effects -10.7% -2.1% -10.4% -7.4% -2.6% 5.0% 24.1% 32.8% 3.5% 10.9%Prescription	volume -33.6% -29.6% -14.2% -18.5% -18.7% 60.0% -4.3% -17.7% -20.4% -8.8%Prescription	size 22.9% 27.5% 3.9% 11.1% 16.1% -54.9% 28.4% 50.5% 23.9% 19.7%Therapeutic choice effects -0.3% 7.6% -12.2% -12.6% 19.4% -17.1% -13.4% -11.6% -9.7% -12.4%Choices	of	drug	sub-classes 0.7% 1.0% -3.3% -1.2% 0.2% 0.1% -0.7% -0.9% -2.5% -2.1%Choices	within	drug	sub-classes -1.0% 6.6% -8.9% -11.5% 19.2% -17.2% -12.7% -10.7% -7.2% -10.3%Price effects -2.4% 4.7% 5.8% 8.0% -13.2% 12.7% 4.0% -5.4% 2.9% 9.8%Prices	paid -1.3% 6.1% 7.3% 10.4% -12.0% 8.4% 6.1% -3.5% 4.5% 12.0%Generic	use -1.1% -1.4% -1.5% -2.4% -1.2% 4.3% -2.1% -1.9% -1.6% -2.2%Table	3.1d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch8 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-13%NewBrunswick+15%NovaScotia+16%Newfoundlandand Labrador+8%Prince Edward I.-3%Alberta+10%Saskatchewan-17%Manitoba-12% Quebec+1%Ontario+4%Volume effectsPrice effectsTherapeutic choice effectsAntidepressantsFigure	3.1h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.1g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n8 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $40.29 $39.54 $40.24 $32.34 $39.75 $39.15 $41.64 $48.15 $53.46 $47.44 $42.912012/13 $41.56 $37.56 $42.68 $33.03 $35.08 $42.35 $42.63 $49.58 $50.12 $41.32 $47.39Average	annual	change 0.6% -1.0% 1.2% 0.4% -2.5% 1.6% 0.5% 0.6% -1.3% -2.7% 2.0%Average	annual	change	predicted	by	aging 1.5% 1.8% 2.3% 1.5% 1.3% 1.6% 1.1% 0.7% 0.7% 1.7% 0.7%Age-standardized avg. annual change -0.9% -2.8% -1.0% -1.1% -3.7% 0.0% -0.7% -0.1% -2.0% -4.4% 1.3%Volume effects 0.3% -1.0% -1.2% -0.1% -0.8% -0.2% 2.6% 3.0% 1.7% -1.5% 3.9%Prescription	volume 1.9% -1.5% -1.6% -0.8% 0.2% 1.9% 4.3% 4.1% 0.8% -1.6% 3.9%Prescription	size -1.5% 0.4% 0.4% 0.7% -1.0% -2.0% -1.7% -1.0% 0.9% 0.1% 0.0%Therapeutic choice effects 3.3% 2.4% 2.7% 1.0% 0.6% 5.7% 2.0% 1.1% 1.2% 0.9% 0.6%Choices	of	drug	sub-classes 0.3% 0.2% 0.3% 0.5% 0.3% 0.3% 0.4% 0.5% 0.5% 0.4% 0.2%Choices	within	drug	sub-classes 3.0% 2.1% 2.4% 0.5% 0.4% 5.4% 1.6% 0.5% 0.7% 0.5% 0.4%Price effects -4.6% -4.1% -2.5% -2.0% -3.5% -5.5% -5.3% -4.2% -4.9% -3.8% -3.2%Prices	paid -3.8% -3.9% -2.3% -1.8% -3.5% -5.3% -2.8% -4.2% -4.8% -3.2% -2.8%Generic	use -0.7% -0.2% -0.2% -0.2% 0.0% -0.2% -2.5% 0.0% -0.1% -0.6% -0.4%AntidepressantsSources of age-standardized changeLower prices of drugs purchased was the major driver of the decrease in age-standardized average spending on antidepressants between 2007/08 and 2012/13 across Canada. Owing mostly to savings resulting from lower unit prices for particular drug products, average prices paid for antidepressants decreased.However, the downward effects of lower prices were countered by changes in the types of drugs selected for treatment, with more expensive options being chosen in 2012/13 than in 2007/08, particularly in Ontario.Changes in the volumes of prescription drugs purchased also contributed to changes in average spending across Canada, but the direction of change was inconsistent across the country.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of antidepressants increased by an average of 0.6% per year between 2007/08 and 2012/13, for a total change of just 3%. Some provinces experienced small increases in spending per capita on antidepressants, while others experienced notable decreases. In Prince Edward Island, spending decreased by an average of 2.7% per year (−13% in total). On the other hand, spending in Newfoundland & Labrador increased by an average of 2.0% per year (10% in total). Population aging alone would have caused spending per capita in the provinces to increase by 0.7% to 2.3% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted annual rates of change in spending per capita ranged from −4.4% (PE) to 1.3% (NL).Table	3.1e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch8 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%Antidepressants-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-3%NewBrunswick0%NovaScotia-2%Newfoundlandand Labrador+1%Prince Edward I.-4%Alberta-1%Saskatchewan-1%Manitoba-4% Quebec-1%Ontario0%Volume effectsPrice effectsTherapeutic choice effectsFigure	3.1j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.1i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n8 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 96.7% 98.8% 98.6% 98.8% 99.6% 98.8% 97.4% 99.4% 99.3% 99.3% 99.6%Private	insurers 91.2% 95.0% 96.5% 95.8% 98.6% 92.3% 92.7% 97.2% 96.7% 96.5% 97.9%%-point	diff.	btw.	prov.	&	private	plans 5.5% 3.8% 2.1% 3.0% 1.0% 6.5% 4.8% 2.3% 2.6% 2.8% 1.7%Uninsured	patients	/	below	deductibles 92.8% 94.5% 94.1% 96.1% 98.1% 94.1% 93.8% 97.5% 96.4% 98.5% 97.4%%-pt.	diff.	btw.	prov.	plan	&	uninsured 3.9% 4.2% 4.6% 2.7% 1.5% 4.7% 3.6% 2.0% 2.9% 0.9% 2.2%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 34.9% 34.1% 36.6% 10.4% 16.2% 53.5% 24.1% 6.9% 8.5% 4.6% 3.8%Private	insurers 52.6% 55.0% 51.4% 30.3% 26.2% 63.0% 73.6% 33.3% 41.1% 44.0% 28.8%%-point	diff.	btw.	prov.	&	private	plans -17.7% -20.9% -14.8% -19.9% -10.0% -9.5% -49.5% -26.5% -32.6% -39.4% -25.0%Uninsured	patients	/	below	deductibles 45.8% 47.2% 46.0% 31.6% 23.6% 54.9% 70.8% 28.3% 35.6% 25.9% 29.3%%-pt.	diff.	btw.	prov.	plan	&	uninsured -10.9% -13.2% -9.4% -21.2% -7.4% -1.3% -46.7% -21.4% -27.1% -21.3% -25.4%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $1.08 $1.00 $1.19 $0.97 $1.05 $1.15 $0.89 $0.93 $0.87 $0.97 $1.00Private	insurers $1.32 $1.27 $1.32 $1.13 $1.10 $1.33 $1.49 $1.15 $1.08 $1.23 $1.20%	diff.	btw.	provincial	&	private	plans -18.6% -21.6% -9.8% -14.2% -4.5% -13.4% -40.2% -19.4% -19.9% -21.4% -16.6%Uninsured	patients	/	below	deductibles $1.24 $1.19 $1.26 $1.15 $1.09 $1.18 $1.46 $1.09 $1.04 $1.04 $1.18%	diff.	btw.	provincial	plan	&	uninsured -12.9% -16.3% -5.3% -16.3% -4.0% -2.9% -39.1% -15.0% -16.4% -6.9% -15.5%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $41.60 $37.60 $42.70 $33.00 $35.10 $42.30 $42.60 $49.60 $50.10 $41.30 $47.40%	Provincial	drug	plans 35% 34% 35% 32% 29% 36% 29% 26% 26% 19% 30%%	Private	insurance 43% 35% 44% 35% 33% 43% 50% 54% 56% 53% 50%%	Uninsured	/	below	deductibles 22% 30% 19% 30% 35% 20% 21% 19% 17% 27% 19%%	Federal	drug	plans 1% 2% 2% 3% 4% 1% 0% 1% 1% 1% 1%Public (provincial and federal) drug plans covered an estimated 36% of spending on antidepressants in Canada; private drug plans covered an estimated 43%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $1.08, 19% less than the cost per day for prescriptions paid for by private drug plans.The difference in costs per day by payer type was largely because of differences in the prescribing of single-source brands.AntidepressantsTable	3.1i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	3.1h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	3.1g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	3.1f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch8 93.2OpioidsNervous systemt h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n9 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) OpioidsPercent of prescriptionsPercent of spendingAcetaminophen/Caffeine/Codeine 29.3% 9.5%Hydromorphone 21.6% 21.3%Oxycodone 13.3% 28.7%Morphine 12.6% 8.7%Acetaminophen/Tramadol 6.4% 7.5%Percent of prescriptionsPercent of spendingOxycodone 13.3% 28.7%Hydromorphone 21.6% 21.3%Fentanyl 5.2% 11.1%Acetaminophen/Caffeine/Codeine 29.3% 9.5%Morphine 12.6% 8.7%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $6.00 $5.60 100 80 $60.00 $70.00Multi-source	brand $7.00 $8.30 130 120 $53.85 $69.17Multi-source	generic $6.00 $5.00 190 150 $31.58 $33.33Sourced	only	by	generics $1.70 $1.10 30 20 $56.67 $55.00$717>95%25%$19$21$21$20460380 62%26%11%46%29%24%2%51%49%Estimates not availableEstimates not availableFigure	1b»	Share of spending by sex, age group, and payer, 2012/13Figure	1a»	Summary of sales, spending, and use, 2012/13Table	3.2c»	Spending, use, and cost, by drug source, 2012/13Table	3.2b»	Leading drugs, by spending, 2012/13Table	3.2»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch9 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredOpioidsProvincial formulary coverageProvinces provided restricted or unrestricted coverage for five (ON) to nine of the 10 types of opioid drugs that had more than $10,000 in sales in each province.Weighted by national sales, the drugs covered in most provinces accounted for nearly the entire (98%) $600-million Canadian market for opioids. Ontario was the exception, covering drugs that accounted for 63% of national sales in this therapeutic category.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 10 drugs covered% market value of drugsDrugs includedNatural opium alkaloids, phenylpiperidine derivatives, and others. (Note: methadone not included.)Examples of indicated conditionsCancer-related pain, post-surgical pain, and fractures and dislocations. Clinical uses and considerations The clinical effects of opioids include pain relief, euphoria, sedation, respiratory depression, and decreased bowel motility. Prescription opioids are used for both short-term and long-term relief of pain, including cancer pain, postsurgical pain, and pain caused by a variety of other conditions (arthritis, neuropathy, mechanical back pain, etc.). There are significant risks associated with prescrip-tion opioid use, including physical dependence and withdrawal, addiction, and potentially fatal overdose. How might usage differ across age groups?Opioids may be taken at any age; however, most of their use is concentrated among older adults, reflect-ing the epidemiology of many pain conditions. The prevalence of chronic pain increases with increasing age; studies have estimated that approximately one in four Canadian adults experiences some type of chronic pain. Osteoarthritis, neuropathic pain, and mechanical back pain are all more common in older adults. How might usage differ between sexes?Some pain conditions are more prevalent among women than among men—for example, chronic low back pain and fibromyalgia. Other common condi-tions, including osteoarthritis, affect women and men equally. Studies suggest that women experience more severe pain, more frequent pain, and more anatomi-cally diffuse pain than do men and that this may be explained by biological differences. Further, women may be more likely than men to seek medical attention and treatment for pain.Figure	3.2c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n9 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $21 per capita on opioid drugs at retail pharmacies in 2012/13 ($21 for women and $20 for men). Average spending per capita was insignificant for children but increased sharply with increasing age. Average spending per capita was $8 in the 19–39 age group, and more than four times higher ($38) in the 40–64 age group.Average spending per capita was comparable for women and men aged 19–39, 10% higher for men aged 40–64, and 22% higher for women aged 65 and older. For men, average spending per capita was highest in the 40–64 age group ($38); for women, it was highest in the 65+ age group ($39).Provincial spending by age and sexAcross provinces, average spending per capita ranged from $15 (QC) to $26 (AB) for women and from $14 (QC) to $25 (NL) for men. Differences in average spending per capita by age and sex were similar  across provinces.Despite similar age gradients, there was notable variation across provinces in average spending per capita in all age groups. In absolute and relative terms, provincial variations were greater for women than for men in all age groups.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$35$39$0$8$1$8$38$32OpioidsFigure	3.2e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.2d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch9 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada Canada$0$20NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PEFemales age 19–39 Males age 19–39Females of all ages Males of all ages$0$20NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE0$20$40NLPENSNBQCONMBSKBC AB$ 0$60$20$40$60NLPENSNBQCONMBSKBC AB$Females age 65+ Males age 65+0$20$40NLPENSNBQCONMBSKBC AB$ 0$60$20$40$60NLPENSNBQCONMBSKBC AB$Females age 40–64 Males age 40–64$0$20NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PEFemales age 0–18 Males age 0–18OpioidsFigure	3.2f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n9 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on opioid drugs was driven primarily by volume effects and therapeutic choice effects. Residents of Western Canada purchased significantly more drugs than residents of other provinces; however, residents of British Columbia and Manitoba tended to purchase less expensive types of drugs than residents of other provinces. Residents of Ontario were prescribed more expensive types of drugs than residents of the rest of Canada.Price effects contributed modestly to provincial varia-tion in spending on opioids.Population age and provincial spendingBecause opioid drugs are taken by adults of all ages, differences in provincial population ages would predict only some provincial variation in spending per capita.For example, based on population age alone, predicted spending per capita in Alberta would be 9.3% below the average for the rest of Canada; in Newfoundland & Labrador, it would be 8.3% above the average for the rest of Canada.After the figures were adjusted for differences in population age, significant provincial differences in spending on opioid drugs remained, although this therapeutic category had the least provincial variation in this atlas. In Alberta and Ontario, age-standardized spending was more than 24% above the average for the rest of Canada, while in Quebec it was 37% below the average for the rest of Canada.OpioidsBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $20.19 $23.63 $20.70 $20.58 $23.24 $14.64 $21.05 $22.55 $18.94 $22.48Spending	per	capita	in	rest	of	Canada $20.60 $20.16 $20.54 $20.54 $18.84 $22.32 $20.53 $20.49 $20.55 $20.52Unadjusted	difference	in	spending	per	capita -2.0% 17.2% 0.8% 0.2% 23.3% -34.4% 2.5% 10.1% -7.8% 9.6%Difference	predicted	by	population	age 3.6% -9.3% -6.2% -5.4% -0.6% 3.9% 6.7% 6.9% 4.6% 8.3%Age-standardized difference -5.4% 29.2% 7.4% 5.9% 24.1% -36.9% -3.9% 3.0% -11.9% 1.1%Volume effects 25.1% 33.0% 11.9% 39.7% 8.6% -47.1% -12.2% 7.6% 5.9% -10.7%Prescription	volume 18.5% 20.3% -1.2% 25.0% -10.1% -8.8% -13.9% -17.2% -13.4% 2.0%Prescription	size 6.6% 12.7% 13.1% 14.7% 18.7% -38.3% 1.7% 24.8% 19.3% -12.7%Therapeutic choice effects -27.3% -5.1% -6.6% -34.4% 19.1% 2.2% 4.5% -4.0% -16.5% 4.3%Choices	of	drug	sub-classes -2.8% -2.4% 0.2% -7.0% 1.1% 2.3% -0.8% -2.1% -1.9% 3.9%Choices	within	drug	sub-classes -24.6% -2.8% -6.8% -27.4% 18.0% -0.1% 5.3% -1.9% -14.6% 0.5%Price effects -3.2% 1.3% 2.1% 0.6% -3.7% 8.1% 3.8% -0.6% -1.2% 7.5%Prices	paid -2.6% 1.0% 1.6% 0.7% -4.0% 7.4% 4.0% -1.1% -1.2% 7.0%Generic	use -0.6% 0.3% 0.5% -0.1% 0.3% 0.7% -0.2% 0.5% -0.1% 0.5%Table	3.2d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch9 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%OpioidsFigure	3.2h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.2g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-5%NewBrunswick-4%NovaScotia+3%Newfoundlandand Labrador+1%Prince Edward I.-12%Alberta+29%Saskatchewan+7%Manitoba+6% Quebec-37%Ontario+24%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n9 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $18.96 $17.29 $20.47 $16.53 $17.59 $23.65 $12.57 $18.78 $18.80 $12.98 $15.812012/13 $20.54 $20.19 $23.63 $20.70 $20.58 $23.24 $14.64 $21.05 $22.55 $18.94 $22.48Average	annual	change 1.6% 3.1% 2.9% 4.6% 3.2% -0.4% 3.1% 2.3% 3.7% 7.9% 7.3%Average	annual	change	predicted	by	aging 1.6% 2.0% 2.3% 1.4% 1.3% 1.7% 1.3% 0.9% 0.8% 1.8% 0.8%Age-standardized avg. annual change 0.0% 1.1% 0.6% 3.2% 1.9% -2.0% 1.7% 1.4% 2.8% 6.0% 6.5%Volume effects -0.4% 0.1% -1.0% 2.4% 1.8% -1.7% 2.1% -0.5% 0.7% 3.6% 1.3%Prescription	volume 0.3% -1.0% -0.6% 3.0% 2.0% -1.1% 2.9% 0.3% 1.5% 1.5% 3.1%Prescription	size -0.7% 1.1% -0.4% -0.6% -0.3% -0.6% -0.8% -0.8% -0.8% 2.1% -1.8%Therapeutic choice effects 0.8% 1.9% 1.3% 1.4% 0.5% -0.1% 0.9% 2.0% 2.0% 3.0% 4.6%Choices	of	drug	sub-classes 0.3% 0.8% 0.4% -0.3% -0.1% 0.2% 0.2% 0.1% 0.0% 0.7% 0.5%Choices	within	drug	sub-classes 0.5% 1.1% 0.9% 1.7% 0.6% -0.3% 0.7% 1.8% 2.0% 2.3% 4.1%Price effects -0.4% -0.8% 0.3% -0.5% -0.4% -0.2% -1.3% 0.0% 0.1% -0.7% 0.6%Prices	paid 0.6% -0.6% 0.8% 0.2% -0.1% 0.5% 0.9% 0.5% 0.7% 0.3% 1.2%Generic	use -0.9% -0.3% -0.5% -0.7% -0.3% -0.8% -2.2% -0.5% -0.6% -0.9% -0.6%Sources of age-standardized changeThe change in the use of opioids was not consistent across Canada, with some provinces purchasing  more drugs in 2012/13 than in 2007/08 (notably Prince Edward Island) and other provinces purchasing fewer drugs. There was a general shift toward more expensive drug treatment options in almost all provinces, which had a modest impact on age-standardized spending per capita. In Prince Edward Island and Newfoundland & Labrador, however, these therapeutic choices alone would have increased age-standardized spending per capita by over 3% per year (more than 16% in total).The combined effects of changes in prices paid and generic substitutions were modest in most provinces. They were greatest in Quebec, where increased generic drug use alone would have reduced age-standardized spending per capita by 2.2% per year (−10% in total).Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of opioids per Canadian increased by an average of 1.6% per year between 2007/08 and 2012/13, for a total change of 8%. Spending per capita increased in all provinces except Ontario, where spending per capita decreased by an average of 0.4% per year (−1.7% in total). The greatest increase occurred in Prince Edward Island and Newfoundland & Labrador, where spending per capita increased by an average of more than 7.3% per year (over 42% in total).Population aging alone would have caused spending per capita in the provinces to increase by 0.8% to 2.3% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted annual rates of change in spending per capita ranged from −2.0% (ON) to 6.5% (NL).OpioidsTable	3.2e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch9 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia+1%NewBrunswick+1%NovaScotia+3%Newfoundlandand Labrador+6%Prince Edward I.+6%Alberta+1%Saskatchewan+3%Manitoba+2% Quebec+2%Ontario-2%Volume effectsPrice effectsTherapeutic choice effectsOpioidsFigure	3.2j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.2i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n9 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $20.50 $20.20 $23.60 $20.70 $20.60 $23.20 $14.60 $21.10 $22.50 $18.90 $22.50%	Provincial	drug	plans 46% 40% 45% 51% 43% 49% 46% 32% 38% 21% 23%%	Private	insurance 29% 25% 30% 16% 17% 30% 23% 42% 44% 52% 48%%	Uninsured	/	below	deductibles 24% 31% 21% 25% 31% 20% 30% 24% 17% 27% 28%%	Federal	drug	plans 2% 4% 3% 8% 9% 1% 0% 2% 1% 0% 0%Public (provincial and federal) drug plans covered an estimated 48% of spending on opioid drugs in Canada; private drug plans covered an estimated 29%.Almost a quarter of spending in this category was for prescriptions paid for by patients who were uninsured or below their deductibles.OpioidsNote:	Estimates	not	available	for	cost	per	day	of	treatment,	spending	on	single	source	brands,	and	generic	substitution	rate.Table	3.2f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch9 93.3Nervous systemAntipsychoticst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 0 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.)AntipsychoticsPercent of prescriptionsPercent of spendingQuetiapine 42.9% 30.6%Risperidone 20.1% 17.0%Olanzapine 15.2% 17.1%Aripiprazole 5.3% 11.9%Clozapine 3.9% 8.2%Percent of prescriptionsPercent of spendingQuetiapine 42.9% 30.6%Olanzapine 15.2% 17.1%Risperidone 20.1% 17.0%Aripiprazole 5.3% 11.9%Paliperidone 1.1% 8.3%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $5.50 $7.00 60 60 $91.67 $116.67Multi-source	brand $4.30 $4.80 70 60 $61.43 $80.00Multi-source	generic $6.60 $8.10 320 290 $20.63 $27.93Sourced	only	by	generics $1.20 $1.50 50 50 $24.00 $30.00$68290%23%$21$20$18$214904703,2403,900$5$529%14%4%68%18%12%2%46%54%52%Figure	3.3b»	Share of spending by sex, age group, and payer, 2012/13Figure	3.3a»	Summary of sales, spending, and use, 2012/13Table	3.3b»	Leading drugs, by spending, 2012/13Table	3.3c»	Spending, use, and cost, by drug source, 2012/13Table	3.3a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 0 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredAntipsychoticsProvincial formulary coverageAll provinces provided restricted or unrestricted coverage for at least 16 (PE) of the 22 types of antipsychotic drugs that had more than $10,000 in sales in each province. Saskatchewan was the only province to provide some form of coverage for all 22 drugs.Weighted by national sales, the drugs covered in each province accounted for 77% (PE) or more  of the $680-million Canadian antipsychotic  drug market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 22 drugs covered% market value of drugsDrugs includedOlder (first-generation) antipsychotics and atypical (second- and third- generation) antipsychotics.Examples of indicated conditionsSchizophrenia and psychosis.Clinical uses and considerations Antipsychotics are mainly used for managing the symptoms of acute and chronic psychosis, includ-ing schizophrenia. The symptoms of psychosis that antipsychotics work to decrease include hallucinations, delusions, agitation, and highly disorganized thinking. Some antipsychotics are also used in elderly patients for treatment of delirium and behavioural symptoms related to dementia. These drugs may also be used for other psychiatric conditions, such as bipolar disorder, insomnia, depression, and anxiety. Antipsychotics may be divided into two main categories: the older first-generation antipsychot-ics and the newer second- and third-generation antipsychotics. First-generation antipsychotics are used less commonly than the newer drugs because of an increased risk of serious side effects, including potentially irreversible movement disorders. Side effects of second-generation antipsychotics include weight gain, diabetes, high cholesterol, and movement disorders, although at a lower rate than first-generation antipsychotics.How might usage differ across age groups?Antipsychotics may be used throughout the lifespan. Schizophrenia often develops between the late-teen years and the mid-30s. Since most individuals who use these drugs to manage chronic psychotic disorders will use them for a long time, usage may be expected to increase with increasing age as more patients  are diagnosed. How might usage differ between sexes?There is a slightly higher incidence of schizophrenia  in men than in women, and men present with symptoms of schizophrenia at a younger age than women. Bipolar disorder affects women and men in similar proportions.Figure	3.3c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 0 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $20 per capita on anti-psychotic drugs at retail pharmacies in 2012/13 ($18 for women and $21 for men). The level of spending generally increased with increasing age, peaking at $29 per capita in the 40–64 age group.Differences in average spending per capita were significant and varied across age groups. For the 0–18 age group, average spending was more than two times higher for boys than for girls. For the 19–39 age group, average spending was 80% higher for men than for women. The level of spending for women and men was similar in the 40–64 age group. Finally, in the 65+ age group, average spending was 30% higher for women than for men.Provincial spending by age and sexAcross provinces, average retail spending per capita on antipsychotic drugs ranged from $13 (NL) to $25 (QC) for women and from $17 (NS) to $31 (QC) for men. Differences in average spending per capita between women and men in each age group were roughly com-parable across provinces. The ratio of average spending per capita in the 40–64 age group to average spending per capita in the 65+ age group varied substantially across provinces, ranging from 0.9 to 1.6 for women and from 1.2 to 2.3 for men. Relative variations across provinces were greatest for children. Quebec and New Brunswick had the two highest average levels of spending per capita for women and for men in all adult age groups. Variations across other provinces were modest in all age/sex groups (coefficient of variation below 20%).Spending per capita$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177Spending per capitaNumberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645$28$21$2$14$6$26$30$16AntipsychoticsFigure	3.3e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.3d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 0 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages0$20$40NLPENSNBQCONMBSKBC AB$ 0$20$40NLPENSNBQCONMBSKBC AB$Males of all agesFemales age 65+ Males age 65+0$20$40NLPENSNBQCONMBSKBC AB$ 0$60$20$40$60NLPENSNBQCONMBSKBC AB$Females age 40–64 Males age 40–640$20$40NLPENSNBQCONMBSKBC AB$ 0$20$40NLPENSNBQCONMBSKBC AB$0$20$40NLPENSNBQCONMBSKBC AB$ 0$20$40NLPENSNBQCONMBSKBC AB$Females age 19–39 Males age 19–39$0$20NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PEFemales age 0–18 Males age 0–18AntipsychoticsFigure	3.3f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 0 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on antipsychotic drugs was driven by all three categories of cost drivers.Residents of New Brunswick and Quebec purchased more antipsychotics than other Canadians.In Manitoba and the Atlantic provinces, the choice of less expensive antipsychotic drugs contributed to lower average spending than in the rest of Canada.Differences in prices paid and rates of generic use also contributed to provincial variation. The unit prices for particular antipsychotic drug products in Alberta and Newfoundland & Labrador were more than 14% higher than the average for the rest of Canada. Resi-dents of Quebec were less likely than other Canadians to receive available generics.Population age and provincial spendingBecause spending on antipsychotic drugs is not highly concentrated among older adults, differences in provincial population ages would predict relatively little provincial variation in spending per capita. For example, based on age differences alone, predicted spending per capita in all but three provinces would be within 3% of the average for the rest of Canada: residents of Saskatchewan would spend 4.2% below the average for the rest of Canada and residents of Newfoundland & Labrador would spend 3.4% above the average for the rest of Canada.However, even after the figures were adjusted for differences in population age, spending per capita on antipsychotic drugs deviated by more than 30% in two provinces. In Newfoundland & Labrador, age-standardized average spending was 27% below the average for the rest of Canada, while in Quebec it was 60% above the average for the rest of Canada.AntipsychoticsBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $18.06 $17.04 $15.29 $15.96 $16.91 $27.66 $26.23 $15.42 $16.46 $14.88Spending	per	capita	in	rest	of	Canada $19.78 $19.86 $19.69 $19.69 $21.22 $17.11 $19.40 $19.67 $19.56 $19.62Unadjusted	difference	in	spending	per	capita -8.7% -14.2% -22.3% -18.9% -20.3% 61.6% 35.2% -21.6% -15.9% -24.2%Difference	predicted	by	population	age 1.8% -2.8% -4.2% -3.6% -0.2% 1.2% 2.3% 2.8% 0.8% 3.4%Age-standardized difference -10.3% -11.7% -18.9% -15.9% -20.1% 59.7% 32.1% -23.8% -16.5% -26.7%Volume effects -18.0% -23.3% -17.9% -6.3% -11.1% 56.0% 37.9% -6.2% 4.4% -16.1%Prescription	volume -27.4% -40.1% -67.2% -21.8% -29.7% 110.8% -2.4% -49.2% -55.6% -53.7%Prescription	size 9.4% 16.8% 49.3% 15.5% 18.6% -54.8% 40.2% 43.0% 60.1% 37.6%Therapeutic choice effects 7.4% -1.3% -3.3% -17.0% 0.1% 0.8% -13.1% -13.6% -24.0% -23.2%Choices	of	drug	sub-classes 0.4% 1.5% -0.4% -0.3% 1.6% -2.1% 0.1% -3.3% -4.1% -3.1%Choices	within	drug	sub-classes 7.0% -2.8% -2.9% -16.7% -1.5% 2.9% -13.2% -10.3% -19.9% -20.1%Price effects 0.3% 12.9% 2.3% 7.5% -9.1% 2.9% 7.3% -3.9% 3.0% 12.6%Prices	paid 2.1% 14.5% 3.0% 11.3% -7.2% -4.2% 9.4% -1.6% 3.8% 14.8%Generic	use -1.8% -1.6% -0.6% -3.9% -1.9% 7.2% -2.1% -2.3% -0.8% -2.2%Table	3.3d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 0 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%AntipsychoticsFigure	3.3h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.3g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-10%NewBrunswick+32%NovaScotia-24%Newfoundlandand Labrador-27%Prince Edward I.-17%Alberta-12%Saskatchewan-19%Manitoba-16% Quebec+60%Ontario-20%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 0 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $21.38 $21.11 $18.28 $17.92 $21.22 $18.68 $28.10 $27.14 $19.32 $19.51 $18.992012/13 $19.55 $18.06 $17.04 $15.29 $15.96 $16.91 $27.66 $26.23 $15.42 $16.46 $14.88Average	annual	change -1.8% -3.1% -1.4% -3.1% -5.5% -2.0% -0.3% -0.7% -4.4% -3.3% -4.8%Average	annual	change	predicted	by	aging 1.4% 1.6% 2.1% 1.7% 1.3% 1.4% 1.0% 0.6% 0.7% 1.5% 0.5%Age-standardized avg. annual change -3.1% -4.6% -3.5% -4.7% -6.7% -3.3% -1.3% -1.2% -5.0% -4.8% -5.3%Volume effects 0.5% -0.7% -0.7% -0.1% -0.1% 0.1% 2.4% 4.2% 0.7% -0.5% 1.3%Prescription	volume 3.4% -0.7% 0.2% -1.3% 3.4% 2.6% 5.9% 9.3% 5.1% 0.3% 2.4%Prescription	size -2.9% 0.0% -0.9% 1.1% -3.5% -2.5% -3.5% -5.1% -4.4% -0.8% -1.1%Therapeutic choice effects 6.0% 5.0% 4.6% 2.4% 1.9% 8.2% 5.3% 1.4% 4.3% 2.7% 1.5%Choices	of	drug	sub-classes 0.9% 0.6% 0.5% 1.2% 1.4% 0.7% 1.2% 1.3% 1.3% 1.8% 1.2%Choices	within	drug	sub-classes 5.1% 4.4% 4.1% 1.3% 0.5% 7.5% 4.0% 0.1% 3.0% 0.9% 0.3%Price effects -9.6% -9.0% -7.3% -7.0% -8.6% -11.7% -8.9% -6.9% -10.0% -7.0% -8.1%Prices	paid -2.4% -1.1% -1.5% -0.2% -2.1% -4.1% -2.0% -0.9% -2.6% -2.6% -1.0%Generic	use -7.1% -7.8% -5.8% -6.7% -6.5% -7.6% -6.9% -6.0% -7.4% -4.4% -7.0%Sources of age-standardized changeLower prices of drugs purchased was the major driver of reduction in age-standardized spending per capita on antipsychotics across Canada. Owing mostly to savings resulting from generic substitutions, average prices paid for antipsychotics decreased.However, the downward effects of lower prices were countered by changes in the types of drugs selected for treatment, with more expensive options being chosen in 2012/13 than in 2007/08, particularly in Ontario.Changes in the volumes of prescription drugs pur-chased contributed to changes in age-standardized spending per capita in some provinces, most notably in New Brunswick, where more drugs were purchased in 2012/13 than in 2007/08.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of antipsychotic drugs decreased by an average of 1.8% per year between 2007/08 and 2012/13, for a total change of −9%.Spending per capita on antipsychotic drugs decreased in all provinces. The greatest change occurred in Manitoba, where spending per capita decreased by an average of 5.5% per year (−25% in total). Quebec experienced the smallest change, with a decrease of 0.3% per year (−2% in total).Population aging alone would have caused spending per capita in the provinces to increase by 0.5% to 2.1% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted spending per capita decreased by annual rates ranging from 1.2% (NB) to 6.7% (MB).AntipsychoticsTable	3.3e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 0 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-5%NewBrunswick-1%NovaScotia-5%Newfoundlandand Labrador-5%Prince Edward I.-5%Alberta-3%Saskatchewan-5%Manitoba-7% Quebec-1%Ontario-3%Volume effectsPrice effectsTherapeutic choice effectsAntipsychoticsFigure	3.3j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.3i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 0 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 80.3% 80.2% 90.4% 76.1% 95.3% 83.9% 83.5% 89.7% 96.9% 89.8% 98.9%Private	insurers 70.5% 76.7% 83.3% 69.5% 90.0% 73.0% 70.0% 73.8% 90.0% 93.1% 86.0%%-point	diff.	btw.	prov.	&	private	plans 9.8% 3.5% 7.2% 6.6% 5.3% 10.9% 13.5% 15.9% 6.9% -3.3% 12.9%Uninsured	patients	/	below	deductibles 78.3% 79.4% 83.6% 78.9% 92.3% 78.7% 80.8% 84.6% 92.5% 90.7% 89.0%%-pt.	diff.	btw.	prov.	plan	&	uninsured 2.0% 0.8% 6.9% -2.8% 2.9% 5.3% 2.7% 5.1% 4.3% -0.9% 9.9%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 32.0% 33.8% 30.3% 25.3% 17.2% 39.3% 37.6% 21.3% 23.4% 22.2% 7.9%Private	insurers 36.1% 32.9% 35.0% 26.6% 26.3% 43.3% 47.5% 34.0% 32.1% 23.3% 20.2%%-point	diff.	btw.	prov.	&	private	plans -4.1% 0.9% -4.7% -1.2% -9.2% -4.0% -9.9% -12.7% -8.7% -1.1% -12.2%Uninsured	patients	/	below	deductibles 25.9% 25.5% 28.4% 21.1% 17.1% 30.6% 34.4% 21.4% 25.8% 12.4% 19.0%%-pt.	diff.	btw.	prov.	plan	&	uninsured 6.0% 8.3% 2.0% 4.2% 0.1% 8.7% 3.2% -0.1% -2.5% 9.8% -11.1%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $5.42 $6.10 $6.21 $5.40 $4.95 $4.96 $4.94 $5.07 $4.08 $5.53 $3.97Private	insurers $5.93 $5.59 $6.27 $5.44 $5.37 $5.76 $5.96 $5.96 $4.75 $4.77 $5.15%	diff.	btw.	provincial	&	private	plans -8.7% 9.3% -0.9% -0.9% -7.8% -13.9% -17.1% -14.9% -14.2% 16.1% -22.9%Uninsured	patients	/	below	deductibles $5.28 $5.42 $5.94 $4.85 $4.81 $4.97 $5.04 $5.16 $4.20 $4.58 $5.02%	diff.	btw.	provincial	plan	&	uninsured 2.6% 12.7% 4.5% 11.2% 2.9% -0.2% -1.9% -1.7% -2.8% 20.7% -20.8%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $19.60 $18.10 $17.00 $15.30 $16.00 $16.90 $27.70 $26.20 $15.40 $16.50 $14.90%	Provincial	drug	plans 68% 76% 62% 65% 63% 64% 71% 65% 58% 51% 61%%	Private	insurance 18% 9% 21% 12% 12% 22% 19% 21% 25% 27% 25%%	Uninsured	/	below	deductibles 12% 12% 12% 14% 17% 14% 10% 12% 15% 20% 13%%	Federal	drug	plans 2% 3% 5% 9% 7% 1% 0% 2% 2% 1% 1%Public (provincial and federal) drug plans covered an estimated 70% of spending on antipsychotics in Canada, making this one of the most publicly-subsi-dized drug classes.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $5.42, 9% less than the cost per day for prescriptions paid for by private drug plans.For every 100 prescriptions for multi-sourced drugs, 10 more were filled with generics under public drug plans than under private drug plans.AntipsychoticsTable	3.3i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	3.3h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	3.3g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	3.3f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 0 93.4Nervous systemPregabalin and gabapentint h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 1 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) Pregabalin and gabapentinPercent of prescriptionsPercent of spendingPregabalin 50.5% 68.7%Gabapentin 49.5% 31.3%Percent of prescriptionsPercent of spendingPregabalin 50.5% 68.7%Gabapentin 49.5% 31.3%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $0.00 $0.00 0 0 n/a n/aMulti-source	brand $9.10 $6.40 110 60 $82.73 $106.67Multi-source	generic $4.00 $2.90 100 70 $40.00 $41.43Sourced	only	by	generics $0.10 $0.10 0 0 n/a n/a$396>95%19%$7$11$13$92101302,6602,010$4.97$4.6957%35%8%44%36%18%1%59%41%Figure	3.4b»	Share of spending by sex, age group, and payer, 2012/13Figure	3.4a»	Summary of sales, spending, and use, 2012/13Table	3.4c»	Spending, use, and cost, by drug source, 2012/13Table	3.4b»	Leading drugs, by spending, 2012/13Table	3.4a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 1 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredPregabalin and gabapentinProvincial formulary coverageAll provinces provided restricted or unrestricted coverage for at least one of the two types of drugs in this therapeutic category that had over $10,000 in sales in each province.Weighted by national sales, the drug covered by most provinces accounted for 31% of the $400-million Canadian market for this therapeutic category. As Saskatchewan and Quebec covered both drugs, expenditure weighting does not contribute to our analysis for these provinces.0%50%100%NLNS PENBQCONMBSKBC AB0%100%NLNS PENBQCONMBSKBC AB% of 2 drugs covered% market value of drugs20%40%60%80%Drugs includedGabapentin and pregabalin.Examples of indicated conditionsSeizures, neuropathic pain, and fibromyalgia.Clinical uses and considerationsIn Canada, gabapentin is indicated only for  adjunctive treatment of epilepsy; however, it is commonly prescribed off-label for the management of many other conditions, including neuropathic pain, restless legs syndrome, migraine headaches, and menopausal symptoms.Pregabalin has been shown to have faster absorption and higher bioavailability than gabapentin. It is used to manage the symptoms of fibromyalgia as well as neuropathic pain associated with diabetes, spinal cord injury, or complications of shingles. Many of the conditions that patients take these drugs for lack large long-term randomized controlled trials to support the widespread prescribing of the drugs.There are also increasing concerns that gabapentin and pregabalin may be prone to diversion, as cases of abuse and addiction have been reported.How might usage differ across age groups?These drugs are used throughout the lifespan, but usage increases with advancing age. This may be explained by the epidemiology of the conditions these drugs commonly treat; for example, fibromyalgia, postherpetic neuralgia, and neuropathic pain are all increasingly prevalent at older ages. Patients taking these drugs for epilepsy and migraine prophylaxis will often continue on these drugs for a long time; thus, more usage is expected with age as more patients are diagnosed.How might usage differ between sexes?The incidence of epilepsy is similar in women and men; however, fibromyalgia and migraine occur more commonly in women. Women may also be more likely to seek medical attention for pain and or migraine than men.Figure	3.4c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 1 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $11 per capita on pregabalin and gabapentin at retail pharmacies in 2012/13 ($13 for women and $9.40 for men). Spending on these medicines was highly concentrated among adults aged 40 and older. Average spending per capita was $18 for the 40–64 age group and $27 for the 65+ age group.Average spending per capita was 37% higher for women aged 40–64 than for men in the same age group and 24% higher for women aged 65 and older than for men in that age group. Average spending per capita across all age groups was 41% higher for women than for men, because a greater share of women live to the high-spending age of 65 and older. Provincial spending by age and sexAcross provinces, average spending per capita ranged from $7.90 (NL) to $23 (QC) for women and from $6.50 (NL) to $17 (QC) for men. In all provinces, the level of spending was higher for women than for men at all ages. Age gradients differed across provinces, with the ratio of average spending per capita in the 65+ age group to average spending per capita in the 40–64 age group ranging from 0.8 to 1.7 for women and from 1.0 to 1.7 for men. Within each age group, there was notable variation across provinces in average spending per capita. Greatest variation occurred in the 65+ age group (coef-ficient of variation: 44%), driven largely by the signifi-cantly higher average spending in Quebec than in all other provinces. Least variation occurred in the 19–39 age group (coefficient of variation: 26%). The level of variation across provinces within each age group was similar for women and men.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$21$29$0.18$4$0.14 $3$15$23Pregabalin and gabapentinFigure	3.4e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.4d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 1 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$40 $40$20$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$20Females age 0–18 Males age 0–18$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$20Females age 19–39 Males age 19–39$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$40 $40$20Females age 40–64 Males age 40–64$0NLNSNBQCONMBSKBC AB PE$0$20$20NLNSNBQCONMBSKBC AB PE$40 $40$60$60Females age 65+ Males age 65+Pregabalin and gabapentinFigure	3.4f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 1 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationVolume effects and therapeutic choice effects were the most important drivers of provincial variation in age-standardized average retail spending on pregabalin and gabapentin.Residents of Newfoundland & Labrador purchased significantly fewer drugs than other Canadians, while residents of Quebec and Nova Scotia purchased significantly more.In most provinces, choice effects contributed to lower levels of provincial spending than in the rest of Canada. Residents of Quebec received by far the most expensive mix of drugs than other Canadians. Prices were also important in this therapeutic category. Prices paid per unit of particular drug products in Manitoba were 15.1% above the average for the rest of Canada. Residents of Quebec used generics in this class less often than other Canadians.Population age and provincial spendingBecause spending on pregabalin and gabapentin is concentrated among older adults, differences in provincial population ages would predict moderate provincial variation in spending per capita.For example, based on age differences alone, predicted spending in Alberta would be 12% below the average for the rest of Canada; in provinces east of Ontario, it would be 5.5% to 9.2% above the average for the rest  of Canada. However, even after the figures were adjusted for differences in population age, significant provincial variation in spending per capita remained. In Quebec, age-standardized average spending on pregabalin and gabapentin was more than double the average for the rest of Canada, while in Newfoundland & Labrador it was 37% below the average for the rest of Canada.Pregabalin and gabapentinBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $8.84 $9.07 $9.62 $8.80 $7.90 $19.98 $14.04 $14.81 $15.87 $7.18Spending	per	capita	in	rest	of	Canada $11.73 $11.63 $11.40 $11.45 $13.53 $8.76 $11.29 $11.25 $11.33 $11.41Unadjusted	difference	in	spending	per	capita -24.6% -22.1% -15.6% -23.1% -41.6% 128.1% 24.4% 31.6% 40.1% -37.0%Difference	predicted	by	population	age 4.1% -12.1% -5.8% -5.5% -0.8% 4.8% 7.6% 7.6% 5.5% 9.2%Age-standardized difference -27.6% -11.3% -10.4% -18.7% -41.1% 117.6% 15.6% 22.3% 32.8% -42.3%Volume effects 5.1% 11.8% 6.2% 0.3% -18.5% 40.1% 30.2% 39.0% 25.9% -58.6%Prescription	volume -32.6% -30.8% -22.2% -27.7% -56.1% 175.4% -25.6% -45.1% -37.8% -97.4%Prescription	size 37.7% 42.6% 28.4% 28.0% 37.7% -135.4% 55.9% 84.2% 63.8% 38.8%Therapeutic choice effects -29.7% -30.9% -23.8% -33.6% -19.8% 75.9% -17.6% -10.9% 3.6% 12.1%Choices	of	drug	sub-classes -0.1% 1.4% -2.7% -6.2% 1.1% 0.4% 1.4% 5.3% 2.0% 9.6%Choices	within	drug	sub-classes -29.6% -32.3% -21.1% -27.4% -21.0% 75.5% -19.1% -16.2% 1.6% 2.4%Price effects -3.0% 7.7% 7.1% 14.6% -2.8% 1.7% 3.0% -5.8% 3.3% 4.2%Prices	paid -2.4% 8.0% 7.5% 15.1% -2.9% -0.7% 4.1% -4.1% 3.8% 4.0%Generic	use -0.6% -0.3% -0.3% -0.5% 0.1% 2.4% -1.1% -1.7% -0.6% 0.2%Table	3.4d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 1 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Pregabalin and gabapentinFigure	3.4g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.4h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-28%NewBrunswick+16%NovaScotia+22%Newfoundlandand Labrador-42%Prince Edward I.+33%Alberta-11%Saskatchewan-10%Manitoba-19% Quebec+118%Ontario-41%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 1 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $7.01 $8.42 $6.28 $5.40 $5.69 $4.77 $10.68 $7.50 $8.74 $9.42 $3.772012/13 $11.35 $8.84 $9.07 $9.62 $8.80 $7.90 $19.98 $14.04 $14.81 $15.87 $7.18Average	annual	change 10.1% 1.0% 7.6% 12.2% 9.1% 10.6% 13.3% 13.4% 11.1% 11.0% 13.7%Average	annual	change	predicted	by	aging 1.8% 2.1% 2.4% 1.3% 1.3% 1.8% 1.6% 1.0% 0.8% 1.9% 1.0%Age-standardized avg. annual change 8.2% -1.1% 5.1% 10.8% 7.7% 8.7% 11.5% 12.3% 10.2% 8.9% 12.6%Volume effects 10.1% 3.7% 7.4% 9.7% 9.9% 14.3% 9.4% 17.2% 15.7% 11.6% 13.9%Prescription	volume 12.2% 2.4% 8.2% 9.7% 11.8% 16.1% 13.8% 19.3% 14.7% 10.3% 12.2%Prescription	size -2.2% 1.3% -0.8% 0.0% -1.9% -1.8% -4.4% -2.1% 1.0% 1.3% 1.7%Therapeutic choice effects 1.5% 0.9% 0.9% 3.5% 0.3% -1.7% 3.8% -1.4% -1.4% 0.0% 0.9%Choices	of	drug	sub-classes 0.1% -0.5% -0.2% 2.3% -1.9% -1.0% 0.7% -1.3% -0.8% -0.6% 0.2%Choices	within	drug	sub-classes 1.4% 1.4% 1.1% 1.2% 2.3% -0.7% 3.1% -0.1% -0.6% 0.6% 0.8%Price effects -3.3% -5.7% -3.2% -2.4% -2.6% -4.0% -1.7% -3.6% -4.1% -2.7% -2.2%Prices	paid -3.0% -5.7% -3.1% -2.2% -2.5% -3.9% -1.2% -3.4% -3.8% -2.5% -2.0%Generic	use -0.3% -0.1% -0.1% -0.2% 0.0% -0.2% -0.5% -0.2% -0.2% -0.2% -0.2%Sources of age-standardized changeMost of the increase in age-standardized spending per capita on gabapentin and related drugs was driven by increased use of these drugs between 2007/08 and 2012/13, especially in Atlantic Canada. In some provinces (particularly Saskatchewan and Quebec), changes in the types of drugs selected for treatment contributed considerably to the increase in age-standardized spending per capita.Owing mostly to savings resulting from lower unit prices, average prices paid for drugs in this therapeutic category decreased. On their own, these price changes would have reduced age-standardized spending per capita by more than 15% in most provinces.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of pregabalin and gabapen-tin drugs increased by an average of 10.1% per year between 2007/08 and 2012/13, for a total change  of 62%.Spending per capita on gabapentin and related drugs increased in all provinces. The greatest change in spending per capita occurred in Newfoundland & Labrador, with an average increase of 12.6% per year (90% in total). The smallest change occurred British Columbia, where spending per capita increased by an average of 1.0% per year (5.0% in total).Population aging alone would have caused spending per capita in the provinces to increase by 0.8% to 2.4% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted annual rates of change in spending per capita remained relatively high, ranging from −1.1% (BC) to 17.2% (NB).Pregabalin and gabapentinTable	3.4e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 1 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-1%NewBrunswick+12%NovaScotia+10%Newfoundlandand Labrador+13%Prince Edward I.+9%Alberta+5%Saskatchewan+11%Manitoba+8% Quebec+12%Ontario+9%Volume effectsPrice effectsTherapeutic choice effectsPregabalin and gabapentinFigure	3.4i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.4j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 1 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 61.9% 94.7% 91.4% 83.5% 96.5% 87.6% 55.7% 92.9% 88.5% 93.7% 85.3%Private	insurers 33.2% 51.8% 53.9% 57.9% 72.4% 27.3% 46.5% 38.2% 40.5% 24.7% 24.5%%-point	diff.	btw.	prov.	&	private	plans 28.7% 42.9% 37.5% 25.6% 24.2% 60.3% 9.2% 54.7% 48.0% 69.0% 60.8%Uninsured	patients	/	below	deductibles 41.1% 60.0% 48.5% 63.1% 75.8% 35.4% 55.6% 47.8% 51.3% 46.8% 36.6%%-pt.	diff.	btw.	prov.	plan	&	uninsured 20.8% 34.7% 42.8% 20.4% 20.7% 52.2% 0.1% 45.1% 37.2% 46.9% 48.7%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Private	insurers 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%%-point	diff.	btw.	prov.	&	private	plans 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Uninsured	patients	/	below	deductibles 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%%-pt.	diff.	btw.	prov.	plan	&	uninsured 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $4.36 $3.00 $3.66 $3.81 $3.98 $2.65 $4.42 $3.37 $3.16 $3.42 $3.83Private	insurers $5.58 $4.70 $4.93 $4.80 $4.71 $5.85 $4.82 $5.41 $4.94 $5.95 $5.72%	diff.	btw.	provincial	&	private	plans -21.9% -36.2% -25.9% -20.6% -15.4% -54.7% -8.3% -37.7% -36.0% -42.5% -32.9%Uninsured	patients	/	below	deductibles $5.21 $4.44 $5.20 $4.71 $4.81 $5.51 $4.24 $5.17 $4.75 $5.29 $5.57%	diff.	btw.	provincial	plan	&	uninsured -16.3% -32.5% -29.8% -19.0% -17.2% -51.9% 4.1% -34.9% -33.4% -35.2% -31.2%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $11.30 $8.80 $9.10 $9.60 $8.80 $7.90 $20.00 $14.00 $14.80 $15.90 $7.20%	Provincial	drug	plans 44% 39% 42% 49% 39% 26% 63% 23% 24% 18% 11%%	Private	insurance 36% 33% 37% 23% 25% 53% 22% 60% 62% 65% 68%%	Uninsured	/	below	deductibles 18% 26% 18% 20% 29% 21% 15% 16% 13% 17% 20%%	Federal	drug	plans 1% 3% 3% 8% 7% 1% 0% 1% 1% 0% 0%Public (provincial and federal) drug plans covered an estimated 45% of spending on pregabalin and gabapentin in Canada; private drug plans covered an estimated 36%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $4.36, 22% less than the cost per day for prescriptions paid for by private drug plans.For every 100 prescriptions for multi-sourced drugs, 20 more were filled with generics under public drug plans than under private drug plans.Pregabalin and gabapentinTable	3.4i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	3.4h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	3.4g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	3.4f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 1 93.5Nervous systemDrugs for ADHDt h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 2 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.)Drugs for ADHDPercent of prescriptionsPercent of spendingMethylphenidate 61.3% 52.3%Lisdexamfetamine 12.1% 15.6%amphetamine/dextroamphetamine 9.0% 12.7%Atomoxetine 8.0% 10.9%Dextroamphetamine 7.7% 6.3%Percent of prescriptionsPercent of spendingMethylphenidate 61.3% 52.3%Lisdexamfetamine 12.1% 15.6%amphetamine/dextroamphetamine 9.0% 12.7%Atomoxetine 8.0% 10.9%Dextroamphetamine 7.7% 6.3%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $3.10 $6.10 30 60 $103.33 $101.67Multi-source	brand $3.10 $6.70 30 60 $103.33 $111.67Multi-source	generic $0.90 $1.60 20 30 $45.00 $53.33Sourced	only	by	generics $0.00 $0.10 0 0 n/a n/a$376>95%16%$7$11$7$14801602,7205,410$2.62$2.67   61%15%21%57%21%1%33%67%1%22%Figure	3.5b»	Share of spending by sex, age group, and payer, 2012/13Figure	3.5a»	Summary of sales, spending, and use, 2012/13Table	3.5b»	Leading drugs, by spending, 2012/13Table	3.5c»	Spending, use, and cost, by drug source, 2012/13Table	3.5a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 2 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredDrugs for ADHDProvincial formulary coverageProvinces provided restricted or unrestricted coverage for two to four of the six types of drugs for ADHD with more than $10,000 in sales in each province.Weighted by national sales, the drugs covered in most provinces accounted for approximately 60% of the $380-million Canadian ADHD drug market. Saskatchewan, Ontario, and Quebec covered drugs that accounted for 72% to 87% of this market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 6 drugs covered% market value of drugsDrugs includedMethylphenidate, lisdexamfetamine, and others.Examples of indicated conditionsAttention deficit hyperactivity disorder (ADHD).Clinical uses and considerationsThese drugs are used to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Most drugs in this category are stimulants that cause release of catecholamines in the brain and seem to provide short-term improvement in concentration, although the exact mechanism for this benefit is unclear. Some of these drugs are also used to treat narcolepsy. The diagnosis of ADHD has increased dramatically since drug treatments became available, raising concerns about over-diagnosis and treatment of what might be normal variations in attention and activity levels. How might usage differ across age groups?This category of drugs is most commonly used  among those younger than 19. ADHD is usually diagnosed during childhood, when the goal of drug treatment is to improve focus and performance at school. Drugs in this category are also approved for use by adults; however, adults are more likely than children to manage symptoms consistent with ADHD with cognitive therapies or non-stimulant drugs such as antidepressants. How might usage differ between sexes?Boys are diagnosed with and treated for ADHD more often than girls. The reasons for this are complex and likely reflect both biological differences and gender differences in social norms and conditioning. Boys are more likely to present with hyperactivity and impulsive behaviours that are noticeably disruptive both at school and at home. In contrast, girls more often present with inattentive symptoms of ADHD, which are more likely to be overlooked by parents and teachers or mistaken for laziness.Figure	3.5c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 2 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $11 per capita on drugs for ADHD at retail pharmacies in 2012/13 ($7.10 for females and $14 for males). Spending on these medicines was highly concentrated among children. Average spending per capita decreased from $31 in the 0–18 age group to $8.40 in the 19–39 age group, and continued to decrease to just $0.90 per capita for the 65+ age group.Average spending per capita on drugs for ADHD was nearly three times higher for boys aged 0–18 ($45) than for girls ($16). This difference between sexes decreased with age because the use of these drugs decreased more sharply after childhood for men than for women. Within the 19–39 age group, average spending per capita on drugs for ADHD was 30% higher for men ($9.50) than for women ($7.30). Dif-ferences between women and men were not significant beyond age 40.Provincial spending by age and sexAcross provinces, average spending per capita on drugs for ADHD ranged from $4.20 (NL) to $11.40 (QC) for women and from $8.50 (BC) to $23 (QC) for men. In all provinces, spending was highly concen-trated in the 0–18 age group.Though there was moderate variation in spending per capita in all age groups (coefficients of variation greater than 30%), by far the greatest variation occurred in the 0–18 age group (coefficient of variation: 47%). Average spending per capita in this age group ranged from $7.60 (BC) to $35 (QC) for girls and from $23 (BC) to $89 (QC) for boys.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$5$1$16$7$45$9$5$1Drugs for ADHDFigure	3.5e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.5d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 2 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0NLNSNBQCONMBSKBC AB PE$0$20$20NLNSNBQCONMBSKBC AB PEFemales age 65+ Males age 65+$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$20$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$40 $40$20$60$80$100$60$80$100Females age 0–18 Males age 0–18$0NLNSNBQCONMBSKBC AB PE$0$20$20NLNSNBQCONMBSKBC AB PEFemales age 40–64 Males age 40–64$0NLNSNBQCONMBSKBC AB PE$0$20$20NLNSNBQCONMBSKBC AB PEFemales age 19–39 Males age 19–39Drugs for ADHDFigure	3.5f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 2 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on drugs for ADHD was driven largely by volume effects.Residents of Western Canada and Ontario purchased significantly fewer drugs than those of Atlantic Canada and Quebec. Residents of Quebec purchased a significantly higher volume of treatment than residents of other provinces.Therapeutic choice effects contributed to provincial variation in age-adjusted spending per capita for some provinces. Notably, residents of Newfoundland & Labrador purchased a much less costly mix of drugs than other Canadians.Price effects contributed modestly to provincial  variation in age-adjusted spending per capita.Population age and provincial spendingBecause spending on drugs for ADHD is almost entirely concentrated among children, differences in provincial population ages would predict modest provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta, Saskatchewan, and Manitoba would be approximately 8% above the average for the rest of Canada; in other provinces, except Ontario, spending per capita would range from 2.2% to 6.5% below the average for the rest of Canada.However, even after the figures were adjusted for differences in population age, provincial variation in spending per capita on drugs for ADHD remained. In Quebec, age-standardized average spending was double the average for the rest of Canada, while in Manitoba it was 40% below the average for the rest  of Canada.Drugs for ADHDBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $6.67 $10.00 $8.67 $7.08 $9.18 $17.38 $8.78 $12.33 $11.67 $7.31Spending	per	capita	in	rest	of	Canada $11.40 $10.87 $10.84 $10.91 $11.77 $8.79 $10.81 $10.73 $10.77 $10.82Unadjusted	difference	in	spending	per	capita -41.5% -8.0% -20.0% -35.1% -22.0% 97.8% -18.8% 14.9% 8.4% -32.4%Difference	predicted	by	population	age -4.4% 8.1% 8.1% 8.7% 0.9% -4.1% -5.6% -6.5% -2.2% -7.3%Age-standardized difference -38.8% -14.9% -26.0% -40.3% -22.7% 106.2% -14.0% 23.0% 10.8% -27.1%Volume effects -30.7% -19.3% -25.4% -24.1% -25.5% 96.2% -3.4% 47.5% 22.5% 12.0%Prescription	volume -40.3% -31.6% -25.6% -36.1% -43.0% 143.2% 2.3% 3.3% 14.7% 9.1%Prescription	size 9.6% 12.3% 0.2% 12.0% 17.4% -47.0% -5.7% 44.3% 7.8% 2.9%Therapeutic choice effects -9.5% 2.7% -7.8% -6.6% 2.5% 10.0% -11.4% -18.5% -11.1% -41.0%Choices	of	drug	sub-classes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Choices	within	drug	sub-classes -9.5% 2.7% -7.8% -6.6% 2.5% 10.0% -11.4% -18.5% -11.1% -41.0%Price effects 1.4% 1.8% 7.1% -9.6% 0.3% 0.0% 0.8% -6.0% -0.6% 1.9%Prices	paid 0.9% 0.6% 3.9% -8.4% 2.6% -3.8% 4.9% -1.9% 1.4% 3.7%Generic	use 0.5% 1.2% 3.2% -1.2% -2.3% 3.9% -4.1% -4.2% -2.0% -1.8%Table	3.5d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 2 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Drugs for ADHDFigure	3.5g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.5h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-39%NewBrunswick-14%NovaScotia+23%Newfoundlandand Labrador-27%Prince Edward I.+11%Alberta-15%Saskatchewan-26%Manitoba-40% Quebec+106%Ontario-23%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 2 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $6.49 $4.25 $6.67 $4.32 $4.98 $6.66 $7.99 $5.86 $8.00 $8.40 $3.822012/13 $10.77 $6.67 $10.00 $8.67 $7.08 $9.18 $17.38 $8.78 $12.33 $11.67 $7.31Average	annual	change 10.7% 9.4% 8.4% 14.9% 7.3% 6.6% 16.8% 8.4% 9.0% 6.8% 13.9%Average	annual	change	predicted	by	aging 0.4% 0.7% 1.6% 1.4% 0.8% 0.3% 0.1% -0.6% -0.7% 0.1% -0.7%Age-standardized avg. annual change 10.2% 8.7% 6.8% 13.4% 6.4% 6.3% 16.7% 9.1% 9.8% 6.7% 14.7%Volume effects 7.8% 5.8% 4.7% 6.3% 5.4% 4.2% 13.3% 8.7% 10.6% 8.3% 15.7%Prescription	volume 8.5% 5.4% 3.2% 6.3% 5.6% 5.2% 13.4% 8.9% 10.5% 6.8% 14.6%Prescription	size -0.7% 0.4% 1.5% -0.1% -0.3% -1.0% -0.1% -0.2% 0.2% 1.5% 1.1%Therapeutic choice effects 2.8% 1.7% 1.8% 6.0% 3.2% 3.1% 3.3% 1.9% -0.7% -0.9% -1.3%Choices	of	drug	sub-classes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Choices	within	drug	sub-classes 2.8% 1.7% 1.8% 6.0% 3.2% 3.1% 3.3% 1.9% -0.7% -0.9% -1.3%Price effects -0.3% 1.1% 0.2% 1.1% -2.1% -1.0% 0.0% -1.5% -0.2% -0.7% 0.3%Prices	paid 0.7% 1.8% 0.8% 1.4% -1.3% 0.3% 0.7% 0.5% 1.4% 0.6% 1.2%Generic	use -1.0% -0.7% -0.6% -0.2% -0.9% -1.3% -0.7% -1.9% -1.6% -1.3% -0.9%Sources of age-standardized changeThe major driver of the increase in age-standardized spending per capita on ADHD drugs across Canada was increased use of these drugs, especially in  Eastern Canada. In some provinces, the use of more expensive drug treatment options contributed considerably to increased spending. In Saskatchewan, these changes in therapeutic choices alone would have increased inflation-adjusted spending per capita by a total of 35% (6.0% per year) between 2007/08 and 2012/13.The combined effects of changes in prices paid and generic substitutions were inconsistent across the country and generally had modest effects on changes in inflation-adjusted spending per capita.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of drugs for ADHD increased by an average of 11% per year between 2007/08 and 2012/13, for a total change of 66%.Spending per capita on ADHD drugs increased in all provinces. The greatest change occurred in Quebec, where spending per capita increased by 17% per year (117% in total). The smallest change, which was still large, occurred in Ontario, with an average of 6.6% per year (38% in total).Population aging alone would have caused spending per capita to decrease slightly in some provinces (NB, NS, and NL) and increase slightly in others. However, age-standardized and inflation-adjusted annual rates of change in spending per capita remained very high, ranging from 6.3% (ON) to 17% (QC).Drugs for ADHDTable	3.5e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 2 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia+9%NewBrunswick+9%NovaScotia+10%Newfoundlandand Labrador+15%Prince Edward I.+7%Alberta+7%Saskatchewan+13%Manitoba+6% Quebec+17%Ontario+6%Volume effectsPrice effectsTherapeutic choice effectsDrugs for ADHDFigure	3.5i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.5j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 2 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 40.4% 48.5% 43.2% 12.5% 39.4% 57.6% 43.6% 88.0% 81.0% 76.5% 97.2%Private	insurers 24.0% 27.9% 17.6% 22.8% 33.6% 29.4% 35.1% 46.4% 46.8% 36.7% 42.6%%-point	diff.	btw.	prov.	&	private	plans 16.4% 20.6% 25.6% -10.3% 5.8% 28.2% 8.5% 41.7% 34.2% 39.7% 54.6%Uninsured	patients	/	below	deductibles 40.6% 43.2% 22.3% 30.0% 41.8% 51.9% 46.3% 77.0% 69.7% 52.9% 74.3%%-pt.	diff.	btw.	prov.	plan	&	uninsured -0.2% 5.3% 20.9% -17.5% -2.4% 5.7% -2.7% 11.1% 11.4% 23.6% 22.9%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 41.9% 52.0% 60.7% 6.1% 23.2% 53.8% 46.0% 49.1% 62.9% 55.8% 21.6%Private	insurers 41.7% 51.3% 52.8% 27.8% 30.8% 41.5% 45.3% 41.2% 52.2% 51.8% 31.1%%-point	diff.	btw.	prov.	&	private	plans 0.2% 0.7% 7.8% -21.7% -7.6% 12.3% 0.7% 7.9% 10.7% 4.0% -9.5%Uninsured	patients	/	below	deductibles 46.8% 54.1% 53.7% 34.5% 31.7% 50.9% 43.0% 47.8% 53.1% 44.1% 26.3%%-pt.	diff.	btw.	prov.	plan	&	uninsured -4.9% -2.2% 7.0% -28.4% -8.5% 2.9% 2.9% 1.3% 9.8% 11.7% -4.7%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $2.35 $2.13 $2.19 $2.74 $1.91 $2.27 $2.52 $1.58 $1.67 $1.60 $1.05Private	insurers $2.84 $2.79 $2.92 $2.69 $2.14 $2.86 $2.78 $2.93 $2.57 $2.68 $2.49%	diff.	btw.	provincial	&	private	plans -17.2% -23.7% -24.9% 1.9% -11.0% -20.7% -9.5% -46.1% -35.2% -40.5% -57.6%Uninsured	patients	/	below	deductibles $2.61 $2.62 $2.75 $2.22 $2.12 $2.59 $2.63 $2.33 $2.17 $2.04 $1.70%	diff.	btw.	provincial	plan	&	uninsured -9.9% -18.7% -20.3% 23.3% -10.2% -12.3% -4.1% -32.1% -23.1% -21.6% -38.1%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $10.80 $6.70 $10.00 $8.70 $7.10 $9.20 $17.40 $8.80 $12.30 $11.70 $7.30%	Provincial	drug	plans 21% 22% 15% 49% 30% 17% 27% 9% 13% 9% 19%%	Private	insurance 57% 43% 56% 25% 36% 61% 58% 71% 68% 71% 59%%	Uninsured	/	below	deductibles 21% 34% 27% 19% 29% 21% 15% 19% 18% 20% 22%%	Federal	drug	plans 1% 2% 2% 7% 5% 0% 0% 1% 0% 0% 1%Public (provincial and federal) drug plans covered an estimated 22% of spending on ADHD drugs in Canada; private drug plans covered an estimated 57%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $2.35, 17% less than the cost per day for prescriptions paid for by private drug plans.For every 100 prescriptions for multi-sourced drugs, 16 more were filled with generics under public drug plans than under private drug plans.Drugs for ADHDTable	3.5i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	3.5h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	3.5g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	3.5f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 2 93.6Nervous systemBenzodiazepinest h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 3 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) BenzodiazepinesPercent of prescriptionsPercent of spendingLorazepam 35.8% 24.5%Zopiclone 26.0% 47.1%Oxazepam 12.5% 6.8%Temazepam 7.7% 5.1%Alprazolam 5.4% 5.1%Percent of prescriptionsPercent of spendingZopiclone 26.0% 47.1%Lorazepam 35.8% 24.5%Oxazepam 12.5% 6.8%Alprazolam 5.4% 5.1%Temazepam 7.7% 5.1%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $1.00 $0.50 50 30 $20.00 $16.67Multi-source	brand $1.10 $0.60 70 40 $15.71 $15.00Multi-source	generic $5.00 $3.10 440 260 $11.36 $11.92Sourced	only	by	generics $5.00 $3.00 180 110 $27.78 $27.27$33690%58%$9$10$12$775043016,73010,490$0.72$0.68   9%40%36%32%30%1%63%37%1%50%Figure	3.6b»	Share of spending by sex, age group, and payer, 2012/13Figure	3.6a»	Summary of sales, spending, and use, 2012/13Table	3.6c»	Spending, use, and cost, by drug source, 2012/13Table	3.6b»	Leading drugs, by spending, 2012/13Table	3.6a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 3 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredBenzodiazepinesProvincial formulary coverageAll provinces provided restricted or unrestricted coverage for at least 11 (QC) of the 14 types of benzodiazepines that had more than $10,000 in sales in each province. Four provinces (AB, MB, NB, PE) provided unrestricted coverage for all drugs in this therapeutic category.Weighted by national sales, the drugs covered in most provinces accounted for nearly the entire (98% or more) $330-million Canadian benzodi-azepine market. In three provinces (SK, ON, QC) they only accounted for 50% of the market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 14 drugs covered% market value of drugsDrugs includedBenzodiazepines, benzodiazepine derivatives, and related “Z” drugs (e.g., zopiclone).Examples of indicated conditionsInsomnia and anxiety.Clinical uses and considerations Benzodiazepines are sedative-hypnotic drugs used primarily for treatment of insomnia and anxiety disorders. They may also be used for a variety of other conditions, including management of alcohol withdrawal and seizures. One of the major differences among the drugs in this class is the time to onset and duration of action. Individuals taking benzodiazepines may develop tolerance and dependence; any abrupt discontinua-tion or reduction in use could lead to symptoms of withdrawal, including anxiety, tremors, psychosis, or seizures. Other side effects include sedation, cognitive or learning impairment, and increased risks of falls in the elderly.Benzodiazepine derivatives and related “Z” drugs are primarily used for insomnia by helping to reduce time to the onset of sleep and prolonging total sleep time. How might usage differ across age groups?Prevalence of insomnia and anxiety disorders increase with increasing age, and it is expected that the use of benzodiazepines and related drugs will also increase with age. Further, despite the potential adverse effects and recommendations that these drugs be used only for short periods of time, many individuals remain on these drugs for long periods. How might usage differ between sexes?Insomnia is more common in women than in men. This may be because of the higher prevalence of anxiety, depression, and some pain conditions in women, all of which commonly contribute to sleep disturbances. Studies suggest that of those diagnosed with insomnia, women and men are equally likely to be treated with a benzodiazepine-type medication.Figure	3.6c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 3 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $10 per capita on benzodiazepines at retail pharmacies in 2012/13 ($12 for women and $7.20 for men). Average spending per capita was insignificant for Canadians aged 0–18 but increased with age thereafter. Average spending per capita in the 65+ age group ($26) was almost twice the average spending in the 40–64 age group ($14).Age-related increases in average spending per capita were similar for women and men. However, average spending per capita was more than 50% higher for women than for men in each age group older  than 0–18.Provincial spending by age and sexAcross provinces, average spending per capita ranged from $8.60 (ON) to $23 (NB) for women and from $5.20 (ON) to $14 (NB) for men. Differences in average spending per capita by age and sex were roughly comparable across provinces. However, levels of average spending per capita by age and sex differed.For almost all age/sex groups, New Brunswick had the highest average spending per capita on benzodiaz-epines and Ontario had the lowest average. Variations across other provinces were modest in the 40–64 and 65+ age groups (coefficients of variation less than 15%). Substantial variation remained in average spending per capita for women and for men in the 19–39 age group (coefficients of variation greater  than 30%).$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$17$31$0$4$1 $3$10$20BenzodiazepinesFigure	3.6e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.6d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 3 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20 $20$10Males of all agesFemales age 19–39$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Males age 19–39Females age 40–64$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20 $20$10$30 $30Males age 40–64$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20 $20$10$30$40$50$40$30$50Females age 65+ Males age 65+Females age 0–18$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Males age 0–18BenzodiazepinesFigure	3.6f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 3 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationProvincial variation in age-standardized average retail spending on benzodiazepines was driven by all three categories of cost drivers.Residents of British Columbia, Saskatchewan, and Ontario purchased significantly fewer benzodiazepines than residents of other provinces.Quebec residents were prescribed more expensive benzodiazepines and related drugs than other Cana-dians, while Alberta residents were prescribed more costly drugs than other Canadians.Residents of the Atlantic provinces tended to pay lower unit prices for particular benzodiazepine drug products than other Canadians, while Quebec resi-dents paid higher unit prices.Population age and provincial spendingBecause spending on benzodiazepines is concentrated among older adults, differences in provincial popula-tion ages would predict relatively significant provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 13% below the average for the rest of Canada; in Newfoundland & Labrador, it would be 8.6% above the average for the rest of Canada.However, even after the figures were adjusted for differences in population age, significant provincial variation in average spending remained. In New Brunswick, age-standardized average spending was approximately 84% above the average for the rest of Canada, while in Ontario it was 38% below the average for the rest of Canada.BenzodiazepinesBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $10.07 $11.11 $7.96 $11.75 $6.95 $11.79 $18.65 $11.28 $11.62 $14.23Spending	per	capita	in	rest	of	Canada $9.55 $9.44 $9.68 $9.54 $11.31 $8.97 $9.42 $9.58 $9.61 $9.55Unadjusted	difference	in	spending	per	capita 5.4% 17.7% -17.7% 23.2% -38.6% 31.4% 97.9% 17.7% 20.8% 48.9%Difference	predicted	by	population	age 4.3% -13.0% -5.0% -5.1% -1.0% 5.3% 7.9% 8.3% 5.6% 8.6%Age-standardized difference 1.1% 35.2% -13.4% 29.8% -38.0% 24.8% 83.5% 8.7% 14.4% 37.1%Volume effects -22.5% 7.7% -41.5% 20.4% -29.3% 33.6% 76.5% 25.5% 24.4% 34.6%Prescription	volume -31.7% -15.2% -40.4% 9.2% -44.7% 86.3% 64.3% -18.2% -11.8% 14.4%Prescription	size 9.2% 22.9% -1.1% 11.3% 15.4% -52.7% 12.2% 43.7% 36.2% 20.2%Therapeutic choice effects 24.7% 34.4% 22.0% 11.0% -3.1% -30.9% 16.4% -0.7% 12.5% 10.9%Choices	of	drug	sub-classes 18.1% 26.7% 18.6% 8.0% -2.2% -25.7% 11.4% 5.1% 10.4% 3.6%Choices	within	drug	sub-classes 6.6% 7.7% 3.4% 3.0% -0.9% -5.2% 5.0% -5.8% 2.1% 7.3%Price effects -1.1% -6.9% 6.1% -1.6% -5.6% 22.2% -9.5% -16.0% -22.5% -8.4%Prices	paid -0.2% -5.9% 6.7% 0.6% -7.0% 22.1% -8.5% -16.6% -21.8% -7.0%Generic	use -0.9% -1.0% -0.6% -2.3% 1.4% 0.1% -1.0% 0.6% -0.7% -1.4%Table	3.6d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 3 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%BenzodiazepinesFigure	3.6g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.6h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia+1%NewBrunswick+84%NovaScotia+9%Newfoundlandand Labrador+37%Prince Edward I.+14%Alberta+35%Saskatchewan-13%Manitoba+30% Quebec+25%Ontario-38%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 3 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $8.69 $8.75 $9.66 $6.61 $9.52 $6.95 $10.49 $14.59 $10.11 $11.70 $10.242012/13 $9.62 $10.07 $11.11 $7.96 $11.75 $6.95 $11.79 $18.65 $11.28 $11.62 $14.23Average	annual	change 2.0% 2.8% 2.8% 3.8% 4.3% 0.0% 2.4% 5.0% 2.2% -0.1% 6.8%Average	annual	change	predicted	by	aging 1.9% 2.2% 2.5% 1.3% 1.4% 1.9% 1.7% 1.2% 1.2% 2.1% 1.4%Age-standardized avg. annual change 0.2% 0.6% 0.3% 2.5% 2.9% -1.9% 0.6% 3.8% 1.0% -2.2% 5.4%Volume effects -2.9% -2.7% -1.9% -2.1% 0.5% -4.2% -2.7% -0.4% -0.8% -3.7% 0.6%Prescription	volume -1.5% -2.9% -1.9% -2.2% 2.9% -2.5% -0.8% 1.2% -1.4% -4.0% 1.0%Prescription	size -1.4% 0.2% 0.0% 0.1% -2.4% -1.7% -1.9% -1.6% 0.6% 0.3% -0.3%Therapeutic choice effects 1.0% 1.2% 0.6% 1.9% 0.5% 0.6% 1.3% 1.9% 0.1% 1.0% 1.5%Choices	of	drug	sub-classes 1.6% 1.2% 0.7% 1.9% 0.2% 1.9% 1.6% 2.0% 1.6% 1.6% 1.7%Choices	within	drug	sub-classes -0.6% 0.0% -0.1% 0.0% 0.3% -1.3% -0.3% -0.1% -1.5% -0.6% -0.1%Price effects 2.0% 2.1% 1.7% 2.7% 1.9% 1.7% 2.0% 2.2% 1.8% 0.5% 3.2%Prices	paid 2.4% 1.9% 1.6% 2.7% 1.8% 2.5% 2.3% 2.3% 1.5% 0.6% 3.2%Generic	use -0.4% 0.1% 0.0% 0.0% 0.0% -0.8% -0.2% -0.1% 0.2% -0.1% 0.0%Sources of age-standardized changeHigher prices of drugs purchased contributed to an increase in age-standardized spending per capita on benzodiazepines across all provinces. The upward effects of higher prices were reinforced by changes in the types of drugs selected, with more expensive options being chosen in 2012/13 than in 2007/08 in most provinces.However, changes in the volumes of prescription drugs purchased generally contributed to a decrease in age-standardized spending per capita in most provinces.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of benzodiazepines increased by an average of 2.0% per year between 2007/08 and 2012/13, for a total change of 11%.Even though spending per capita on benzodiazepines increased at the national level, some provinces expe-rienced no change, while others experienced either increases or decreases. In Newfoundland & Labrador, spending increased by an average of 6.8% per year (39% in total). In contrast, spending in Prince Edward Island decreased by 0.1% per year (−0.7% in total). Population aging alone would have caused spending per capita in the provinces to increase by 1.2% to 2.5% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted annual rates of change in spending per capita ranged from −2.2% (PE) to 5.4% (NL).BenzodiazepinesTable	3.6e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 3 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia+1%NewBrunswick+4%NovaScotia+1%Newfoundlandand Labrador+5%Prince Edward I.-2%Alberta0%Saskatchewan+2%Manitoba+3% Quebec+1%Ontario-2%Volume effectsPrice effectsTherapeutic choice effectsBenzodiazepinesFigure	3.6i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.6j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 3 8Public	and	private	spending	across	Canada,	2012/13Public (provincial and federal) drug plans covered an estimated 38% of spending on benzodiazepines in Canada; private drug plans covered an estimated 32%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $0.63, 19% less than the cost per day for prescriptions paid for by private drug plans.CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 88.4% 98.1% 95.3% 97.8% 98.7% 97.3% 97.6% 98.5% 97.2% 99.0% 99.0%Private	insurers 84.8% 92.2% 92.9% 95.1% 98.5% 90.0% 87.6% 96.9% 93.7% 95.5% 97.6%%-point	diff.	btw.	prov.	&	private	plans 3.6% 5.9% 2.4% 2.7% 0.2% 7.2% 10.0% 1.6% 3.5% 3.5% 1.4%Uninsured	patients	/	below	deductibles 87.1% 94.5% 86.9% 95.6% 98.0% 91.6% 88.6% 97.7% 93.1% 96.5% 98.0%%-pt.	diff.	btw.	prov.	plan	&	uninsured 1.2% 3.6% 8.4% 2.1% 0.7% 5.6% 8.9% 0.8% 4.1% 2.5% 1.0%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 5.3% 21.1% 9.7% 3.9% 4.0% 1.3% 2.5% 6.5% 0.3% 1.0% 11.4%Private	insurers 9.9% 14.2% 14.7% 8.9% 5.9% 11.4% 10.3% 9.3% 7.5% 6.9% 16.1%%-point	diff.	btw.	prov.	&	private	plans -4.6% 6.9% -4.9% -5.0% -1.9% -10.1% -7.8% -2.8% -7.2% -5.8% -4.7%Uninsured	patients	/	below	deductibles 8.8% 11.8% 14.8% 7.0% 5.3% 9.9% 11.6% 8.1% 10.5% 6.3% 16.8%%-pt.	diff.	btw.	prov.	plan	&	uninsured -3.5% 9.2% -5.1% -3.1% -1.3% -8.6% -9.1% -1.6% -10.2% -5.3% -5.4%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $0.63 $0.72 $0.68 $0.67 $0.63 $0.51 $0.52 $0.65 $0.55 $0.51 $0.59Private	insurers $0.78 $0.82 $0.74 $0.83 $0.71 $0.76 $0.77 $0.70 $0.64 $0.61 $0.65%	diff.	btw.	provincial	&	private	plans -19.4% -11.4% -7.3% -19.1% -10.2% -32.0% -32.2% -7.4% -13.2% -16.3% -8.9%Uninsured	patients	/	below	deductibles $0.77 $0.80 $0.73 $0.84 $0.69 $0.76 $0.79 $0.62 $0.62 $0.53 $0.63%	diff.	btw.	provincial	plan	&	uninsured -18.9% -8.9% -6.4% -20.0% -7.9% -32.2% -33.8% 3.5% -11.2% -4.0% -6.0%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $9.60 $10.10 $11.10 $8.00 $11.80 $6.90 $11.80 $18.70 $11.30 $11.60 $14.20%	Provincial	drug	plans 36% 30% 48% 23% 31% 28% 34% 34% 38% 14% 47%%	Private	insurance 32% 28% 30% 22% 22% 38% 32% 35% 39% 41% 33%%	Uninsured	/	below	deductibles 30% 41% 19% 52% 36% 33% 34% 29% 22% 44% 20%%	Federal	drug	plans 1% 1% 3% 3% 10% 0% 0% 1% 1% 0% 1%BenzodiazepinesTable	3.6i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	3.6h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	3.6g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	3.6f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 3 93.7Nervous systemDrugs for dementiat h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 4 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) Drugs for dementiaPercent of prescriptionsPercent of spendingDonepezil 56.1% 68.0%Galantamine 23.4% 13.1%Rivastigmine 11.4% 11.6%Memantine 9.1% 7.3%Percent of prescriptionsPercent of spendingDonepezil 56.1% 68.0%Galantamine 23.4% 13.1%Rivastigmine 11.4% 11.6%Memantine 9.1% 7.3%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $6.70 $4.20 80 40 $83.75 $105.00Multi-source	brand $0.60 $0.40 10 10 $60.00 $40.00Multi-source	generic $0.90 $0.60 20 10 $45.00 $60.00Sourced	only	by	generics $0.50 $0.30 20 10 $25.00 $30.00$24990%12%$7$7$9$6130701,9101,260$4.54$4.41   97%74%9%17%3%39%61%Figure	3.7b»	Share of spending by sex, age group, and payer, 2012/13Figure	3.7a»	Summary of sales, spending, and use, 2012/13Table	3.7c»	Spending, use, and cost, by drug source, 2012/13Table	3.7b»	Leading drugs, by spending, 2012/13Table	3.7a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 4 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredDrugs for dementiaProvincial formulary coverageMost provinces provided restricted or unre-stricted coverage for at least two (NL) of the three types of drugs for dementia that had more than $10,000 in sales in each province. British Columbia and Manitoba were the only provinces that did not provide any form of coverage for any drugs in this therapeutic category.For seven of the eight provinces providing some form of coverage, the covered drugs accounted for the entire $230-million Canadian dementia drug market when weighted by national sales.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 3 drugs covered% market value of drugsDrugs includedCholinesterase inhibitors and memantine.Examples of indicated conditionsAlzheimer disease and other types of dementia.Clinical uses and considerations These drugs are used to slow the progression of symptoms related to Alzheimer disease and other forms of dementia. However, they do not stop the underlying disease processes; there is no known cure for dementia. Symptoms of dementia include a progressive impair-ment in memory, judgment, and language, eventually impairing the individual’s ability to care for her/himself. Although drugs in this category are only officially indicated for the treatment of Alzheimer disease, they are used in other types of dementia as well because of the similar range of symptoms and the lack of alternative treatment options. Cholinesterase inhibitors work by blocking the break-down of the neurotransmitter acetylcholine, thereby increasing its levels in the brain. Memantine appears to exert a neuroprotective effect by blocking the receptor for the neurotransmitter glutamate. The two types of drugs may be used in combination in patients with moderate to severe Alzheimer disease. How might usage differ across age groups?These drugs are used almost exclusively in those aged 65 and older, as dementia is predominantly a disease of the elderly. How might usage differ between sexes?More women than men suffer from dementia, partly because of their longer life expectancy, and partly because of biological sex differences. Estrogen appears to exert a protective effect during a woman’s repro-ductive years, and the decline in its levels following menopause may contribute to the higher prevalence of Alzheimer disease in older women.Figure	3.7c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 4 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $7.10 per capita on drugs for dementia at retail pharmacies in 2012/13 ($8.70 for women and $5.50 for men). Average spending per capita was insignificant for Canadians under age 40 and under $1 for women and men aged 40–64. By contrast, average spending per capita was $46 in the 65+ age group.Average spending per capita on drugs for dementia was 31% higher for women aged 65 and older than for men of the same age. The average spending per capita for women of all ages was 57% higher than for men of all ages because a greater share of women live to be 65 and older.Provincial spending by age and sexAcross provinces, average spending ranged from $3 (SK and MB) to $9 (ON). Virtually all of this difference stems from spending in the 65+ age group, in which average spending ranged from $17 (SK) to $63 (ON) for women and from $17 (SK) to $53 (ON) for men.Ontario and Quebec had the two highest levels of spending per capita and Saskatchewan and Manitoba had the two lowest levels of spending per capita for women and men both overall and aged 65 and older. Variations in average spending per capita across other provinces were modest (coefficients of variation less than 20%).In the 65+ age group, the difference between women and men in average spending varied across provinces, ranging from no difference in Saskatchewan to 61% higher for women in Newfoundland & Labrador.$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$1$52$0 $0 $0 $0 $1$40Drugs for dementiaFigure	3.7e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.7d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 4 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10$0NLNSNBQCONMBSKBC AB PE$0$10$10NLNSNBQCONMBSKBC AB PE$20 $20$30$30$40$50$60$40$50$60Females age 65+ Males age 65+$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 0–18 Males age 0–18$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 19–39 Males age 19–39$0NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$10Females age 40–64 Males age 40–64Drugs for dementiaFigure	3.7f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 4 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationVolume effects explained most of the variation in age-standardized average retail spending on drugs  for dementia. Residents of Western Canada purchased significantly fewer drugs than other Canadians. In contrast, resi-dents of Ontario purchased significantly more drugs than other Canadians.Therapeutic choice effects influenced the level of spending for Ontario and Quebec, with Ontario having a lower-cost mix of drugs for dementia than other provinces and Quebec having a higher-cost mix.Price effects on provincial variation were modest. Residents of British Columbia and Quebec paid higher unit prices for particular drug products than residents of other provinces, while residents of Ontario paid lower unit prices.Population age and provincial spendingBecause spending on drugs for dementia is restricted to the elderly, differences in provincial population ages would predict significant provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 27% below the average for the rest of Canada; in Nova Scotia, it would be 16% above the average for the rest of Canada.However, even after figures were adjusted for differ-ences in population age, spending per capita on drugs for dementia deviated by more than 14% in most prov-inces, among the highest levels of variation in average spending observed in this atlas. This was largely because age-standardized spending per capita in Ontario and Quebec was well above age-standardized spending per capita in the rest of Canada.Drugs for dementiaBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $5.72 $3.67 $2.58 $3.40 $8.81 $8.33 $6.70 $6.45 $6.50 $5.19Spending	per	capita	in	rest	of	Canada $7.34 $7.56 $7.27 $7.27 $6.07 $6.77 $7.14 $7.15 $7.13 $7.16Unadjusted	difference	in	spending	per	capita -22.1% -51.4% -64.5% -53.2% 45.2% 23.1% -6.1% -9.7% -8.8% -27.5%Difference	predicted	by	population	age 7.5% -26.7% -1.5% -4.6% -2.5% 11.2% 14.1% 15.5% 9.8% 11.7%Age-standardized difference -27.6% -33.6% -64.0% -50.9% 49.0% 10.7% -17.8% -21.8% -17.0% -35.1%Volume effects -43.4% -29.8% -73.0% -54.2% 75.5% -9.4% -9.2% -13.3% -7.9% -37.7%Prescription	volume -63.1% -83.0% -114.8% -88.6% 62.2% 46.8% -64.9% -83.4% -64.7% -102.5%Prescription	size 19.7% 53.2% 41.8% 34.4% 13.3% -56.3% 55.7% 70.1% 56.9% 64.8%Therapeutic choice effects 5.4% -2.8% 3.9% 1.5% -17.3% 13.7% -6.6% -3.3% -6.0% 3.3%Choices	of	drug	sub-classes -0.2% -0.3% 0.4% 0.4% -0.4% 0.3% 0.4% 1.0% -0.1% 0.7%Choices	within	drug	sub-classes 5.6% -2.5% 3.4% 1.1% -16.9% 13.4% -7.0% -4.3% -5.9% 2.5%Price effects 10.4% -1.1% 5.2% 1.8% -9.3% 6.4% -1.9% -5.2% -3.1% -0.6%Prices	paid 3.4% 1.7% 4.4% 1.2% -0.6% -2.3% 2.9% 0.1% 1.3% 3.1%Generic	use 7.0% -2.7% 0.7% 0.5% -8.7% 8.7% -4.9% -5.4% -4.4% -3.7%Table	3.7d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 4 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Drugs for dementiaFigure	3.7g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.7h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-28%NewBrunswick-18%NovaScotia-22%Newfoundlandand Labrador-35%Prince Edward I.-17%Alberta-34%Saskatchewan-64%Manitoba-51% Quebec+11%Ontario+49%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 4 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $7.08 $4.30 $4.56 $3.48 $4.08 $9.91 $6.25 $6.44 $7.88 $7.89 $4.532012/13 $7.13 $5.72 $3.67 $2.58 $3.40 $8.81 $8.33 $6.70 $6.45 $6.50 $5.19Average	annual	change 0.1% 5.9% -4.2% -5.8% -3.6% -2.3% 5.9% 0.8% -3.9% -3.8% 2.7%Average	annual	change	predicted	by	aging 3.1% 3.4% 3.4% 1.1% 1.9% 3.1% 3.4% 2.9% 2.9% 3.0% 3.5%Age-standardized avg. annual change -2.9% 2.4% -7.3% -6.8% -5.4% -5.2% 2.4% -2.1% -6.6% -6.6% -0.8%Volume effects -0.1% 1.8% -3.5% -5.3% -3.6% -0.4% 1.0% 3.9% -1.7% -1.0% 2.1%Prescription	volume 3.7% 4.3% -2.4% -5.9% 2.1% 3.2% 5.5% 7.0% -0.6% 0.1% 1.5%Prescription	size -3.8% -2.4% -1.1% 0.6% -5.7% -3.6% -4.5% -3.1% -1.1% -1.1% 0.6%Therapeutic choice effects 0.0% 0.4% -0.7% -0.4% -1.0% -0.7% 1.8% -1.2% -0.5% 0.3% 0.0%Choices	of	drug	sub-classes -0.1% 0.1% -0.2% 0.0% 0.0% 0.0% -0.1% 0.0% 0.0% 0.0% 0.0%Choices	within	drug	sub-classes 0.0% 0.3% -0.5% -0.5% -1.0% -0.7% 1.9% -1.1% -0.5% 0.4% 0.0%Price effects -2.8% 0.2% -3.1% -1.1% -0.8% -4.2% -0.4% -4.8% -4.4% -5.9% -2.9%Prices	paid 0.5% 1.0% 1.1% 1.2% 0.8% 0.8% 0.9% 0.3% 0.7% -1.1% 0.8%Generic	use -3.3% -0.9% -4.2% -2.3% -1.5% -5.0% -1.3% -5.2% -5.1% -4.8% -3.6%Sources of age-standardized changeChanges in both volumes of treatment purchased  and prices paid for drugs contributed to changes in age-standardized spending per capita on drugs  for dementia. The change in the use of drugs in this therapeutic class was not consistent across Canada, with some provinces purchasing more drugs (notably New Brunswick) and other provinces purchasing fewer drugs. Lower prices of drugs purchased was a significant driver of decreased age-standardized spending per capita in many provinces. Owing mostly to savings resulting from wider use of available generics, average prices paid for drugs for dementia decreased.Changes in the types of dementia drugs selected had little influence on changes in age-standardized spending per capita.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of drugs for dementia increased by an average of 0.1% per year between 2007/08 and 2012/13, for a total change of just 0.6%.Some provinces experienced little change in spending, while others experienced notable increases or decreases in spending. In British Columbia, spending increased by an average of 5.9% per year (33% in total), while spending in Saskatchewan decreased by 5.8% per year (−26% in total). Population aging would have caused per capita retail spending in the provinces to rise by 1.1% to 3.5% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted annual rates of change in spending per capita ranged from −7.3% (AB) to 2.4% (BC and QC).Drugs for dementiaTable	3.7e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 4 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia+2%NewBrunswick-2%NovaScotia-7%Newfoundlandand Labrador-1%Prince Edward I.-7%Alberta-7%Saskatchewan-7%Manitoba-5% Quebec+2%Ontario-5%Volume effectsPrice effectsTherapeutic choice effectsDrugs for dementiaFigure	3.7j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.7i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 4 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 72.2% 4.5% 97.5% 82.6% 94.2% 98.5% 91.7% 99.3% 99.5% 98.2% 98.6%Private	insurers 73.8% 53.8% 79.6% 24.5% 42.4% 83.7% 77.7% 96.4% 94.1% 94.0% 96.6%%-point	diff.	btw.	prov.	&	private	plans -1.7% -49.3% 17.9% 58.1% 51.8% 14.8% 14.0% 2.9% 5.4% 4.2% 2.0%Uninsured	patients	/	below	deductibles 77.6% 55.1% 83.9% 49.7% 54.1% 91.0% 90.7% 97.5% 95.2% 99.6% 97.6%%-pt.	diff.	btw.	prov.	plan	&	uninsured -5.4% -50.6% 13.6% 32.8% 40.2% 7.5% 1.0% 1.8% 4.4% -1.4% 1.0%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 82.1% 71.1% 81.1% 90.0% 89.8% 84.3% 84.0% 73.3% 76.8% 74.6% 83.0%Private	insurers 58.7% 63.8% 69.9% 73.0% 82.1% 42.1% 75.9% 64.1% 72.0% 50.9% 78.9%%-point	diff.	btw.	prov.	&	private	plans 23.4% 7.3% 11.2% 17.1% 7.7% 42.2% 8.1% 9.2% 4.8% 23.7% 4.1%Uninsured	patients	/	below	deductibles 53.4% 61.7% 57.9% 72.9% 83.5% 28.9% 57.0% 61.7% 66.0% 47.3% 75.7%%-pt.	diff.	btw.	prov.	plan	&	uninsured 28.7% 9.4% 23.2% 17.1% 6.3% 55.4% 27.0% 11.7% 10.8% 27.3% 7.4%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $4.43 $5.36 $4.45 $5.39 $4.60 $4.11 $4.46 $3.79 $3.90 $3.37 $4.55Private	insurers $4.66 $4.77 $4.50 $5.40 $4.63 $4.73 $4.71 $3.86 $4.03 $3.37 $4.42%	diff.	btw.	provincial	&	private	plans -4.8% 12.3% -1.2% -0.3% -0.6% -13.0% -5.2% -1.9% -3.1% -0.1% 3.0%Uninsured	patients	/	below	deductibles $4.68 $4.84 $4.47 $5.28 $4.71 $4.59 $4.32 $3.99 $3.99 $3.64 $4.47%	diff.	btw.	provincial	plan	&	uninsured -5.2% 10.8% -0.5% 2.1% -2.2% -10.4% 3.4% -5.1% -2.1% -7.4% 1.8%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $7.10 $5.70 $3.70 $2.60 $3.40 $8.80 $8.30 $6.70 $6.50 $6.50 $5.20%	Provincial	drug	plans 74% 51% 72% 59% 41% 81% 77% 53% 59% 66% 36%%	Private	insurance 9% 18% 10% 8% 11% 7% 6% 25% 22% 21% 34%%	Uninsured	/	below	deductibles 17% 31% 18% 32% 47% 12% 17% 22% 19% 13% 30%%	Federal	drug	plans 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%Public (provincial and federal) drug plans covered an estimated 74% of spending on drugs for dementia in Canada, making this one of the most publicly-subsidized drug classes.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $4.43, 5% less than the cost per day for prescriptions paid for by private drug plans.Drugs for dementiaTable	3.7i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	3.7h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	3.7g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	3.7f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 4 93.8Nervous systemDrugs for migrainest h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 5 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) Drugs for migrainesPercent of prescriptionsPercent of spendingRizatriptan 26.5% 26.4%Sumatriptan 23.6% 25.2%Zolmitriptan 20.9% 17.4%Eletriptan 10.0% 11.5%Almotriptan 9.1% 10.6%Percent of prescriptionsPercent of spendingRizatriptan 26.5% 26.4%Sumatriptan 23.6% 25.2%Zolmitriptan 20.9% 17.4%Eletriptan 10.0% 11.5%Almotriptan 9.1% 10.6%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $3.70 $0.90 30 10 $123.33 $90.00Multi-source	brand $1.20 $0.20 10 0 $120.00 n/aMulti-source	generic $0.80 $0.20 10 0 $80.00 n/aSourced	only	by	generics $1.80 $0.50 20 0 $90.00 n/a$164>95%17%$6$5$7.59$1.756010630150$11.87$11.3920%9%20%61%17%1%82%18%1%70%Figure	3.8b»	Share of spending by sex, age group, and payer, 2012/13Figure	3.8a»	Summary of sales, spending, and use, 2012/13Table	3.8c»	Spending, use, and cost, by drug source, 2012/13Table	3.8b»	Leading drugs, by spending, 2012/13Table	3.8a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 5 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredDrugs for migrainesProvincial formulary coverageAlmost all provinces provided restricted or unrestricted coverage for at least five (PE) of the seven types of migraine drugs that had more than $10,000 in sales in each province. Ontario was the exception, as it covered only one of the drugs in this category. Only one province (BC) provided unrestricted coverage for all seven drugs.Weighted by national sales, the drugs covered by all provinces except Ontario accounted for 69% or more of the $140-million Canadian market for migraine drugs.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 7 drugs covered% market value of drugsDrugs includedErgot alkaloids and selective serotonin  agonists (triptans).Examples of indicated conditionsMigraine headaches.Clinical uses and considerations These drugs are used to treat acute migraine head-aches. Triptans are a newer drug class and account for the majority of prescriptions in this category as a result of greater efficacy and a more favourable adverse effect profile than ergots. Triptans are thought to counteract the processes in the brain that cause migraine headaches, and are therefore considered to be a more “specific” treatment for migraine than other pain medications that decrease pain more generally. Many patients self-treat mild to moderate migraine symptoms with non-prescription drugs; this use is not captured in this analysis. How might usage differ across age groups?Migraine drugs are used throughout the lifespan, with a concentration in use among young and middle-aged adults. This corresponds to the prevalence of migraine headaches, which rises between childhood and early adult years, peaks in the 30s and 40s, and then starts  to decline. Use of these drugs is less common in people aged 65 and older. This is partially because of a reduction in hormone-induced migraine headaches in many women following menopause. In addition, these classes of migraine drugs are not recommended in patients with uncontrolled hypertension, coronary artery disease, and cerebrovascular disease, all of which are more common in older patients. How might usage differ between sexes?Migraines affect women two to three times more fre-quently than men. Migraines may have many triggers, but for women fluctuations in estrogen levels may be the most important trigger, which may explain some of the differences between the sexes.Figure	3.8c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 5 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $4.70 per capita on migraine drugs at retail pharmacies in 2012/13  ($7.60 for women and $1.70 for men). Average spending per capita was insignificant in the 0–18  age group. Spending per capita was highest in the  40–64 age group ($9.40), followed by the 19–39 age group ($3.20). Average spending per capita was three to five times higher for women than for men in the same age groups. Overall, average spending was four times higher among women than among men. Provincial spending by age and sexAcross provinces, average spending per capita ranged from $4.30 (NL) to $11 (QC) for women and from $0.80 (NL) to $2.60 (QC) for men. Differences in average spending per capita by age and sex were roughly comparable across provinces.Despite similar age gradients, there was notable varia-tion across provinces in average spending per capita within age groups (coefficients of variation greater than 30%). The level of variation was similar among women and men. The highest spending province was Quebec and the lowest spending province was New-foundland & Labrador; variations in the remaining provinces were more modest (coefficients of variation less than 20%).$20$15$10$0 $0$5$20$15$10$5Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$15$4$0.40$6$0.10$1$4$1Drugs for migrainesFigure	3.8e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	3.8d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 5 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0NLNSNBQCONMBSKBC AB PE$0$5NLNSNBQCONMBSKBC AB PE$10 $10$5$0NLNSNBQCONMBSKBC AB PE$0$5NLNSNBQCONMBSKBC AB PE$10 $10$5Females age 19–39 Males age 19–39$0NLNSNBQCONMBSKBC AB PE$0$5NLNSNBQCONMBSKBC AB PE$10$5$15$10$20$15$20Females age 40–64 Males age 40–64$0NLNSNBQCONMBSKBC AB PE$0$5$5NLNSNBQCONMBSKBC AB PEFemales age 65+ Males age 65+$0NLNSNBQCONMBSKBC AB PE$0$5NLNSNBQCONMBSKBC AB PE$5Females age 0–18 Males age 0–18Drugs for migrainesFigure	3.8f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 5 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationVolume effects were the most important driver of provincial variation in age-standardized average retail spending on migraine drugs.Residents of Quebec purchased significantly more drugs than residents of other provinces. They also tended to purchase more expensive types of drugs than other Canadians. In other provinces, volume of treatment purchased generally contributed to lower levels of spending than in the rest of Canada.In all provinces except Quebec, therapeutic choice effects contributed to lower levels of spending.Price effects contributed modestly to provincial variation in age-adjusted spending per capita. Notably, residents of Ontario paid higher unit prices for particular drug products and residents of Quebec used fewer available generics.Population age and provincial spendingBecause persons aged 65 years and older accounted for a relatively small share of spending on migraine drugs, differences in provincial population ages would predict modest provincial variation in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 6.6% below the average for the rest of Canada; in Newfoundland & Labrador, it would be 5.8% above the average for the rest of Canada.However, even after figures were adjusted for differ-ences in population age, spending per capita in most provinces deviated by more than 23% from the average for the rest of Canada. In Newfoundland & Labrador, average spending per capita was 48% below the average for the rest of Canada, while in Quebec it was 61% above the average for the rest of Canada.Drugs for migrainesBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $4.13 $4.41 $2.91 $2.75 $4.39 $6.68 $3.09 $3.74 $3.30 $2.60Spending	per	capita	in	rest	of	Canada $4.78 $4.73 $4.75 $4.77 $4.88 $4.09 $4.73 $4.72 $4.70 $4.72Unadjusted	difference	in	spending	per	capita -13.6% -6.6% -38.8% -42.3% -10.0% 63.2% -34.7% -20.7% -29.7% -44.9%Difference	predicted	by	population	age 2.5% -4.2% -6.6% -5.2% -0.1% 1.5% 3.3% 3.7% 2.3% 5.8%Age-standardized difference -15.7% -2.5% -34.5% -39.1% -9.9% 60.7% -36.8% -23.5% -31.3% -47.9%Volume effects -0.2% 11.2% -25.8% -18.9% -19.1% 45.4% -23.4% -5.5% -32.4% -37.0%Prescription	volume -18.8% -1.1% -5.4% -17.2% -30.3% 77.1% -22.6% -15.1% -32.9% -31.4%Prescription	size 18.6% 12.2% -20.4% -1.7% 11.2% -31.7% -0.9% 9.5% 0.6% -5.6%Therapeutic choice effects -5.2% -5.9% -5.2% -11.0% -1.5% 12.2% -9.1% -8.1% -0.1% -7.3%Choices	of	drug	sub-classes -0.4% -0.2% 0.0% 0.2% -0.4% 0.8% 0.0% 0.4% 0.5% -1.2%Choices	within	drug	sub-classes -4.8% -5.7% -5.2% -11.2% -1.2% 11.4% -9.1% -8.5% -0.5% -6.2%Price effects -10.3% -7.8% -3.6% -9.2% 10.7% 3.2% -4.2% -9.8% 1.1% -3.5%Prices	paid -9.1% -6.2% -2.1% -6.9% 12.9% -3.1% -3.0% -8.0% 2.3% -1.5%Generic	use -1.1% -1.6% -1.5% -2.2% -2.2% 6.2% -1.3% -1.9% -1.2% -2.0%Table	3.8d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 5 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Drugs for migrainesFigure	3.8g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	3.8h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-16%NewBrunswick-37%NovaScotia-23%Newfoundlandand Labrador-48%Prince Edward I.-31%Alberta-2%Saskatchewan-35%Manitoba-39% Quebec+61%Ontario-10%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 5 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $5.63 $5.58 $5.74 $3.26 $4.13 $5.63 $6.50 $4.26 $5.56 $4.72 $3.822012/13 $4.69 $4.13 $4.41 $2.91 $2.75 $4.39 $6.68 $3.09 $3.74 $3.30 $2.60Average	annual	change -3.6% -5.9% -5.1% -2.3% -7.8% -4.8% 0.6% -6.2% -7.6% -6.9% -7.4%Average	annual	change	predicted	by	aging 1.3% 1.6% 2.1% 1.5% 1.2% 1.4% 0.8% 0.3% 0.3% 1.5% 0.2%Age-standardized avg. annual change -4.8% -7.4% -7.1% -3.7% -8.9% -6.1% -0.2% -6.5% -7.9% -8.3% -7.6%Volume effects -1.8% -3.1% -2.3% 1.1% -2.1% -3.1% 1.5% 0.0% -1.7% -5.0% -1.0%Prescription	volume -2.7% -3.8% -3.6% -0.1% -4.0% -4.1% -0.7% -0.8% -2.7% -7.1% -3.0%Prescription	size 0.9% 0.7% 1.3% 1.3% 1.9% 1.0% 2.1% 0.8% 1.0% 2.1% 2.0%Therapeutic choice effects -2.0% -2.6% -3.1% -2.6% -4.4% -2.2% -1.7% -3.0% -3.8% -1.5% -3.6%Choices	of	drug	sub-classes 0.1% 0.1% 0.1% 0.2% 0.1% 0.1% 0.1% 0.1% 0.1% 0.8% 0.1%Choices	within	drug	sub-classes -2.1% -2.7% -3.2% -2.9% -4.5% -2.3% -1.9% -3.1% -3.9% -2.2% -3.8%Price effects -1.0% -1.6% -1.7% -2.2% -2.4% -0.7% 0.0% -3.5% -2.3% -1.8% -3.0%Prices	paid 0.6% 0.2% 0.5% 0.6% 0.6% 0.7% 0.9% -0.5% 0.0% 0.1% 0.2%Generic	use -1.5% -1.9% -2.2% -2.8% -3.0% -1.5% -0.9% -3.0% -2.3% -1.9% -3.2%Sources of age-standardized changeAll three categories of drivers contributed modestly to changes in age-standardized spending per capita on migraine drugs. Volumes of treatment purchased were inconsistent across the country, but decreased slightly in  most provinces. There was a general shift toward less expensive drug treatment options in all provinces. On their own,  these changes would have reduced national age-standardized spending per capita by 2.0% per year (9.5% in total).Owing to greater use of available generics, prices  were lower in 2012/13 than in 2007/08 in all provinces with the exception of Quebec, where no change  was observed.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of migraine drugs decreased by a total of 17% between 2007/08 and 2012/13, or an average of −3.6% per year. Spending per capita decreased in all provinces except Quebec, where spending per capita increased by an average of 0.6% per year (2.8% in total). The greatest decrease in spending occurred in Manitoba, with an average of −7.8% per year (−33% in total).Population aging alone would have caused spending per capita in the provinces to increase by 0.2% to 2.1% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted spending per capita decreased by annual rates ranging from 0.2% (QC) to 8.9% (MB).Drugs for migrainesTable	3.8e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 5 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-7%NewBrunswick-7%NovaScotia-8%Newfoundlandand Labrador-8%Prince Edward I.-8%Alberta-7%Saskatchewan-4%Manitoba-9% Quebec0%Ontario-6%Volume effectsPrice effectsTherapeutic choice effectsDrugs for migrainesFigure	3.8i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	3.8j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 5 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 57.1% 91.9% 78.9% 89.7% 92.5% 50.7% 80.4% 96.1% 91.5% 100.0% 95.8%Private	insurers 61.0% 62.3% 73.8% 74.6% 77.7% 72.6% 64.5% 73.6% 73.0% 70.4% 81.5%%-point	diff.	btw.	prov.	&	private	plans -3.9% 29.6% 5.1% 15.1% 14.8% -22.0% 16.0% 22.5% 18.5% 29.6% 14.3%Uninsured	patients	/	below	deductibles 59.4% 57.8% 62.3% 78.4% 76.1% 66.9% 57.6% 79.5% 79.7% 77.2% 74.5%%-pt.	diff.	btw.	prov.	plan	&	uninsured -2.2% 34.1% 16.6% 11.4% 16.4% -16.2% 22.9% 16.6% 11.8% 22.8% 21.3%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 45.9% 32.7% 42.6% 39.2% 18.4% 46.7% 38.5% 18.9% 21.2% 12.6% 42.8%Private	insurers 50.9% 53.7% 53.7% 52.3% 32.6% 46.0% 49.7% 37.4% 46.9% 51.9% 40.6%%-point	diff.	btw.	prov.	&	private	plans -4.9% -21.0% -11.1% -13.1% -14.2% 0.8% -11.1% -18.5% -25.6% -39.3% 2.3%Uninsured	patients	/	below	deductibles 46.8% 46.4% 53.0% 48.4% 34.6% 43.1% 49.5% 35.0% 38.7% 44.1% 40.0%%-pt.	diff.	btw.	prov.	plan	&	uninsured -0.9% -13.7% -10.4% -9.1% -16.3% 3.7% -11.0% -16.1% -17.5% -31.5% 2.8%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $10.30 $7.55 $9.12 $9.10 $7.75 $11.23 $12.15 $7.32 $7.27 $6.75 $6.13Private	insurers $12.51 $10.47 $10.71 $11.19 $8.81 $13.24 $13.66 $10.61 $10.17 $12.38 $10.30%	diff.	btw.	provincial	&	private	plans -17.6% -27.9% -14.8% -18.7% -12.0% -15.2% -11.1% -31.0% -28.5% -45.4% -40.5%Uninsured	patients	/	below	deductibles $11.64 $9.76 $10.86 $10.16 $8.59 $12.67 $12.66 $9.10 $8.95 $10.03 $10.46%	diff.	btw.	provincial	plan	&	uninsured -11.5% -22.6% -16.0% -10.5% -9.7% -11.4% -4.0% -19.5% -18.8% -32.6% -41.4%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $4.70 $4.10 $4.40 $2.90 $2.80 $4.40 $6.70 $3.10 $3.70 $3.30 $2.60%	Provincial	drug	plans 17% 24% 24% 9% 21% 3% 32% 4% 5% 2% 4%%	Private	insurance 61% 46% 56% 56% 45% 73% 54% 81% 80% 82% 76%%	Uninsured	/	below	deductibles 20% 29% 19% 33% 31% 23% 14% 14% 14% 16% 18%%	Federal	drug	plans 1% 1% 1% 3% 3% 1% 0% 1% 1% 0% 1%Private drug plans covered a greater share (61%) of spending on migraine drugs than of spending in any other drug class.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $10.30, 18% less than the cost per day for prescriptions paid for by private drug plans.This was one of the only drug classes in which private drug plans had a higher rate of generic substitution than public drug plans.Drugs for migrainesTable	3.8i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	3.8h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	3.8g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	3.8f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 5 94.1Gastrointestinal tract and metabolismAcid-reducing drugst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 6 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.)Acid-reducing drugsPercent of prescriptionsPercent of spendingPantoprazole 40.0% 31.0%Rabeprazole	Sodium 14.8% 10.0%Esomeprazole 14.4% 29.8%Lansoprazole 10.1% 9.8%Omeprazole 10.0% 12.0%Percent of prescriptionsPercent of spendingPantoprazole 40.0% 31.0%Esomeprazole 14.4% 29.8%Omeprazole 10.0% 12.0%Rabeprazole	Sodium 14.8% 10.0%Lansoprazole 10.1% 9.8%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $1.80 $1.30 30 20 $60.00 $65.00Multi-source	brand $14.20 $10.20 210 140 $67.62 $72.86Multi-source	generic $17.80 $13.70 650 460 $27.38 $29.78Sourced	only	by	generics $7.10 $5.70 120 90 $59.17 $63.33$1,253>95%24%$49$36$41$311,01071036,69027,650$1.11$1.128%45%43%37%18%1%57%43%1%46%Figure	4.1b»	Share of spending by sex, age group, and payer, 2012/13Figure	4.1a»	Summary of sales, spending, and use, 2012/13Table	4.1c»	Spending, use, and cost, by drug source, 2012/13Table	4.1b»	Leading drugs, by spending, 2012/13Table	4.1a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 6 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredProvincial formulary coverageAll provinces provided restricted or unrestricted coverage for at least seven (NB) of the 10 types of acid-reducing drugs that had over $10,000 in sales in each province. British Columbia, Sas-katchewan, and Quebec provided some form of coverage for all 10 of these drugs.Weighted by national sales, the drugs covered in each province accounted for 69% or more of the $1.22-billion Canadian acid-reducing  drug market.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 10 drugs covered% market value of drugsAcid-reducing drugsDrugs includedProton pump inhibitors (PPIs), histamine receptor antagonists (H2RAs), and sucralfate.Examples of indicated conditionsGastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD).Clinical uses and considerationsDrugs in this category are used to prevent and treat ulcers and reflux disease. The leading drug classes—PPIs and H2RAs—reduce the amount of acid produced in the stomach, which can help to prevent and heal ulcers, decrease esophageal damage, and reduce symptoms such as heartburn. Sucralfate provides a protective barrier in the stomach, which  can help prevent ulcers and speed ulcer healing. However, there are concerns about the overuse— particularly the long-term use—of PPIs because of an increased risk of rare but serious side effects, including infection and fracture.How might usage differ across age groups?The use of these drugs increases with age. This may be the result of higher NSAID use in older adults, as well as an age-related increase in the risk of NSAID-related ulcers and gastrointestinal bleeds. Older adults also have higher prevalence of H. pylori infection. Further, as the gastroesophageal junction deteriorates with age, there may be an increased need for gastroesophageal reflux disease symptom management.How might usage differ between sexes?Both women and men experience conditions that may require the use of these drugs. Any differences in use by sex likely reflect sex differences in the risk factors for peptic ulcer disease (PUD), specifically H. pylori infection, NSAID use, and smoking. With declin-ing smoking rates in men and higher NSAID use by women, the previous predominance of PUD among men has diminished. Other differences in use between women and men may be related to differences in care-seeking behaviour.Figure	4.1c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 6 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Acid-reducing drugsNational spending by age and sexCanadians spent an average of $36 per capita on acid-reducing drugs at retail pharmacies in 2012/13 ($41 for women and $31 for men). Average spending per capita on these drugs increased with age, from a low of approximately $2 for the 0–18 age group to $108 for the 65+ age group. Spending per capita among Canadians aged 40–64 was approximately half the spending among Canadians aged 65 and older.For Canadians aged 40 and older, average spending per capita on acid-reducing drugs was about 25% higher for women than for men. There were no notable differ-ences between women and men younger than 40.Provincial spending by age and sexAcross provinces, spending per capita on acid-reducing drugs ranged from $29 (BC) to $65 (NL) for women and from $22 (BC) to $53 (NL) for men. The ratio of average spending per capita in the 65+ age group to average spending per capita in the 40–64 age group varied across provinces, ranging from 1.5 to 2.6 for both women and men.Within each age group, there was substantial varia-tion across provinces in average spending per capita. Greatest variation occurred in the 0–18 age group (coefficient of variation: 68%) and least variation occurred in the 65+ age group (coefficient of variation: 23%). The level of variation across provinces within each age group was similar for women and men. There also appeared to be a geographic gradient, with lower spending in western provinces and higher spending in eastern provinces.Spending per capita$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,031$219-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177Spending per capitaNumberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645$52$118$3$10$2$9$2$42$96Figure	4.1e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	4.1d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 6 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages0$50$100NLPENSNBQCONMBSKBC AB$ 0$50$100$150$200$150$200NLPENSNBQCONMBSKBC AB$Males of all agesFemales age 65+ Males age 65+$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC ABFemales age 0–18PEMales age 0–18$0$50$100NLPENSNBQCONMBSKBC AB$0$50$100NLPENSNBQCONMBSKBC ABFemales age 40–64 Males age 40–64$0$50NLNSNBQCONMBSKBC AB PE$0$50NLNSNBQCONMBSKBC AB PEFemales age 19–39 Males age 19–39$0$50$100NLPENSNBQCONMBSKBC AB$0$50$100NLPENSNBQCONMBSKBC ABAcid-reducing drugsFigure	4.1f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 6 4Variation	in	spending	across	Canada,	2012/13Acid-reducing drugsSources of age-standardized variationProvincial variation in age-standardized average retail spending on acid-reducing drugs was driven by all three categories of cost drivers.Residents of Atlantic Canada purchased significantly more acid-reducing drugs than other Canadians, while residents of British Columbia and Manitoba purchased significantly fewer. Therapeutic choice effects also contributed to provin-cial variation in spending. Residents of Quebec tended to receive a more expensive mix of acid-reducing drugs than all other Canadians.Prices paid per unit of particular acid-reducing drug products in Saskatchewan were 13.9% above the average for the rest of Canada; conversely, they were 13.2% below in Ontario.Population age and provincial spendingBecause spending on acid-reducing drugs is concen-trated among older adults, differences in provincial population ages would predict some provincial varia-tion in spending per capita.For example, based on age differences alone, predicted spending per capita in Alberta would be 14% below the average for the rest of Canada; in Newfoundland & Labrador, it would be 9.1% above the average for the rest of Canada.However, even after the figures were adjusted for dif-ferences in population age, spending on acid-reducing drugs in most provinces deviated by more than 17% from the average in other provinces. In Eastern Canada, age-standardized average spending was 30% or more above the average for the rest of Canada, while in Ontario and the western provinces, it was below the average for the rest of Canada.BC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $25.13 $31.52 $33.35 $28.52 $30.19 $50.15 $54.94 $54.72 $49.44 $59.06Spending	per	capita	in	rest	of	Canada $37.58 $36.48 $36.01 $36.20 $39.55 $31.65 $35.50 $35.40 $35.87 $35.58Unadjusted	difference	in	spending	per	capita -33.1% -13.6% -7.4% -21.2% -23.6% 58.4% 54.7% 54.6% 37.8% 66.0%Difference	predicted	by	population	age 4.5% -14.1% -4.8% -5.1% -1.1% 5.7% 8.4% 8.6% 5.9% 9.1%Age-standardized difference -36.0% 0.6% -2.7% -17.0% -22.8% 49.9% 42.8% 42.4% 30.1% 52.2%Volume effects -32.2% 0.5% -4.1% -25.5% 10.4% 3.3% 49.7% 53.1% 28.6% 54.2%Prescription	volume -57.7% -40.8% -5.4% -28.0% -21.7% 95.6% -6.4% -8.6% -3.1% 7.7%Prescription	size 25.4% 41.3% 1.3% 2.5% 32.1% -92.3% 56.1% 61.7% 31.7% 46.5%Therapeutic choice effects -9.3% -7.7% -13.2% -1.8% -19.5% 33.6% -10.6% -13.6% -4.5% -14.2%Choices	of	drug	sub-classes -4.2% 1.1% -4.8% -4.3% -1.2% 5.8% -3.4% -6.2% -3.7% -6.6%Choices	within	drug	sub-classes -5.2% -8.8% -8.4% 2.5% -18.3% 27.8% -7.2% -7.5% -0.8% -7.6%Price effects 5.5% 7.8% 14.6% 10.3% -13.6% 12.9% 3.6% 2.9% 6.1% 12.2%Prices	paid 3.0% 9.3% 13.9% 10.4% -13.2% 18.0% 4.8% -0.2% 7.6% 14.1%Generic	use 2.5% -1.5% 0.7% -0.1% -0.4% -5.0% -1.2% 3.1% -1.5% -1.8%Table	4.1d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 6 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Acid-reducing drugsFigure	4.1h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	4.1g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-36%NewBrunswick+43%NovaScotia+42%Newfoundlandand Labrador+52%Prince Edward I.+30%Alberta+1%Saskatchewan-3%Manitoba-17% Quebec+50%Ontario-23%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 6 6Trends	in	spending	across	Canada,	2007/08–2012/13Acid-reducing drugsSources of age-standardized changeThe major driver of the decrease in age-standardized spending on acid-reducing drugs across Canada was lower prices of drugs purchased. Average prices paid for drugs decreased because of both lower unit prices and savings resulting from generic substitutions.Although prices decreased over the period 2007/08–2012/13, the age-standardized volume of treatment purchased increased. This increase alone would have increased national age-standardized spending per capita by 10% (1.9% per year). Volume increases were greatest in Eastern Canada.There was also a general shift toward more expensive acid-reducing treatment options in almost all prov-inces. These changes in therapeutic choices alone would have increased national age-standardized spending per capita by 5.5% (1.1% per year); however, they would have increased spending in Manitoba and Prince Edward Island by almost 20% (3.6% per year).Pace of change, 2007/08−2012/13At the national level, inflation-adjusted spending per capita on retail purchases of acid-reducing drugs decreased by an average of 5.9% per year between 2007/08 and 2012/13, for a total change of −26%.Spending per capita decreased in all provinces. The greatest change occurred in Ontario, where spending per capita decreased by an average of 9.3% per year (−39% in total). Newfoundland & Labrador experi-enced the smallest change, decreasing by an average of just 0.5% per year (−2.5% in total).Population aging alone would have caused spending per capita in the provinces to increase by 1.1% to 2.5% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted spending per capita decrease by annual rates ranging from −1.8% (NL) to −11.1% (ON).CAN BC AB SK MB ON QC NB NS PE NL2007/08 $48.64 $34.82 $45.47 $40.27 $34.93 $49.12 $56.79 $60.00 $65.19 $62.49 $60.562012/13 $35.93 $25.13 $31.52 $33.35 $28.52 $30.19 $50.15 $54.94 $54.72 $49.44 $59.06Average	annual	change -5.9% -6.3% -7.1% -3.7% -4.0% -9.3% -2.5% -1.7% -3.4% -4.6% -0.5%Average	annual	change	predicted	by	aging 2.0% 2.3% 2.5% 1.3% 1.4% 2.0% 1.9% 1.3% 1.1% 2.0% 1.3%Age-standardized avg. annual change -7.7% -8.4% -9.4% -4.9% -5.3% -11.1% -4.3% -3.0% -4.5% -6.5% -1.8%Volume effects 1.9% -0.6% 0.4% 1.7% 0.1% 0.7% 3.8% 4.5% 2.7% -0.6% 5.3%Prescription	volume 2.4% -1.5% 0.0% 0.7% 1.7% 1.3% 5.1% 3.8% 1.6% -0.7% 2.5%Prescription	size -0.5% 0.9% 0.4% 1.0% -1.6% -0.6% -1.3% 0.7% 1.2% 0.2% 2.8%Therapeutic choice effects 1.1% 1.6% 0.8% 1.6% 3.6% 1.6% 0.3% 3.3% 0.7% 3.6% 2.7%Choices	of	drug	sub-classes 0.6% 0.4% 0.4% 1.3% 0.6% 0.7% 0.2% 2.8% 2.5% 3.8% 3.1%Choices	within	drug	sub-classes 0.5% 1.3% 0.4% 0.3% 3.0% 0.9% 0.2% 0.6% -1.8% -0.1% -0.3%Price effects -10.7% -9.5% -10.6% -8.2% -9.0% -13.3% -8.4% -10.9% -8.0% -9.6% -9.8%Prices	paid -5.5% -4.7% -5.5% -4.2% -6.1% -7.4% -3.3% -8.3% -5.8% -6.4% -6.4%Generic	use -5.2% -4.8% -5.1% -3.9% -2.9% -5.9% -5.1% -2.6% -2.2% -3.2% -3.4%Table	4.1e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 6 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%Acid-reducing drugs-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia-8%NewBrunswick-3%NovaScotia-5%Newfoundlandand Labrador-2%Prince Edward I.-6%Alberta-9%Saskatchewan-5%Manitoba-5% Quebec-4%Ontario-11%Volume effectsPrice effectsTherapeutic choice effectsFigure	4.1j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	4.1i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 6 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 76.0% 68.5% 88.5% 80.6% 90.0% 82.7% 80.5% 44.8% 75.3% 55.4% 76.2%Private	insurers 65.0% 55.9% 74.3% 61.5% 78.1% 67.5% 69.5% 52.8% 64.4% 66.0% 66.5%%-point	diff.	btw.	prov.	&	private	plans 10.9% 12.6% 14.2% 19.0% 11.8% 15.2% 11.0% -8.0% 10.9% -10.6% 9.7%Uninsured	patients	/	below	deductibles 68.7% 62.5% 70.2% 69.4% 81.9% 71.3% 71.7% 51.9% 67.4% 69.1% 65.9%%-pt.	diff.	btw.	prov.	plan	&	uninsured 7.3% 6.0% 18.2% 11.2% 8.1% 11.4% 8.8% -7.1% 7.9% -13.7% 10.3%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 2.7% 1.4% 0.8% 1.0% 0.7% 0.6% 3.3% 1.5% 1.0% 0.9% 0.8%Private	insurers 6.0% 3.6% 3.8% 1.1% 0.8% 6.7% 5.1% 2.8% 3.1% 4.0% 2.9%%-point	diff.	btw.	prov.	&	private	plans -3.3% -2.2% -3.0% -0.1% -0.1% -6.1% -1.8% -1.3% -2.1% -3.1% -2.1%Uninsured	patients	/	below	deductibles 5.3% 3.2% 4.7% 0.9% 0.8% 6.1% 4.6% 3.6% 4.5% 3.3% 3.3%%-pt.	diff.	btw.	prov.	plan	&	uninsured -2.6% -1.8% -3.8% 0.1% 0.0% -5.5% -1.4% -2.0% -3.5% -2.4% -2.5%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $1.00 $0.98 $1.08 $1.08 $1.14 $0.75 $0.89 $1.01 $0.86 $1.00 $0.92Private	insurers $1.27 $1.24 $1.25 $1.29 $1.18 $1.18 $1.02 $1.18 $1.19 $1.32 $1.20%	diff.	btw.	provincial	&	private	plans -20.8% -21.1% -13.7% -16.1% -3.4% -36.2% -12.4% -14.7% -27.2% -24.4% -23.7%Uninsured	patients	/	below	deductibles $1.17 $1.12 $1.27 $1.19 $1.13 $1.06 $0.98 $1.11 $1.08 $1.08 $1.16%	diff.	btw.	provincial	plan	&	uninsured -13.8% -12.2% -15.5% -8.6% 1.3% -28.7% -9.1% -9.3% -20.1% -7.8% -20.9%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $35.90 $25.10 $31.50 $33.30 $28.50 $30.20 $50.20 $54.90 $54.70 $49.40 $59.10%	Provincial	drug	plans 43% 26% 43% 39% 29% 41% 54% 31% 29% 26% 27%%	Private	insurance 37% 38% 38% 29% 29% 41% 30% 53% 56% 54% 56%%	Uninsured	/	below	deductibles 18% 33% 16% 28% 38% 17% 14% 15% 14% 20% 16%%	Federal	drug	plans 1% 2% 2% 4% 4% 0% 1% 1% 1% 0% 1%Public (provincial and federal) drug plans covered an estimated 45% of spending on acid reducing drugs in Canada; private drug plans covered an estimated 37%.The cost per day of treatment for prescriptions paid for by provincial drug plans was $1.00, 21% less than the cost per day for prescriptions paid for by private  drug plans.For every 100 prescriptions for multi-sourced drugs, 11 more were filled with generics under public drug plans than under private drug plans.Acid-reducing drugsTable	4.1i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	4.1h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	4.1g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	4.1f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 6 94.2Gastrointestinal tract and metabolismDrugs for diabetes:Non-insulinst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 7 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) Drugs for diabetes: Non-insulinsPercent of prescriptionsPercent of spendingMetformin 57.5% 31.6%Gliclazide 14.6% 8.9%Glyburide 10.6% 4.1%Sitagliptin 5.8% 21.6%Metformin/Sitagliptin 2.3% 9.2%Percent of prescriptionsPercent of spendingMetformin 57.5% 31.6%Sitagliptin 5.8% 21.6%Metformin/Sitagliptin 2.3% 9.2%Liraglutide 1.1% 9.2%Gliclazide 14.6% 8.9%Spending per capita Prescriptions per 1,000 pop. Cost per prescriptionFemale Male Female Male Female MaleSingle-source	brand $9.30 $12.70 80 100 $116.25 $127.00Multi-source	brand $1.20 $1.50 50 50 $24.00 $30.00Multi-source	generic $7.00 $9.30 410 430 $17.07 $21.63Sourced	only	by	generics $0.80 $1.10 60 70 $13.33 $15.71$748>95%27%$19$21$18$2560066018,92025,550$0.96$0.97   51%47%44%36%18%2%43%57%3%Figure	4.2b»	Share of spending by sex, age group, and payer, 2012/13Figure	4.2a»	Summary of sales, spending, and use, 2012/13Table	4.2c»	Spending, use, and cost, by drug source, 2012/13Table	4.2b»	Leading drugs, by spending, 2012/13Table	4.2a»	Leading drugs, by prescription volume, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 7 1IntroductionRestricted coverageUnrestricted coverageListed; coverage status unknownNot coveredDrugs for diabetes: Non-insulinsProvincial formulary coverageProvinces provided restricted or unrestricted coverage for seven (MB) to 14 (NB) of the 16 types of non-insulin drugs for diabetes that had more than $10,000 in sales in each province.Weighted by national sales, the drugs covered in each province accounted for 51% (MB) to 97% (ON) of the $680-million Canadian market for non-insulin drugs for diabetes.0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB0%20%40%60%80%100%NLNS PENBQCONMBSKBC AB% of 16 drugs covered% market value of drugsDrugs includedMetformin, acarbose, sulfonamides, dipeptidyl pepti-dase 4 inhibitors, and others.Examples of indicated conditionsType 2 diabetes mellitus (T2DM).Clinical uses and considerations Individuals with type 2 diabetes mellitus (T2DM) have high blood sugar levels, caused by a combination of impaired insulin secretion by the pancreas and/or increased insulin resistance. The goal of treatment is to decrease the blood sugar levels in order to reduce the risk of diabetes complications. Microvascular compli-cations of diabetes include damage to kidneys, nerves, or eyes, while macrovascular complications include heart attack and stroke. The drugs in this category work in a variety of ways to reduce blood sugar. In order to achieve target blood glucose levels, these drugs are often used in combina-tion with each other or with insulin. Liraglutide and exenatide are injectable drugs,  while the others in this category are tablets that are taken orally.How might usage differ across age groups?The use of these drugs is concentrated in older adults. Insulin resistance and decreased insulin production both occur gradually over time in predisposed patients with a combination of genetic and lifestyle factors. How might usage differ between sexes?Men have a somewhat higher prevalence of T2DM than women, but reasons for this sex difference have not been well established. Some studies suggest that women with diabetes may have worse prognoses  than men.Figure	4.2c»	Percentage of drugs and their market values listed on provincial formularies, 2013t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 7 2Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13National spending by age and sexCanadians spent an average of $21 per capita on non-insulin drugs for diabetes at retail pharmacies in 2012/13 ($18 for women and $25 for men). Spending per capita was insignificant for children and low ($2.00) for Canadians aged 19–39. Average spending increased sharply with age, reaching $30 per capita in the 40–64 age group and $67 per capita in the 65+  age group.The level of spending was approximately 50% higher for men than for women aged 40 and older. Among those younger than 40, average spending by women and men was similar. Provincial spending by age and sexAcross provinces, average spending per capita ranged from $11 (SK) to $21 (ON) for women and from $16 (SK) to $29 (QC) for men. Differences in average spending per capita by age and sex were roughly comparable across provinces.There were moderate variations across provinces in average spending per capita within age/sex groups. Average levels of spending per capita for women and men aged 65 and older were highest in Quebec and Ontario. Remaining variations across provinces were modest and similar for women and men (coefficients of variation less than 20%).$100$75$50$0 $0$25$100$75$50$25Numberof people0-18 years3,584,03119-39 years4,972,509 people40-64 years6,149,631 people65+2,865,177 Numberof people0-18 years3,779,380 people19-39 years5,097,112 people40-64 years6,111,006 people65+2,321,645Spending per capitaSpending per capita$25$54$0 $2 $0 $2$36$84Drugs for diabetes: Non-insulinsFigure	4.2e» Per capita spending on prescriptions for males, by age group, in Canada, 2012/13Figure	4.2d» Per capita spending on prescriptions for females, by age group, in Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 7 3Levels	of	spending	across	Canada	by	age	group	and	sex,	2012/13Canada CanadaFemales of all ages Males of all ages$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$20Females age 19–39 Males age 19–39$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$40 $40$20$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$40 $40$20Females age 40–64 Males age 40–64$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$40$60$80$100$20$40$60$80$100Females age 65+ Males age 65+$0NLNSNBQCONMBSKBC AB PE$0$20NLNSNBQCONMBSKBC AB PE$20Females age 0–18 Males age 0–18Drugs for diabetes: Non-insulinsFigure	4.2f» Per capita spending on prescriptions for Canadians by age group, sex, and province, 2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 7 4Variation	in	spending	across	Canada,	2012/13Sources of age-standardized variationVariation in age-standardized average retail spending on non-insulin drugs for diabetes was driven by all three categories of cost drivers. Residents of British Columbia, Saskatchewan, and Prince Edward Island purchased significantly fewer non-insulin drugs for diabetes than other Canadians.Residents of Ontario were much more likely than other Canadians to purchase more expensive options for non-insulin drugs for diabetes.Residents of Quebec and Manitoba paid higher prices per unit of particular drug products. In Saskatchewan, residents paid the lowest prices but were much less likely than other Canadians to receive available generics, which offset the cost-reducing effect of lower unit drug prices.Population age and provincial spendingDifferences in provincial population ages would predict considerable variation in spending per capita on non-insulin drugs for diabetes.For example, based on age differences alone, predicted spending per capita in Alberta would be 16% below the average for the rest of Canada; in Nova Scotia and Newfoundland & Labrador, it would be 10% or more above the average for the rest of Canada.However, even after the figures were adjusted for dif-ferences in population age, significant provincial dif-ferences in spending on non-insulin drugs for diabetes remained. In Ontario, age-standardized spending was 24% above the average for the rest of Canada, while in Prince Edward Island it was 33% below the average for the rest of Canada.Drugs for diabetes: Non-insulinsBC AB SK MB ON QC NB NS PE NLSpending	per	capita	in	province $15.39 $16.87 $13.75 $17.42 $24.14 $24.90 $21.18 $19.83 $14.28 $21.61Spending	per	capita	in	rest	of	Canada $22.37 $22.02 $21.69 $21.60 $19.74 $20.41 $21.45 $21.49 $21.48 $21.44Unadjusted	difference	in	spending	per	capita -31.2% -23.4% -36.6% -19.3% 22.3% 22.0% -1.3% -7.7% -33.5% 0.8%Difference	predicted	by	population	age 4.9% -15.5% -5.5% -5.6% -1.2% 6.3% 9.5% 10.0% 7.0% 10.9%Age-standardized difference -34.4% -9.3% -32.9% -14.5% 23.8% 14.8% -9.9% -16.1% -37.9% -9.2%Volume effects -30.1% -12.9% -22.0% -3.0% 12.8% 11.0% -2.1% -5.3% -32.7% 3.6%Prescription	volume -57.6% -51.6% -33.0% -16.2% -25.4% 95.8% -36.0% -42.9% -65.7% -26.5%Prescription	size 27.5% 38.7% 11.0% 13.2% 38.2% -84.9% 33.9% 37.6% 32.9% 30.1%Therapeutic choice effects -4.7% 2.1% -8.4% -22.4% 20.6% -9.4% -5.5% -8.1% -1.1% -17.3%Choices	of	drug	sub-classes -14.1% 2.7% -5.6% -23.6% 12.5% -3.1% -8.8% -19.7% -11.2% -25.0%Choices	within	drug	sub-classes 9.5% -0.6% -2.8% 1.2% 8.1% -6.3% 3.3% 11.6% 10.1% 7.7%Price effects 0.3% 1.5% -2.5% 10.8% -9.6% 13.2% -2.3% -2.7% -4.0% 4.5%Prices	paid 0.5% 2.7% -15.3% 12.6% -7.6% 11.3% -1.3% -1.7% -3.0% 5.3%Generic	use -0.2% -1.2% 12.8% -1.8% -2.1% 1.8% -1.0% -1.0% -1.0% -0.8%Table	4.2d» Magnitude and sources of difference between per capita spending in each province and per capita spending in the rest of Canada, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 7 5Variation	in	spending	across	Canada,	2012/13-10 to +10%+11 to +30%+31 to +60%> +60%-11 to -30%< -60%-31 to -60%Drugs for diabetes: Non-insulinsFigure	4.2h» Sources of age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13Figure	4.2g» Age-standardized difference from per capita spending in the rest of Canada, by province, 2012/13-60%-30%+30%+60%+90%-60%-30%+30%+60%+90%-30%+30%+60%-30%+30%+60%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%0%0%BritishColumbia-34%NewBrunswick-10%NovaScotia-16%Newfoundlandand Labrador-9%Prince Edward I.-38%Alberta-9%Saskatchewan-33%Manitoba-15% Quebec+15%Ontario+24%Volume effectsPrice effectsTherapeutic choice effectst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 7 6Trends	in	spending	across	Canada,	2007/08–2012/13CAN BC AB SK MB ON QC NB NS PE NL2007/08 $18.54 $13.03 $18.40 $16.81 $17.81 $18.41 $21.63 $23.91 $20.64 $14.44 $21.512012/13 $21.45 $15.39 $16.87 $13.75 $17.42 $24.14 $24.90 $21.18 $19.83 $14.28 $21.61Average	annual	change 3.0% 3.4% -1.7% -3.9% -0.4% 5.6% 2.9% -2.4% -0.8% -0.2% 0.1%Average	annual	change	predicted	by	aging 2.0% 2.3% 2.5% 1.2% 1.4% 2.2% 1.9% 1.3% 1.3% 2.2% 1.7%Age-standardized avg. annual change 0.9% 1.1% -4.1% -5.0% -1.8% 3.4% 1.0% -3.7% -2.0% -2.4% -1.6%Volume effects 1.6% 1.1% -0.1% 1.0% 1.7% 2.7% 0.2% 2.7% 2.7% -0.8% 2.6%Prescription	volume 2.0% -0.2% -0.7% -1.2% 0.5% 2.8% 3.0% 1.7% 0.5% -2.4% -0.4%Prescription	size -0.4% 1.2% 0.6% 2.1% 1.2% -0.1% -2.7% 1.0% 2.2% 1.6% 3.0%Therapeutic choice effects 3.6% 4.1% 1.0% -2.1% -0.5% 6.4% 3.4% -1.9% 0.4% 2.7% -0.4%Choices	of	drug	sub-classes 1.5% 1.2% -2.2% -2.6% -1.4% 2.6% 2.5% -3.6% -1.8% -0.1% -2.7%Choices	within	drug	sub-classes 2.0% 2.9% 3.2% 0.5% 0.9% 3.9% 0.9% 1.7% 2.2% 2.8% 2.4%Price effects -4.3% -4.1% -5.1% -3.9% -3.0% -5.8% -2.7% -4.5% -5.2% -4.2% -3.8%Prices	paid -1.9% -1.8% -1.3% -0.2% -0.6% -2.3% -1.2% -2.2% -2.4% -2.7% -1.4%Generic	use -2.4% -2.3% -3.8% -3.7% -2.4% -3.5% -1.4% -2.3% -2.8% -1.5% -2.4%Sources of age-standardized changeLower prices of drugs purchased was a significant driver of decreased age-standardized spending per capita on non-insulin drugs for diabetes across Canada. Owing to both savings resulting from lower unit prices for particular drug products and wider use of available generics, average prices decreased.However, the downward effects of lower prices were countered by changes in the types of drugs selected for treatment, with more expensive options being chosen in 2012/13 than in 2007/08. In Ontario, these changes alone would have increased age-standardized spending per capita by 6.4% per year (37% in total). Volumes of non-insulin drugs for diabetes purchased contributed modestly to increased age-standardized spending per capita in all provinces except Alberta, Quebec, and Prince Edward Island.Pace of change, 2007/08–2012/13At the national level, inflation-adjusted spending per capita on retail purchases of non-insulin drugs for diabetes increased by an average of 3.0% per year between 2007/08 and 2012/13, for a total change of 16%.Some provinces experienced sharp increases in spending and some experienced considerable decreases. In Saskatchewan, spending per capita decreased by an average of 3.9% per year (−18% in total). At the other extreme, spending per capita in Ontario increased by 5.6% per year (30% in total). Population aging alone would have caused spending per capita in the provinces to increase by 1.2% to 2.5% per year between 2007/08 and 2012/13. Therefore, age-standardized and inflation-adjusted annual rates of change in spending per capita ranged from −5.0% (SK) to 3.4% (ON).Drugs for diabetes: Non-insulinsTable	4.2e» Magnitude and sources of change in inflation-adjusted per capita spending in Canada and the provinces, 2007/08–2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 7 7Trends	in	spending	across	Canada,	2007/08–2012/13-2 to +2%+3 to +5%+6 to +10%> +10%-3 to -5%< -10%-6 to -10%-10%-5%+5%+10%+15%-10%-5%+5%+10%+15%-10%0%+5%-5%+5%+10%NLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBCNLPENSNBQCONMBSKABBC0%0%-5%0%BritishColumbia+1%NewBrunswick-4%NovaScotia-2%Newfoundlandand Labrador-2%Prince Edward I.-2%Alberta-4%Saskatchewan-5%Manitoba-2% Quebec+1%Ontario+3%Volume effectsPrice effectsTherapeutic choice effectsDrugs for diabetes: Non-insulinsFigure	4.2j» Sources of change in age-standardized, inflation-adjusted per capita spending, by province, 2007/08–2012/13Figure	4.2i» Age-standardized average annual rate of change in inflation-adjusted per capita spending, by province, 2007/08–2012/13t h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 7 8Public	and	private	spending	across	Canada,	2012/13CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 90.5% 95.8% 97.8% 44.6% 94.8% 89.8% 91.2% 97.5% 94.3% 92.2% 99.3%Private	insurers 88.0% 87.9% 95.5% 39.0% 93.2% 88.5% 86.7% 95.8% 94.1% 89.0% 97.6%%-point	diff.	btw.	prov.	&	private	plans 2.6% 7.9% 2.3% 5.7% 1.6% 1.3% 4.6% 1.7% 0.2% 3.2% 1.7%Uninsured	patients	/	below	deductibles 86.7% 89.0% 93.2% 41.7% 94.1% 89.7% 80.7% 96.9% 93.5% 93.7% 98.3%%-pt.	diff.	btw.	prov.	plan	&	uninsured 3.8% 6.8% 4.6% 3.0% 0.7% 0.1% 10.6% 0.6% 0.8% -1.5% 1.0%Public (provincial and federal) drug plans covered an estimated 46% of spending on non-insulin drugs in Canada; private drug plans covered an estimated 36%.The cost per day of treatment for prescriptions paid  for by provincial drug plans was $0.84, 32% less than the cost per day for prescriptions paid for by private drug plans.The difference in costs per day by payer type was largely because of differences in the prescribing of single-source brands.CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments 46.1% 21.2% 23.9% 31.3% 14.9% 61.7% 56.2% 15.5% 13.0% 1.9% 4.2%Private	insurers 60.8% 60.3% 57.7% 46.9% 35.0% 69.6% 75.3% 55.3% 56.1% 81.0% 40.4%%-point	diff.	btw.	prov.	&	private	plans -14.7% -39.1% -33.8% -15.6% -20.1% -7.9% -19.1% -39.9% -43.1% -79.1% -36.2%Uninsured	patients	/	below	deductibles 45.6% 45.0% 55.2% 36.5% 23.5% 55.3% 68.9% 32.1% 39.2% 45.9% 30.9%%-pt.	diff.	btw.	prov.	plan	&	uninsured 0.5% -23.8% -31.3% -5.2% -8.6% 6.4% -12.7% -16.6% -26.2% -44.1% -26.8%CAN BC AB SK MB ON QC NB NS PE NLProvincial	governments $0.84 $0.62 $0.65 $0.69 $0.69 $0.96 $0.90 $0.54 $0.55 $0.46 $0.42Private	insurers $1.22 $1.15 $1.11 $0.86 $0.91 $1.33 $1.46 $1.01 $1.04 $2.02 $0.78%	diff.	btw.	provincial	&	private	plans -31.5% -45.9% -41.8% -19.5% -23.7% -28.4% -38.0% -46.4% -46.7% -77.4% -46.0%Uninsured	patients	/	below	deductibles $0.92 $0.84 $1.06 $0.72 $0.79 $0.94 $1.23 $0.68 $0.78 $0.86 $0.65%	diff.	btw.	provincial	plan	&	uninsured -8.9% -25.9% -38.7% -3.6% -11.9% 2.0% -26.3% -20.0% -28.9% -46.9% -34.6%CAN BC AB SK MB ON QC NB NS PE NLSpending	per	capita,	2012/13 $21.40 $15.40 $16.90 $13.70 $17.40 $24.10 $24.90 $21.20 $19.80 $14.30 $21.60%	Provincial	drug	plans 44% 24% 38% 41% 22% 48% 54% 24% 29% 43% 30%%	Private	insurance 36% 41% 42% 26% 33% 35% 33% 56% 55% 42% 50%%	Uninsured	/	below	deductibles 18% 33% 17% 25% 38% 16% 13% 17% 14% 14% 18%%	Federal	drug	plans 2% 2% 2% 8% 7% 1% 1% 2% 2% 1% 2%Drugs for diabetes: Non-insulinsTable	4.2i» Generic substitution rate for multi-source prescriptions by primary payer, Canada and provinces, 2012/13Table	4.2h» Share of spending on single-source brands by primary payer, Canada and provinces, 2012/13Table	4.2g» Average cost per day of treatment by primary payer, Canada and provinces, 2012/13Table	4.2f» Share of per capita spending by primary payer, Canada and provinces, 2012/13UBC  C e n t r e  f o r  h e a lt h  s e r v i C e s  a nd  p o l i C y  r e s e a r Ch1 7 94.3Gastrointestinal tract and metabolismDrugs for diabetes:Insulinst h e  C a n a d i a n  r x  a t l a s ,  t h i r d  e d i t i o n1 8 0IntroductionFemalesMales0-1819-3940-6465+Provincial drug plansPrivate insuranceUninsured/below deductiblesFederal drug plansDrugstore sales ($-million)SexAge groupPrimary payerPer capita spending 			2007/2008				2012/2013Per capita spending 			Females				MalesPrescriptions per 1,000 population 			Females				MalesDays of treatment per 1,000 population 			Females				MalesEstimated cost per day of treatment 			Females				MalesDrugstore sales as percent of all sales, including hospitalsShare of spending accounted for by pharmacist fees (est.) Drugs for diabetes: InsulinsPercent of prescriptionsPercent of spendingInsulin	Glargine 23.2% 32.3%Insulin	Aspart 19.3% 18.3%Human	Insulin	Isophane 18.9% 11.3%Insulin	Lispro 14.5% 12