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British Columbia Rx atlas Morgan, Steve; Schaub, Peter; Mooney, Dawn; Lam, Jonathan; Caetano, Patricia; McMahnon, Meghan; Rahim-Jamal, Sherin, 1963- 2005

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The British ColumbiaRx AtlasSteve Morgan, PhDPeter Schaub, BADawn Mooney, BAJonathan Lam, BScPatricia Caetano, PhDMeghan McMahon, BASherin Rahim-Jamal, MScDecember 2005“The British Columbia Rx Atlas” (The British Columbia Prescription Drug Atlas) was produced by:Centre for Health Services and Policy Research The University of British Columbia 429-2194 Health Sciences Mall  Vancouver, BC  Canada  V6T 1Z3Tel: (604) 822-1949 Fax: (604) 822-5690Email: enquire@chspr.ubc.caYou can download this publication from our website at www.chspr.ubc.ca.This publication is protected by copyright. It may be distributed for educational and non-commercial use, provided the Centre for Health Services and Policy Research is credited.Library and Archives Canada Cataloguing in PublicationBritish Columbia Rx atlas / Steve Morgan ... [et al.].ISBN 1-897085-03-61. Drugs--Prices--British Columbia.  2. Drug utilization--British Columbia. 3. Drugs--Prescribing--British Columbia.  I. Morgan, Steve  II. University of BritishColumbia.  Centre for Health Services and Policy ResearchRA410.55.C35B75 2005                   338.4’36151’09711                       C2005-906940-6British Columbia Rx Atlas | 1Table of ContentsAbout CHSPR ...................................................................................................................2Acknowledgements ........................................................................................................3Introduction .....................................................................................................................4Methods ...........................................................................................................................6How to Use This Atlas .....................................................................................................8Overall Drug Expenditure .............................................................................................12Variation in Overall Drug Expenditure, 2003 ..............................................................14Total Expenditure and Subsidy, 1996 ...........................................................................16Total Expenditure and Subsidy, 2003 ...........................................................................18Hypertension Treatments .............................................................................................20Psychoanaleptics ............................................................................................................24Serum Lipid Reducing Agents ......................................................................................28Drugs for Alimentary Acid Related Disorders .............................................................32Psycholeptics ..................................................................................................................36Drugs for Obstructive Airway Diseases ........................................................................40Drugs Used in Diabetes .................................................................................................44Antiinflammatory and Antirheumatic Products ..........................................................48Analgesics ......................................................................................................................52Antibacterials for Systemic Use ....................................................................................54Sex Hormones ................................................................................................................56Antiepileptics .................................................................................................................58Immunosuppressive Agents ..........................................................................................60Immunostimulants ........................................................................................................62Urologicals .....................................................................................................................642 | Centre for Health Services and Policy ResearchAbout CHSPRThe Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. CHSPR’s mission is to stimulate scientific enquiry into issues of health in population groups, and ways in which health services can best be organized, funded and delivered. Our researchers carry out a diverse program of applied health services and population health research under this agenda.CHSPR aims to contribute to the improvement of population health by ensuring our research is rel-evant to contemporary health policy concerns and by working closely with decision makers to actively translate research findings into policy options. Our researchers are active participants in many policy-making forums and provide advice and assistance to both government and non-government organiza-tions in British Columbia (BC), Canada and abroad. CHSPR receives core funding from the BC Ministry of Health to support research with a direct role in informing policy decision-making and evaluating health care reform, and to enable the ongoing devel-opment of the BC Linked Health Database. Our researchers are also funded by competitive external grants from provincial, national and international funding agencies. Much of CHSPR’s research is made possible through the BC Linked Health Database, a valuable resource of data relating to the encounters of BC residents with various health care and other systems in the province. These data are used in an anonymized form for applied health services and population health research deemed to be in the public interest.CHSPR has developed strict policies and procedures to protect the confidentiality and security of these data holdings and fully complies with all legislative acts governing the protection and use of sensitive information. CHSPR has over 30 years of experience in handling data from the BC Ministry of Health and other professional bodies, and acts as the access point for researchers wishing to use these data for research in the public interest.For more information about CHSPR, please visit www.chspr.ubc.caBritish Columbia Rx Atlas | 3AcknowledgementsThis Rx Atlas was produced with support from the BC Ministry of Health, an Operating Grant from the Canadian Institutes of Health Research (CIHR), and a Research Unit Infrastructure Award from the Michael Smith Foundation for Health Research (MSFHR). Steve Morgan holds a New Investigator Award from CIHR and a Scholar Award from MSFHR. All results and conclusions in this report are solely those of the authors; no endorsement by the project sponsors is intended or should be inferred.Access to PharmaNet data was obtained with permission of the BC Ministry of Health and the College of Pharmacists of British Columbia. Therapeutic classification codes were assigned to each drug iden-tification number with the assistance of the College of Pharmacists of BC and the Canadian Institute for Health Information (CIHI). No endorsement of the findings by the College of Pharmacists of BC or CIHI is intended or should be inferred. Assistance in the production of this report was also provided by a number of staff at CHSPR, including Chris Balma, Gillian Hanley and Colette Raymond. We dedicate this Atlas to the memory of our extraordinary friend and colleague, Peter Schaub [1978-2005]. As with many of the illustrative and informative products of the Centre for Health Services and Policy Research, this Atlas would not have been possible without Peter’s geographic expertise, creative talent, and dedicated spirit.4 | Centre for Health Services and Policy ResearchIntroductionThe Rx AtlasAt nearly $20 billion and growing by 10% per year, prescription drugs are the second largest cost component of the Canadian health care system. Given the scale of expenditure, sur-prisingly little is known about the underlying dynamics that determine the magnitude and distribution of pharmaceutical costs across individuals, regions, and therapeutic classes. Part of the reason for the lack of detailed infor-mation about drug utilization and expenditure patterns has been a historic lack of data and analytic methods.This Rx Atlas takes the first step towards addressing the drug utilization and expenditure information gap for one Canadian province. We combine population-based and patient-specific data for pharmaceuticals and health care services to explore the drivers of change in pharmaceutical expenditure over time and variations across regions.Determinants of Drug ExpenditureA common claim across the health care system is that an aging population is driving up costs. Older populations have higher (and different) medical needs than younger populations, and can be reasonably assumed to use more pre-scription drugs.Beyond the effect of aging, variation in expendi-ture—over time or across regions—could result from a straightforward increase or decrease in the amount of prescription drugs actually being used, as a result of medical needs or changing patterns of care. Changes in drug costs can also result from changes in the type or mix of drugs used to treat a given illness. For example, treating uncomplicated hypertension with Angioten-sin Converting Enzyme (ACE) inhibitors instead of lower-cost thiazide diuretics would increase expenditure without reflecting a change in the underlying need for treatment, nor, it can be argued, the ultimate health ben-efit from treatment.Drug costs can also change simply because of increases in the prices charged by drug manu-facturers. Alternatively, costs can be lowered by the choice of generic over brand drugs, the most common type of policy intervention aimed at controlling escalating prescription drug expenditure. Using a model pioneered by researchers at the Centre for Health Services and Policy Research, we analysed seven utilization and cost dynam-ics that fall into the four broad categories of expenditure determinants just described:Aging: the impact of population ageUtilization: the rate and breadth of drug therapy useChoices: the cost of drugs chosen  per course of therapyPrices: the price of drugs purchasedIn addition to assessing trends and regional pat-terns for overall drug expenditure, we focus on the 15 largest categories of drugs in terms of expenditure.| 5British Columbia Rx Atlas Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Key FindingsBetween 1996 and 2003, expenditure per capita grew at rates between 10% and 13% per year across the province.In most regions, the major determinant of change in expenditure was the increased utili-zation of prescription drugs.More is spent on hypertension drugs than on any other therapeutic drug category. Trends towards choosing newer, more costly classes of hypertension treatments increased per capita expenditure on this class of medicines by 3% to 4% a year.Drugs commonly used to treat depression and anxiety (psychoanaleptics) comprised the sec-ond-largest category of medicine in terms of spending in 2003. Growth in spending on these drugs was fastest for residents aged over 85.The third-largest category of spending was cholesterol-lowering drugs. Expenditure on these drugs more than tripled between 1996 and 2003, driven almost exclusively by increased utilization.Increases in spending on antacids and antipsy-chotic medicines (psycholeptics) were driven primarily by the selection of more expensive drug treatments.Spending on diabetes drugs more than doubled between 1996 and 2003, and grew most rapidly among baby boomers (those aged 45 to 64).The cost of analgesics varied more across regions than any other therapeutic drug cat-egory studied in this Atlas.Growth in drug expenditure was slowest for antibacterials, one of the largest categories of drug therapy for children.While overall expenditure on immunos-timulants was relatively small, costs per user exceeded $10,000 in 2003.Basis for Future ResearchThis Rx Atlas provides what we believe to be the world’s most detailed portrait of the deter-minants of the use and cost of pharmaceuticals to date. However, it is a descriptive report that deliberately contains minimal analysis and interpretation of findings.The findings highlighted above (and throughout this Rx Atlas) only provide signposts to areas for further investigation by those policy mak-ers, practitioners and researchers best placed to focus on the underlying dynamics and pos-sibilities for policy intervention.6 | Centre for Health Services and Policy ResearchMethodsDataThis Rx Atlas combines population-based and patient-specific information for pharmaceuti-cals and health care services.Prescription drug claims data from 1996 to 2003 were extracted from BC PharmaNet, a dataset containing records of every pre-scription dispensed in the province. These data reflect purchases in the community and long-term care facilities but not acute care hospitals. Non-prescription drugs and medi-cal supplies were also excluded.The study cohort comprised all 4.1 million resi-dents of British Columbia except First Nations, veterans, and Royal Canadian Mounted Police (approximately 4% of the population).Analyses were conducted for each of the 16 Health Service Delivery Areas (HSDAs) in British Columbia. Within each HSDA, the population was further stratified into five age categories.Expenditure and UtilizationExpenditure information includes both private and public contributions and excludes pharma-cists’ dispensing fees unless otherwise stated (e.g. section on public subsidy).Utilization was measured as the number of patients that filled one or more prescriptions for any drug within the therapeutic category in a given year. The World Health Organization’s Anatomi-cal Therapeutic Chemical classification codes classify drugs in the database into a hierarchy of 64 mutually exclusive therapeutic categories and 248 mutually exclusive drug classes. Analyses of use and expenditure were conduct-ed for the 15 therapeutic categories exhibiting the largest per capita expenditure in 2003.Measures of VariationRegional values were compared to provincial averages using log-deviations: the log of the regional observation divided by the log of the provincial average. This standardizes differ-ences so that, for example, a region that spends half the provincial average receives a deviation value that is comparable to a region that spends twice the provincial average. The log-devia-tions for these two regions would be –0.69% and +0.69%, respectively.Variation across regions was measured using the coefficient of variation (CV). The CV is the standard deviation of all regional measures divided by the mean of the regional measures. The larger the CV, the greater the relative varia-tion across regions.Fast factsData sources: BC PharmaNet and the BC Linked Health DatabasePopulation studied: All beneficiaries of the BC Medical Service PlanPopulation size: Approx. 4.1 millionPeriod: 1996 to 2003, inclusiveTotal prescription records: 214 millionSpecific regions: 16 Health Service Delivery Areas (HSDAs)Statistical methods: Index-theoretic| 7British Columbia Rx Atlas Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).DiagnosesDiagnoses of conditions for which certain drug classes are commonly used in treatment were sought from Medical Services Plan and hospi-tal discharge records for 2003. Conditions were identified using Expanded Diagnostic Clusters, a tool that groups ICD-9 diagnosis codes into specific diseases or symptoms.Determinants of ExpenditureThe conceptual framework used in this Rx Atlas takes advantage of the therapeutic classifica-tions for drugs to calculate seven types of uti-lization and cost dynamics that determine drug expenditures. As illustrated in the conceptual framework below, these determinants of drug expenditure fall into four broad categories: Aging: the impact of population ageUtilization: the rate and breadth of drug therapy useChoices: the cost of drugs chosen  per course of therapyPrices: the price of drugs purchasedFor methodological details and specific results for the overall provincial population, see: Morgan, SG. Booming Prescription Drug Expenditure. Medical Care 2005; 43(10): 996-1008. Price changes = change in expenditure per capita due to price inflation for brand and generic drug products.Generic use = change in expenditure per capita due to changes in age-specific rates of generic drug use.Drug mix = change in expenditure per capita due to changes in the age-specific mix of drugs selected from within drug classes.Drug class mix = change in expenditure per capita due to changes in the age-specific mix of drug classes selected from within therapeutic categories.Poly-therapy = change in expenditure per capita due to changes in age-specific rates of exposure to multiple therapeutic categories.Overall exposure = change in expenditure per capita due to changes in age-specific rates at which residents use one or more prescriptions.Population aging = change in expenditure per capita due to changes in the proportion of population falling into different age categories.Population aging0-19 20-44 45-64 65-84 85+Price changes$0.01/tab $0.10/tab .../tabGeneric useBrand A Generic ABrand B Generic BDrug class mix Beta-Blockers ACE-IsThiazidesDrug mix25 mg captopril 2.5 mg enalapril Overall exposure 0 Rx 1+ RxPoly-therapy Nervous HypertensionGIAgingUtilizationChoicesPricesMeasured determinants of prescription drug expenditure8 | Centre for Health Services and Policy ResearchHow to Use This Atlas1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years45-64 years65-84years85+yrs0-19 years20-44 years45-64 years65-84years85+yrsNumberof persons$5.00$10.00$20.00$35.00$55.00$70.00$8.00$25.00$45.00$60.001,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsDrugs in this therapeutic category:  •  •  • Indications for use: • • • This Atlas describes drug use and re-lated expenditures for 15 therapeutic categories. The eight categories for which diagnostic information could be associated with drug use are described in more detail than the remaining seven categories.Expenditure per capita over the life-course, province-wide data, 1996 and 2003This chart illustrates drug expenditures over the life-course in 1996 and 2003. The width of each bar represents the relative size of the population in the respective age category. The height of each bar represents the average expenditure per capita in the given age category. Combining this information, the area of each age-specific bar is a measure of the total expenditure of drugs for each age category. Both the change in the population size and the change in cost are thereby represented in these illustrations.| 9British Columbia Rx Atlas Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).How to Use This AtlasComponents of change by health service delivery area (HSDA), 1996-2003This chart shows the unadjusted expenditure per capita in each HSDA for 1996 and 2003. It lists the average annual growth rate over the period and the annual growth contributions made by four categories of expenditure determinants. The 16 HSDAs are listed in descending order of average annual growth rate.NorthwestNorth IslandNortheastFraser EastOkanaganCentral IslandKootenay BoundarySouth IslandFraser NorthEast KootenayNorthern InteriorThompson CaribooN. Shore/Coast Gar.Fraser SouthVancouverRichmond$101$140$99$144$123$183$153$173$154$195$162$147$158$156$136$152$236$324$228$325$274$398$332$368$321$402$333$292$311$306$261$28612.9%12.8%12.6%12.3%12.1%11.8%11.7%11.4%11.0%10.9%10.8%10.3%10.2%10.1%9.7%9.5%1.6%2.1%2.2%1.7%2.0%0.9%1.3%1.4%0.8%0.5%0.5%0.7%1.4%0.7%1.1%0.5%7.1%6.5%6.7%6.6%6.5%6.8%6.1%6.0%5.9%6.0%6.3%5.2%6.1%5.5%4.7%4.6%5.1%4.9%4.8%4.9%4.6%5.3%5.1%4.8%5.2%5.3%5.1%5.4%4.1%4.9%5.0%5.5%-1.3%-1.1%-1.5%-1.2%-1.4%-1.4%-1.1%-1.2%-1.2%-1.2%-1.4%-1.2%-1.7%-1.2%-1.3%-1.3%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices Prices10 | Centre for Health Services and Policy ResearchHow to Use This Atlas��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=13%CV=9%CV=4%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaNortheastNorthern InteriorNorthwestThompson CaribooFraser EastKootenay BoundaryEast KootenayFraser SouthRichmondN. Shore/Coast Gar.North IslandFraser NorthSouth IslandOkanaganCentral IslandVancouver����$56$53$53$52$52$52$51$51$49$49$46$46$46$46$45$44����$23$28$26$29$27$26$27$26$24$26$23$26$27$25$23$24143%89%104%79%93%100%89%96%104%88%100%77%70%84%96%83%������ ��� �������+0.21+0.15+0.15+0.13+0.13+0.13+0.11+0.11+0.07+0.07+0.01+0.01+0.01+0.01-0.01-0.03Age-adjusted users per 1,000 populationNortheastNorthern InteriorNorthwestThompson CaribooFraser EastKootenay BoundaryEast KootenayFraser SouthRichmondN. Shore/Coast Gar.North IslandFraser NorthSouth IslandOkanaganCentral IslandVancouver����147146145142142137137136135135134133132131125122����97103989198939494919395959193878252%43%48%55%45%47%46%45%49%44%41%40%45%41%44%49%������ ��� �������+0.09+0.09+0.08+0.06+0.06+0.02+0.02+0.02+0.01+0.01+0.00-0.01-0.01-0.02-0.07-0.09Cost per userNortheastNorthern InteriorNorthwestThompson CaribooFraser EastKootenay BoundaryEast KootenayFraser SouthRichmondN. Shore/Coast Gar.North IslandFraser NorthSouth IslandOkanaganCentral IslandVancouver����$359$355$354$353$351$345$343$343$341$338$336$335$333$333$327$326����$280 $299 $281 $277 $260 $271 $252 $274 $285 $288 $251 $261 $254 $263 $240 $266 28%19%26%27%35%27%36%25%19%17%34%29%31%27%36%23%������ ��� �������+0.05+0.04+0.04+0.04+0.03+0.02+0.01+0.01+0.00-0.01-0.01-0.01-0.02-0.02-0.04-0.04Health service delivery area (HSDA) cartograms and data, 1996 and 2003| 11British Columbia Rx Atlas How to Use This Atlas0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Sample Condition” Expanded Diagnosis Cluster XXX00Percent of population with:Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003These maps (called cartograms) illustrate the relative size of each HSDA according to its population. The shading illustrates the relative variation of expenditure/capita, prescription drug users/capita, or the cost/drug user in 2003 from the provincial mean.Regional values were compared to pro-vincial averages using log-deviations: the log of the regional observation divided by the log of the provincial average.The coefficient of variation (CV) mea-sures the degree of variability across regions. The larger the CV, the greater the relative variation of that measure across the HSDAs. This chart illustrates the proportion of the provincial population who were dis-pensed the specific pharmaceutical ther-apy and who either had or did not have a diagnosis for which such a therapy would be indicated. The proportion for whom a relevant medical diagnosis/condition was recorded, but no relevant prescription therapy was dispensed, are also illustrat-ed. The total lengths of the horizontal bars approximate the potential burden-of-illness of the medical condition in each HSDA. 12 | Centre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Overall Drug Expenditure65-84years1996 2003Expenditure per capita$1000$750$500$2500-19 years20-44 years45-64 years85+yrs0-19 years20-44 years 45-64 years65-84years85+yrsNumberof persons$37 $57$195$457$893 $893$106$229$483 $4771,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure By AgePrescription drug expenditure per capita varies significantly with age. In both 1996 and 2003, expenditures per capita more than doubled each step along the age gradient through to the age category 65 to 84.Residents aged 85 and older had slightly lower drug expenditures per capita than those aged 65 to 84 years, possibly reflecting a “healthy survivor” effect and increased institutionaliza-tion in acute care facilities (data reflect only drug use in the community and long-term care facilities).While the elderly consume high levels of drugs and are growing in number, they remain a relatively small proportion of the population. The baby boomer generation, the cohort aged 45 to 64, accounted for 37% of population-wide expenditures (while those aged 65 to 84 accounted for only 34%).Expenditure GrowthPer capita expenditures grew at annual rates ranging from 9.5% to 12.9% across HSDAs. At those annual growth rates, expenditures per capita would double within six to eight years. Northern regions tended to have the most rapid drug expenditure inflation over the study period.Despite the fact that there is a relatively steep age gradient in prescription drug expenditures per capita, aging contributed less than 2% to the annual rate of expenditure growth in all regions but North Island, Northeast and Okanagan.In most regions, the major determinant of drug spending was increased utilization. Regions with the most rapid increase in utilization gen-erally had the most rapid overall expenditure growth.| 13British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Overall Drug ExpenditureNorthwestNorth IslandNortheastFraser EastOkanaganCentral IslandKootenay BoundarySouth IslandFraser NorthEast KootenayNorthern InteriorThompson CaribooN. Shore/Coast Gar.Fraser SouthVancouverRichmond$101$140$99$144$123$183$153$173$154$195$162$147$158$156$136$152$236$324$228$325$274$398$332$368$321$402$333$292$311$306$261$28612.9%12.8%12.6%12.3%12.1%11.8%11.7%11.4%11.0%10.9%10.8%10.3%10.2%10.1%9.7%9.5%1.6%2.1%2.2%1.7%2.0%0.9%1.3%1.4%0.8%0.5%0.5%0.7%1.4%0.7%1.1%0.5%7.1%6.5%6.7%6.6%6.5%6.8%6.1%6.0%5.9%6.0%6.3%5.2%6.1%5.5%4.7%4.6%5.1%4.9%4.8%4.9%4.6%5.3%5.1%4.8%5.2%5.3%5.1%5.4%4.1%4.9%5.0%5.5%-1.3%-1.1%-1.5%-1.2%-1.4%-1.4%-1.1%-1.2%-1.2%-1.2%-1.4%-1.2%-1.7%-1.2%-1.3%-1.3%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices PricesThe impact of choosing higher cost options per course of drug treatment increased expendi-ture per capita by roughly 5% per year in all regions.In regions around the greater Vancouver area, where utilization increased by 6% or less, therapeutic choices were as significant a cost-driver as utilization.Prices fell in all regions, driven by increased use of generic drugs and related price competi-tion between brand and generic alternatives.14 | Centre for Health Services and Policy ResearchVariation in Overall Drug Expenditure, 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average-5%+5%CV=8%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaSouth IslandOkanaganFraser EastCentral IslandThompson CaribooNorth IslandNorthwestFraser SouthNorthern InteriorN. Shore/Coast Gar.Fraser NorthEast KootenayKootenay BoundaryNortheastVancouverRichmond����$371$362$355$347$339$337$331$330$329$323$315$310$309$303$294$271����$176$165$168$168$158$156$152$167$158$155$156$162$147$135$152$144111%120%111%107%115%116%118%98%108%109%102%91%110%124%94%88%������ ��� �������0.020.020.010.010.000.000.000.000.000.00-0.01-0.01-0.01-0.02-0.02-0.03Variation Across RegionsIn contrast to growth in drug expenditures over time, variations in age-adjusted drug expendi-tures were modest across geographic regions of BC in 2003.Age-adjusted expenditures within most HSDAs were within 10% of the provincial average of $330 per capita.Variation in crude expenditure per capita (fac-ing page, CV=18%) was much greater than that of age-adjusted expenditure per capita (illustra-tion below, CV=8%). This is because much of the variation in crude expenditure per capita is explained by differences in the age profi le of the regions.For example, while Northeast and Northwest had crude expenditures per capita that were about 30% below the provincial average, the age of the populations in these regions was suf-fi ciently different from the provincial average to explain most of this difference. Age differ-ences in these regions explained 18.8 and 14.3 percentage points of the more than 28% differ-ence between their per capita spendingand the provincial average.Sources of VariationDifferences in utilization were also a signifi -cant source of variation in overall expenditures on prescription drugs across regions.Outliers include Vancouver, Northwest, and Richmond, where lower utilization of medi-cines, in and of itself, would render expendi-tures per capita 13%, 16%, and 18% below the provincial average respectively. It is notable that these differences are in addition to age-related differences in the populations of those areas.Therapeutic choices explained a moder-ate share of variation across regions. South Island was 3.6% above average in this regard, whereas the eastern regions were below aver-age. As with the effects of differences in Health service delivery area (HSDA) cartogram and data, 1996 and 2003| 15British Columbia Rx Atlas Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Variation in Overall Drug Expenditure, 2003South IslandOkanaganCentral IslandFraser EastKootenay BoundaryThompson CaribooNorth IslandN. Shore/Coast Gar.East KootenaySouth FraserFraser NorthVancouverNorthern InteriorRichmondNortheastNorthwest$402$398$368$333$332$325$324$321$311$306$292$286$274$261$236$228$330$330$330$330$330$330$330$330$330$330$330$330$330$330$330$33021.7%20.6%11.3%0.7%0.5%-1.6%-1.8%-2.9%-6.0%-7.5%-11.7%-13.5%-17.1%-21.1%-28.7%-31.0%11.0%13.4%11.5%-3.3%9.1%2.4%1.1%3.1%2.4%-6.3%-6.0%-0.8%-12.1%-2.5%-18.8%-14.3%4.4%6.3%-1.4%5.6%-6.5%-1.8%-1.7%-8.0%-4.3%0.4%-7.1%-13.0%-4.1%-18.1%-5.9%-16.2%3.6%0.9%1.1%-0.6%-3.2%-2.1%-1.4%1.9%-4.1%-1.6%1.1%0.0%-2.1%-1.5%-7.3%-1.8%1.3%-0.9%0.1%-0.8%1.8%0.0%0.2%0.6%0.0%-0.2%0.0%0.3%0.4%0.3%0.6%-2.2%HSDA BC Difference AgingDeterminants of expenditureExpenditure per capitaUtilization Choices Pricesutilization, the impact of therapeutic choices on costs is in addition to the effects of differ-ences in the age of the populations (i.e., that captured by the “Aging” measure).Prices did not vary considerably across regions. The rates at which generic drugs were used were comparable across regions, and the prices of the actual brands and generics selected did not differ significantly. The lat-ter finding is consistent with reimbursement policies based on “actual acquisition costs” (variation in dispensing fees is not consid-ered as a price component in this study).Components of variation across health service delivery area (HSDA), 200316 | Centre for Health Services and Policy ResearchTotal Expenditure and Subsidy, 1996��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=5%CV=2%CV=12%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted subsidy for non-seniorsOkanaganVancouverFraser EastCentral IslandThompson CaribooSouth IslandKootenay BoundaryNorth IslandFraser SouthFraser NorthNorthern InteriorEast KootenayN. Shore/Coast Gar.NorthwestNortheastRichmond$47$42$45$45$44$47$39$37$38$35$37$37$33$32$27$25$119$109$118$121$117$126$106$107$116$109$113$115$112$110$97$9539%39%38%38%37%37%37%34%33%33%32%32%30%29%28%27%��� �������0.120.110.080.080.070.060.06-0.01-0.06-0.07-0.08-0.08-0.16-0.19-0.21-0.26������������������������������Age-adjusted expenditure and subsidy per capitaFraser EastOkanaganVancouverCentral IslandNorth IslandSouth IslandKootenay BoundaryFraser SouthThompson CaribooFraser NorthRichmondEast KootenayNorthern InteriorN. Shore/Coast Gar.NorthwestNortheast����������$94$92$84$92$85$95$79$89$83$82$73$82$80$75$73$65���������$168$165$152$168$156$176$147$167$158$156$144$162$158$155$152$13556%56%55%55%54%54%54%53%53%53%51%51%51%49%48%48%�������������� �������0.050.040.030.020.020.010.010.00-0.01-0.01-0.05-0.05-0.05-0.09-0.11-0.11Age-adjusted subsidy for seniorsFraser EastFraser SouthNorth IslandFraser NorthOkanaganRichmondCentral IslandSouth IslandVancouverThompson CaribooKootenay BoundaryNorthern InteriorN. Shore/Coast Gar.East KootenayNorthwestNortheast$409$416$392$380$379$378$387$404$347$337$336$358$345$372$335$304$486$495$469$456$455$456$467$492$424$414$413$443$429$463$419$38184%84%83%83%83%83%83%82%82%81%81%81%81%80%80%80%��� �������0.020.020.010.010.010.000.00-0.01-0.01-0.01-0.01-0.02-0.02-0.03-0.03-0.03������������������������������Health service delivery area (HSDA) cartograms and data, 1996 | 17British Columbia Rx Atlas Total Expenditure and Subsidy,1996Measuring Provincial SubsidyPublic subsidy is an important part of overall financing for prescription drug purchases. The primary source of public subsidy for medicines in the province is the BC PharmaCare program. First Nations, veterans and the Royal Canadian Mounted Police, who are covered by federal drug programs, are excluded from this analysis.To describe public subsidy for medicines, we combined expenditure on ingredient costs (the prices for the drugs themselves) and the dis-pensing fees paid to pharmacists.Furthermore, because there is an age-gradient in both total drug expenditure and public sub-sidy, data used to measure public share of total costs have been age-adjusted. Consequently, the results in this section of the report will not be exactly equal to data presented in the analy-sis of causes of variation across regions and trends over time.Provincial Subsidy for Drug Spending in 1996The overall share of total expenditures on pre-scription drugs that was paid for by the provin-cial government was 53% in 1996.According to a recent report from the Canadian Institute for Health Information (CIHI)—“Drug Expenditures in Canada 1985-2004”—the BC government paid 47% of total prescription drug costs in 1996. The CIHI statistic differs from that reported here due to the exclusion of medical supplies from this Rx Atlas. However, the CIHI data show that provincial subsidy of prescription drug costs was higher in BC than any other prov-ince (range = 21% to 43% ; average = 40%).Within BC, variation across HSDAs in the age-adjusted share of expenditures paid for by the government was modest in 1996 (CV=5%), ranging from 48% in Northeast and Northwest, to 56% in Okanagan and Fraser East.Most of the age-adjusted variation in over-all public subsidy that occurred in 1996 was the result of age-adjusted variations in the public share of expenditures for non-seniors (CV=12%). Non-seniors’ public subsidy ranged from 27% in Richmond to 39% in Okanagan and Vancouver.In contrast, the provincial government paid for a relatively even share of seniors’ drug expenditures across HSDAs in 1996: the age-adjusted public subsidy for seniors ranged from 80% to 84% (CV=2%). In 1996, seniors were primarily responsible for paying the dispensing fees for their drug purchases; the government covered virtually all ingredient costs.18 | Centre for Health Services and Policy ResearchTotal Expenditure and Subsidy, 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=8%CV=6%CV=15%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted subsidy for seniorsFraser EastKootenay BoundaryOkanaganNorthern InteriorNortheastThompson CaribooVancouverRichmondFraser NorthFraser SouthEast KootenayNorth IslandCentral IslandNorthwestSouth IslandN. Shore/Coast Gar.$615$510$567$526$484$531$479$486$515$527$517$554$513$487$500$458$940$800$892$836$770$865$781$796$845$876$862$929$880$837$956$87965%64%64%63%63%61%61%61%61%60%60%60%58%58%52%52%��� �������0.090.060.060.050.050.030.030.020.020.010.000.00-0.02-0.03-0.13-0.14������������������������������Age-adjusted subsidy for non-seniorsOkanaganCentral IslandVancouverKootenay BoundaryThompson CaribooFraser EastNorth IslandSouth IslandNorthern InteriorEast KootenayNortheastFraser NorthFraser SouthNorthwestN. Shore/Coast Gar.Richmond$118$101$81$85$89$90$83$94$79$67$67$67$68$68$62$47$272$256$212$226$250$256$237$272$243$217$223$225$238$245$228$18243%39%38%38%36%35%35%34%33%31%30%30%29%28%27%26%��� �������0.250.160.130.110.060.050.040.03-0.03-0.08-0.11-0.12-0.15-0.19-0.20-0.27������������������������������Age-adjusted expenditure and subsidy per capitaOkanaganKootenay BoundaryVancouverFraser EastCentral IslandThompson CaribooNorth IslandNorthern InteriorEast KootenayNortheastFraser NorthSouth IslandFraser SouthRichmondNorthwestN. Shore/Coast Gar.����������$183$147$139$166$160$153$151$144$133$128$132$153$135$110$129$120���������$362$309$294$355$347$339$337$329$310$303$315$371$330$271$331$32351%47%47%47%46%45%45%44%43%42%42%41%41%41%39%37%�������������� �������0.150.080.080.070.060.040.030.00-0.02-0.03-0.04-0.06-0.07-0.07-0.12-0.16Health service delivery area (HSDA) cartograms and data, 2003| 19British Columbia Rx Atlas Total Expenditure and Subsidy, 2003Recent Policy ChangesIn 2002, the BC government implemented new co-payments under the seniors drug program. Low-income seniors were required to pay $10 toward the total cost (including dispensing fee) of each of the first 20 prescriptions they filled in the year. After the 20th prescription, Phar-maCare would pay 100% of costs. All other seniors were required to pay $25 toward the total cost of each of the first 11 prescriptions they filled, after which PharmaCare would pay 100% of costs.Then, in May 2003, the government elimi-nated the special drug program for seniors and creating a new drug benefit program, called Fair PharmaCare, for residents of all ages. Deductibles for public coverage under Fair PharmaCare would be a percentage of house-hold income, ranging from zero for households earning $15,000 or less, to 3% for households earning over $30,000.Provincial Subsidy for Drug Spending in 1996The changes in BC PharmaCare policy that occurred in 2002 and 2003 reduced the provin-cial subsidy for drug costs from 52% in 2001 to 48% in 2002, and then to 44% in 2003.Statistics from the Canadian Institute for Health Information (CIHI)—“Drug Expenditures in Canada 1985-2004”—also indicated that the share of drug spending paid for by the BC gov-ernment have fallen. CIHI data show that the BC government subsidized 43% of total pre-scription drug costs in 2003, which is closer to the national average of 40% than had been the case from 1996 to 2001.Within BC, age-adjusted variation in the public share of expenditures was higher in 2003 than it was in 1996. The age-adjusted public subsidy in 2003 ranged from 37% in North Shore/Coast Garibaldi to 51% in Okanagan (CV=8%).As in 1996, most of the 2003 variation in age-adjusted public subsidy stemmed from variation in the public share of expenditure for non-seniors. The age-adjusted provincial subsidy for non-seniors’ drug expenditure ranged from 26% in Richmond to 43% in Okanagan (CV=15%).Variation in public subsidy increased slightly for seniors (CV=6%), who received an average, age-adjusted subsidy ranging from 52% in North Shore/Coast Garibaldi to 65% in Fraser East.Because the Fair PharmaCare program began in 2003, the changes in regional allocation of provincial subsidy for pharmaceuticals in 2003 likely reflect variations in needs relative to average household incomes.20 | Centre for Health Services and Policy ResearchHypertension TreatmentsDrugs in this therapeutic category: • Diuretics (e.g. hydrocholrothiazide) • Beta blocking agents (e.g. atenolol) • Calcium channel blockers    (e.g. nifedipine) • Angiotensin converting enzyme      inhibitors (e.g. ramipril)  • Angiotensin receptor blockers    (e.g. losartan)Indications for use: • Reduction of high blood pressureExhibit 2.2a: Expenditure per capita over the lifespan, province-wide data, 1996 and 20011996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years45-64 yrs65-84years 85+yrs0-19 years20-44 years45-64 years65-84years 85+yrsNumberof persons$0.16 $0.35$4.97$57.56$195.99$2.68$34.24$119.83 $114.55$188.681,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure per capita over the life-course, province-wide data, 1996 and 2003Hypertension drugs are the largest thera-peutic category in terms of expenditure per capita in BC: $45 per capita in 2003. Most of this expenditure is for the purchase of ACE-inhibitors (43%), calcium channel blockers (27%), and angiotensin receptor blockers (15%). Beta-blockers and diuretics account for only 14% of expenditure in this category because they are a fraction of the cost of top-selling ACE-inhibitors, calcium channel blockers, and angiotensin receptor blockers, eventhough they are used by 47% of the users of antihypertensive drugs in BC.Among populations aged 45 years and older, expenditure on hypertension thera-pies increases rapidly with age. Per capita spending among the elderly (over age 65) was nearly $200 in 2003—four times that of residents aged 45 to 64, and 50 times that of residents under age 45.| 21British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Hypertension TreatmentsNortheastNorthwestNorthern InteriorThompson CaribooNorth IslandN. Shore/Coast Gar.Central IslandOkanaganKootenay BoundaryRichmondEast KootenaySouth IslandVancouverFraser NorthFraser SouthFraser East$14.94$19.13$18.61$21.72$24.59$21.74$28.66$29.55$26.75$23.21$26.55$31.06$21.97$23.27$25.10$29.84$35.12$43.43$41.30$46.79$49.48$42.47$55.93$56.76$49.96$43.20$47.59$54.60$38.38$40.14$43.12$50.7113.0%12.4%12.1%11.6%10.5%10.0%10.0%9.8%9.3%9.3%8.7%8.4%8.3%8.1%8.0%7.9%3.0%4.1%3.6%2.8%3.4%1.3%2.1%1.4%2.0%1.8%2.1%0.7%0.7%1.1%1.1%0.8%6.1%5.9%5.5%5.7%5.0%5.1%5.1%5.2%4.6%4.5%5.1%4.9%4.4%4.3%4.7%4.7%4.3%3.2%3.5%3.3%2.4%4.2%3.3%3.9%3.2%3.9%2.3%3.4%4.0%3.4%3.0%3.3%-0.8%-1.1%-0.9%-0.5%-0.5%-0.8%-0.8%-0.9%-0.7%-1.2%-1.0%-0.7%-1.0%-0.9%-1.0%-1.0%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices PricesThe steep age gradient for hypertension drugs expenditure is reflected in the impact of popu-lation aging on expenditure trends in many HSDAs. Hypertension expenditure per capita grew by 8% to 13% per year across HSDAs, with aging explaining over 3% of the annual growth rate in some regions.Utilization was the most significant driver of expenditure across all the HSDAs, ranging from just over 6% in Northeast to 4.4% in Vancouver.The increased availability of generic drugs in this therapeutic category resulted in lower average prices, reducing expenditure growth by approximately 1% per year.Despite increased use of generic versions of older hypertension treatments, gradual trends in choices towards newer, more costly classes of hypertension drugs (ACE-inhibitors, calci-um channel blockers, and angiotensin receptor blockers) increased expenditures per capita by 3% to 4% per year in nearly every HSDA.Combined with steady increases in the age-adjusted use of hypertension treatments, these results indicate more people were receiving more costly treatments for hypertension in all regions of BC in 2003.22 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Hypertension TreatmentsVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthAge-adjusted expenditure per capitaNorthwestFraser EastNorthern InteriorNortheastFraser SouthOkanaganEast KootenayCentral IslandThompson CaribooNorth IslandFraser NorthSouth IslandRichmondKootenay BoundaryVancouverN. Shore/Coast Gar.����$53$52$51$49$48$48$46$46$46$46$45$45$44$44$41$41����$28$29$27$24$28$27$26$27$25$26$24$23$22$24$22$2189%78%91%107%74%77%79%72%86%76%87%93%97%80%83%97%������ ��� �������+0.15+0.13+0.11+0.07+0.06+0.05+0.02+0.01+0.01+0.01-0.00-0.02-0.04-0.04-0.11-0.11VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthAge-adjusted users per 1,000 populationNorthwestFraser EastNorthern InteriorNortheastFraser SouthNorth IslandRichmondEast KootenaySouth IslandFraser NorthCentral IslandOkanaganThompson CaribooKootenay BoundaryVancouverN. Shore/Coast Gar.����147146145142142137136136135135134133131131122121����98103999199949393919395919392878351%43%47%55%43%46%47%46%49%44%41%46%41%42%40%46%������ ��� �������+0.09+0.09+0.08+0.06+0.06+0.02+0.02+0.01+0.01+0.01-0.00-0.01-0.02-0.02-0.09-0.10VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthCost per userNorthwestNorth IslandFraser EastRichmondNorthern InteriorSouth IslandNortheastFraser NorthFraser SouthEast KootenayN. Shore/Coast Gar.Central IslandVancouverKootenay BoundaryOkanaganThompson Cariboo����$359$355$354$353$351$345$343$343$341$338$336$335$333$333$327$326����$286$290$283$278$269$271$258$274$279$288$248$261$255$263$246$24625%22%25%27%30%27%33%25%22%17%35%29%31%27%33%33%������ ��� �������+0.05+0.04+0.04+0.04+0.03+0.02+0.01+0.01+0.00-0.01-0.01-0.01-0.02-0.02-0.04-0.04��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=8%CV=6%CV=3%| 23British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Hypertension Treatments0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Hypertension” Expanded Diagnosis Cluster CAR02Percent of population with:Of the 15 leading therapeutic drug classes, hypertension treatments exhibited the lowest regional variations in age-adjusted expendi-ture and use; and the second lowest variation in cost per user.Age-adjusted expenditure per capita on hyper-tension treatments in 2003 was highest in Northwest, Fraser East, and Northern Interior. North Shore/Coast Garibaldi and Vancouver had the lowest cost per capita. As with expenditure per capita, use of hyper-tension treatments was highest in Northwest, Fraser East, and Northern Interior; and lowest in North Shore/Coast Garibaldi and Vancouver. Costs per user deviated by less than 5%.Nearly 15% of the provincial population (age-adjusted) filled a prescription for antihyper-tensive medication. Approximately two-thirds of these people also had medical records indi-cating a diagnosis of hypertension in 2003. Between 15% and 20% of those diagnosed with hypertension did not fill a prescription for a hypertension drug.24 | Centre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Psychoanaleptics1996 2003Expenditure per capita$80$60$40$200-19 years20-44 years45-64 years 65-84years85+yrs0-19 years20-44 years45-64 years 65-84years85+yrsNumberof persons$3.00$5.78$29.98$47.14 $46.26$73.10$14.00$20.12$16.52$19.401,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsPer capita expenditure on psychoanaleptics in BC more than doubled from $13 in 1996 to $32 in 2003. Almost all (91%) of the expenditure in this therapeutic category is on antidepressants, and over half (55%) is on selective serotonin reuptake inhibitors.Expenditure on psychoanaleptics was rela-tively evenly distributed across adult age categories: nearly three-quarters (72%) of the 2003 expenditure was accounted for by populations aged 20 to 64.Although the age-gradient in expenditures per capita is not steep for this therapeutic category, growth in psychoanaleptics expenditure was highest among the elderly. Particularly notable is the growth in expen-ditures per resident over age 85, which increased from approximately $20 in 1996 to $73 in 2003.Drugs in this therapeutic category:  • Antidepressants: selective serotonin         reumtake inhibitors (e.g. paroxetine) • Antidepressants: other (e.g. venlafaxine)  •  Antidepressants:: nonselective     monoamine reuptake inhibitors   (e.g. amitriptyline) • Psychostimulants (e.g. methylphenidate)  • Antidementia drugs (e.g. donepezil)Indications for use:  • Antidepressants: treatment of       depression and anxiety • Pyschostimulants: treatment of     Attention Deficit Hyperactivity     Disorder (ADHD) • Antidementia drugs: symptomatic     treatment of dementia caused by     diseases such as Alzheimer’s | 25British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).PsychoanalepticsNorthwestNorth IslandNortheastFraser EastOkanaganCentral IslandKootenay BoundarySouth IslandFraser NorthEast KootenayNorthern InteriorThompson CaribooN. Shore/Coast Gar.Fraser SouthVancouverRichmond$9.59$11.31$8.01$12.42$14.78$14.25$11.52$17.21$10.93$11.97$12.22$14.04$14.42$12.56$12.91$9.62$29.14$33.16$22.63$34.47$40.37$38.34$30.49$43.61$27.62$29.81$30.18$34.21$34.17$29.73$26.83$19.8717.2%16.6%16.0%15.7%15.4%15.2%14.9%14.2%14.2%13.9%13.8%13.6%13.1%13.1%11.0%10.9%0.9%0.9%0.7%0.1%0.5%0.5%0.6%-0.1%0.1%0.5%1.1%0.3%0.1%0.3%0.1%0.4%11.6%10.0%10.0%9.2%9.6%9.2%9.4%8.5%8.1%8.8%8.5%8.5%8.6%7.7%6.8%6.2%7.2%7.5%7.7%8.4%7.3%7.5%6.6%7.8%7.8%7.0%6.4%6.8%6.4%7.2%6.5%6.7%-2.9%-2.2%-2.7%-2.4%-2.3%-2.4%-2.0%-2.3%-2.2%-2.7%-2.5%-2.3%-2.3%-2.3%-2.5%-2.4%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices Prices!!Data stability warning: one or more population cells with less than 100 individuals!Across HSDAs, annual growth in per capita psychoanaleptics expenditure ranged from 10.9% to 17.2%. The modest impact of popula-tion aging on expenditures reflects the relatively flat age-gradient.Prices paid for psychoanaleptic drugs fell due to use of generic medicines. But this was more than offset by trends toward the selection of more expensive classes of drug and more expensive drugs from within such classes. These choices increased psychoanaleptics expenditure by about 7% per year in most HSDAs.Increased utilization of psychoanaleptics con-tributed significantly to expenditure trends. Accounting for between 6% and 11% growth per year, variations in the trend toward great-er (age-adjusted) use of psychoanaleptics explained most of the variation in expenditure growth rates across HSDAs.26 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Psychoanaleptics��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=17%CV=17%CV=6%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaSouth IslandOkanaganCentral IslandFraser EastThompson CaribooN. Shore/Coast Gar.North IslandNorthern InteriorFraser SouthNorthwestEast KootenayKootenay BoundaryFraser NorthVancouverNortheastRichmond����$41$39$37$36$34$33$33$32$31$31$30$29$28$26$25$20����$17$15$14$13$14$14$12$13$13$10$12$12$11$12$9$10148%170%160%181%140%138%185%140%141%198%143%154%159%114%180%107%������ ��� �������+0.26+0.21+0.14+0.13+0.06+0.05+0.04-0.01-0.01-0.04-0.07-0.08-0.11-0.19-0.25-0.46Age-adjusted users per 1,000 populationOkanaganSouth IslandFraser EastCentral IslandThompson CaribooNorth IslandNorthern InteriorKootenay BoundaryNorthwestFraser SouthEast KootenayN. Shore/Coast Gar.NortheastFraser NorthVancouverRichmond����117116114110109108102989594939284837460����6771696567596456496157564752504274%63%65%70%61%83%60%74%97%54%63%64%80%58%47%42%������ ��� �������+0.22+0.20+0.18+0.15+0.14+0.13+0.08+0.03+0.01-0.00-0.02-0.03-0.12-0.14-0.24-0.46Cost per userN. Shore/Coast Gar.South IslandVancouverFraser NorthRichmondOkanaganCentral IslandFraser SouthNorthwestEast KootenayFraser EastThompson CaribooNorthern InteriorNorth IslandKootenay BoundaryNortheast����$363$356$353$345$336$335$335$332$321$319$318$311$308$308$300$294����$249$234$244$210$230$216$218$212$212$214$187$209$206$197$205$18846%52%45%64%46%55%53%57%52%49%71%49%50%56%46%56%������ ��� �������+0.08+0.06+0.05+0.03+0.00-0.00-0.00-0.01-0.05-0.05-0.05-0.08-0.08-0.09-0.11-0.13| 27British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Psychoanaleptics0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Depression, Anxiety, Neuroses” Expanded Diagnosis Cluster PSY01Percent of population with:Age-adjusted expenditure per capita on psy-choanaleptics varied moderately across HSDAs (CV=17%). Expenditure per capita in 2003 ranged from approximately $20 in Richmond to approximately $40 in South Vancouver Island and Okanagan.Virtually all of the expenditure varia-tion stemmed from variation in utilization (CV=17%). The number of users per 1,000 population ranged from approximately 60 in Richmond to nearly 117 in South Vancouver Island and Okanagan.The proportion of the population diagnosed with depression ranged from 9% to 15% across HSDAs. About half of these resi-dents purchased psychoanaleptic prescrip-tions in all HSDAs except Richmond and Vancouver (~43%). Approximately one-third of residents who filled psychoanaleptic prescriptions did not have a recorded diagnosis of depres-sion in 2003.28 | Centre for Health Services and Policy ResearchSerum Lipid Reducing Agents1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years45-64 years65-84years85+yrs0-19 years 20-44 years45-64 years65-84years85+yrsNumberof persons$0.02 $0.02$2.99$43.88$122.89$40.53$1.04$17.60$41.37$3.881,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsBetween 1996 and 2003, per capita expen-diture on serum lipid reducing agents (choles-terol drugs) more than tripled from $9 to $29. Almost all  of the expenditure in this therapeutic category is for HMG-CoA reductase inhibitors (statins, 94%) and fibrates (5%).Residents aged 45 and older accounted for vir-tually all expenditure in this category.In 2003, $44 was spent on cholesterol drugs per resident aged 45 to 64, accounting for 40% of total expenditures on this therapeutic cat-egory. However, an even greater share (53%) of expenditures were concentrated among resi-dents aged 65 to 84, for whom $123 per capita was spent on cholesterol drugs.Expenditure growth was most rapid among residents over the age of 85. Cholesterol drug expenditure among residents in this age group increased nearly ten-fold (from under $4 to $41).Drugs in this therapeutic category:  • HMG-CoA reductase inhibitors    (e.g. atorvastatin) • Fibrates (e.g. gemfibrozil)  • Bile acid sequestrants (e.g. colestyramine) • Nicotinic acid and derivatives   (e.g. niacin)Indications for use:  • Reduction of serum lipid levels     (treatment of high cholesterol)Expenditure per capita over the life-course, province-wide data, 1996 and 2003| 29British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Serum Lipid Reducing AgentsNortheastNorthwestNorthern InteriorKootenay BoundaryNorth IslandThompson CaribooN. Shore/Coast Gar.Fraser NorthFraser EastEast KootenayCentral IslandFraser SouthVancouverRichmondSouth IslandOkanagan$3.69$4.22$6.73$6.26$8.19$8.67$7.86$8.51$11.17$8.03$12.06$9.86$7.79$9.46$12.79$12.39$18.93$21.11$28.01$24.45$31.48$30.69$27.26$26.54$34.70$24.54$36.39$29.52$23.16$27.43$35.11$33.9826.3%25.9%22.6%21.5%21.2%19.8%19.5%17.6%17.6%17.3%17.1%17.0%16.9%16.4%15.5%15.5%2.3%1.4%3.2%0.0%1.3%2.2%-0.1%0.7%-0.9%1.4%1.3%0.6%0.2%0.9%-0.8%0.0%24.9%24.9%20.8%22.3%21.1%18.5%20.0%17.9%20.0%18.2%17.2%17.3%17.7%16.3%17.7%17.6%1.2%2.4%0.9%2.8%2.2%2.2%1.9%1.6%1.8%1.6%1.6%1.6%1.9%1.5%1.8%1.7%-2.3%-3.0%-2.6%-3.3%-3.3%-3.2%-2.3%-2.5%-2.9%-3.6%-2.9%-2.5%-2.8%-2.2%-2.9%-3.5%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices Prices!!!!!!!!!!!Data stability warning: one or more population cells with less than 100 individuals!The average annual growth in expenditures on cholesterol drugs ranged from 15.5% to 26.3% across HSDAs (rates at which expenditure doubles every three to five years).Because utilization of cholesterol drugs is very low among young adults and children, the cell sizes (e.g. users by HSDA/age/year) were less than 100 for certain expenditure determinant calculations (see cautions). Nevertheless, the consistent finding across HSDAs is that utili-zation drove expenditure in this therapeutic category.Increased use of generic drugs generated price savings that were nearly offset by trends toward the choice of more costly drug types. Trends in choices reflected a decline in the share of lipid lowering drug users that received fibrates and an increase in the share receiving statins.30 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Serum Lipid Reducing Agents��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=14%CV=13%CV=3%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaFraser EastNorthern InteriorFraser SouthSouth IslandFraser NorthNorth IslandCentral IslandRichmondThompson CaribooOkanaganN. Shore/Coast Gar.NortheastVancouverNorthwestEast KootenayKootenay Boundary����$36$33$33$30$30$30$30$29$28$27$26$26$25$24$23$21����$11$9$11$11$9$9$10$10$9$10$7$5$8$6$8$6221%266%206%183%218%244%188%186%229%173%252%386%211%339%195%275%������ ��� �������+0.21+0.14+0.12+0.04+0.03+0.03+0.02-0.00-0.02-0.06-0.11-0.12-0.16-0.17-0.21-0.30Age-adjusted users per 1,000 populationFraser EastFraser SouthNorthern InteriorNorth IslandFraser NorthSouth IslandRichmondCentral IslandOkanaganThompson CaribooNortheastVancouverNorthwestN. Shore/Coast Gar.East KootenayKootenay Boundary����73696863636161605756555352514944����23221818202122212017111812151512220%210%276%246%213%189%177%192%186%223%403%201%330%235%222%263%������ ��� �������+0.19+0.13+0.13+0.04+0.04+0.01+0.01+0.00-0.05-0.06-0.09-0.12-0.14-0.16-0.19-0.31Cost per userN. Shore/Coast Gar.Thompson CaribooSouth IslandFraser EastCentral IslandNorthern InteriorKootenay BoundaryFraser NorthFraser SouthRichmondNorth IslandOkanaganEast KootenayNortheastNorthwestVancouver����$507$502$500$493$491$488$488$478$478$477$476$474$474$470$469$466����$483$494$510$491$499$502$472$471$484$461$478$497$517$487$459$4525%2%-2%0%-2%-3%3%2%-1%3%0%-5%-8%-3%2%3%������ ��� �������+0.05+0.04+0.03+0.02+0.02+0.01+0.01-0.01-0.01-0.01-0.01-0.02-0.02-0.03-0.03-0.04| 31British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Serum Lipid Reducing Agents0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Disorders of Lipid Metabolism” Expanded Diagnosis Cluster CAR11Percent of population with:Age-adjusted expenditure per capita on serum lipid reducing agents varied modestly across HSDAs (CV=14%) in 2003. Kootenay Bound-ary was an outlier at roughly $21 per capita, compared to a $29 provincial average.As with trends over time, variations in cho-lesterol drug expenditure across regions are explained by utilization. The age-adjusted number of cholesterol drug users per 1,000 population ranged from 44 to 73 (CV=13%) in 2003. In contrast, costs per user varied less in this category than did costs per user in any other leading therapeutic category (CV=3%).The proportions of the population that filled one or more prescriptions for a cholesterol drug in 2003 ranged from 4.7% to 7.8% across HSDAs.Drug use was, on average, more than twice as prevalent as the primary related diagnosis. For instance, the age-adjusted rates of diagnosed disorders of lipid metabolism ranged from only 1.6% to 3.1%. Across all HSDAs, between 70% and 83% of residents who filled a prescription for cholesterol drugs did not have any record of a diagnosed lipid disorder.32 | Centre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Drugs in this therapeutic category:  • Antacids (e.g. aluminum hydroxide) • Proton pump inhibitors   (e.g. omeprazole) • H2-receptor antagonists   (e.g. cimetadine)Indications for use:  • Reduction of stomach acidity • Treatment of ulcer and gastro-    esophageal reflux disease  rates, expenditure per capita would double every four to six years.Unlike other leading categories of treatment, therapeutic choices were the predominant determinants of expenditure trends for antacids across all HSDAs. This included the selection of more costly drug classes from within this Drugs for Alimentary Acid Related Disorders1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years45-64 years65-84years85+yrs 0-19 years20-44 years45-64 years65-84years85+yrsNumberof persons$0.20 $0.58$7.48$29.04$68.20$74.19$3.38$12.35$31.14$31.891,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure on antacids per capita grew by nearly 150% from $8 in 1996 to $20 in 2003. Expenditure in this therapeutic category was predominantly for proton pump inhibitors (87%) and H2-receptor antagonists (11%), both of which are used to treat heartburn and ulcers. While expenditure in each age group more than doubled, expenditure for those aged 19 and under nearly tripled from $0.20 to $0.58.There is a steady age-gradient in antacid expenditures. Expenditure per capita roughly doubled across each step of the age profile from children through to those aged 65 to 84. Expen-ditures among residents aged 85 and older were slightly higher than among residents aged 65 to 84. Because of the age gradient, elderly resi-dents accounted for nearly half (48%) of total expenditure on antacids in BC.Per capita expenditure on antacids grew by more than 10% per year in all HSDAs—by 19.1% per year in Northwest. At these growth | 33British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Drugs for Alimentary Acid Related DisordersNorthwestNorth IslandNortheastNorthern InteriorKootenay BoundaryFraser EastEast KootenayThompson CaribooOkanaganN. Shore/Coast Gar.Central IslandFraser SouthRichmondFraser NorthSouth IslandVancouver$5.66$8.13$5.67$6.23$8.14$7.95$8.52$8.73$10.41$7.92$11.33$7.47$5.91$7.32$12.45$7.40$19.29$24.16$16.36$17.52$22.77$21.77$23.15$23.39$27.60$20.49$29.12$18.22$14.35$17.61$28.06$15.1819.1%16.8%16.3%15.9%15.8%15.5%15.4%15.1%14.9%14.6%14.4%13.6%13.5%13.4%12.3%10.8%3.0%2.7%2.0%2.7%1.6%0.8%1.8%2.2%1.2%1.1%1.9%1.0%1.6%1.0%0.6%0.7%4.4%4.0%4.2%3.7%4.0%3.3%3.5%3.3%3.4%2.9%3.3%2.9%1.5%2.2%3.6%0.5%11.5%9.4%9.9%9.2%9.8%11.3%10.4%9.4%10.2%10.3%8.9%9.6%10.5%10.1%8.2%9.9%-0.7%0.1%-0.4%-0.4%-0.1%-0.4%-0.8%-0.3%-0.3%-0.2%-0.2%-0.2%-0.4%-0.2%-0.3%-0.4%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices Pricestherapeutic category—increased use of proton pump inhibitors and reduced use of H2-recep-tor antagonists—and the choice of more expen-sive drugs within those drug classes.Increased utilization contributed to growing antacid drug expenditures across the province. Although prices fell due to generic competi-tion, the total cost of treatment rose due to the increasingly costly therapeutic choices.34 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Drugs for Alimentary Acid Related Disorders��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=13%CV=7%CV=12%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaCentral IslandSouth IslandNorth IslandOkanaganFraser EastEast KootenayThompson CaribooNorthwestNortheastKootenay BoundaryNorthern InteriorFraser SouthN. Shore/Coast Gar.Fraser NorthVancouverRichmond����$25$24$23$23$23$22$22$22$21$21$20$20$20$19$16$15����$10$10$9$9$8$9$9$7$8$8$8$8$8$8$7$6147%136%166%167%183%162%150%192%163%169%152%147%161%144%114%138%������ ��� �������+0.18+0.17+0.13+0.12+0.09+0.09+0.08+0.05+0.01-0.00-0.01-0.03-0.04-0.06-0.28-0.31Age-adjusted users per 1,000 populationFraser EastNortheastNorthwestFraser SouthThompson CaribooNorth IslandNorthern InteriorEast KootenayKootenay BoundaryCentral IslandOkanaganSouth IslandFraser NorthVancouverN. Shore/Coast Gar.Richmond����81807574747473737372706868656463����7062626567646366596563586266576015%29%22%14%10%15%16%10%23%12%11%18%9%0%12%5%������ ��� �������+0.14+0.12+0.07+0.05+0.05+0.04+0.04+0.04+0.03+0.02-0.01-0.03-0.04-0.07-0.10-0.12Cost per userSouth IslandCentral IslandOkanaganNorth IslandN. Shore/Coast Gar.East KootenayThompson CaribooNorthwestFraser NorthKootenay BoundaryFraser EastNorthern InteriorFraser SouthNortheastRichmondVancouver����$357$341$331$319$309$307$300$288$285$281$279$276$268$260$242$238����$178$155$138$138$133$129$132$121$128$128$113$127$124$127$107$111101%121%140%131%132%137%127%139%123%120%146%117%117%104%126%115%������ ��� �������+0.20+0.16+0.13+0.09+0.06+0.05+0.03-0.01-0.02-0.04-0.05-0.05-0.08-0.12-0.19-0.20| 35British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Drugs for Alimentary Acid Related Disorders0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Gastrointestinal Signs and Symptoms” Expanded Diagnosis Cluster GAS01Percent of population with:Variation in age-adjusted expenditure per capita across the HSDAs in this category of drugs was relatively low (CV = 13%) in 2003. Expendi-ture per capita ranged from $15 in Richmond to $25 in Central Vancouver Island.In contrast to most of the other drug classes, expenditure variation was better explained by the variation of cost per user rather than utilization.  Users living in South Vancouver Island paid $357 for prescription antacids; users in Van-couver paid $238 (CV=12%). The age-adjusted number of users per 1,000 population did not vary greatly across regions (CV=7%).Approximately 8% of the population pur-chased prescription drugs for the treatment of acid-related gastric symptoms. Of these, about three-quarters had no associated diag-nosis. Age-adjusted rates of recorded diag-nosis ranged more broadly across HSDAs (2.5% to 7.5%) than did rates of prescription use (6.7% to 8.5%).Across the HSDAs, between 30% and 50% of those diagnosed with gastrointestinal symp-toms filled a related prescription.36 | Centre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Expenditure per capita on psycholeptics grew at widely varying rates across HSDAs—from 13.5% per year in North Shore/Coast Garibaldi to 23.9% per year in Northeast.Consistent with the flat age-gradient in expen-ditures, population aging had little effect on psycholeptic expenditure trends. The expenditure-impact of changes in utilization Psycholeptics1996 2003Expenditure per capita$80$60$40$200-19 years20-44 years45-64 years65-84years85+yrs0-19 years20-44 years45-64 years 65-84years85+yrsNumberof persons$0.35$2.39$18.11$22.84$20.67$33.44$5.69 $7.40$9.79$13.391,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure on psycholeptics per British Columbian grew from under $6 in 1996 to over $16 in 2003. In 1996, over half (52%) of expenditure in this category was for anxiolyt-ics,  hypnotics, and sedatives; by 2003 nearly 80% of the expenditure in this category was for antipsychotics.Per capita expenditures were more evenly dis-tributed across age categories for psycholeptic drugs than for other leading therapeutic catego-ries.While low in absolute value, expenditure per child increased most rapidly—from approxi-mately $0.35 to $2.40.Expenditure per capita was roughly $20 in 2003 for residents ages 20 to 84, and then spiked to $33 for residents over 85.Because of the relatively flat age-gradient, adults aged 20 to 64 accounted for over 75% of overall expenditure in this category.Drugs in this therapeutic category:  • Antipsychotics (e.g. olanzapine) • Anxiolytics (e.g. lorazepam) • Hypnotics and sedatives (e.g. zopiclone)Indications for use:  • Antipsychotics: treatment of psychosis,    such as schizophrenia  • Anxiolytics: treatment of anxiety • Hypnotics and sedatives: symptomatic    relief of insomnia| 37British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).PsycholepticsNortheastNorthern InteriorNorth IslandVancouverFraser NorthNorthwestSouth IslandCentral IslandKootenay BoundaryOkanaganThompson CaribooFraser EastEast KootenayFraser SouthRichmondN. Shore/Coast Gar.$2.67$3.64$3.27$6.65$4.71$3.60$6.56$5.38$4.91$7.17$4.71$5.23$4.01$4.91$3.99$5.50$11.94$14.16$12.70$22.83$16.02$11.30$20.28$16.56$15.05$21.47$13.68$14.25$10.81$13.04$10.54$13.3523.9%21.4%21.4%19.3%19.1%17.7%17.5%17.4%17.4%17.0%16.5%15.4%15.2%15.0%14.9%13.5%0.0%-3.1%0.5%0.3%-0.2%-0.1%-0.8%0.0%0.5%-0.5%-1.0%-0.1%0.3%0.0%0.1%0.1%7.4%6.3%4.7%-0.3%1.0%4.8%2.6%3.3%2.3%4.7%4.8%1.4%4.7%1.2%-0.4%1.3%17.0%19.6%16.6%20.4%19.6%14.0%16.2%14.4%15.0%13.4%13.3%15.3%11.4%14.6%16.5%13.2%-1.4%-1.4%-1.1%-1.0%-1.1%-1.3%-0.7%-0.6%-0.7%-1.1%-0.9%-1.2%-1.5%-0.9%-1.0%-1.1%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices Pricesranged from slightly negative in Vancouver and Richmond to significantly positive (7.4% per year) in Northeast.Increasingly costly choices explained most of the increase in psycholeptic expenditure across all HSDAs. In particular, trends in this category were dominated by the increased use of, and expenditure on, relatively costly antipsychotic drugs. The use of anxiolytics, hypnotics, and sedatives remained relatively stable.In all HSDAs, the prices of drugs fell as a result of generic competition.38 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Psycholeptics��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=23%CV=9%CV=19%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaVancouverOkanaganSouth IslandCentral IslandFraser NorthFraser EastKootenay BoundaryNorthern InteriorThompson CaribooFraser SouthN. Shore/Coast Gar.NortheastNorth IslandNorthwestEast KootenayRichmond����$22$21$20$16$16$15$15$15$14$14$13$13$13$12$11$11����$6$7$6$5$5$5$5$4$5$5$5$3$3$4$4$4251%210%217%211%240%178%202%245%187%165%145%323%270%216%165%157%������ ��� �������+0.31+0.27+0.18+0.00+0.00-0.08-0.10-0.12-0.17-0.17-0.21-0.23-0.24-0.32-0.41-0.43Age-adjusted users per 1,000 populationSouth IslandOkanaganCentral IslandFraser SouthFraser EastThompson CaribooN. Shore/Coast Gar.North IslandVancouverNorthwestKootenay BoundaryFraser NorthEast KootenayNortheastNorthern InteriorRichmond����10610610497959594939187878685838279����9382868987778574896774826657707914%29%20%8%10%24%10%26%2%29%17%5%29%45%17%0%������ ��� �������+0.13+0.13+0.10+0.03+0.01+0.01+0.00-0.01-0.03-0.08-0.08-0.09-0.10-0.13-0.14-0.17Cost per userVancouverOkanaganFraser NorthSouth IslandNorthern InteriorKootenay BoundaryCentral IslandFraser EastNortheastThompson CaribooFraser SouthN. Shore/Coast Gar.North IslandNorthwestRichmondEast Kootenay����$244$201$190$183$178$170$158$158$157$144$142$141$138$136$134$127����$71$84$59$66$60$66$61$62$54$63$58$63$47$56$52$62245%140%224%178%196%158%159%153%193%131%144%122%194%145%158%106%������ ��� �������0.340.150.090.050.02-0.02-0.10-0.10-0.10-0.19-0.20-0.21-0.23-0.24-0.26-0.31| 39British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Psycholeptics0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Schizophrenia and Affective Psychosis” Expanded Diagnosis Cluster PSY07Percent of population with:Age-adjusted expenditure per capita on psycholeptics ranged from a low of $11 in Richmond to a high of $22 in Vancouver (CV=23%) in 2003.Psycholeptics was one of only three leading therapeutic categories for which variation in expenditure per capita across the province was not driven by variation in age-adjusted utiliza-tion rates (CV=9%).The pattern of psycholeptic expenditure across HSDAs closely mirrored the pattern of average costs per user. Cost per user ranged from $127 to $244 (CV=19%).Age-adjusted rates of diagnosed psychosis var-ied from 0.8% to 1.7%.Across all HSDAs, roughly two-thirds (63% to 69%) of residents with a diagnosis of psy-chosis filled at least one prescription for a psycholeptic.Approximately 90% of users of psycholeptics (88% to 94% across HSDAs) did not have a recorded diagnosis of psychosis. These patients may have been treating less severe conditions such as anxiety or insomnia.40 | Centre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003The annual growth rate across HSDAs ranged from 4.3% to 9.4%. The impact of population aging on expendi-tures per capita varied across the province from approximately 0% to 2.2% per year. Similarly, changes in utilization caused expenditures per Drugs for Obstructive Airway Diseases1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years45-64 years65-84years 85+yrs 0-19 years20-44 years45-64 years65-84years85+yrsNumberof persons$3.15 $4.19$5.50$12.92$40.38$39.29$3.36$8.64$31.75$29.531,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsPer capita expenditure on drugs used for the treatment of obstructive airway diseases increased by nearly 50% between 1996 and 2003—from roughly $8 to $12. Spending in this category was dominated by inhaled anti-asthmatic drugs; however, the fastest growing segment of this category was in drugs for sys-temic use (e.g. montelukast).Expenditure per capita on drugs for obstruc-tive airway diseases was relatively high for those aged 19 and under (more than $4 per capita) in 2003, making this the third-largest therapeutic category in terms of expenditures on children and adolescents.Following steady growth across age categories, expenditures in this category increased sharply at age 65. Despite this increase in expenditures at age 65, the elderly still accounted for less than half (48%) of total expenditures on this category of drugs.Drugs in this therapeutic category:  • Inhaled adrenergics (e.g. salbutamol) • Inhaled glucocorticoids (e.g. fluticasone) • Inhaled anticholinergics   (e.g. ipratropium) • Systemic drugs for obstructive airway    disease (e.g. montelukast)Indications for use:  • Treatment of obstructive pulmonary    diseases, such as asthma, chronic     bronchitis, emphysema| 41British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Drugs for Obstructive Airway DiseasesNorthwestNorthern InteriorKootenay BoundaryOkanaganFraser EastNortheastEast KootenayThompson CaribooNorth IslandFraser NorthN. Shore/Coast Gar.Fraser SouthSouth IslandCentral IslandRichmondVancouver$5.91$6.99$8.77$10.55$8.40$6.80$8.92$10.27$9.62$6.94$7.66$7.88$9.90$11.18$5.98$7.20$11.10$12.11$14.61$17.12$13.29$10.50$13.54$15.51$14.35$10.22$11.20$11.47$14.28$15.38$8.05$9.699.4%8.2%7.6%7.2%6.8%6.4%6.1%6.1%5.9%5.7%5.6%5.5%5.4%4.7%4.3%4.3%2.2%1.7%1.1%0.8%0.3%1.5%1.1%1.8%2.0%0.5%0.6%0.5%0.0%1.3%0.8%0.2%3.4%1.6%2.6%1.7%0.9%2.5%2.2%1.4%0.9%-0.2%0.0%0.3%1.2%1.0%-1.3%-0.4%5.2%6.2%4.4%5.0%6.6%2.7%4.3%3.8%2.8%5.9%5.3%5.1%4.6%2.7%4.9%5.1%-1.6%-1.5%-0.7%-0.5%-1.0%-0.4%-1.5%-1.1%0.0%-0.5%-0.4%-0.4%-0.4%-0.4%-0.1%-0.6%1996 2003 AAGR** AAGR = average annual growth rate Data stability warning: one or more population cells with less than 100 individualsAgingDeterminants of expenditureExpenditure per userUtilization Choices Prices!!!capita to fall slightly in some regions and rise moderately (>2% per year) in others.Expenditure inflation was largely driven by therapeutic choices—particularly the rising cost per patient treated with relatively new drug classes within the therapeutic category.Generic competition caused prices to fall across all regions.42 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Drugs for Obstructive Airway Diseases��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=14%CV=12%CV=8%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaThompson CaribooOkanaganNorth IslandNorthern InteriorFraser EastNortheastCentral IslandKootenay BoundaryEast KootenaySouth IslandNorthwestFraser SouthFraser NorthN. Shore/Coast Gar.VancouverRichmond����$15$14$14$14$13$13$13$13$13$13$13$12$11$11$10$8����$11$9$10$9$8$10$10$8$9$8$8$8$7$7$7$741%63%37%53%64%38%34%63%47%53%60%47%49%47%37%30%������ ��� �������+0.19+0.16+0.14+0.13+0.10+0.10+0.09+0.08+0.08+0.05+0.04+0.01-0.09-0.12-0.20-0.36Age-adjusted users per 1,000 populationFraser EastThompson CaribooNorthern InteriorFraser SouthNorth  IslandNorthwestOkanaganCentral IslandSouth IslandNortheastEast KootenayKootenay BoundaryFraser NorthN. Shore/Coast Gar.VancouverRichmond����79727169696867666564616059575748����746561676851626260525249615759536%10%16%2%2%34%10%5%8%23%18%22%-3%0%-5%-10%������ ��� �������+0.21+0.12+0.11+0.08+0.07+0.07+0.06+0.03+0.02+0.00-0.05-0.05-0.08-0.11-0.12-0.28Cost per userKootenay BoundaryEast KootenayOkanaganNortheastThompson CaribooNorth IslandCentral IslandSouth IslandNorthern InteriorN. Shore/Coast Gar.Fraser NorthNorthwestFraser SouthRichmondVancouverFraser East����$220$217$214$211$206$206$203$197$196$191$190$186$179$177$177$171����$165$174$143$189$162$153$159$140$149$130$124$156$125$122$123$11033%25%49%11%27%34%28%41%32%47%53%19%43%45%44%55%������ ��� �������+0.14+0.12+0.11+0.09+0.07+0.07+0.06+0.03+0.02-0.00-0.01-0.03-0.07-0.08-0.08-0.12| 43British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Drugs for Obstructive Airway Diseases0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Asthma” Expanded Diagnosis Cluster ALL02Percent of population with:Age-adjusted expenditures on obstructive airway drugs varied modestly across HSDAs (CV=14%) in 2003. These ranged from $8 (Richmond) to $15 (Thompson Cariboo).Variation in age-adjusted utilization rates (CV=12%) explained most of the variation in expenditures across the province.Although variation in the cost per user was relatively low (CV=8%), areas displaying higher utilization tended to have lower costs per user. For example, Fraser East simulta-neously had the highest utilization rate and lowest cost per user.The proportion of the population who filled one or more prescriptions from this therapeutic cat-egory ranged from 5% to 8% across HSDAs. Over two-thirds (66% to 77% across HSDAs) of residents who filled an obstructive airway prescription had no record of a primary diag-nosis of asthma.In contrast, approximately two-thirds (62% to 71% across HSDAs) of residents who had diagnosed asthma filled a prescription for an obstructive airway drug.Many patients using medications in this class may have been treating other respiratory dis-eases such as emphysema.44 | Centre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Across HSDAs, the rate of growth in expendi-tures on blood glucose lowering drugs varied from 10% per year (Vancouver) to 15% per year (Northeast).Drugs Used in Diabetes1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years 45-64 years65-84years85+yrs0-19 years 20-44 years45-64 years65-84years85+yrsNumberof persons$0.54 $1.00$2.84$13.67$25.52$10.59$1.46$6.28$12.96$6.961,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsPer capita expenditure on drugs used in the treatment of diabetes more than doubled from $3.75 in 1996 to $8.30 in 2003. Whereas insu-lins accounted for 52% of expenditure in this therapeutic category in 1996, they accounted for only 39% of expenditure in 2003, owing to the increasing use and cost of oral blood glu-cose lowering drugs.Diabetes drug expenditure doubled along the age-gradient, with each successive age cohort spending twice as much per capita as the prior cohort. Expenditures per capita in 2003 peaked at $25 among adults between age 65 and 84.Despite the age-gradient, it was the expenditure per baby boomer (age 45 to 64) that accounted for most of the spending on blood glucose low-ering drugs (44%). Moreover, expenditure per baby boomer increased by 118% (from about $6 to $14), the largest rate of increase among all age groups.Drugs in this therapeutic category:  • Insulins and analogues    (e.g. insulin  aspart) • Oral blood glucose lowering drugs    (e.g. glyburide)Indications for use:  • Insulin: control of blood glucose levels    for patients with type 1 diabetes, or     severe type 2 diabetes • Oral blood glucose lowering agents:     control of insulin levels for patients     with type 2 diabetes| 45British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Drugs Used in DiabetesNortheastNorthern InteriorThompson CaribooCentral IslandOkanaganEast KootenayN. Shore/Coast Gar.North IslandNorthwestSouth IslandFraser SouthFraser EastRichmondFraser NorthKootenay BoundaryVancouver$2.77$3.30$3.67$4.03$3.89$3.39$2.78$3.88$3.76$4.43$3.74$4.49$3.80$3.78$4.05$3.56$7.41$8.54$9.35$10.13$9.09$7.84$6.38$8.90$8.46$9.85$8.32$9.58$7.71$7.67$8.13$7.0615.1%14.5%14.3%14.1%12.9%12.7%12.6%12.6%12.3%12.1%12.1%11.4%10.6%10.6%10.5%10.3%2.1%2.6%2.0%1.6%1.1%1.3%0.8%2.5%3.0%0.5%0.8%0.7%1.3%0.9%1.7%0.7%6.9%6.4%5.5%6.4%5.4%6.3%5.5%5.1%6.5%5.9%5.8%5.6%5.0%4.8%4.8%4.8%7.3%7.2%8.0%7.4%8.0%7.1%8.1%6.4%5.1%7.6%7.4%7.0%6.5%6.9%4.9%6.8%-1.8%-2.1%-1.7%-1.8%-1.9%-2.3%-2.0%-1.8%-2.5%-2.1%-2.1%-2.0%-2.3%-2.2%-1.2%-2.1%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices Prices!!Data stability warning: one or more population cells with less than 100 individuals!Population aging had a modest impact, ranging from 0.5% to 3% per year across HSDAs.Prices fell in this therapeutic category, due in part to savings generated by generic drug use.Growth in expenditure on diabetes drugs was driven both by the choice of more expensive drugs from within this therapeutic category and by increased utilization. Both of these dynamics reflect the trend toward oral blood glucose lowering agents for the management of type 2 diabetes.Increasingly costly therapeutic choices were the most significant cost-driver in all HSDAs but Northwest.46 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Drugs Used in Diabetes��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=12%CV=13%CV=7%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaFraser EastNorthern InteriorNorthwestNortheastFraser SouthSouth IslandThompson CaribooCentral IslandNorth IslandFraser NorthRichmondOkanaganEast KootenayVancouverKootenay BoundaryN. Shore/Coast Gar.����$10$10$10$9$9$9$9$9$9$8$8$8$8$7$7$6����$5$4$5$4$4$4$4$4$4$4$4$3$3$4$4$3121%132%98%145%125%131%137%141%108%104%96%134%124%107%94%131%������ ��� �������+0.19+0.16+0.14+0.11+0.08+0.07+0.06+0.05+0.03+0.01-0.04-0.06-0.09-0.11-0.12-0.30Age-adjusted users per 1,000 populationNorthwestFraser EastNorthern InteriorFraser SouthNortheastRichmondFraser NorthThompson CaribooVancouverCentral IslandSouth IslandEast KootenayNorth IslandOkanaganKootenay BoundaryN. Shore/Coast Gar.����38363535333232313130292929272722����2323222220212119201817181917181464%60%63%64%66%51%53%61%51%68%69%67%55%57%52%59%������ ��� �������+0.20+0.16+0.14+0.14+0.08+0.04+0.04+0.01+0.00-0.02-0.05-0.05-0.07-0.14-0.14-0.33Cost per userSouth IslandNorth IslandOkanaganCentral IslandThompson CaribooNortheastFraser EastN. Shore/Coast Gar.Kootenay BoundaryNorthern InteriorEast KootenayFraser NorthNorthwestFraser SouthRichmondVancouver����$304$297$291$288$283$279$278$277$275$274$261$260$255$255$247$240����$223$220$196$200$192$189$201$190$215$192$194$195$211$185$191$17537%35%49%44%47%47%38%46%28%43%34%33%21%37%30%37%������ ��� �������+0.12+0.10+0.08+0.07+0.05+0.04+0.03+0.03+0.02+0.02-0.03-0.03-0.06-0.06-0.08-0.11| 47British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Drugs Used in Diabetes0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Diabetes Mellitus” Expanded Diagnosis Cluster END01Percent of population with:Variation in age-adjusted expenditure per capita was moderately low for diabetes drugs (CV=12%) in 2003. Yet despite this, North Shore/Coast Garibaldi residents spent an age-adjusted $6.14 per resident on diabetes drugs, a result well below the provincial average of $8.30.Age-adjusted utilization (CV=13%) explained most of the variation in expenditure. Indeed, this was the only leading class of drug where variation in utilization was larger than varia-tion in expenditure. The variation in cost per user (CV=7%) was such that areas with relatively high utilization rates had relatively low costs per user (e.g. Northwest and Fraser South), and vice versa (e.g. North Shore/Coast Garibaldi).The age-adjusted proportion of the popula-tion diagnosed with diabetes ranged from about 3% to 5%. Approximately two-thirds of those diagnosed also filled a prescription for drugs to treat diabetes. The remaining population with a diabetes diagnosis are likely being treated through diet and lifestyle modifications. Over 80% of those who filled prescriptions had a record of diagnosed dia-betes. This is the highest correlation between prescription use and diagnosis among the leading drug classes.48 | Centre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Antiinflammatory and Antirheumatics1996 2003Cost per capita$80$60$40$200-19 years 20-44 years 45-64 years65-84years85+yrs0-19 years 20-44 years45-64 years65-84years 85+yrsNumberof persons$0.29 $0.31$4.08$14.00$20.40$14.90$2.88$7.07$10.84 $8.011,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure per capita for antiinflammatory and antirheumatic products roughly doubled from about $4 to $8 between 1996 and 2003. Launched in 1999, cox-2 inhibitor drugs (e.g. celicoxib and rofecoxib) accounted for 61% of expenditure in this category by 2003.Expenditure on antiinflammatory drugs is vir-tually zero among those aged 19 and under. Among adults over 45, expenditure is relatively high and rises modestly with age.Expenditure among the baby boomers—those between age 45 and 64—grew more rapidly than among the rest of the population. More-over, this age cohort accounted for nearly half (46%) of the total spending in the province dur-ing 2003.The rate of growth in spending on antiinflam-matory and antirheumatic products varied considerably across regions. Northwest had the highest annual growth rate (15.8%) while Vancouver had the lowest (7%).Drugs in this therapeutic category:  • Antiinflammatory and antirheumatic     products, non-steroids (e.g. celicoxib) • Specific antirheumatic agents    (e.g. auranofin)Indications for use:  • Relief of muscle or joint painAs with several other leading therapeutic cate-gories, increased expenditure on antiinflamma-tory and antirheumatic products was predomi-nantly explained by increasingly costly product choices, which caused expenditures to grow by between 5.1% to 10.5% across HSDAs. Most of this is the result of the rapid increase in the use of cox-2 inhibitor drugs, approximately two-thirds of which was offset by the reduced use of other medicines in this category.| 49British Columbia Rx Atlas Components of change by health service delivery area (HSDA), 1996-2003Sources: Authors’ calculations based on BC PharmaNet (Claims History) andBCLHD (Population Registry).Antiinflammatory and AntirheumaticsNorthwestNorth IslandSouth IslandN. Shore/Coast Gar.Thompson CaribooCentral IslandKootenay BoundaryOkanaganNortheastFraser EastFraser SouthFraser NorthRichmondEast KootenayNorthern InteriorVancouver$3.60$3.95$4.55$3.74$4.70$4.28$3.59$4.56$3.25$4.52$4.51$4.09$3.33$5.26$4.36$3.72$10.05$9.65$10.52$8.19$10.24$9.29$7.20$9.07$6.34$8.64$8.29$7.40$5.94$8.87$7.24$5.9715.8%13.6%12.7%11.9%11.8%11.7%10.4%10.3%10.0%9.7%9.1%8.8%8.6%7.7%7.5%7.0%2.3%1.8%0.5%0.4%1.6%1.1%1.4%0.9%1.7%0.5%0.7%0.7%0.9%1.3%1.8%0.3%5.0%2.2%2.9%1.9%1.9%1.7%1.9%0.9%3.2%1.6%1.0%0.6%0.5%1.2%1.1%0.2%9.7%10.2%10.2%10.5%9.1%9.5%7.8%9.5%6.3%8.8%8.5%8.6%8.4%7.1%5.1%7.6%-1.7%-0.9%-1.0%-1.0%-1.0%-0.8%-0.8%-1.0%-1.5%-1.3%-1.2%-1.1%-1.1%-1.8%-0.6%-1.1%1996 2003 AAGR** AAGR = average annual growth rateAgingDeterminants of expenditureExpenditure per capitaUtilization Choices Prices!Data stability warning: one or more population cells with less than 100 individuals!Aging and increased utilization played a less significant role in the growth rate. The impact of utilization was an increase of spending from 0.2% to 5% per year. Aging increased spending by 0.3% to 2.3% per year.Prices fell, largely due to the use of generic drug versions of older medicines in this category.50 | Centre for Health Services and Policy ResearchHealth service delivery area (HSDA) cartograms and data, 1996 and 2003Antiinfl ammatory and Antirheumatics��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=16%CV=15%CV=13%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorExpenditure per capitaNorthwestThompson CaribooSouth IslandNorth IslandFraser EastFraser SouthEast KootenayCentral IslandNorthern InteriorOkanaganFraser NorthN. Shore/Coast Gar.NortheastKootenay BoundaryVancouverRichmond����$11$10$9$9$9$9$9$8$8$8$8$8$8$7$6$6����$4$5$4$4$5$5$5$4$5$4$4$4$4$3$4$3150%105%135%125%96%87%62%105%57%98%85%119%86%91%67%75%������ ��� �������+0.31+0.18+0.15+0.14+0.12+0.10+0.06+0.00-0.00-0.01-0.02-0.03-0.05-0.20-0.29-0.29Age-adjusted users per 1,000 populationNorthwestFraser EastNortheastFraser SouthThompson CaribooEast KootenayNorthern InteriorFraser NorthNorth IslandOkanaganCentral IslandN. Shore/Coast Gar.VancouverSouth IslandRichmondKootenay Boundary����147138133133129118114112111106103101100969594����1071271041281201131121101071071019510086948437%9%28%4%7%4%2%2%3%-1%2%6%0%12%1%12%������ ��� �������+0.27+0.21+0.17+0.17+0.14+0.05+0.02-0.00-0.01-0.05-0.08-0.11-0.11-0.15-0.17-0.18Cost per userSouth IslandNorth IslandCentral IslandN. Shore/Coast Gar.Thompson CaribooOkanaganNorthwestEast KootenayFraser NorthNorthern InteriorKootenay BoundaryFraser SouthFraser EastRichmondVancouverNortheast����$98$84$79$78$76$75$75$73$71$71$70$67$66$64$61$58����$47$38$39$38$40$38$41$47$39$46$41$37$37$37$36$40109%118%101%107%91%100%82%56%81%54%70%80%80%73%67%45%������ ��� �������+0.31+0.15+0.09+0.08+0.05+0.04+0.04+0.01-0.02-0.02-0.03-0.07-0.09-0.12-0.18-0.23| 51British Columbia Rx Atlas  Age-adjusted rates of prescription and/or related diagnosis, province-wide, 2003Antiinflammatory and Antirheumatics0% 5% 10% 15% 20%East KootenayKootenay BoundaryOkanaganThompson CaribooFraser EastFraser NorthFraser SouthRichmondVancouverN. Shore/Coast Gar.South IslandCentral IslandNorth IslandNorthwestNorthern InteriorNortheastDiagnosis and prescription Prescription, no diagnosis Diagnosis, no prescriptionMeasure of diagnosis based on “Degenerative Joint Disease” Expanded Diagnosis Cluster MUS03Percent of population with:Variation in expenditure per capita on antiin-flammatory and antirheumatic products was moderate across HSDAs (CV=16%). Age-adjusted expenditure per capita ranged from $6 (Richmond) to $11 (Northwest) in 2003.Variation in expenditure across regions was the result of moderate to high variation in both utilization (CV=15%) and costs per user (CV=13%). Several regions that had the lowest utilization rates (e.g. Vancouver Island HSDAs and North Shore/Coast Garib-aldi) had the highest costs per user. Similarly, areas with higher than average utilization had lower than average costs per user (e.g. Fraser East and  Northeast).Age-adjusted rates of antiinflammatory and antirheumatic product use ranged from 9% to 15%. Approximately 90% of these users had no record of the predominant diagnosis of arthritis. Moreover, less than half (41% to 49% across HSDAs) of those with a diagnosis of arthritis filled a prescription for antiinflammatory and antirheumatic products.The lack of concordance between drug use and arthritis diagnosis may be explained by the use of this therapeutic class in the treatment of muscle pain and the use of over-the-counter medicines to manage arthritis.52 | Centre for Health Services and Policy ResearchCentre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Analgesics65-84years1996 2003Expenditure per capita$80$60$40$200-19 years20-44 years45-64 years85+yrs0-19 years20-44 years45-64 years 65-84years85+yrsNumberof persons$0.16 $0.31$8.53$20.79$16.29$21.84$4.40$9.68$7.52$9.651,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure per capita on analgesics nearly doubled between 1996 and 2003. While growth in expenditure was most rapid among the most elderly (those over 85), individuals between the ages of 45 and 64 accounted for over half of total spending on these medicines in 2003.Among the drug categories examined, anal-gesics had the highest variation in age-adjust-ed expenditure per capita across HSDAs (CV=25%) in 2003. Age-adjusted utilization and costs per user varied significantly.Across most regions, utilization remained sta-ble or decreased, while cost per user increased substantially from 1996 to 2003.Drugs in this therapeutic category:  • Opioids (e.g. morphine) • Antimigraine preparations   (e.g. sumatriptan)Indications for use:  • Opioids: relief of pain • Antimigraine preparations: treatment    of migrainesBritish Columbia Rx Atlas | 53Health service delivery area (HSDA) cartograms and data, 1996 and 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=25%CV=14%CV=20%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaSouth IslandKootenay BoundaryOkanaganThompson CaribooCentral IslandFraser EastEast KootenayN. Shore/Coast Gar.North IslandFraser SouthNorthern InteriorFraser NorthNortheastVancouverNorthwestRichmond����$15$15$14$14$14$13$12$12$12$11$10$9$9$8$8$6����$6$6$6$5$6$5$6$5$4$5$4$5$3$4$4$3142%162%136%188%125%130%98%123%192%113%125%100%193%109%107%75%������ ��� �������+0.32+0.30+0.24+0.24+0.23+0.13+0.05+0.05+0.05-0.02-0.10-0.19-0.22-0.34-0.36-0.63Age-adjusted users per 1,000 populationFraser EastThompson CaribooCentral IslandOkanaganNorthern InteriorNorthwestNorth IslandFraser SouthNortheastKootenay BoundarySouth IslandEast KootenayN. Shore/Coast Gar.Fraser NorthVancouverRichmond����15714814714714514113913913513513112712712010386����1571411461361391401401471161231301271271331181010%5%1%8%4%1%-1%-5%16%10%1%1%0%-10%-13%-15%������ ��� �������+0.20+0.14+0.13+0.13+0.11+0.09+0.08+0.07+0.05+0.04+0.02-0.01-0.02-0.07-0.23-0.40Cost per userSouth IslandKootenay BoundaryOkanaganThompson CaribooCentral IslandN. Shore/Coast Gar.East KootenayNorth IslandFraser EastFraser SouthVancouverFraser NorthNorthern InteriorRichmondNortheastNorthwest����$117$112$97$96$95$92$92$84$80$79$77$76$70$69$66$55����$49$47$44$35$42$41$47$28$35$35$32$34$32$33$26$27141%139%119%176%124%122%97%194%130%125%140%122%116%106%152%105%������ ��� �������+0.31+0.26+0.11+0.10+0.09+0.06+0.06-0.03-0.07-0.09-0.12-0.12-0.21-0.23-0.26-0.45Analgesics54 | Centre for Health Services and Policy ResearchCentre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Antibacterials for Systemic Use1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years45-64 years65-84years85+yrs 0-19 years 20-44 years 45-64 years65-84years85+yrsNumberof persons$7.12 $8.50$9.22$11.85$16.60$17.88$7.02 $8.66$14.33$16.201,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsGrowth in expenditure on antibacterials was lowest among the categories studied. Between 1996 and 2003, expenditure per capita increased by only 30%: ~$8 to ~$10.Per capita expenditure on antibacterials is relatively even across the age profile, with those aged 19 and under accounting for a greater share of spending than any other drug category studied.Variation in age-adjusted expenditure on anti-bacterials was low (CV=11%), due to only minor variations in utilization and costs per user (CV ~ 6%). Low-utilization regions also had low costs per user (e.g. Richmond and the Kootenays HSDAs).Drugs in this therapeutic category:  • Beta-lactams (e.g. amoxicillin) • Sulfonamides (e.g. trimethoprim and     sulfamethoxasole) • Macrolides (e.g. clarithromycin) • Quinolones (e.g. ciprofloxacin)Indications for use:  • Treatment of infectious diseases caused    by bacteriaBritish Columbia Rx Atlas | 55Health service delivery area (HSDA) cartograms and data, 1996 and 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=11%CV=7%CV=6%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaFraser EastFraser SouthNorthwestSouth IslandFraser NorthNortheastN. Shore/Coast Gar.Thompson CaribooNorthern InteriorNorth IslandCentral IslandVancouverOkanaganEast KootenayRichmondKootenay Boundary����$12$12$12$12$11$11$11$11$11$10$10$10$10$9$9$8����$9$9$9$8$9$7$8$9$10$7$8$9$8$9$8$645%32%30%53%34%62%36%25%7%41%30%11%25%2%7%43%������ ��� �������+0.14+0.13+0.07+0.06+0.05+0.05+0.00-0.01-0.01-0.04-0.05-0.09-0.11-0.16-0.22-0.25Age-adjusted users per 1,000 populationFraser EastFraser SouthNorthwestNortheastFraser NorthThompson CaribooN. Shore/Coast Gar.OkanaganNorthern InteriorCentral IslandSouth IslandNorth IslandEast KootenayVancouverRichmondKootenay Boundary����354353347325323317317316315314310309306298283276����393403374346390368369369383364343363379373366322-10%-12%-7%-6%-17%-14%-14%-15%-18%-14%-10%-15%-19%-20%-23%-14%������ ��� �������+0.10+0.10+0.08+0.02+0.01-0.01-0.01-0.01-0.01-0.02-0.03-0.03-0.04-0.07-0.12-0.14Cost per userSouth IslandFraser NorthFraser EastNortheastFraser SouthN. Shore/Coast Gar.Northern InteriorThompson CaribooNorth IslandNorthwestVancouverCentral IslandOkanaganRichmondKootenay BoundaryEast Kootenay����$37$35$35$35$35$34$34$34$34$34$33$33$31$31$30$30����$22$22$22$20$23$22$26$23$20$24$24$22$21$22$18$2469%61%61%72%51%59%31%45%66%41%39%51%46%38%67%27%������ ��� �������+0.09+0.04+0.03+0.03+0.03+0.01+0.00-0.00-0.01-0.01-0.02-0.03-0.10-0.10-0.11-0.11Antibacterials for Systemic Use56 | Centre for Health Services and Policy ResearchCentre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Sex Hormones1996 2003Expenditure per capita$80$60$40$200-19 years20-44 years 45-64 years65-84years85+yrs0-19 years20-44 years45-64 years65-84years85+yrsNumberof persons$1.65 $3.51$16.36$10.04$5.59 $2.04$12.62 $10.70$6.78 $4.171,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsPer capita expenditure on sex hormones increased by 17% between 1996 and 2003.  Sex hormone expenditure is highest among residents aged 20 to 44. Increased expendi-ture for this age cohort and for residents under age 20 explained all of the increase in overall expenditure in BC.Variation in age-adjusted expenditure per cap-ita was moderate across HSDAs (CV=13%) in 2003. Variation in age-adjusted utilization (CV=12%) was greater than variation in cost per user (CV=9%). Drugs in this therapeutic category: • Hormonal contraceptives (e.g.     progestogen and estrogen combinations) • Androgens, estrogens and progestogens,    either by themselves or in combination • Gonadotropins and other ovulation     stimulants (e.g. clomiphene) • Antiandrogens (e.g. cypoterone) • Other sex hormones (e.g. raloxifene)Indications for use:  • Contraceptives: birth control • Androgens: treatment of testosterone    deficiency • Estrogen replacement/in combination    with other sex hormones: prevention    of osteoporosis and/or the relief of     menopausal symptoms • Gonadotropins: treatment of infertility    caused by gonadotropin deficiency • Antiandrogens: treatment of prostate    cancerBritish Columbia Rx Atlas | 57Health service delivery area (HSDA) cartograms and data, 1996 and 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=13%CV=12%CV=9%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaN. Shore/Coast Gar.South IslandOkanaganThompson CaribooCentral IslandFraser SouthEast KootenayFraser NorthNorth IslandKootenay BoundaryNortheastNorthern InteriorVancouverFraser EastNorthwestRichmond����$13$12$11$11$10$10$9$9$9$9$9$9$9$9$9$8����$11$9$9$9$9$9$9$8$8$8$8$8$7$8$8$717%30%22%25%11%15%8%13%23%20%13%7%23%11%3%11%������ ��� �������+0.25+0.21+0.10+0.07+0.01-0.02-0.07-0.07-0.08-0.09-0.09-0.10-0.11-0.11-0.13-0.20Age-adjusted users per 1,000 populationOkanaganSouth IslandThompson CaribooN. Shore/Coast Gar.Central IslandEast KootenayNortheastNorth IslandNorthwestFraser SouthNorthern InteriorKootenay BoundaryFraser EastFraser NorthVancouverRichmond����104101100100979593898786868484797067����979689999483878282848473848070717%6%13%1%4%15%6%8%5%3%3%15%1%-1%0%-5%������ ��� �������+0.17+0.15+0.14+0.13+0.11+0.09+0.06+0.02-0.01-0.01-0.01-0.03-0.03-0.10-0.22-0.26Cost per userN. Shore/Coast Gar.VancouverSouth IslandRichmondFraser NorthFraser SouthKootenay BoundaryThompson CaribooOkanaganFraser EastNorthern InteriorCentral IslandNorth IslandNorthwestNortheastEast Kootenay����$129$128$122$121$118$114$108$107$106$106$105$105$103$101$98$98����$111$104$99$104$103$102$104$97$93$96$101$98$91$103$93$10516%23%23%17%14%12%4%11%14%10%4%6%13%-2%6%-6%������ ��� �������0.120.110.060.050.03-0.01-0.06-0.07-0.07-0.08-0.09-0.09-0.11-0.12-0.15-0.16Sex Hormones58 | Centre for Health Services and Policy ResearchCentre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Antiepileptics1996 2003Expenditure per capita$80$60$40$20 0-19 years 20-44 years 45-64 years65-84years85+yrs0-19 years20-44 years 45-64 years65-84years85+yrsNumberof persons$0.98 $1.30$6.90$10.75 $9.67 $8.99$2.98 $2.79 $2.09$1.351,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsBetween 1996 and 2003, expenditure per capita for antiepileptics tripled from just over $2 to approximately $7. Expenditure per resi-dent aged over 85 increased nearly six-fold.Despite rapid growth in spending among the elderly, adults between 20 and 64 accounted for approximately 76% of total spending on antiepileptics.Variation in age-adjusted expenditure per capita was relatively high (CV=16%). This is largely explained by variation in utiliza-tion (CV=13%), rather than in cost per user (CV=8%). High use regions tended to have above average costs per user.Drugs in this therapeutic category:  • Barbiturates (e.g. phenobarbital) • Benzodiazepine derivatives   (e.g. clonazepam) • Hydatoin (e.g. phenytoin) • Fatty acid derivatives (e.g. valproic acid) • Other antiepilepticsIndications for use:  • Treatment of epilepsyBritish Columbia Rx Atlas | 59Health service delivery area (HSDA) cartograms and data, 1996 and 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=16%CV=13%CV=8%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaSouth IslandCentral IslandFraser EastOkanaganKootenay BoundaryN. Shore/Coast Gar.Northern InteriorFraser SouthFraser NorthEast KootenayNorth IslandThompson CaribooVancouverNorthwestNortheastRichmond����$9$9$8$8$7$7$7$7$7$6$6$6$6$6$5$5����$3$2$2$3$3$2$2$2$2$3$2$2$2$2$2$2234%269%258%196%163%191%194%195%203%148%240%161%197%175%220%182%������ ��� �������+0.28+0.23+0.17+0.08+0.02-0.00-0.05-0.05-0.07-0.08-0.09-0.09-0.09-0.12-0.25-0.33Age-adjusted users per 1,000 populationSouth IslandFraser EastCentral IslandThompson CaribooOkanaganKootenay BoundaryFraser SouthNorthern InteriorN. Shore/Coast Gar.VancouverNorth IslandNorthwestFraser NorthNortheastEast KootenayRichmond����31303030292727272626262525232219����15141217151414121516131213131111108%116%144%76%98%100%90%128%79%68%104%106%92%78%97%66%������ ��� �������+0.14+0.12+0.12+0.10+0.09+0.02+0.02-0.00-0.02-0.03-0.03-0.08-0.09-0.18-0.19-0.36Cost per userSouth IslandEast KootenayCentral IslandFraser EastRichmondFraser NorthN. Shore/Coast Gar.Kootenay BoundaryOkanaganNorthwestNorthern InteriorNorth IslandVancouverNortheastFraser SouthThompson Cariboo����$301$291$290$273$268$266$264$261$258$250$248$247$244$243$243$215����$188$231$192$165$158$168$163$199$172$187$193$148$138$135$157$14560%26%51%66%70%58%62%31%50%33%29%67%77%80%55%48%������ ��� �������+0.15+0.11+0.11+0.05+0.03+0.02+0.02+0.00-0.01-0.04-0.04-0.05-0.06-0.07-0.07-0.19Antiepileptics60 | Centre for Health Services and Policy ResearchCentre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Immunosuppressive Agents1996 2003Expenditure per capita$80$60$40$20 0-19 years 20-44 years 45-64 years65-84years85+yrs0-19 years20-44 years45-64 years 65-84years85+yrsNumberof persons$0.06 $0.51$5.30$11.54 $11.86$1.05$0.26 $0.51 $0.63$0.191,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure on immunosuppressive agents increased twenty-fold over the period studied, from $0.30 in 1996 to over $6 in 2003.Immunosuppressive drug expenditures are highest among adults aged 45 to 84. However, over 28% of overall expenditure on these drugs is for patients aged 20 to 44.Age-adjusted expenditure per capita on immu-nosuppressive agents varied substantially across HSDAs (CV=23%). This variation was driven by variation in age-adjusted utilization (CV=16%) and by variation in cost per user (which ranged from roughly $2,500 to $4,600; CV=16%).Drugs in this therapeutic category:  • Selective immunosuppressive agents     excluding corticosteroids   (e.g. cyclosporine) • Other immunosuppressive agents,     excluding corticosteroids   (e.g. methotrexate)Indications for use:  • Reduction of risk of rejection in    organ transplantation • Treatment of autoimmune diseaseBritish Columbia Rx Atlas | 61Health service delivery area (HSDA) cartograms and data, 1996 and 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=23%CV=16%CV=16%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaKootenay BoundaryOkanaganN. Shore/Coast Gar.Thompson CaribooSouth IslandFraser NorthCentral IslandFraser EastFraser SouthNorthwestRichmondNorth IslandVancouverNorthern InteriorEast KootenayNortheast����$10$9$8$7$7$7$6$6$6$6$6$6$5$5$5$5����$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$01996%1935%2251%3242%3158%1805%2944%1439%2013%2179%1888%2011%1627%3384%1560%1705%������ ��� �������+0.42+0.27+0.21+0.13+0.12+0.05-0.05-0.06-0.07-0.08-0.13-0.18-0.23-0.27-0.34-0.38Age-adjusted users per 1,000 populationOkanaganKootenay BoundaryFraser NorthNortheastRichmondNorth IslandNorth Shore/Coast Gar.Thompson CaribooFraser SouthFraser EastNorthwestSouth IslandVancouverCentral IslandEast KootenayNorthern Interior����1.00.70.60.60.60.50.50.50.50.50.50.50.50.40.40.4����0.40.10.10.10.10.10.10.20.10.10.10.10.00.20.20.2213%179%193%172%218%233%278%235%224%247%158%285%251%296%202%193%������ ��� �������+0.29+0.21+0.07+0.03+0.02+0.01-0.00-0.00-0.01-0.05-0.06-0.07-0.08-0.10-0.34-0.35Cost per userN. Shore/Coast Gar.Kootenay BoundarySouth IslandThompson CaribooNorthern InteriorCentral IslandEast KootenayFraser EastFraser NorthOkanaganNorthwestFraser SouthRichmondVancouverNorth IslandNortheast����$4,596$4,587$4,474$4,211$4,056$3,892$3,728$3,692$3,645$3,636$3,635$3,501$3,207$3,183$3,075$2,468����$738$610$529$422$342$506$679$831$561$559$412$537$513$646$485$372523%652%746%898%1087%669%449%344%550%550%783%552%525%392%534%564%������ ��� �������+0.21+0.21+0.19+0.13+0.09+0.05+0.00-0.01-0.02-0.02-0.02-0.06-0.15-0.15-0.19-0.41Immunosuppressive Agents62 | Centre for Health Services and Policy ResearchCentre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Immunostimulants1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years 45-64 years65-84years85+yrs 0-19 years20-44 years 45-64 years65-84years85+yrsNumberof persons$0.41 $0.21$8.10$11.48$1.96 $0.15$0.63 $0.94 $0.34 $0.001,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsExpenditure per capita on immunostimulants increased ten-fold from $0.60 in 1996 to over $6 in 2003. Adults aged 20 to 64 account for virtually all (95%) of the expenditure in this therapeutic category.While per capita spending on immunostimu-lants is relatively small, expenditure per user in BC exceeded $10,000 in 2003.Variation in age-adjusted expenditure per capita is high for this therapeutic category (CV=22%). This is due almost entirely to significant varia-tion in age-adjusted utilization (CV=28%). Drugs in this therapeutic category:  • Colony stimulating factors   (e.g. filgrastim) • Interferons (e.g. interferon alfa-2a)Indications for use:  • To decrease the incidence of infection    due to febrile neutropenia • Treatment of chronic hepatitis • Treatment of patients with cancers such    as chronic myelogenous leukemia, or    multiple myeloma • Treatment of patients with multiple     sclerosisBritish Columbia Rx Atlas | 63Health service delivery area (HSDA) cartograms and data, 1996 and 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=22%CV=28%CV=12%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaN. Shore/Coast Gar.East KootenayNorthern InteriorNorth IslandNortheastNorthwestSouth IslandOkanaganCentral IslandFraser EastKootenay BoundaryFraser SouthThompson CaribooRichmondFraser NorthVancouver����$10$9$9$8$8$8$7$7$7$6$6$6$6$5$5$5����$2$0$0$1$0$1$1$1$0$0$0$0$1$0$1$1549%2834%2046%1274%2959%706%1229%946%2049%1471%1178%1117%999%933%692%608%������ ��� �������+0.45+0.37+0.36+0.20+0.19+0.19+0.10+0.09+0.07+0.03-0.04-0.09-0.11-0.20-0.21-0.30Age-adjusted users per 1,000 populationN. Shore/Coast Gar.East KootenayNorthern InteriorSouth IslandOkanaganNorth IslandCentral IslandNorthwestKootenay BoundaryFraser EastThompson CaribooFraser SouthNortheastFraser NorthRichmondVancouver����1.00.70.60.60.60.50.50.50.50.50.50.50.50.40.40.4����0.40.10.10.10.10.10.10.20.10.10.10.10.00.20.20.2156%823%876%406%446%322%317%225%496%456%326%325%1011%166%136%113%������ ��� �������+0.68+0.34+0.19+0.09+0.09+0.03+0.03-0.01-0.02-0.05-0.08-0.09-0.11-0.19-0.22-0.31Cost per userNortheastNorthwestNorthern InteriorNorth IslandFraser EastCentral IslandEast KootenayRichmondVancouverSouth IslandOkanaganFraser SouthFraser NorthKootenay BoundaryThompson CaribooN. Shore/Coast Gar.����$15,780$14,213$13,969$13,833$12,740$12,180$12,120$12,000$11,881$11,842$11,828$11,669$11,512$11,494$11,377$9,283����$5,731$5,729$6,353$4,247$4,513$2,363$3,814$2,742$3,571$4,511$6,170$4,075$3,862$5,359$4,407$3,666175%148%120%226%182%415%218%338%233%163%92%186%198%114%158%153%������ ��� �������+0.30+0.19+0.18+0.17+0.08+0.04+0.03+0.02+0.01+0.01+0.01-0.00-0.02-0.02-0.03-0.23Immunostimulants64 | Centre for Health Services and Policy ResearchCentre for Health Services and Policy ResearchExpenditure per capita over the life-course, province-wide data, 1996 and 2003Urologicals1996 2003Expenditure per capita$80$60$40$200-19 years 20-44 years45-64 years65-84years85+yrs0-19 years 20-44 years45-64 years65-84years 85+yrsNumberof persons$0.04 $0.05 $1.82$8.74$15.55 $9.74$0.18 $1.39$6.97$6.501,004,179persons1,547,234persons836,359persons439,987persons986,163persons46,517persons1,523,155persons1,075,951persons495,564persons65,727personsPer capita expenditure on urological drugs in British Columbia nearly tripled from $1.32 in 1996 to $5.13 in 2003.Per capita expenditure in this category increas-es across the age profile and then falls for residents over age 85. Approximately 85% of total spending on urological drugs in BC is for adults aged 45 to 84.There was modest variation in age-adjust-ed expenditure per capita across HSDAs (CV=12%). Both utilization and costs per user varied slightly (CV=9% in both cases). Drugs in this therapeutic category: • Urinary antispasmodic (e.g. oxybutynin)  • Drugs used to treat erectile      dysfunction (e.g. sildenafil) • Drugs used in benign prostatic     hypertrophy (e.g. finasteride)Indications for use: • Antispasmodic: symptomatic     management of overactive bladder • Treatment of erectile dysfunction • Treatment of benign prostatic     hyperplasiaBritish Columbia Rx Atlas | 65Health service delivery area (HSDA) cartograms and data, 1996 and 2003��� ������ � ����� �������������� ������ �� �������������������� ������Provincial average (2003)-5%-10%-20%in excess of 20% log deviation below provincial mean+5%+10%+20%In excess of 20% log deviation above provincial meanCV=12%CV=9%CV=9%VancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwest NorthernInteriorNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthVancouverSouth IslandCentralIslandNorth IslandN. Shore/Coast GaribaldiNorthwestNortheastThompsonCaribooOkanaganFraser EastKootenayBoundaryEastKootenayRichmondFraser SouthFraser NorthNorthernInteriorAge-adjusted expenditure per capitaSouth IslandN. Shore/Coast Gar.North IslandVancouverCentral IslandThompson CaribooFraser SouthFraser NorthOkanaganEast KootenayNorthern InteriorNorthwestFraser EastRichmondNortheastKootenay Boundary����$6$6$5$5$5$5$5$5$5$5$5$5$4$4$4$4����$2$1$2$1$1$1$1$1$1$2$1$1$1$1$1$1248%498%202%329%245%323%244%361%282%152%288%352%288%195%282%343%������ ��� �������+0.17+0.15+0.07-0.00-0.01-0.02-0.02-0.03-0.03-0.05-0.06-0.11-0.14-0.16-0.19-0.27Age-adjusted users per 1,000 populationNorthwestN. Shore/Coast Gar.South IslandNorth IslandThompson CaribooCentral IslandFraser SouthNorthern InteriorOkanaganFraser EastFraser NorthNortheastEast KootenayVancouverRichmondKootenay Boundary����36353333333232323131303030292625����1312141411121211121211121110128170%198%137%132%191%174%161%176%166%164%185%142%167%182%114%205%������ ��� �������+0.13+0.11+0.05+0.05+0.04+0.04+0.02+0.02-0.01-0.02-0.03-0.05-0.05-0.07-0.19-0.22Cost per userSouth IslandVancouverN. Shore/Coast Gar.RichmondNorth IslandFraser NorthEast KootenayOkanaganFraser SouthCentral IslandKootenay BoundaryThompson CaribooNorthern InteriorFraser EastNortheastNorthwest����$185$176$172$170$168$166$165$161$158$157$157$155$153$147$143$129����$126$116$86$123$128$102$175$112$120$125$108$106$109$100$91$7747%52%101%38%31%62%-6%43%32%26%45%46%40%47%58%68%������ ��� �������+0.11+0.07+0.04+0.03+0.02+0.01+0.00-0.03-0.04-0.05-0.05-0.07-0.08-0.12-0.14-0.24Urologicals

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