Applied Science, Faculty of
Community and Regional Planning (SCARP), School of
Non UBC
Medicine, Faculty of
Population and Public Health (SPPH), School of
DSpace
The Canadian prescription drug atlas
University of British Columbia. Centre for Health Services and Policy Research
Morgan, Steve
Raymond, Colette
Mooney, Dawn
Martin, Daniel
"Canadian governments, employers, unions, and patients currently spend more money on prescription drugs (about $20 billion in 2007) than is spent on all services provided by physicians in Canada. At the same time, prescription drug spending per capita varies by over 50% across provinces. Surprisingly little information is systematically collected to determine which drugs account for most of the spending in Canada, what factors drive interprovincial variations in spending, and whether population age is an important cause of spending variations across provinces and trends over time. The 2nd edition of The Canadian Rx Atlas significantly enhances our understanding of medicine use by providing the first-ever portrait of age-specific patterns of prescription drug use and costs across provinces. It breaks down nearly $20 billion in prescription drug spending (private and public) and provides a comprehensive portrait of the factors that drive trends over time and variations across provinces." -CHSPR website
Steve Morgan, PhDColette Raymond, PharmD MScDawn Mooney, BADaniel MartinThe CanadianRx Atlas2nd EditionDecember 2008NewBrunswickNovaScotiaNewfoundlandand LabradorPrince Edward I.QuebecOntarioTh e Canadian Rx Atlas, 2nd Edition (Th e Canadian Prescription Drug Atlas) was produced by: Th e Centre for Health Services and Policy Research University of British Columbia #201 – 2206 East Mall (LPC) Vancouver, BC V6T 1Z3 Phone: 604-822-4969 Email: enquire@chspr.ubc.caYou can download this publication from our website, at www.chspr.ubc.caTh is publication is protected by copyright. It may be distributed for educational and non-commercial use, provided that the UBC Centre for Health Services and Policy Research is credited.Library and Archives Canada Cataloguing in PublicationTh e Canadian Rx atlas / Steve Morgan ... [et al.]. -- 2nd ed.ISBN 978-1-897085-16-51. Drugs--Prices--Canada. 2. Drug utilization--Canada. 3. Drugs--Prescribing--Canada. I. Morgan, Steve II. University of British Columbia. Centre for Health Services and Policy ResearchRA410.55.C35C36 2008 338.4’361510971 C2008-908139-0 2 About CHSPR 3 Acknowledgments 5 Introduction 6 Methods 10 Key fi ndings 16 How to use this atlas 22 1 Overall spending Cardiovascular drugs 28 2.1 Antihypertensives 34 2.2 Statins 40 2.3 Antithrombotics Neurological drugs 46 3.1 Antidepressants 52 3.2 Antipsychotics 58 3.3 Benzodiazepines and related drugs 64 3.4 Gabapentin, pregabalin, topiramate 70 3.5 Psychostimulants & atomoxetine 76 3.6 Cholinesterase inhibitors 82 3.7 Drugs for Parkinson’s disease 88 4 Acid-reducing drugs 94 5 Inhaled drugs for respiratory conditions Analgesics 98 6.1 Opioid drugs104 6.2 Nonsteroidal anti-infl ammatory drugs Diabetes drugs 110 7.1 Oral drugs 116 7.2 Insulins 120 8 Oral antibiotics126 9 Bisphosphonates 132 10 Hormonal contraceptives 138 11 Drugs for erectile dysfunction 144 Characteristics of provincial populations ContentsU B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N2About CHSPRTh e Centre for Health Services and Policy Research (CHSPR) is an independent research centre based at the University of British Columbia. Our mission is to stimulate scientifi c enquiry into ways in which health care services can best be organized, funded, and delivered to promote the health of populations.CHSPR faculty and staff carry out a diverse program of research, training, knowledge translation, and data development activities related to health services research and health care policy. We promote an interdisciplinary, collaborative approach to these activities, recognizing that contemporary problems in health systems and policy transcend traditional academic boundaries.CHSPR aims to contribute to the health of populations by ensuring that our research is relevant to contemporary health policy concerns and by working closely with decision-makers to translate research fi ndings into policy options. Our researchers are active participants in many policy-making forums and provide government and non-government organizations in British Columbia, Canada, and abroad with advice and assistance.CHSPR receives core funding from the British Columbia Ministry of Health to support research with a direct role in informing policy decision-making and evaluating health care reform. Our researchers are also funded by competitive external grants from provincial, national, and international funding agencies. For more information about CHSPR, please visit www.chspr.ubc.ca U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H3AcknowledgmentsTh is project was made possible by in-kind contributions of research data and technical expertise from IMS Health Canada, Inc. We would particularly like to thank Brian Carter, Allan Gillman, and the Public Aff airs and Government Relations department for their assistance in accessing and analyzing the IMS Health databases. Th e Canadian Institute for Health Information (CIHI)—Michael Hunt and Michele Arthur, in particular—also supported this project with data from the National Prescription Drug Utilization Information System. Production of this report was made possible with the fi nancial support of CHSPR, which itself is supported, in part, by contributions from the British Columbia Ministry of Health Services.Th is study was not directed in any way by IMS, CIHI, or the British Columbia Ministry of Health Services. All results and conclusions in this report are solely those of the authors; no endorsement by supporting organizations is intended or should be inferred.Drs. Charlyn Black, James Wright, and Barbara Mintzes helped us to organize and describe World Health Organization drug categories in ways that can be meaningfully interpreted by Canadian audiences. Merrie-Ellen Wilcox provided professional editing that has helped to make this atlas as accessible as possible for those who will use it.We would like to dedicate this atlas to the memory of our friend and colleague Peter Schaub (1978-2005). Peter left an indelible mark on CHSPR and continues to inspire works like this.Steve Morgan, PhDColette Raymond, PharmD MScDawn Mooney, BADaniel MartinT H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N4U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H5What you will fi nd in The Canadian Rx Atlas, 2nd EditionIntroductionPrescription drug spendingAs a result of changes in technology, demography, and policy, prescription drugs have become one of the most important components of modern health care. Refl ecting this, prescription drug spending in Canada grew from 6% of total health care costs in 1977 to 14% in 2007.Nearly three out of four Canadians now fi ll at least one prescription each year, for a total cost of approximately $20 billion, borne by governments, employers, unions, and patients.Th e average amount spent on prescription drugs varies dramatically across provinces, with spending per capita more than 50% higher in some provinces than in others.Important questionsTh e levels, trends, and variations in the amounts Canadians spend on prescription drugs raise important questions: What types of medicine account for most spending? Why do some provinces spend more than others? Are the costs of prescription drugs “out of control” in some provinces?Despite their importance, there are surprisingly few answers to these questions. Th is is because very few provinces systematically collect and monitor information about the use, impact, and cost of prescription drugs. Important information can nevertheless be produced using market-level data, as is done in this atlas.Illustrating fi rst-of-kind informationTh e 2nd edition of Th e Canadian Rx Atlas signifi cantly enhances our understanding of medicine use by providing the fi rst-ever portrait of age-specifi c patterns of prescription drug use and costs across provinces. Th is was done by analyzing unique, province-level datasets from IMS Health Canada (a leading pharmaceutical market research fi rm).In the pages that follow, we quantify and illustrate diff erences in per capita spending by age groups and across provinces as they occurred in 2007.We also illustrate the magnitude and causes of province-specifi c changes in per capita spending between 1998 and 2007.We present separate analyses for each of 20 top therapeutic categories in terms of national spending, some of which are grouped by major treatment area (such as “cardiovascular” or “neurological” treatments).Evidence on popular hypothesesTh is 2nd edition of Th e Canadian Rx Atlas provides considerable information to help readers critically assess common hypotheses about why spending is higher in some provinces than in others.In addition to providing the fi rst-ever age-specifi c estimates of spending, this report also provides information about the number of prescription drugs covered on provincial formularies within each therapeutic category. Th is atlas also contains information about the characteristics of provincial populations that may (or may not) explain some of the fi ndings in this atlas.We do not draw conclusions about policy or practices in this document. Instead, we hope that the data presented here will serve as a valuable guide for the policy-makers, practitioners, and researchers who are best positioned to determine which areas are worthy of further investigation or potential policy intervention.T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N6MethodsDataWe report information on retail sales of all prescription-only medicines sold in Canada, regardless of dosage form (e.g., tablets, liquids, creams, inhaled medicines). Th is excludes drugs sold over the counter. IMS Health’s Second Generation Canadian CompuScript Audit (based on data collected from over 5,000 retail pharmacies stratifi ed by province) provided 2007 retail sales volumes in terms of prescriptions, units, and dollars for every province.IMS Health’s Anonymized Longitudinal Patient Dataset (based on anonymous patient-specifi c data from a sample of retail pharmacies across Canada) provided 2007 estimates of age-specifi c shares of prescriptions fi lled for every province and for every type of drug.Linking the above IMS Health data at the product level yielded province-specifi c estimates of the number, size, and cost of prescriptions fi lled by persons in four age groups (0–19, 20–44, 45–64, and 65+ years of age). Our population estimates came from Statistics Canada.We suppressed data when drug use within a given age group and therapeutic category was too low to record reliable estimates at the provincial level.Cost informationOur cost information pertains to total retail sales, including both private and public sources of payment. Th is includes all markups and pharmacists’ fees. Our price estimates therefore include the amount of pharmacists’ fees paid per unit of drugs received. Therapeutic codingWe assigned drugs into hierarchical, mutually exclusive groupings using the World Health Organization’s Anatomical Th erapeutic Chemical (ATC) drug classifi cation system. Th e ATC system groups drug products based on the anatomic system on which they act, their therapeutic properties, and their chemical characteristics.Our therapeutic categories were based on the level of ATC codes that groups drugs together on the basis of therapeutic or pharmacological properties (e.g., the ATC value N06A is for “antidepressants”). We clustered some of these ATC groupings where they generally had a common primary indication: for example, our “hypertension” category includes drugs from ATC groupings for thiazide diuretics, beta blockers, calcium channel blockers, angiotensin converting enzyme (ACE)-inhibitors, and angiotensin II receptor blockers.In total, our database contained information about 7,436 brand and generic versions of 3,185 drugs identifi ed by active ingredient and dosage. Th ese were grouped into 160 mutually exclusive classes of drug and then into 35 therapeutic categories.Determining spending levels and causesWe used economic indexes designed to separate the eff ect of population age on per capita spending from other determinants of spending across regions or over time. We computed the impact of six age-standardized pharmaceutical cost-drivers that fall into three broad categories: volume eff ects, therapeutic choice eff ects, and price eff ects.Age-standardizationTh e fi rst step in our analysis was to compare and adjust for diff erences in drug utilization and spending across age groups. For all medicines in the market and for each therapeutic category analyzed in detail, we therefore illustrate the age-specifi c levels of drug spending in Canada and for every province.We used direct age-standardization (based on each province’s age-specifi c spending profi le and U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H7the national age distribution) and indirect age-standardization (based on the national age-specifi c spending profi le and each province’s age distribution). Th e geometric mean of these two measures was our fi nal estimate of age-standardized per capita spending for each province.Age-standardized cost-drivers Our methods show the impact of six factors that fall into three broad categories of pharmaceutical cost-drivers: volume eff ects, therapeutic choice eff ects, and price eff ects. Th is is illustrated to the right.Volume eff ectsVolume eff ects relate to the absolute amount of prescription drug therapy received by a population aft er adjusting for population age.Th ese cost-drivers include the “prescription volume,” which is the per capita volume of prescriptions received from the broad categories of treatment studied, and “prescription size,” which is the average amount of drug received per prescription.Diff erences in the age-standardized volume of therapy are not necessarily a cause for concern if driven by diff erences in health needs. Diff erences may, however, indicate areas of potential underuse or overuse.Th erapeutic choice eff ectsTh erapeutic choice eff ects relate to the average selection of general and specifi c types of drug per course of treatment aft er adjusting for population age.Broad choices, referred to as “therapeutic mix,” refl ect the cost impact of decisions concerning the drug classes from which prescriptions are written. Th is includes such choices as beta blockers or ACE-inhibitors within the antihypertensives category.Narrow choices, referred to as “drug mix,” refl ect the selection of specifi c drug types within a particular drug class. Th is includes choices such as between enalapril and ramipril within the drug class of ACE-inhibitors.Age-standardized diff erences in therapeutic choice eff ects may refl ect health needs or diff erences in the cost-eff ectiveness of prescribing patterns.Price eff ectsPrice eff ects are factors that infl uence spending without altering the quantity or type of drug used.Th ese cost-drivers include “generic use,” which is the average savings generated by generic drug use aft er Age-standardized deviation/growthDifference (across provinces or over time) in per capita spending after adjusting for population age=Volume effectsPrice effectsTherapeuticchoice effects+Prescription volumeDifference in number of prescriptions filledfrom 35 broad therapeutic categoriesPrescription sizeDifference in average number of units per prescription filled++PricesDifference in prices paid per unit of 7,436 brand and generic versions of drugsGeneric useDifference in average price paid per unit of 3,185 drugs due to use of generics++Therapeutic mixDifference in average mix of 160 drug classes selected from within 35 therapeutic categoriesDrug mixDifference in average mix of 3,185 drugs selected from within 160 drug classesTotalFramework for determining the causes of spendingT H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N8adjusting for population age. Th is will be infl uenced by the availability of generics, the relative price of generics versus brands, and the extent to which generics are selected when available.“Prices” are a cost-driver that simply refl ects the average price paid per unit of a given brand or generic drug. In this study, such prices are partly determined by length of prescription written, because dispensing fees are included in our cost data.Price eff ects generally have no impact on the quality of health outcomes obtained per course of therapy. As such, they are common targets for policy intervention.Changes over timeMethods similar to those above were used for the analysis of changes in spending over time.To conduct analyses of changes over time, we added 1998 data from the First Generation Canadian CompuScript Audit (G1) to our research dataset. Th e 1998 data combined Prince Edward Island and Newfoundland & Labrador due to sample sizes. Moreover, the 1998 data were only available for drugs sold as oral solids (e.g., tablets and capsules).We estimated 1998 sales of non-oral drugs within each narrowly defi ned drug class by using the class-specifi c ratios of oral to non-oral sales in 2007. No inter-temporal analyses were done for therapeutic categories containing few or no oral-solids (e.g., insulins and inhaled medicines for respiratory disorders). Because we did not have age-specifi c spending data for 1998, we used indirect age standardization only to age-standardize growth rates in spending. Th is involved multiplying the 2007 age-profi le of spending for each province by the 1998 population structure for the respective province.Studies indicate that drug spending has been growing most rapidly for the fastest growing age groups (persons over age 45). Our age-standardization of growth rates will therefore tend to over-state the impact of population age on drug spending growth, because changes in the size of this population receive the proportionally higher expenditure weights according to 2007 spending, rather than those of the 1998 spending levels (see Morgan 2005b).IndexesTh e results presented throughout this atlas depict the impact of age-standardized cost-drivers in an additive fashion. Th e actual computations required to quantify the analytic framework used are based on economic indexes that interact multiplicatively; however, for ease of reading, we have converted these indexes to an additive format using logarithms. Th us, individual cost-drivers add up to the three respective sub-totals, and these sub-totals add up to the total diff erences observed. Provincial formulariesProvincial formularies list medicines that are eligible for public subsidy under the drug benefi t programs operated by each province.Variations in the drugs listed on formularies may explain some of the interprovincial diff erences in prescription drug spending. We therefore determined the shares of the products within each therapeutic category that were listed on provincial formularies as of December 2006.Data sourcesWe obtained formulary data for eight provinces (British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia, and Newfoundland & Labrador) from the National Prescription Drug Utilization Information System at the Canadian Institute for Health Information, and U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H9for Quebec directly from the Conseil du médicament. Data for Prince Edward Island were not readily available.Formulary data reported here pertain to the largest program for each province. In most provinces, this is the program that covers senior citizens.We did not access coverage information for special condition-specifi c programs (such as cancer, HIV/AIDS, etc.); related medicines were therefore excluded from our analysis of formulary listings. We also excluded drugs with less than $1,000 in national sales during 2006.ListingsUsing the World Health Organization’s ATC therapeutic coding system, we grouped products according to active chemical substances (e.g., N06AB03 = fl uoxetine), inclusive of all strengths and brands of a given drug. We then searched provincial formulary data to determine if any drugs within these groups were listed.A drug was deemed to have “unrestricted coverage” if at least one version of it (e.g., a generic) received unrestricted coverage under a provincial formulary. A drug was deemed to have “restricted coverage” if public subsidy was available only under certain conditions. For example, some provinces only cover certain medicines if a special authority request is submitted by the prescribing physician.Measures of coverageWe characterized provincial coverage with and without national expenditure weighting. Th e unweighted percentage of all of the drugs analyzed (in a given therapeutic category) that were covered under a given provincial formulary indicated “breadth” of coverage. Th is measures the crude variety of drugs (within the therapeutic category) covered by a provincial formulary.To give a sense of the relative (fi nancial) importance of drugs covered by each province, we also weighted all coverage decisions by total national sales of each drug (within the therapeutic category). While it is not always true that the economic and clinical importance of medicines are correlated, the expenditure-weighting gauges the relative importance of drugs covered, in the sense that coverage for many drugs with minimal national sales volume receives less weight than coverage of fewer drugs with greater national sales. Th e weighted measure is in no way intended to mean that any province in question actually does pay for the respective portions of national purchases. In fact, no province covers even 50% of drug expenditures within its own jurisdiction. ReferencesTh e methods used in determining spending levels and causes are based on the approach described in the following:Morgan, S. (2005a) “Drug expenditure trends in the Canadian provinces: Magnitude and causes from 1998 to 2004.” Healthcare Policy 1(1): 85–99.Morgan, S. (2005b) “Booming prescription drug expenditure: A population-based analysis of age dynamics.” Medical Care 43(10): 996–1008.T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 0Key fi ndings0-19 yearsNumberof people$1327,776,058 people20-44 years$27111,740,792 people45-64 years$7748,936,632 people65+$1,7784,417,805$500$250$750$1,000$1,250$1,500$1,750Per capita spending in Canada by age group, 2007Spending levels by ageCanadians spent $578 per capita on retail purchases of prescription drugs in 2007. Th is amounted to almost $19 billion in total.As illustrated to the right, average spending on prescription drugs increased steadily across age groups in 2007. Per capita spending peaked at $1,778 for the age group of Canadians aged 65 and older. Th at is more than twice the cost of medicines purchased by the average Canadian aged 45–64 and over six times that of Canadians aged 20–44.Th e large cohort of Canadians aged 45–64 (including the “baby boomers”) accounted for 36% of all Canadian retail spending on prescription drugs in 2007.Spending by therapeutic categoryOne out of every four dollars spent on prescription drugs in Canada in 2007 was used to pay for cardiovascular drugs: antihypertensives (14.5% of total spending), statins (10%), and antithrombotics (1.7%).Neurological treatments also accounted for a large share of spending on prescriptions in 2007, led by antidepressants (6.1% of total spending) and antipsychotics (3.3%).Canadians spent $1.4 billion (7.4% of total spending) on prescription drugs to reduce stomach acid in 2007, and $888 million (4.7%) on inhaled prescription drugs for respiratory conditions.Interprovincial variation in spendingIn 2007, per capita spending on prescription drugs within the provinces varied from 25% below the national average in British Columbia to 18% above the national average in Quebec.U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 1Name of therapeutic category Spending percapita ($)Total spending($-millions)Share of total spending on all drugs (%)1 All prescription drugs on the Canadian retail market $577.70 $18,989 100.0%Cardiovascular drugs 2.1 Antihypertensives $83.60 $2,748 14.5% 2.2 Statins $57.80 $1,898 10.0% 2.3 Antithrombotics $9.80 $324 1.7%Neurological drugs 3.1 Antidepressants $35.30 $1,162 6.1% 3.2 Antipsychotics $19.10 $629 3.3% 3.3 Benzodiazepines and related drugs $7.50 $247 1.3% 3.4 Gabapentin, pregabalin, topiramate $7.30 $239 1.3% 3.5 Psychostimulants and atomoxetine $5.50 $180 1.0% 3.6 Cholinesterase inhibitors $4.90 $162 0.9% 3.7 Drugs for Parkinson’s disease $2.60 $86 0.5%4 Acid-reducing drugs $42.70 $1,405 7.4%5 Inhaled drugs for respiratory conditions $27.00 $888 4.7%Analgesics 6.1 Opioid drugs $14.80 $485 2.6% 6.2 Nonsteroidal anti-infl ammatory drugs $11.90 $390 2.1%Diabetes drugs 7.1 Oral drugs $17.10 $563 3.0% 7.2 Insulins $6.90 $226 1.2%8 Oral antibiotics $20.20 $665 3.5%9 Bisphosphonates $10.30 $338 1.8%10 Hormonal contraceptives $10.10 $332 1.7%11 Drugs for erectile dysfunction $4.40 $145 0.8%All other therapeutic categories $178.90 $179 30.9%Retail spending on prescription drugs in Canada by therapeutic category, 2007Note: Rows may not add up due to rounding.T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 2AB-14-19-26-26+2-12+12-4+2-34-27-6-17+3-1+2-19+3-25-2+8SK-15+4-28+19-23-20-29-14-32-44-7-17-21-18+2-10+7-9-22-13-22MB-9-7-27+19-40+6-19-21-420-29-25-26-5-7-27-3-55-25-30ON0-5+1-3-6-14-20-31+5+28-2+1-10+27+8-10+8+9-11+12QC+18+23+32+17+7+33+21+50+21+1+15+16+11-25+2+160-11+36+28-13NB+17+12+12+25+19+29+70-1-8+2-3+28+5+3+37+33+57+5-27+27-24NS+13+20+15+9+33-8+17+13+25+28-2+39+9+1+15+14+81+8-19+27-32NL+8+20+17+18+6-8+15-52-40-30-5+23-10-6+6+14+105+47-40+11-37PE+5+11-3+7+12-6+29+14+31+17+6+27-1-36+15-24+113+7-31+25-27BC-25-22-30-17-3-40+16-40-38+3-30-37-25-36-31-22-12-35-19+13AB-4-3-11-7+8-8+24+5-5-13-10+6-10+10+9+17-13+6-7-9+19SK-160-30+12-20-17-29-12-37-52-12-18-23-15+3-12+8-8-27-7-20MB-8-6-26+200+2+9-17-28-43+1-27-25-23-2-5-25-3-55-23-27ON+2-2+3-1-4-13-19-29+3+300+3-9+29+10+1+1+8+11-12+14QC+13+16+25+10+3+30+16+44+26-5+9+11+8-28-2+10-3-11+29+31-18NB+11+4+3+17+15+25+62-6-2-6-11+21+1-2+31+25+52+4-34+32-30NS+8+11+6-1+29-10+10+7+31+17-11+31+4-4+9+6+75+7-28+33-38NL+3+11+8+11+1-12+8-56-35-33-11+16-12-12-1+6+99+45-45+17-44PE+1+4-90+11-7+25+11+30+9-1+22-4-38+11-28+110+7-37+32-30BC-28-26-34-21-5-6-3+13-37-41-1-33-38-27-38-34-24-13-38-18+9Overall spendingAntihypertensivesStatinsAntithromboticsAntidepressantsAntipsychoticsBenzodiazepines and related drugsGabapentin, pregabalin, topiramatePsychostimulants and atomoxetineCholinesterase inhibitorsDrugs for Parkinson’s diseaseAcid reducing drugsInhaled drugs for respiratory conditionsOpioid drugsNonsteroidal anti-inflammatory drugsOral drugsInsulinsOral antibioticsBisphosphonatesHormonal contraceptivesDrugs for erectile dysfunctionCardiovascular drugsNeurological drugsAnalgesicsDiabetes drugs-40%-30%-20%-10%-5%+0+5%+10%+20%+30%+40%Total variation (%) Age-standardized variation (%)Variation from national average per capita spending by province, 2007Adjusting for population age brought some provinces (such as Alberta and Nova Scotia) closer to the national average. Yet even age-standardized prescription drug spending per capita varied considerably across provinces—from 28% below the national average in British Columbia to 13% above the national average in Quebec.Sources of age-standardized variationsMost interprovincial variations in age-standardized prescription drug spending per capita stemmed from variations in the volume of drugs purchased.On an age-standardized basis, residents of western provinces purchase fewer prescription drugs in 2007 than residents of eastern provinces.Th erapeutic choice eff ects contributed to interprovincial variations in age-standardized spending per capita, particularly within some therapeutic categories—such as oral diabetes drugs.Interprovincial variations in the prices paid for drugs, taking into account savings from use of generic drugs, contributed modestly to overall variations in age-standardized prescription drug spending per capita.Overall cost impact of variationsTh e aggregate impacts on variations in cost-drivers were dramatic for some provinces.If age-standardized cost-drivers in Quebec were the same as the national average, total spending on prescription drugs in that province would be $595 million lower than was actually the case in 2007. Most of the diff erence ($308 million) was a result of higher age-standardized volumes of prescription drugs purchased per capita. Higher prices, due to less generic U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 3AB0-1-12+7+5-17+2+21-9-15-7+1-13+16+11-4-14+10+80+24SK-12-11-32+6-9-4-41+11-17-56-3-7-21-14+3-20-21+18-28-11-20MB-7-13-28+1-2-30-4-18-43+3-17-14-44+1-6-20+9-47-18-22ON+4+5+5+3+2-7-16-26-1+29+13+10-9+10+15+5-6+9+14-17+10QC+7+3+21+3-10+23+22+29+26-3-8-3+12-11-16+4+6-26+18+35-16NB+14+14+2+9+17+32+69-9+1-9-7+32+22-13+36+3+44+7-27+27-35NS+16+17+10-4+38+6+26+5+37+15-4+52+22+2+16+3+77+13-22+31-37NL+12+18+12+3-5-7+20-66-11-36-14+36+4+24-2+8+96+57-38+12-44PE+6+11-11-14+11+19+35-1+27+2+1+33+9-18+23-21+85+19-34+31-30BC-18-14-31-17-3-6-20+27-30-41-5-21-32-13-23-23-22-6-27-20+16AB-4+10-14+6+4+29-12+50-1+7+2-40+23+1-2-10+10SK-5+4-3-1-2-15+14-15-220-11-14-7-2+1+18-7-23-500MB-200+16+2+5+14-12-80-5-11-12+19-3-4-4-13-70-1ON0-2+10-1-3-4-1+30-7-6-1+21-3-1+4-1+3+10QC+1+300-1+3-16+7+30+8+10-1-23+6-4-3+12-1-10NB-4-9-2+8+1-3+6+1-70-3-16-21+5-3+220-3-6-20NS-6-5-3+4-2-11+2+50+1-7-19-17-7-3+6-7-5-2+20NL-10-8-6+8+1-7+3+8-22+1-6-23-16-42+2-1-9-6-7+3-1PE-5-6-3+12-2-19+11+7+2+2-5-18-15-24-14-1+9-10-8-1-1BC-8-9-1-3+1-1+16-10-50+1-11-6-9-13-8+1-6-10+20AB-1-2+10-3+5-6-40+1-2-2+2-3-1-3+1-2-4-10-5SK+1+7+5+7-9+2-2-8+2+4+2+3+4+1-1-10-6-4+7+3+1MB+2+6+2+4-10-5-1-3+1+20+1+2-1+5-1+20-5-4ON-2-5-3-4-6-4+2-2+2+1-6-2+1-2-2-3+30-7+4+4QC+6+11+4+7+15+4+10+9-2-2+9+4-3+6+8+10-6+2+11-2-1NB+1-1+40-3-4-13+1+4+3-1+5+1+5-20+80-1+8+5NS-2-2-1-1-6-6-18-3-600-2-1+1-5-4+50-300NL+1+2+20+5+3-15+2-2+2+9+3-1+6-1-1+12-60+2+1PE+1-1+5+1+2-6-22+5+1+5+3+7+2+5+2-7+16-2+5+2+1BC-2-2-1-1-3+1+1-4-2-1+300-5-3-2-30-10-6Totalimpact($-millions)Volumeeffects($-millions)Therapeutic choice effects($-millions)Priceeffects($-millions)BC -$701 -$455 -$208 -$38AB -$89 $6 -$70 -$24SK -$92 -$68 -$29 $6MB -$52 -$49 -$14 $11ON $140 $274 $9 -$142QC $595 $308 $40 $247NB $49 $63 -$18 $5NS $41 $87 -$35 -$11PE $1 $4 -$4 $1NL $8 $34 -$30 $4Overall impact of age-standardized variations in cost-drivers on total spending within provinces, 2007Volume effects (%) Therapeutic choice effects (%)Sources of age-standardized variation from the national average per capita spending by province, 2007Price effects (%)drug use and higher pharmacists’ fees paid per unit, also explained much of this variation ($247 million).If cost-drivers in British Columbia were the same as the national average on an age-standardized basis, total spending on prescription drugs in that province would be $701 million higher than was the case in 2007. Most of this diff erence ($455 million) was a result of British Columbia residents purchasing fewer prescription drugs on an age-standardized basis. Th e selection of lower-cost treatment options within therapeutic categories also explained a sizable amount ($208 million) of the low spending in British Columbia.Potential explanation: formulary listingsDiff erences in provincial formularies do not appear to explain interprovincial variations in prescription drug spending.Ontario listed the smallest total number of drug types across all therapeutic categories; yet spending per capita in Ontario was slightly (2%) above the national average on an age-standardized basis.T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 4Overall, British Columbia listed slightly more types of prescription drugs on its formulary than did Quebec; yet age-standardized prescription drug spending per capita was more than 50% higher in Quebec than in British Columbia.Potential explanation: population characteristicsAn examination of population characteristics that might explain variations in age-standardized spending per capita on prescription drugs—such as income, health status or access to health care—does not point to any clear causes of observed variations.Th e two provinces that diff er most in terms of age-standardized prescription drug spending per capita—British Columbia and Quebec—do not systematically diff er in population characteristics that might explain the variation in prescription drug use and cost. Th ey diff er most in immigration rates: 28% for British Columbia and 12% for Quebec.However, immigration rates alone do not explain interprovincial variations in drug spending. Ontario had the same rate of immigration as British Columbia but 40% higher prescription drug spending on an age-standardized basis.Despite diff erences in prescription drug spending, British Columbia and Quebec both had lower total levels of health care spending than the rest of Canada; and the overall health status of both provinces was comparable to the national average.Changes in spending per capita, 1998–2007Retail spending on prescription drugs per Canadian grew at an infl ation-adjusted annual average rate of 6% per year between 1998 and 2007.Total retail spending on prescription drugs roughly doubled in infl ation-adjusted terms: from $9.72 billion to $18.99 billion (2007 dollars).BC+5+6+10+10+3+9+2+26+13+16-1+6+60+120+130+43AB+6+6+12+10+3+8+3+27+13+23+1+7+60+16-1+130+42SK+7+7+13+12+5+13+3+26+6+12-1+9+13+1+17-1+13+1+46MB+8+8+13+14+6+11+6+30+18+14+3+9+11+2+18+2+120+38ON+5+4+9+13+3+14+1+26+17+26+1+5+90+14-2+160+38QC+7+6+10+15+7+130+35+23+26+6+10+7+2+12-2+20+1+47NB+6+5+12+13+6+120+27+13+23+1+8+7+2+17-2+14-1+33 PE+NL+6+6+17+12+7+13+1+32+14+24+1+7+6-1+150+22-2+27NS+5+4+11+11+5+13-1+30+16+250+6+6+0+110+19-1+32CA+6+5+10+13+4+12+1+29+17+23+2+7+80+14-1+170+40BC+4+4+8+8+2+8+1+25+13+15-2+5+5-1+110+12+1+42AB+5+5+11+9+2+8+2+26+14+220+6+5-1+14-1+120+40SK+6+6+12+11+4+12+2+25+6+12-2+8+120+16-1+13+1+44MB+8+8+12+14+5+11+5+29+19+14+3+8+10+1+17+2+110+37ON+5+3+8+12+3+130+25+17+25+1+4+8-1+13-2+150+36QC+6+4+8+13+6+12-1+33+24+24+4+8+6+1+10-2+19+2+45NB+5+3+10+11+5+11-1+25+14+220+4+60+15-2+130+31 PE+NL+5+4+15+10+6+130+31+16+22-1+6+5-3+130+19-1+25NS+4+2+9+9+5+12-2+29+17+23-1+5+5-1+10-1+170+30CA+5+4+9+11+4+110+28+18+22+1+6+7-1+12-1+16+1+38Overall spendingAntihypertensivesStatinsAntithromboticsAntidepressantsAntipsychoticsBenzodiazepines and related drugsGabapentin, pregabalin, topiramatePsychotimulants and atomoxetineCholinesterase inhibitorsDrugs for Parkinson’s diseaseAcid reducing drugs Opioid drugsNonsteroidal anti-inflammatory drugsOral drugsOral antibioticsBisphosphonatesHormonal contraceptivesDrugs for erectile dysfunctionCardiovascular drugsNeurological drugsAnalgesicsDiabetes drugs-5+0+5+2.5-2.5+10+15+20Total change (% per year) Age-standardized change (% per year)Average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 5BC+3+4+9+8+4+4-2+27+4+15-2+4+1-3+5-4+120+33AB+3+4+11+8+3+6-1+30+3+210+50-4+6-4+12-1+32SK+4+4+12+9+4+6-1+300+11-1+5+10-2+8-3+150+35MB+4+5+11+12+4+50+31+9+12+3+7+5-2+8-5+14-2+29ON+3+4+9+9+5+7-3+28+6+26+1+4+3-2+5-5+16-1+30QC+4+3+8+8+6+6-3+34+13+26+3+7+20+5-4+22+1+37NB+3+3+10+9+5+4-3+28+4+220+4+2-3+5-5+13-1+25 PE+NL+3+3+15+8+6+3-2+33+7+210+4+2-5+6-4+21-3+19NS+2+2+9+8+5+3-3+30+6+23-1+3+2-3+3-3+17-1+24BC+2+0+1+30+4+1+2+70+1+2+3+2+6+4+20+9AB+2+1+1+4+1+2+2+1+9+1+2+3+5+3+8+3+2+1+9SK+3+2+2+6+2+7+2+1+50+1+4+2+3+9+2-10+10MB+3+1+1+5+1+7+20+90+1+2+3+3+7+6-1+1+8ON+2+0+1+60+6+2+2+11-2+1+2+4+2+8+3+2+1+7QC+2+1+1+7+1+5+1+2+11-1+2+2+2+2+5+3-30+9NB+3+1+2+5+2+8+1+2+100+2+4+4+4+11+3+1+1+6 PE+NL+3+2+2+4+2+11+1+2+80+1+3+4+3+8+40+1+7NS+2+1+1+4+1+9+1+3+100+1+3+3+3+8+3+2+1+7CA+2+1+1+5+1+5+1+1+10-1+1+2+3+2+7+300+8BC00-2-2-20+2-4+20-1-100+10-1+10AB-10-2-3-20+1-5+2+1-2-20-1-10-2+10SK-10-2-4-2-1+1-5+1+1-1-10-1-10-2+1-1MB+1+10-3-10+3-2+1+2-1-1+30+2+1-1+10ON-1-1-2-3-20+1-4+10-1-2+1-10-1-3+1-1QC00-1-1-10+2-200-1-1+1-10000-1NB-10-2-3-2-1+1-400-1-10-1-1-1-200 PE+NL-10-2-2-20+1-400-2-10-1-1-1-2+1-2NS-10-1-3-20+1-4+10-1-1-1-1-1-1-10-1CA00-2-2-20+2-4+10-1-2+1-10-1-2+1-1Volume effects (% per year) Therapeutic choice effects (% per year)Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Price effects (% per year)Increased volume of prescription drugs purchased was generally the most signifi cant driver of age-standardized spending growth in most provinces and therapeutic categories.Changes in the types of drugs selected for treatment constituted the second largest driver of age-standardized drug spending trends overall and for most therapeutic categories.Owing to increased availability and use of generics, overall prices paid for prescription drugs in Canada remained relatively stable between 1998 and 2007.Overall spending per capita grew most rapidly in Manitoba, which began 28% below the national average in 1998. Despite experiencing rapid spending growth, Manitoba ended up with spending per capita 9% below the national average in 2007.Quebec had the second fastest spending growth rate, beginning with per capita spending 7% above the national average in 1998 and ending with per capita spending 18% above the national average in 2007.Sources of change in spending per capitaIn comparison to the scale and causes of interprovincial variations in the levels of prescription drug spending, interprovincial diff erences in the cost-drivers that contributed to changes in spending over time were moderate.Population aging had modest eff ects on growth in retail spending on prescription drugs between 1998 and 2007.T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 6$0$10$20NLPENSNBQCONMBSKBC AB0$10$20NLPENSNBQCONMBSKBC AB$$0$10NLNS PENBQCONMBSKBC ABCanada overall$0$10NLNSNBQCONMBSKBC AB$0$10NLNSNBQCONMBSKBC AB PEAges 65+Ages 45–64Ages 20–44Ages 0–19All agesLevels of spending across Canada and age groupsSpending per capita$80$60$40$200-19 yearsNumberof people$107,776,058 people20-44 years$1211,740,792 people45-64 years$168,936,632 people65+$244,417,805Figure A» Per capita spending in Canada by age group, 2007Figure B» Per capita spending by province and age group, 2007Spending per capita The atlas illustrates age-specifi c levels, trends, and causes of retail spending on all prescription drugs sold in Canada. Separate results are provided for each of 20 top therapeutic categories in terms of spending. Data for each therapeutic category is mapped over six pages. The fi rst two pages examine spending across provinces and age groups. Figure A shows spending over the life-course for Canada. The width of each bar represents the relative size of the population in that age category. The height of each bar represents the average spending per capita in that age category in 2007. Thus the area of each bar shows the relative importance of spending levels by age category.2341 The fi ve parts of Figure B illustrate average spending levels in 2007 by age group and province. The solid line across the top bar chart illustrates the overall Canadian average for all ages. (Age-specifi c fi gures are set to zero when age-specifi c drug use is too low to record reliable spending estimates.)How to use this atlasU B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 70%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 5 drugsPercent of $1.0 billionUnrestricted coverageRestricted coverage Not coveredPer capita spending in Canada: $Drugs in this therapeutic category• • Common goals of therapy• • Examples of indicated conditions• • Figure C» Percentage of drugs and their market value listed on provincial formulariesPercent of 5 drugsPercent of $1.0 billion This sidebar presents the average per capita spending in Canada within the therapeutic category. It also provides examples of drugs in the category, primary goals of therapy, and examples of conditions for which the drugs may be prescribed.5 Figure C illustrates the extent to which drugs within the therapeutic category are covered, with given levels of restriction, by provincial drug plans (i.e., listed on provincial formularies). The top graph shows the percentage of the different drugs in the given class that were listed on each provincial formulary as of December 2006. The bottom graph weights the same analysis by total national spending on each drug. (Note: The bottom graph gives an indication of the relative importance of drugs listed; it is not meant to suggest that provinces actually pay for those shares of drug costs.)6T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 8Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $17.8 $20.9 $18.5 $19.6 $21.8 $18.1 $21.2 $21.9 $21.7 $29.7Total variation from national average -11.9% 3.4% -8.6% -3.2% 7.7% -10.7% 4.6% 8.4% 7.5% 46.7% Variation predicted by population age 0.8% -2.1% -0.2% -0.5% -0.3% 0.7% 1.0% 1.2% 0.9% 1.1%Age-standardized variation -12.5% 5.7% -8.5% -2.7% 8.1% -11.3% 3.5% 7.1% 6.6% 45.2% Prescription volume -5.3% 8.9% 19.8% 7.6% 6.5% -21.6% 2.6% 11.0% 17.1% 46.9% Prescription size -1.0% 1.0% -1.3% 1.2% 2.2% -4.4% 4.2% 1.7% 1.9% 10.1%Volume effects -6.3% 9.8% 18.4% 8.8% 8.7% -26.0% 6.8% 12.6% 19.0% 57.1% Therapeutic mix -4.6% -2.6% -16.0% -7.6% 0.9% 7.3% 1.0% -3.4% -2.3% -1.8% Drug mix -1.5% 0.7% -6.4% -5.8% -1.9% 5.1% -3.8% -1.9% -7.6% -4.1%Therapeutic choice effects -6.1% -1.9% -22.4% -13.3% -1.1% 12.4% -2.8% -5.3% -9.9% -5.9% Prices paid 0.3% -2.1% -2.0% 0.6% -0.2% 0.6% -0.9% -1.3% -4.6% -8.6% Generic use -0.4% -0.2% -2.5% 1.2% 0.7% 1.7% 0.4% 1.1% 2.1% 2.6%Price effects -0.1% -2.3% -4.5% 1.8% 0.4% 2.3% -0.5% -0.2% -2.5% -6.0%Table A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007How to use this atlas Table A lists per capita spending on drugs within the relevant therapeutic category for each province. The table also shows the extent to which different cost-drivers contribute to deviations from the national average. Bold fi gures indicate subtotals for each group of potential sources of variation. The sum of “Volume Effects” plus “Therapeutic Choice Effects” plus “Price Effects” will equal “Age-Standardized Deviation.” Figure D illustrates deviations from national average spending per capita (within the relevant therapeutic category) after adjusting for the population age in each province. The fi rst map in Figure E illustrates the extent to which age-standardized deviations in spending are driven by differences in the volumes of medicines purchased within each province. The second map in Figure E illustrates the extent to which age-standardized deviations in spending are driven by differences in the therapeutic choices made within each province. The third map in Figure E illustrates the extent to which age-standardized deviations in spending are driven by differences in the prices paid for equivalent drugs within each province. Data for each therapeutic category is mapped over six pages. The middle two pages examine the sources of interprovincial variation in drug spending in 2007.789101211U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 9-14%+10%+18%+10%-6%+9%+11%+7%+19%+13%-4%-2%-22%+3%-4%-1%+2%-3%-10%-5%-2%-2%-3%+6%+2%0%+2%-1%-2%0%BritishColumbia-20%NewBrunswick+4%NovaScotia+7%Newfoundlandand Labrador+19%Prince Edward I.+7%Alberta+6%Saskatchewan-8%Manitoba-13% Quebec+15%Ontario+8%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N2 0Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $22 $16 $14 $12 $12 $25 $29 $22 $24 $13Per capita spending in 2007 $58 $40 $43 $42 $42 $58 $76 $64 $67 $65 Average annual rate of change 10.0% 9.7% 11.8% 13.5% 13.1% 8.9% 10.0% 11.5% 10.8% 17.4% Rate of change due to population aging 1.3% 1.4% 1.3% 1.2% 0.9% 1.0% 1.6% 1.7% 1.7% 2.3%Age-standardized rate of change 8.7% 8.4% 10.5% 12.2% 12.2% 7.9% 8.4% 9.8% 9.1% 15.1% Prescription volume 10.0% 11.3% 9.7% 12.5% 11.3% 9.6% 10.1% 7.5% 7.5% 12.3% Prescription size -0.9% -2.0% 1.1% -0.1% 0.0% -1.1% -1.6% 2.2% 1.9% 2.3%Volume effects 9.0% 9.2% 10.8% 12.4% 11.4% 8.6% 8.5% 9.6% 9.4% 14.6% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 1.3% 0.8% 1.3% 2.0% 1.1% 1.4% 1.2% 1.8% 1.2% 2.2%Therapeutic choice effects 1.3% 0.8% 1.3% 2.0% 1.1% 1.4% 1.2% 1.8% 1.2% 2.2% Prices paid -0.2% 0.2% 0.4% 0.3% 0.8% 0.1% -0.3% 0.2% 0.1% 0.2% Generic use -1.4% -1.8% -2.0% -2.5% -1.1% -2.1% -1.0% -1.8% -1.6% -2.0%Price effects -1.6% -1.6% -1.6% -2.1% -0.3% -2.0% -1.3% -1.6% -1.5% -1.8%Table B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007How to use this atlas Table B lists per capita levels of infl ation-adjusted spending on drugs (within the relevant therapeutic category) in 1998 and 2007 for Canada and each province. Costs for 1998 are adjusted for infl ation and expressed in terms of 2007 dollars. The table also shows the extent to which different factors contributed to the average annual rate of growth in spending over the period. Bold fi gures indicate subtotals for each group of potential sources of variation. The sum of “Volume Effects” plus “Therapeutic Choice Effects” plus “Price Effects” will equal “Age-Standardized Deviation.” Figure F illustrates average annual rates of growth in spending (within the relevant therapeutic category), after adjusting for changes in population age within each province. The fi rst map in Figure G illustrates the extent to which age-standardized rates of spending growth are driven by changes in the volumes of medicines purchased within each province. The second map in Figure G illustrates the extent to which age-standardized rates of spending growth are driven by changes in the therapeutic choices made within each province. The third map in Figure G illustrates the extent to which age-standardized rates of spending growth are driven by changes in the prices paid for equivalent drugs within each province. Data for each therapeutic category is mapped over six pages. The last two pages examine changes in spending within provinces between 1998 and 2007.161817151413U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H2 1Note: All fi gures are expressed in the equivalent of year 2007 dollars.-14%+10%+18%+10%-6%+9%+11%+7%+19%+13%-4%-2%-22%+3%-4%-1%+2%-3%-10%-5%-2%-2%-3%+6%+2%0%+2%-1%-2%0%BritishColumbia-20%NewBrunswick+4%NovaScotia+7%Newfoundlandand Labrador+19%Prince Edward I.+7%Alberta+6%Saskatchewan-8%Manitoba-13% Quebec+15%Ontario+8%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N2 2Levels of spending across Canada and age groupsSpending per capita$500$375$625$750$250$1250-19 yearsNumberof people$1327,776,058 people20-44 years$27111,740,792 people45-64 years$7748,936,632 people65+$1,7784,417,8051 Overall spendingSpending in CanadaIMS Health data indicate that Canadians spent approximately $578 per capita on retail purchases of prescription drugs in 2007. Th is amounted to $19 billion in total.Average retail spending on prescription drugs increased steadily with age – more than doubling across each of the age brackets used in this study.Canadians over age 65 purchased medicines costing $1,778 per capita in 2007. Children, in contrast, received prescriptions worth an average of $132.Canadians over age 65 accounted for 41% of retail spending on prescription drugs in 2007. Canadians aged 45–64 (including the “baby boomers”) accounted for 36% of all spending.$0$200$400$600$800NLNS PENBQCONMBSKBC ABCanada overall$0NLNSNBQCONMBSKBC AB PE$200$0$200$400NLNSNBQCONMBSKBC AB PENLPENSNBQCONMBSKBC AB$200$0$600$400$1,000$800NLPENSNBQCONMBSKBC AB$0$400$200$800$600$1,200$1,000$1,600$1,400$2,000$1,800Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 1A» Per capita spending in Canada by age group, 2007Figure 1B» Per capita spending by province and age group, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H2 3Per capita spending in Canada: $577.70Drugs included in this analysisTh is analysis includes all prescription drugs • sold at retail pharmacies in Canada.It includes all dosage forms of those drugs.• Therapeutic categoriesTh is analysis includes all therapeutic • categories of prescription drug.It includes the 20 therapeutic categories • explored in the following pages, and 15 other categories not mapped in this atlas.Spending in provincesWhile total spending levels diff ered signifi cantly across provinces (as explained in the following pages), average spending increased steeply with age in all provinces. Diff erences in drug spending across age groups was greatest in Ontario, where average spending per person over age 65 was 3.2 times the average for all ages. Th is ratio was lowest in Newfoundland & Labrador (2.4) and Manitoba (2.5).Variations in age-specifi c spending across provinces were greatest among children (measured using coeffi cients of variation). Th e ratio of the highest spending per child (NL = $192) to lowest spending per child (BC = $61) was 3.14. Similar ratios for other age groups were between 1.52 and 1.64. For each of the age groups studied, the lowest level of average spending per person was observed in British Columbia. Highest levels of age-specifi c spending per capita are generally found in New Brunswick (under age 65) or Quebec (over age 65).Provincial formulary coverageProvinces provided restricted or unrestricted coverage for between 55% and 73% of all analysed drugs (those with greater than $1,000 in national sales).Weighted by national sales volumes, the drugs covered in each province accounted for more than 85% of the Canadian market.Figure 1C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 796 drugsPercent of $16.5 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N2 4Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.1 Overall spendingabove the national average, while spending in British Columbia, Saskatchewan, and Manitoba was signifi cantly below the national average.Sources of age-standardized variationIn all provinces that diff ered from national average spending levels aft er age-standardization, diff erences in the volume of prescription drugs purchased explained most of the deviation.Th erapeutic choice eff ects accounted for the second largest contribution to regional variation in age-standardized spending. Th e most signifi cant of the choice-related cost-drivers was the broad therapeutic mix of drug classes prescribed from within the therapeutic categories. Residents of British Columbia, who had the lowest age-standardized spending per capita, used fewer medicines than other Canadians, used lower cost options from within therapeutic categories, and paid lower unit prices for drugs purchased.Population age and provincial spendingSome of Canada’s interprovincial variation in retail spending on prescription drugs is explained by diff erences in the ages of provincial populations.Provinces east of Ontario have older populations than the national average, and would therefore be expected to have higher spending per capita. Th e same is true for British Columbia and Saskatchewan.Th e biggest expected diff erence in spending due to population age alone would be for Alberta, which has the youngest population (an especially small proportion over age 65).Age-standardized per capita spending on prescription drugs in Alberta, Ontario, Prince Edward Island, and Newfoundland & Labrador did not diff er signifi cantly (by more than 5%) from the national average. Age-standardized spending per capita in Quebec, New Brunswick, and Nova Scotia was signifi cantly BC AB SK MB ON QC NB NS PE NLPer capita spending in province $432 $496 $491 $525 $580 $681 $674 $655 $606 $622Total variation from national average -25.3% -14.1% -15.0% -9.2% 0.3% 17.8% 16.6% 13.4% 4.9% 7.7% Variation predicted by population age 2.4% -9.6% 0.9% -1.6% -1.6% 4.5% 5.3% 5.8% 3.7% 5.0%Age-standardized variation -27.7% -4.4% -15.9% -7.6% 1.9% 13.4% 11.3% 7.6% 1.2% 2.7% Prescription volume -30.3% -22.5% -5.8% -14.4% -15.5% 44.7% -11.4% -14.0% -9.9% -3.1% Prescription size 12.4% 22.8% -6.0% 7.3% 19.2% -37.8% 25.9% 30.1% 15.5% 14.8%Volume effects -18.0% 0.3% -11.9% -7.1% 3.7% 6.9% 14.5% 16.1% 5.6% 11.7% Therapeutic mix -4.8% -2.8% 0.1% -1.7% -0.9% -0.5% -3.3% -5.7% -4.0% -6.1% Drug mix -3.4% -0.7% -5.2% -0.4% 1.0% 1.4% -0.9% -0.7% -1.3% -4.3%Therapeutic choice effects -8.2% -3.5% -5.1% -2.0% 0.1% 0.9% -4.3% -6.4% -5.3% -10.3% Prices paid -0.8% -0.4% 3.5% 4.8% -1.3% 3.2% 2.3% -1.3% 0.9% 1.3% Generic use -0.7% -0.8% -2.5% -3.2% -0.6% 2.3% -1.3% -0.8% 0.1% 0.0%Price effects -1.5% -1.2% 1.0% 1.5% -1.9% 5.5% 1.1% -2.1% 0.9% 1.3%Table 1A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H2 5-18%0%-12%+12%-7%+4%+7%+14%+6%+16%-8%-4%-5%-10%-2%0%+1%-4%-5%-6%-2%-1%+1%+1%+2%-2%+6%+1%+1%-2%BritishColumbia-28%NewBrunswick+11%NovaScotia+8%Newfoundlandand Labrador+3%Prince Edward I.+1%Alberta-4%Saskatchewan-16%Manitoba-8% Quebec+13%Ontario+2%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 1E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 1D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N2 6Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.1 Overall spendingAge-standardized and infl ation-adjusted growth rates in retail spending on prescription drugs ranged from 4.2% in Nova Scotia to 8% in Manitoba.Increased volume of prescription drugs purchased was the major driver of age-standardized spending growth in most provinces.Changes in the types of drugs selected for treatment constituted the second largest driver of age-standardized drug spending trends in most provinces, and the largest cost-driver in New Brunswick and Nova Scotia.Owing to savings resulting from generic competition, average prices paid for drugs fell slightly in all provinces except Manitoba. Increased unit prices (potentially driven by pharmacists’ fees) more than off set generic savings in Manitoba.Pace of change, 1998–2007Infl ation-adjusted spending on retail purchases of prescription drugs per Canadian grew 78% from 1998 to 2007. Th us, adjusted for the eff ects of general infl ation on the value of a dollar, retail spending on prescription drugs per capita grew at an average rate of 6% per year between 1998 and 2007.Th e most rapid growth was observed in Manitoba, which began 28% below national average in 1998. Quebec had the second fastest growth rate, but began with spending 7% above national average in 1998.Sources of changePopulation aging had modest but varied eff ects on growth in retail spending on prescription drugs in Canadian provinces between 1998 and 2007.Aging caused prescription drug spending to grow by 1% or more per year in provinces east of Ontario and in British Columbia, but less than 0.5% in Manitoba.Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $324 $258 $288 $254 $232 $344 $346 $373 $392 $330Per capita spending in 2007 $578 $432 $496 $491 $525 $580 $681 $674 $655 $619 Average annual rate of change 6.0% 5.3% 5.6% 6.8% 8.5% 5.4% 7.0% 6.1% 5.3% 6.5% Rate of change due to population aging 0.9% 1.0% 0.9% 0.8% 0.5% 0.7% 1.2% 1.2% 1.1% 1.4%Age-standardized rate of change 5.1% 4.3% 4.7% 6.0% 8.0% 4.7% 5.8% 4.9% 4.2% 5.1% Prescription volume 4.0% 3.8% 1.8% 3.7% 4.1% 3.8% 5.5% 1.2% 0.9% 0.8% Prescription size -0.7% -0.9% 1.1% 0.2% 0.3% -0.7% -1.4% 1.5% 1.5% 2.2%Volume effects 3.3% 2.9% 2.9% 3.9% 4.3% 3.2% 4.1% 2.6% 2.4% 3.0% Therapeutic mix 1.4% 1.2% 1.4% 1.9% 1.7% 1.3% 1.4% 1.7% 1.5% 1.6% Drug mix 0.7% 0.5% 1.0% 0.7% 1.4% 0.9% 0.6% 1.2% 0.9% 1.1%Therapeutic choice effects 2.0% 1.7% 2.3% 2.7% 3.0% 2.2% 1.9% 2.9% 2.4% 2.6% Prices paid 0.4% 0.6% 0.4% 0.4% 1.0% 0.3% 0.3% 0.3% 0.2% 0.2% Generic use -0.6% -0.9% -1.0% -1.0% -0.4% -1.0% -0.5% -0.9% -0.8% -0.8%Price effects -0.3% -0.3% -0.6% -0.6% 0.6% -0.7% -0.2% -0.7% -0.7% -0.6%Table 1B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H2 7Note: All fi gures are expressed in the equivalent of year 2007 dollars.+3%+3%+4%+3%+4%+3%+4%+3%+2%+2%+2%+3%+3%+3%+2%+2%+3%+2%0%-1%-1%-1%+1%-1%0%-1%-1%BritishColumbia+4%NewBrunswick+5%NovaScotia+4%Newfoundlandand LabradorandPrince Edward I.+5%Alberta+5%Saskatchewan+6%Manitoba+8% Quebec+6%Ontario+5%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 1G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 1F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N2 8Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$011,740,792 people45-64 years$1108,936,632 people65+$3994,417,8052.1 Cardiovascular: AntihypertensivesSpending in CanadaCanadians spent more money on retail purchases of antihypertensive drugs—nearly $84 per capita—than on any other therapeutic category of prescription drug in 2007. Antihypertensive treatments accounted for a total of $2.7 billion in 2007 (14% of all prescription drug spending in Canada).Spending on antihypertensive drugs is highly concentrated among older adults. In 2007, Canadians aged 65 and older spent an average of $399 on antihypertensive prescriptions; these purchases made up 64% of total retail spending in this therapeutic category. Canadians aged 45–64 spent an average of $110 each.Th ere were insuffi cient purchases of antihypertensive drugs by persons under age 45 to generate reliable age- and province-specifi c estimates of spending per capita for those age groups. (Total fi gures for this therapeutic category exclude estimates for the censored age categories.)$0$100NLNSNBQCONMBSKBC AB PE$0$100$200$300$400NLPENSNBQCONMBSKBC AB$0$100$200NLPENSNBQCONMBSKBC AB$0$100NLNSNBQCONMBSKBC AB PE$0$100NLNS PENBQCONMBSKBC ABCanada overallAges 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 2.1A» Per capita spending in Canada by age group, 2007Figure 2.1B» Per capita spending by province and age group, 2007Levels of spending across Canada and age groupsU B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H2 9Spending in provincesTh e diff erence in antihypertensive drug spending across age groups was greatest in Ontario, where average spending per person aged 65 and older was 4.1 times the average for persons aged 45–64. Th is ratio was lowest in Newfoundland & Labrador (2.5), Manitoba (2.5), and Saskatchewan (2.6).Variations in age-specifi c spending across provinces were higher among persons aged 45–64 than among those aged 65 and older. Despite this, age-specifi c spending per capita varied less in this therapeutic category than in most others (measured using coeffi cients of variation).British Columbia had the lowest levels of average spending per person aged 45–64 ($79), per person aged 65 and older ($304), and per capita for all ages ($65). Newfoundland & Labrador had the highest average level of spending per person aged 45–64 ($151), and Quebec had the highest average spending per person aged 65 and older ($458).Per capita spending in Canada: $83.60Drugs in this therapeutic categoryTh iazide diuretics (e.g. hydrochlorothiazide)• Beta blocking agents (e.g. atenolol)• Calcium channel blockers (e.g. nifedipine)• Angiotensin converting enzyme inhibitors • (e.g. ramipril)Angiotensin II receptor blockers (e.g. • losartan)Common goal of therapyReduce the risk of heart attack and stroke• Examples of indicated conditionsHigh blood pressure• Coronary artery disease• Diabetes mellitus• 0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 56 drugsPercent of $2.9 billionProvincial formulary coverageProvinces provided restricted or unrestricted coverage for over 90% of the 56 types of antihypertensive drug that had at least $1,000 in national sales.Weighted by national sales volumes, the antihypertensive drugs covered in each province except British Columbia accounted for virtually all of the Canadian antihypertensive market. Antihypertensives covered in British Columbia accounted for 84% of the Canadian antihypertensive market.Figure 2.1C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not coveredListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N3 0Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.2.1 Cardiovascular: AntihypertensivesSources of age-standardized variationVolume of treatment purchased was the most important cost-driver for most provinces that deviated signifi cantly from the national average age-standardized retail spending on antihypertensive drugs.Prices also played an important role in this therapeutic category, particularly in Quebec. Average prices per unit of antihypertensive drugs were relatively high in Quebec—probably because small prescription sizes increased the amount of pharmacists’ fees paid per unit dispensed. Residents of Quebec were also less likely to receive available generics than other Canadians.Th erapeutic choice eff ects signifi cantly infl uenced age-standardized antihypertensive spending in some provinces. Residents of Saskatchewan received the most expensive mix of antihypertensive drugs, while residents of British Columbia received the least expensive mix.Population age and provincial spendingBecause of the very steep age gradient in spending on antihypertensive drugs, diff erences in the age of provincial populations alone would predict relatively signifi cant variations in spending per capita in this therapeutic category.Diff erences in population age alone would predict that per capita spending on antihypertensives would range from 16.6% below the national average in Alberta to 9.8% above the national average in Nova Scotia.Aft er fi gures were adjusted for population age, spending levels in several provinces remained signifi cantly diff erent from the national average.Age-standardized antihypertensive spending was more than 10% above the national average in Quebec, Nova Scotia, and Newfoundland & Labrador. Age-standardized antihypertensive spending in British Columbia was 26% below the national average.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $65.1 $67.7 $86.5 $77.5 $79.8 $103.2 $93.9 $100.6 $92.6 $100.0Total variation from national average -22.2% -19.1% 3.5% -7.2% -4.5% 23.4% 12.4% 20.4% 10.8% 19.6% Variation predicted by population age 3.7% -16.6% 4.0% -1.5% -2.4% 7.0% 8.2% 9.8% 6.9% 8.2%Age-standardized variation -25.9% -2.5% -0.4% -5.7% -2.1% 16.4% 4.2% 10.6% 3.9% 11.4% Prescription volume -39.3% -42.1% 11.5% -19.1% -23.2% 58.5% -22.0% -17.7% -34.4% -1.5% Prescription size 25.2% 40.7% -22.6% 6.6% 28.7% -55.9% 35.9% 35.1% 45.5% 19.0%Volume effects -14.1% -1.3% -11.1% -12.6% 5.5% 2.6% 13.9% 17.3% 11.2% 17.5% Therapeutic mix -5.7% 0.3% 2.7% -0.2% -2.3% 3.4% -8.2% -6.1% -6.6% -7.7% Drug mix -3.6% 0.7% 1.2% 0.5% 0.1% -0.4% -0.6% 1.4% 0.8% 0.1%Therapeutic choice effects -9.3% 1.0% 3.9% 0.4% -2.2% 3.0% -8.8% -4.7% -5.8% -7.6% Prices paid -1.3% -1.0% 9.3% 4.8% -4.1% 7.2% 1.2% -1.3% -0.8% 1.7% Generic use -1.1% -1.1% -2.5% 1.7% -1.3% 3.6% -2.1% -0.7% -0.6% -0.2%Price effects -2.5% -2.1% 6.8% 6.5% -5.4% 10.8% -0.9% -2.0% -1.4% 1.5%Table 2.1A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H3 1-14%-1%-11%+18%-13%+5%+3%+14%+11%+17%-9%+1%+4%-8%0%-2%+3%-9%-6%-5%-2%-2%+7%+2%+6%-5%+11%-1%-1%-2%BritishColumbia-26%NewBrunswick+4%NovaScotia+11%Newfoundlandand Labrador+11%Prince Edward I.+4%Alberta-3%Saskatchewan0%Manitoba-6% Quebec+16%Ontario-2%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 2.1E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 2.1D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N3 2Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.2.1 Cardiovascular: Antihypertensivesin 1998 and 2007. Age-standardized antihypertensive spending per capita grew least quickly in Nova Scotia (2.4% per year aft er adjusting for general infl ation), where spending in both 1998 and 2007 was well above the age-standardized national average.Increased volume of antihypertensive drugs purchased was the major driver of age-standardized per capita spending growth in all provinces.Changes in the types of antihypertensive drugs selected contributed modestly to spending between 1998 and 2007. Th erapeutic choice eff ects contributed the most to spending increases (1.8% per year aft er adjusting for general infl ation) in Saskatchewan.In all provinces, the prices paid for particular brands of antihypertensive products increased from 1998 to 2007. Th is was off set to varying extents by increases in generic competition.Pace of change, 1998–2007With infl ation-adjusted growth of 5.1% per year from 1998 to 2007, per capita spending on antihypertensive drugs grew slightly less rapidly than overall prescription drug spending in Canada. Because of the size of this therapeutic category, growth in antihypertensive spending accounted for 13% of the total increase in retail spending on prescription drugs in Canada from 1998 to 2007.Sources of changePopulation aging caused infl ation-adjusted spending per capita on antihypertensive drugs to grow by 1% or more per year in all provinces except Saskatchewan, Manitoba, and Ontario.Age-standardized antihypertensive spending per capita grew most quickly in Manitoba (7.8% per year aft er adjusting for general infl ation), where age-standardized spending was below the national average Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $50.9 $37.8 $37.6 $45.0 $34.4 $53.3 $59.1 $58.2 $68.5 $55.1Per capita spending in 2007 $83.6 $65.1 $67.7 $86.5 $77.5 $79.8 $103.2 $93.9 $100.6 $98.4 Average annual rate of change 5.1% 5.6% 6.1% 6.8% 8.5% 4.1% 5.7% 4.9% 3.9% 6.0% Rate of change due to population aging 1.1% 1.3% 1.2% 0.9% 0.6% 0.8% 1.5% 1.5% 1.5% 1.9%Age-standardized rate of change 4.0% 4.3% 4.9% 5.8% 7.8% 3.3% 4.2% 3.4% 2.4% 4.1% Prescription volume 4.2% 5.5% 2.9% 4.0% 5.1% 4.4% 4.7% 1.2% 0.3% -0.1% Prescription size -0.6% -1.3% 1.2% 0.3% -0.1% -0.8% -1.4% 1.8% 1.3% 2.9%Volume effects 3.5% 4.2% 4.1% 4.3% 5.0% 3.6% 3.2% 3.0% 1.7% 2.9% Therapeutic mix 0.8% 0.6% 0.9% 1.5% 0.7% 0.5% 1.1% 0.3% 0.7% 0.6% Drug mix -0.2% -0.4% 0.2% 0.4% 0.7% -0.3% -0.2% 0.6% 0.4% 1.0%Therapeutic choice effects 0.7% 0.2% 1.1% 1.8% 1.4% 0.2% 0.9% 0.9% 1.1% 1.6% Prices paid 0.3% 0.5% 0.3% 0.2% 1.3% 0.2% 0.4% 0.2% 0.2% 0.0% Generic use -0.6% -0.6% -0.6% -0.5% 0.1% -0.7% -0.3% -0.7% -0.5% -0.3%Price effects -0.2% -0.2% -0.3% -0.3% 1.4% -0.5% 0.1% -0.5% -0.3% -0.3%Table 2.1B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H3 3Note: All fi gures are expressed in the equivalent of year 2007 dollars.+4%+4%+4%+3%+5%+4%+3%+3%+2%0%+1%+2%+2%+1%0%+1%+1%+1%0%0%0%0%+1%-1%0%0%0%BritishColumbia+4%NewBrunswick+3%NovaScotia+2%Newfoundlandand LabradorandPrince Edward I.+4%Alberta+5%Saskatchewan+6%Manitoba+8% Quebec+4%Ontario+3%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 2.1G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 2.1F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N3 4Levels of spending across Canada and age groupsSpending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$011,740,792 people45-64 years$898,936,632 people65+$2514,417,8052.2 Cardiovascular: StatinsSpending in CanadaStatins used to manage cardiovascular risks are the second largest therapeutic category of prescription drugs in terms of retail spending in Canada. Canadians spent approximately $58 per capita on these drugs in 2007, for a total of $1.9 billion (10% of all prescription drug spending in Canada).As with other cardiovascular drugs, spending on statins is highly concentrated among older adults. In 2007, Canadians aged 65 and older spent an average of $251 on statins. Canadians aged 45–64 purchased an average of $89 each and accounted for 42% of all statin sales in Canada.Th ere were insuffi cient purchases of statins by persons under age 45 to generate reliable age- and province-specifi c estimates of spending per capita for those age groups. (Total fi gures for this therapeutic category exclude estimates for the censored age categories.)$0$50NLNSNBQCONMBSKBC AB$0$50NLNSNBQCONMBSKBC AB PE$0$50$100NLPENSNBQCONMBSKBC AB0$50$100$150$200$250NLPENSNBQCONMBSKBC AB$$0$50NLNS PENBQCONMBSKBC ABCanada overallAges 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 2.2A» Per capita spending in Canada by age group, 2007Figure 2.2B» Per capita spending by province and age group, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H3 5Per capita spending in Canada: $57.80Drugs in this therapeutic categoryStatins (e.g. atorvastatin)• Common goal of therapyReduce the risk of heart attack and stroke• Examples of indicated conditionsElevated cholesterol• Coronary artery disease• 0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 8 drugsPercent of $1.9 billionSpending in provincesAge gradients for spending on statins varied across provinces.Th e ratio of average statin spending per person aged 65 and older to that of people aged 45–64 was 3.2 in Ontario and 4.5 in Prince Edward Island. Th is ratio was 2.0 in Saskatchewan and 1.9 in Newfoundland & Labrador.Average retail spending on statins per person aged 45–64 ranged from $55 in British Columbia to over $116 in Quebec and Newfoundland & Labrador.Average spending per person aged 65 and older varied nearly as much in proportional terms: from $152 in Saskatchewan to $297 in Quebec.Provincial formulary coverageProvinces provided unrestricted coverage for between six and eight of the diff erent types of statins that had more than $1,000 in national sales. No restricted listings were used.Weighted by national sales volumes, the drugs covered in each province accounted for virtually the entire Canadian statin market. (Drugs not listed achieved very small sales relative to leading drugs in this class.)Figure 2.2C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverage Not coveredListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N3 6Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.2.2 Cardiovascular: StatinsSources of age-standardized variationVolume of treatment purchased was the most important cost-driver for most provinces that deviated signifi cantly from the national average age-standardized retail spending on statins.Aft er adjusting for population age, residents of Western Canada purchased signifi cantly fewer statins than did other Canadians.Th erapeutic choice eff ects and price diff erences contributed modestly (<5%) to provincial variations in age-adjusted per capita spending on statins.As with other categories, prices paid per unit of particular brands of statins in some provinces may have been infl uenced by the average length of prescriptions. Shorter prescriptions result in higher levels of pharmacists’ fees paid per unit of drug received.Population age and provincial spendingBecause spending on statins is concentrated among older adults, diff erences in the age of provincial populations alone would cause relatively signifi cant variations in spending per capita.Age-standardization alone would predict that per capita spending on statins in Alberta would be 15% below the national average. In contrast, age-standardization would predict statin spending per Nova Scotian to be 9.5% above the national average.Aft er fi gures were adjusted for diff erences in population age, spending on statins deviated by more than 5% from the national average in all provinces except Ontario and New Brunswick.Age-standardized spending on statins was approximately 25% above the national average in Quebec, and more than 25% below the national average in British Columbia, Saskatchewan, and Manitoba.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $40.2 $42.6 $41.9 $42.1 $58.1 $76.1 $64.4 $66.7 $56.2 $67.5Total variation from national average -30.5% -26.2% -27.5% -27.2% 0.6% 31.7% 11.5% 15.5% -2.7% 17.0% Variation predicted by population age 3.5% -15.0% 2.5% -1.6% -2.5% 7.1% 8.2% 9.5% 6.5% 8.8%Age-standardized variation -33.9% -11.2% -30.0% -25.6% 3.1% 24.6% 3.3% 6.0% -9.2% 8.2% Prescription volume -54.2% -51.6% -8.8% -32.0% -26.5% 72.7% -33.2% -27.2% -2.6% -8.1% Prescription size 22.8% 39.3% -22.9% 4.3% 31.9% -52.2% 35.2% 37.4% -8.7% 19.9%Volume effects -31.4% -12.4% -31.7% -27.7% 5.4% 20.5% 2.0% 10.2% -11.3% 11.8% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix -1.4% -0.1% -2.8% -0.2% 1.1% -0.1% -2.3% -3.1% -3.2% -6.0%Therapeutic choice effects -1.4% -0.1% -2.8% -0.2% 1.1% -0.1% -2.3% -3.1% -3.2% -6.0% Prices paid -0.8% 1.6% 6.1% 2.6% -3.0% 3.3% 4.0% -0.8% 5.2% 2.7% Generic use -0.3% -0.3% -1.6% -0.3% -0.4% 0.8% -0.4% -0.3% 0.1% -0.4%Price effects -1.1% 1.3% 4.5% 2.3% -3.4% 4.1% 3.7% -1.1% 5.2% 2.4%Table 2.2A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H3 7-31%-12%-32%+12%-28%+5%+21%+2%-11%+10%-1%0%-3%-6%0%+1%0%-2%-3%-3%-1%+1%+5%+2%+2%-3%+4%+4%+5%-1%BritishColumbia-34%NewBrunswick+3%NovaScotia+6%Newfoundlandand Labrador+8%Prince Edward I.-9%Alberta-11%Saskatchewan-30%Manitoba-26% Quebec+25%Ontario+3%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 2.2E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 2.2D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N3 8Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.2.2 Cardiovascular: Statinsstatin spending per capita grew least rapidly in Ontario (7.9% per year aft er adjusting for general infl ation).Increased volumes of prescriptions purchased from 1998 to 2007 were by far the major driver of age-standardized per capita spending on statins in Canada. Aft er adjusting for population aging and general infl ation, increased prescribing of statins caused spending per capita to rise by more than 8.5% per year in all provinces.Outside British Columbia, changes in the types of statins selected between 1998 and 2007 contributed over 1% per year to the growth in age-standardized, infl ation-adjusted statin spending per capita.Increased availability and use of generic statins between 1998 and 2007 resulted in savings ranging between 1.0% and 2.5% per year within the provinces. Th e prices paid for particular brands of statins increased slightly in most provinces and fell slightly in Quebec.Pace of change, 1998–2007Infl ation-adjusted retail spending on statins per Canadian grew by 158% between 1998 and 2007.Owing to the size of this therapeutic category and the pace of growth in spending within it, statins contributed more to overall growth in spending on prescription drugs than any other therapeutic category of medicines. Statins accounted for 14% of the total increase in prescription drug spending in Canada between 1998 and 2007.Sources of changePopulation aging contributed between 0.9% and 2.3% toward the annual growth of per capita retail spending on statins in Canadian provinces from 1998 to 2007.Age-standardized spending per capita on statin drugs grew most rapidly in Prince Edward Island and Newfoundland & Labrador (15.1% per year aft er adjusting for general infl ation). Age-standardized Canada BC AB SK MB ON QC NB NS PE & NLPer capita spending in 1998 $22.3 $15.9 $13.9 $11.8 $12.3 $24.7 $29.2 $21.7 $23.9 $13.1Per capita spending in 2007 $57.7 $40.2 $42.6 $41.9 $42.1 $58.1 $76.1 $64.4 $66.7 $65.1 Average annual rate of change 10.0% 9.7% 11.8% 13.5% 13.1% 8.9% 10.0% 11.5% 10.8% 17.4% Rate of change due to population aging 1.3% 1.4% 1.3% 1.2% 0.9% 1.0% 1.6% 1.7% 1.7% 2.3%Age-standardized rate of change 8.7% 8.4% 10.5% 12.2% 12.2% 7.9% 8.4% 9.8% 9.1% 15.1% Prescription volume 10.0% 11.3% 9.7% 12.5% 11.3% 9.6% 10.1% 7.5% 7.5% 12.3% Prescription size -0.9% -2.0% 1.1% -0.1% 0.0% -1.1% -1.6% 2.2% 1.9% 2.3%Volume effects 9.0% 9.2% 10.8% 12.4% 11.4% 8.6% 8.5% 9.6% 9.4% 14.6% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 1.3% 0.8% 1.3% 2.0% 1.1% 1.4% 1.2% 1.8% 1.2% 2.2%Therapeutic choice effects 1.3% 0.8% 1.3% 2.0% 1.1% 1.4% 1.2% 1.8% 1.2% 2.2% Prices paid -0.2% 0.2% 0.4% 0.3% 0.8% 0.1% -0.3% 0.2% 0.1% 0.2% Generic use -1.4% -1.8% -2.0% -2.5% -1.1% -2.1% -1.0% -1.8% -1.6% -2.0%Price effects -1.6% -1.6% -1.6% -2.1% -0.3% -2.0% -1.3% -1.6% -1.5% -1.8%Table 2.2B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H3 9Note: All fi gures are expressed in the equivalent of year 2007 dollars.+9%+11%+12%+15%+11%+9%+8%+10%+9%+1%+1%+2%+2%+1%+1%+1%+2%+1%-2%-2%-2%-2%0%-2%-1%-2%-1%BritishColumbia+8%NewBrunswick+10%NovaScotia+9%Newfoundlandand LabradorandPrince Edward I.+15%Alberta+11%Saskatchewan+12%Manitoba+12% Quebec+8%Ontario+8%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 2.2G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 2.2F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N4 0Levels of spending across Canada and age groups2.3 Cardiovascular: AntithromboticsSpending in CanadaWith retail spending at $9.80 per Canadian in 2007, antithrombotic drugs constituted the third largest category of cardiovascular drugs, and the 13th largest therapeutic category overall.Th e $324 million that Canadians spent at retail pharmacies on these medicines accounted for 1.7% of total prescription drug spending in 2007.While this category is smaller in scale than other cardiovascular drug classes, the use and cost of antithrombotic drugs is more concentrated among the elderly. In 2007, 77% of all Canadian spending on antithrombotic drugs was for persons aged 65 and older.Canadians aged 65 and older spent an average of $56.60 on antithrombotic drugs in 2007; those aged 45–64 spent an average of $8.20 on these medicines.Th ere were insuffi cient purchases of antithrombotic drugs by persons under age 45 to generate reliable age- and province-specifi c estimates of spending per capita for those age groups. (Total fi gures for this therapeutic category exclude estimates for the censored age categories.)$0NLNSNBQCONMBSKBC AB PE$10NLPE$0$10NSNBQCONMBSKBC AB$0$10NLNS PENBQCONMBSKBC ABCanada overallNLPENSNBQCONMBSKBC AB$10$0NLPENSNBQCONMBSKBC AB$0$10$20$30$40$60Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 2.3A» Per capita spending in Canada by age group, 2007Figure 2.3B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$011,740,792 people45-64 years$88,936,632 people65+$574,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H4 1Per capita spending in Canada: $9.80Drugs in this therapeutic categoryClopidogrel• Ticlopidine• ASA/dipyridamole• Warfarin• Nicoumalone• Common goals of therapyReduce the risk of heart attack and stroke• Treat and prevent blood clots• Examples of indicated conditionsDeep vein thrombosis• Stroke• Atrial fi brillation• 0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 5 drugsPercent of $0.3 billionSpending in provincesTh e degree of diff erence in spending on antithrombotic drugs per person between those aged 45–64 and those aged 65 and older varied across provinces. In Ontario and British Columbia, the ratio of average antithrombotic spending per person aged 65 and older to that of people aged 45–64 was more than seven; that ratio was less than fi ve in Manitoba and Newfoundland & Labrador.Diff erences in antithrombotic spending by ages across provinces stemmed largely from diff erences in antithrombotic spending per resident aged 45–64, which ranged from $6 in British Columbia to $13 in Manitoba.Spending per person aged 65 and older diff ered more modestly across provinces, varying by 35%: from $46 in British Columbia to $62 in Manitoba.Provincial formulary coverageAll antithrombotic drugs were listed on all provincial formularies. All provinces provided unrestricted coverage for two of the fi ve types of antithrombotic drug, restricted coverage for one of the fi ve, and either restricted or unrestricted coverage for the remaining two drugs. Th e antithrombotics that received restricted coverage in all provinces accounted for a signifi cant majority (72%) of total national sales in this therapeutic category.Figure 2.3C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverage Restricted coverageListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N4 2Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.2.3 Cardiovascular: AntithromboticsSources of age-standardized variationProvincial variations in spending on antithrombotic drugs were driven by all three categories of cost-drivers: volume eff ects, therapeutic choice eff ects, and price eff ects.Volume of treatment purchased was the predominant reason for British Columbia having lower age-standardized retail spending on antithrombotics.Th erapeutic choice eff ects were particularly important determinants of variation in spending, with residents of British Columbia and Alberta receiving less costly antithrombotic drugs than residents in the rest of Canada.Prices were also important in this therapeutic category. Prices paid per unit of particular brands of antithrombotic drug in Saskatchewan, Manitoba, and Quebec were 5% or more above the national average.Population age and provincial spendingBecause spending on antithrombotics is so highly concentrated among the elderly, diff erences in the age of provincial populations alone would predict relatively signifi cant variations in spending per capita in this therapeutic category.Age-standardization alone would predict that per capita spending on antithrombotics in Alberta would be 18% below the national average. Similarly, population age alone would predict that spending in all provinces east of Ontario would be nearly 7% or more above the national average.Aft er fi gures were adjusted for diff erences in population age, per capita spending on antithrombotic drugs deviated by more than 5% from the national average in many provinces.Age-standardized spending on antithrombotics was 20% above the national average in Manitoba, and 21% below the national average in British Columbia.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $8.2 $7.3 $11.7 $11.8 $9.5 $11.5 $12.3 $10.7 $10.5 $11.6Total variation from national average -17.0% -25.6% 18.9% 19.5% -3.4% 16.7% 25.3% 8.9% 6.8% 18.1% Variation predicted by population age 4.1% -18.1% 6.8% -0.8% -2.3% 6.9% 8.6% 9.6% 7.2% 6.8%Age-standardized variation -21.1% -7.5% 12.1% 20.3% -1.2% 9.8% 16.7% -0.7% -0.4% 11.3% Prescription volume -33.1% -31.3% 9.3% -16.7% -19.4% 53.0% -30.1% -43.6% -32.1% -28.7% Prescription size 16.4% 38.1% -3.1% 17.4% 22.5% -50.5% 39.1% 40.1% 18.3% 31.8%Volume effects -16.8% 6.8% 6.2% 0.8% 3.1% 2.5% 9.0% -3.5% -13.8% 3.1% Therapeutic mix -5.2% -14.4% -2.9% 13.8% 3.5% -0.9% 5.0% 2.0% 11.7% 6.2% Drug mix 1.8% 0.2% 1.5% 2.1% -3.4% 1.3% 2.5% 2.0% 0.7% 1.7%Therapeutic choice effects -3.3% -14.2% -1.4% 16.0% 0.1% 0.4% 7.5% 4.0% 12.4% 7.9% Prices paid 0.7% 1.5% 8.7% 5.1% -3.4% 5.5% 1.7% 0.3% 2.5% 2.5% Generic use -1.7% -1.5% -1.5% -1.5% -0.9% 1.4% -1.5% -1.6% -1.5% -2.2%Price effects -1.0% -0.1% 7.3% 3.6% -4.4% 6.9% 0.2% -1.2% 1.0% 0.3%Table 2.3A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H4 3-17%+7%+6%-3%+1%+3%+3%+9%-14%-4%-3%-14%-1%+8%+16%0%0%+8%+12%+4%-1%0%+7%0%+4%-4%+7%0%+1%-1%BritishColumbia-21%NewBrunswick+17%NovaScotia-1%Newfoundlandand Labrador+11%Prince Edward I.0%Alberta-7%Saskatchewan+12%Manitoba+20% Quebec+10%Ontario-1%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 2.3E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 2.3D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N4 4Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.2.3 Cardiovascular: Antithromboticscapita grew least rapidly in British Columbia (8.4%), where spending was average in 1998 and below the national average in 2007.Increased volumes of antithrombotic drugs purchased were the largest drivers of age-standardized spending in all provinces.Th erapeutic choice eff ects were also important determinants of rising costs of antithrombotic drugs between 1998 and 2007. Across provinces, increased use of more expensive antithrombotic drugs caused average annual costs of treatment to rise by between 2.8% per year (British Columbia) and 6.8% per year (Quebec).Increased availability and use of generics and falling prices for existing products generated price savings between 1998 and 2007. Over this period, price savings slowed the rate of antithrombotic spending growth by at least 1.4% per year (Quebec) and as much as 3.7% per year (Saskatchewan). Pace of change, 1998–2007Infl ation-adjusted spending per Canadian on antithrombotic drugs more than doubled between 1998 and 2007.From 1998 to 2007, the average annual rate of growth in retail spending for antithrombotic drugs was 12.6% in Canada.Sources of changeBetween 1998 and 2007, population aging contributed 1% or more to annual growth in infl ation-adjusted retail spending on antithrombotic drugs in all provinces except Saskatchewan, Manitoba, and Ontario.Age-standardized growth in infl ation-adjusted spending per capita on antithrombotic drugs was highest in Manitoba (13.9% per year), where spending was above the national average in both 1998 and 2007. Age-standardized, infl ation-adjusted spending per Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $3.0 $3.3 $2.7 $3.8 $3.1 $2.9 $2.8 $3.7 $3.8 $3.7Per capita spending in 2007 $9.8 $8.2 $7.3 $11.7 $11.8 $9.5 $11.5 $12.3 $10.7 $11.4 Average annual rate of change 12.6% 9.6% 10.3% 12.0% 14.4% 12.6% 15.0% 12.9% 10.8% 12.0% Rate of change due to population aging 1.1% 1.2% 1.0% 0.7% 0.5% 0.8% 1.6% 1.5% 1.4% 2.1%Age-standardized rate of change 11.5% 8.4% 9.3% 11.3% 13.9% 11.8% 13.4% 11.3% 9.4% 9.9% Prescription volume 8.8% 8.0% 4.8% 6.9% 8.8% 9.1% 10.4% 6.0% 4.7% 4.6% Prescription size -0.2% -0.2% 3.2% 2.3% 2.7% -0.4% -2.4% 3.4% 3.4% 3.4%Volume effects 8.6% 7.8% 8.0% 9.2% 11.6% 8.7% 8.0% 9.4% 8.1% 8.0% Therapeutic mix 4.1% 2.6% 3.3% 4.1% 2.6% 4.2% 5.4% 3.6% 2.5% 2.1% Drug mix 1.2% 0.2% 0.7% 1.7% 2.2% 1.7% 1.5% 1.4% 1.6% 2.1%Therapeutic choice effects 5.4% 2.8% 4.0% 5.9% 4.8% 5.9% 6.8% 5.0% 4.1% 4.3% Prices paid -1.0% 0.7% -0.5% -1.8% -1.4% -0.4% -0.8% -0.9% -0.5% -1.0% Generic use -1.5% -2.9% -2.3% -1.9% -1.1% -2.4% -0.6% -2.3% -2.3% -1.4%Price effects -2.5% -2.3% -2.8% -3.7% -2.5% -2.8% -1.4% -3.1% -2.7% -2.3%Table 2.3B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H4 5Note: All fi gures are expressed in the equivalent of year 2007 dollars.+8%+8%+9%+8%+12%+9%+8%+9%+8%+3%+4%+6%+4%+5%+6%+7%+5%+4%-2%-3%-4%-2%-3%-3%-1%-3%-3%BritishColumbia+8%NewBrunswick+11%NovaScotia+9%Newfoundlandand LabradorandPrince Edward I.+10%Alberta+9%Saskatchewan+11%Manitoba+14% Quebec+13%Ontario+12%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 2.3G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 2.3F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N4 6Levels of spending across Canada and age groupsSpending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$3011,740,792 people45-64 years$578,936,632 people65+$684,417,8053.1 Neurological: AntidepressantsSpending in CanadaCanadians spent an average of $35 per capita on retail purchases of antidepressant drugs in 2007. Th is amounted to $1.16 billion in retail spending, making this the largest category of neurological treatments and the fourth largest therapeutic category overall.Th ere is a positive age-gradient in spending on antidepressants. Most notably, spending per person age 45–64 ($57) was nearly double that of persons aged 20–44 ($30).Canadians aged 45–64 accounted for 44% of all spending on antidepressants in Canada—more than any other age group.Th ere were insuffi cient purchases of antidepressant drugs by persons under age 20 to generate reliable age- and province-specifi c estimates of spending per capita for those age groups. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$0NLNSNBQCONMBSKBC AB PE$20$0NLNS PENBQCONMBSKBC AB$20$40 Canada overallNLNSNBQCONMBSKBC AB PE$0$20$40NLPENSNBQCONMBSKBC AB$0$20$60$40NLPENSNBQCONMBSKBC AB$0$20$60$80$40Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 3.1A» Per capita spending in Canada by age group, 2007Figure 3.1B» Per capita spending by province and age group, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H4 7Per capita spending in Canada: $35.30Drugs in this therapeutic categoryNonselective monoamine reuptake • inhibitors (e.g. amitriptyline)Monoamine oxidase inhibitiors (e.g. • phenelzine)Trazodone • Selective serotonin reuptake inhibitors • (e.g. citalopram)Venlafaxine• Mirtazapine• Moclobemide• Bupropion• Common goal of therapyReduce symptoms of clinical depression and • anxietyExample of an indicated conditionMajor depressive disorder• 0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 22 drugsPercent of $1.2 billionSpending in provincesTh e age gradient for antidepressant spending varied across provinces. Th e ratio of antidepressant spending per person age 65 and older to antidepressant spending per person of all ages ranged from 1.25 in Saskatchewan and Manitoba to 2.28 in Ontario.Spending per capita in 2007 varied across provinces the most among the 65 and older age group. Saskatchewan seniors received an average of $34 in antidepressants in 2007, whereas seniors in Ontario and Prince Edward Island received over $75 on average.Provincial formulary coverageAll provinces provided unrestricted coverage for 17 of the 22 types of antidepressant drug that had more than $1,000 in national sales. Th ree of the 22 drugs were not listed on any provincial formulary.Weighted by national retail spending levels, the drugs listed with or without restrictions on provincial formularies accounted for 96% of the antidepressant market.Figure 3.1C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not coveredOlderNewerListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N4 8Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.3.1 Neurological: Antidepressantsnot diff er signifi cantly (by more than 5%) from the national average.Age-standardized antidepressant spending per capita was about 20% below the national average in Saskatchewan, and almost 30% above the national average in Nova Scotia.Th e volume of treatments purchased drove spending in provinces with higher than expected antidepressant spending per capita. One of the high-spending provinces, Alberta, also had more costly patterns of therapeutic choices within the antidepressant category.Residents of Saskatchewan, the lowest spending province, received fewer antidepressants in 2007, were prescribed less costly options from within this therapeutic category, and saved considerably more from the use of generic antidepressants than residents of the rest of Canada.Population age and provincial spendingSpending per capita on antidepressants ranged across provinces from $27.30 in Saskatchewan to $47.20 in Nova Scotia.Because persons aged 45–64 accounted for such a large share of spending on antidepressants, interprovincial diff erences in population ages would predict relatively modest diff erences in antidepressant spending per capita.Population age alone would predict that antidepressant spending per capita would deviate from the national average by less than 5% in all provinces except Alberta. In Alberta, population age alone would predict spending per capita to be 6.3% less than the national average.Sources of age-standardized variationAge-standardized spending per capita on antidepressant drugs in British Columbia, Manitoba, Ontario, Quebec, and Newfoundland & Labrador did BC AB SK MB ON QC NB NS PE NLPer capita spending in province $34.4 $36.0 $27.3 $33.9 $33.4 $37.7 $42.1 $47.2 $39.7 $37.5Total variation from national average -2.6% 1.9% -22.7% -4.0% -5.5% 6.8% 19.2% 33.5% 12.3% 6.2% Variation predicted by population age 2.4% -6.3% -2.9% -3.6% -1.4% 3.4% 4.4% 4.4% 1.7% 4.9%Age-standardized variation -5.0% 8.2% -19.9% -0.5% -4.1% 3.4% 14.8% 29.1% 10.6% 1.3% Prescription volume -15.3% -12.4% -3.4% -9.0% -14.2% 33.3% -8.3% -1.6% -4.7% -13.3% Prescription size 11.8% 17.9% -5.8% 7.5% 16.7% -43.7% 25.0% 39.6% 15.6% 8.4%Volume effects -3.5% 5.5% -9.2% -1.5% 2.5% -10.3% 16.6% 38.0% 10.9% -4.9% Therapeutic mix 0.8% 2.1% -2.9% 0.6% -0.7% 0.1% 1.0% -3.1% -2.9% 2.0% Drug mix 0.7% 3.8% 0.9% 1.3% -0.3% -1.6% 0.1% 0.6% 0.6% -0.7%Therapeutic choice effects 1.5% 5.9% -2.0% 1.9% -1.0% -1.5% 1.0% -2.5% -2.3% 1.2% Prices paid -1.2% -1.7% 0.1% 3.6% -2.8% 7.3% 1.4% -2.7% 1.5% 4.1% Generic use -1.9% -1.4% -8.9% -4.4% -2.8% 7.9% -4.3% -3.7% 0.5% 0.9%Price effects -3.0% -3.1% -8.7% -0.9% -5.6% 15.2% -2.9% -6.4% 2.0% 5.0%Table 3.1A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H4 9-3%+5%-9%-5%-2%+2%-10%+17%+11%+38%+1%+6%-2%+1%+2%-1%-1%+1%-2%-2%-3%-3%-9%+5%-1%-6%+15%-3%+2%-6%BritishColumbia-5%NewBrunswick+15%NovaScotia+29%Newfoundlandand Labrador+1%Prince Edward I.+11%Alberta+8%Saskatchewan-20%Manitoba0% Quebec+3%Ontario-4%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 3.1E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 3.1D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N5 0Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.3.1 Neurological: Antidepressantsadjusting for general infl ation). Age-standardized spending in Quebec was below the national average in 1998 and above the national average in 2007.Infl ation-adjusted and age-standardized antidepressant spending per capita grew least quickly in Alberta (2.2% per year).Increased volume of purchases was the largest driver of increased age-standardized per capita antidepressant spending in all provinces.Use of more costly drug classes within the antidepressant category contributed to increased spending between 1998 and 2007; this was partially off set by use of lower-cost drug options in older drug classes.In all provinces, the unit prices paid for particular brands of antidepressants increased from 1998 to 2007. Th is was more than off set by increases in generic competition.Pace of change, 1998–2007With infl ation-adjusted growth of 4.5% per year from 1998 to 2007, per capita spending on antidepressant drugs grew slightly less rapidly than overall prescription drug spending in Canada. Because of the size of this therapeutic category, growth in spending on antidepressants accounted for 5% of the total increase in retail spending on prescription drugs in Canada from 1998 to 2007.Sources of changeBecause persons aged 45–64 accounted for a signifi cant amount of spending in this therapeutic category, population aging was not a major cause of antidepressant spending growth in Canada between 1998 and 2007. Population aging caused infl ation-adjusted antidepressant spending per capita to grow by less than 1% per year in all provinces.Age-standardized antidepressant spending per capita grew most quickly in Quebec (6.2% per year aft er Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $22.8 $25.1 $26.7 $16.8 $19.7 $23.9 $19.1 $23.4 $28.0 $19.5Per capita spending in 2007 $35.3 $34.4 $36.0 $27.3 $33.9 $33.4 $37.7 $42.1 $47.2 $38.0 Average annual rate of change 4.5% 3.2% 3.0% 4.9% 5.6% 3.4% 7.0% 6.1% 5.3% 6.9% Rate of change due to population aging 0.7% 0.7% 0.8% 0.7% 0.5% 0.6% 0.9% 0.9% 0.7% 0.9%Age-standardized rate of change 3.8% 2.4% 2.2% 4.2% 5.0% 2.8% 6.2% 5.2% 4.6% 5.9% Prescription volume 5.2% 4.2% 1.8% 4.5% 4.4% 5.0% 7.7% 3.8% 3.2% 3.4% Prescription size -0.4% -0.4% 1.0% -0.8% -0.2% -0.2% -1.7% 1.6% 1.7% 2.3%Volume effects 4.7% 3.9% 2.8% 3.6% 4.3% 4.8% 6.0% 5.4% 5.0% 5.7% Therapeutic mix 1.6% 1.1% 1.4% 2.2% 1.8% 1.4% 1.7% 2.2% 2.1% 2.3% Drug mix -1.0% -1.0% -0.4% -0.1% -0.5% -1.2% -0.8% -0.6% -0.7% -0.4%Therapeutic choice effects 0.6% 0.1% 1.0% 2.1% 1.3% 0.2% 0.9% 1.7% 1.4% 1.8% Prices paid 0.4% 0.7% 0.3% 0.9% 0.8% 0.2% 0.5% 0.3% 0.1% 0.4% Generic use -2.0% -2.2% -1.8% -2.5% -1.4% -2.4% -1.3% -2.2% -1.8% -1.9%Price effects -1.6% -1.5% -1.5% -1.6% -0.6% -2.2% -0.8% -1.9% -1.7% -1.6%Table 3.1B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H5 1Note: All fi gures are expressed in the equivalent of year 2007 dollars.+4%+3%+4%+6%+4%+5%+6%+5%+5%0%+1%+2%+2%+1%0%+1%+2%+1%-2%-2%-2%-2%-1%-2%-1%-2%-2%BritishColumbia+2%NewBrunswick+5%NovaScotia+5%Newfoundlandand LabradorandPrince Edward I.+6%Alberta+2%Saskatchewan+4%Manitoba+5% Quebec+6%Ontario+3%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 3.1G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 3.1F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N5 2Levels of spending across Canada and age groupsSpending per capita$80$60$40$200-19 yearsNumberof people$47,776,058 people20-44 years$1811,740,792 people45-64 years$298,936,632 people65+$304,417,8053.2 Neurological: AntipsychoticsSpending in CanadaAntipsychotic drugs represent the second largest category of neurological drugs and the seventh largest therapeutic category overall in terms of retail spending on prescription drugs in Canada. Canadians spent approximately $19.10 per capita on these drugs in 2007, for a total of $629 million.Spending on antipsychotic drugs is less concentrated among older adults than spending on other therapeutic categories of this size (in terms of total retail spending in Canada). On average in 2007, Canadians aged 45–64 purchased approximately the same amount of antipsychotic drugs as Canadians age 65 and older. Both of these age groups spent approximately $30 per capita on antipsychotics in 2007.Canadians aged 19 and under spent nearly $4 per capita on antipsychotic drugs in 2007. Th ose aged 20–44 purchased an average of nearly $18 per capita and accounted for 33% of total spending on this therapeutic category.$0$10NLNSNBQCONMBSKBC AB PE$20$0NLNSNBQCONMBSKBC AB PE$5$20$30$40NLPENSNBQCONMBSKBC AB$10$0NLPENSNBQCONMBSKBC AB$0$10$20$30$0$10NLNS PENBQCONMBSKBC AB$20 Canada overallAges 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 3.2A» Per capita spending in Canada by age group, 2007Figure 3.2B» Per capita spending by province and age group, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H5 3Per capita spending in Canada: $19.10Drugs in this therapeutic categoryAtypical antipsychotics (olanzapine, • risperidone, quetiapine)Older antipsychotics (e.g. haloperidol)• Common goal of therapyReduce symptoms of psychosis• Example of an indicated conditionSchizophrenia• 0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 21 drugsPercent of $0.6 billionSpending in provincesTh e age gradients for spending on antipsychotic drugs had similar “slopes” (in terms of ratios of spending across age groups) but quite diff erent levels (in terms of the actual amount spent per person within each age group). Average retail spending on antipsychotic drugs per person age 19 and under varied nearly three-fold across provinces, from $2.30 in Quebec to $6.40 in Manitoba.Average spending per person age 65 and older varied nearly as much in proportional terms – from $14.10 in Saskatchewan to $34.80 in New Brunswick.Provincial formulary coverageProvinces provided unrestricted or restricted coverage for 76% (Ontario) or more of the 21 diff erent types of antipsychotic drug that had more than $1,000 in national sales.Weighted by national sales volumes, the antipsychotic drugs covered in each province accounted for 93% or more of the entire Canadian antipsychotic drug market.Figure 3.2C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not coveredListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N5 4Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.3.2 Neurological: AntipsychoticsSources of age-standardized variationVolume of treatment purchased was one of the most important determinants of interprovincial variations in age-standardized spending on antipsychotic drugs.Aft er adjusting for population age, residents in New Brunswick and Quebec purchased far more antipsychotics in 2007 than did other Canadians.Th ere were also considerable diff erences in the cost of therapeutic choices made in diff erent provinces. Th e choice of antipsychotic drugs caused age-adjusted per capita spending to be much lower in Saskatchewan and the Atlantic provinces than in the rest of Canada.Diff erences in prices and rates of generic utilization also contributed to provincial variations in age-adjusted per capita spending on antipsychotics. On average, Albertans paid 5.4% higher unit prices for antipsychotics than other Canadians.Population age and provincial spendingBecause spending on antipsychotic drugs is not highly concentrated among older adults, interprovincial diff erences in population age alone would predict relatively little variation in spending per capita in this therapeutic category.Age-standardization alone would predict that all but three provinces would be within 3% of the national average in terms of per capita spending on antipsychotics. Age-standardization would predict that residents of Alberta would spend 4.3% below the national average and residents of New Brunswick and Newfoundland & Labrador would spend 3.7% and 3.2% above the national average, respectively.Although population age would not predict major diff erences in spending per capita on antipsychotic drugs, age-standardized spending in this category varied from nearly 17% below the national average in Saskatchewan to 30% above the national average in Quebec.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $18.4 $16.8 $15.4 $19.0 $16.4 $25.5 $24.6 $17.6 $18.0 $17.5Total variation from national average -4.0% -12.3% -19.6% -0.5% -14.4% 33.2% 28.9% -7.9% -5.7% -8.4% Variation predicted by population age 1.8% -4.3% -2.8% -2.8% -1.1% 2.9% 3.7% 2.6% 1.0% 3.2%Age-standardized variation -5.8% -8.0% -16.8% 2.4% -13.4% 30.3% 25.1% -10.5% -6.7% -11.5% Prescription volume -4.8% -26.3% -47.6% -17.9% -19.6% 55.1% -27.7% -50.8% -38.9% -45.7% Prescription size -1.2% 9.0% 43.5% 15.3% 13.0% -31.9% 59.4% 56.9% 57.4% 38.7%Volume effects -5.9% -17.2% -4.1% -2.6% -6.6% 23.2% 31.8% 6.2% 18.5% -7.0% Therapeutic mix 3.2% 5.8% 0.6% -0.7% -0.7% -1.6% 0.6% -5.5% -7.9% -3.2% Drug mix -3.8% -1.6% -15.2% 5.8% -2.4% 4.6% -3.6% -5.0% -11.2% -4.2%Therapeutic choice effects -0.6% 4.2% -14.6% 5.1% -3.1% 3.0% -3.0% -10.6% -19.0% -7.4% Prices paid 0.7% 5.4% 1.5% 0.7% -0.8% -0.7% -2.0% -6.0% -3.0% 2.9% Generic use 0.0% -0.4% 0.4% -0.8% -2.8% 4.8% -1.6% -0.1% -3.2% 0.0%Price effects 0.7% 5.0% 1.9% -0.1% -3.6% 4.1% -3.6% -6.1% -6.1% 2.9%Table 3.2A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H5 5-6%-17%-4%-7%-3%-7%+23%+32%+19%+6%-1%+4%-15%-7%+5%-3%+3%-3%-19%-11%+1%+5%+2%+3%0%-4%+4%-4%-6%-6%BritishColumbia-6%NewBrunswick+25%NovaScotia-10%Newfoundlandand Labrador-12%Prince Edward I.-7%Alberta-8%Saskatchewan-17%Manitoba+2% Quebec+30%Ontario-13%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 3.2E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 3.2D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N5 6Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.3.2 Neurological: Antipsychoticscontributed signifi cantly to infl ation-adjusted and age-standardized spending growth in all provinces.Increased volumes of antipsychotics purchased from 1998 to 2007 caused spending to rise by 4% or more per year (aft er adjusting for population aging and general infl ation) in all provinces except Nova Scotia, Prince Edward Island, and Newfoundland & Labrador.Although Atlantic Canada experienced slower growth in the volume of antipsychotic purchases, the cost of antipsychotics purchased there grew more rapidly than in the rest of Canada. Changes in the types of antipsychotic drugs selected between 1998 and 2007 contributed over 7.5% per year to growth in age-standardized, infl ation-adjusted spending per capita in the Atlantic provinces.Increased availability and use of generic antipsychotics resulted in savings of approximately 1% per year in most provinces; these savings were partially off set by increased unit prices of particular brands. Pace of change, 1998–2007Infl ation-adjusted retail spending on antipsychotic drugs per Canadian grew by a total of 208% between 1998 and 2007. As a result, antipsychotics accounted for 5% of the total increase in prescription drug spending in Canada between 1998 and 2007.Sources of changePopulation aging contributed less than 1% per year toward antipsychotic spending growth in any province between 1998 and 2007.From 1998 to 2007, age-standardized spending per capita on antipsychotic drugs grew most rapidly in Ontario (13.3% per year aft er adjusting for general infl ation). Age-standardized per capita spending on antipsychotics grew least rapidly in Alberta (7.6% per year aft er adjusting for general infl ation).In this therapeutic category, both the volume of treatment and the choice of treatment options Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $6.2 $7.8 $7.6 $4.7 $6.4 $4.5 $7.7 $8.2 $5.2 $5.0Per capita spending in 2007 $19.1 $18.4 $16.8 $15.4 $19.0 $16.4 $25.5 $24.6 $17.6 $17.6 Average annual rate of change 11.9% 8.9% 8.3% 12.7% 11.5% 13.9% 12.7% 11.6% 13.0% 13.5% Rate of change due to population aging 0.6% 0.6% 0.7% 0.5% 0.3% 0.5% 0.7% 0.8% 0.5% 0.6%Age-standardized rate of change 11.3% 8.3% 7.6% 12.2% 11.2% 13.3% 12.0% 10.8% 12.4% 12.8% Prescription volume 9.0% 8.1% 6.3% 5.8% 6.4% 10.8% 10.4% 4.0% 3.6% 2.1% Prescription size -2.7% -3.7% -0.1% 0.4% -1.8% -3.5% -3.9% 0.0% -0.5% 0.6%Volume effects 6.3% 4.5% 6.2% 6.3% 4.6% 7.3% 6.5% 4.0% 3.1% 2.7% Therapeutic mix 7.3% 4.9% 4.0% 8.1% 7.7% 8.7% 7.6% 8.7% 10.5% 12.4% Drug mix -2.2% -0.8% -2.3% -1.5% -0.6% -2.3% -2.5% -1.2% -1.2% -1.8%Therapeutic choice effects 5.1% 4.1% 1.7% 6.6% 7.1% 6.4% 5.1% 7.6% 9.3% 10.5% Prices paid 0.5% 0.6% 0.5% 0.2% 0.0% 0.6% 0.4% 0.3% 0.4% 0.6% Generic use -0.6% -0.8% -0.8% -0.9% -0.5% -1.1% 0.0% -1.0% -0.3% -1.1%Price effects -0.1% -0.2% -0.2% -0.7% -0.5% -0.5% 0.4% -0.7% 0.1% -0.4%Table 3.2B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H5 7Note: All fi gures are expressed in the equivalent of year 2007 dollars.+4%+6%+6%+3%+5%+7%+6%+4%+3%+4%+2%+7%+11%+7%+6%+5%+8%+9%0%0%-1%0%0%0%0%-1%0%BritishColumbia+8%NewBrunswick+11%NovaScotia+12%Newfoundlandand LabradorandPrince Edward I.+13%Alberta+8%Saskatchewan+12%Manitoba+11% Quebec+12%Ontario+13%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 3.2G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 3.2F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N5 8Levels of spending across Canada and age groups3.3 Neurological: Benzodiazepines and related drugsSpending in CanadaBenzodiazepines and the related drugs zopiclone and zaleplon (hereaft er referred to as benzodiazepines) represents the third largest neurological drug class and the fourteenth largest therapeutic category of prescription drugs in terms of overall retail spending in Canada.Approximately $7.50 per capita was spent on retail purchases of these drugs across Canada in 2007, for a total of $247 million.Spending on benzodiazepines was concentrated among older adults. Canadians age 65 and older spent an average of $23 on benzodiazepines in 2007. Th ose aged 45–64 spent an average of $12 each.Canadians aged 45–64 accounted for the largest age-specifi c share of all benzodiazepines sales in 2007 (43% versus 41% for Canadians age 65 and older).Th ere were insuffi cient purchases of benzodiazepines by persons aged 19 and under to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$0NLNSNBQCONMBSKBC AB PE$10$0$10NLNS PENBQCONMBSKBC ABCanada overall$0$10NLNSNBQCONMBSKBC AB PE$20NLPENSNBQCONMBSKBC AB$10$0NLPENSNBQCONMBSKBC AB$0$10$20$30$40Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 3.3A» Per capita spending in Canada by age group, 2007Figure 3.3B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$311,740,792 people45-64 years$128,936,632 people65+$234,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H5 9Per capita spending in Canada: $7.50Drugs in this therapeutic categoryBenzodiazepines (e.g. lorazepam)• Zopiclone• Zaleplon• Common goal of therapyReduce symptoms of short term insomnia • and anxietyExample of an indicated conditionInsomnia related to a stressful life event• Spending in provincesIn 2007, the age gradient for per capita spending on benzodiazepines was steeper in some provinces than others. Levels of spending within age groups also diff ered across provinces. Th e ratio of benzodiazepine spending per person aged 65 and older to those aged 45–64 ranged from 1.4 in Manitoba to 2.3 in Quebec.Average retail spending on benzodiazepines per person aged 45–64 ranged from $8.10 in Saskatchewan to $19.10 in New Brunswick. Average spending per person age 65 and older varied similarly from $15.50 in Saskatchewan to $35.50 in New Brunswick.Provincial formulary coverageProvinces provided unrestricted coverage for 10 or more of the 13 diff erent types of benzodiazepines that had more than $1,000 in national sales. Weighted by national sales volumes, the drugs covered in each province accounted for varying degrees of the Canadian benzodiazepine market.Drugs that were not listed in Saskatchewan, Ontario, and Quebec were ones that achieved signifi cant national sales.Figure 3.3C» Percentage of drugs and their market value listed on provincial formularies0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 13 drugsPercent of $0.3 billionUnrestricted coverageRestricted coverage Not coveredListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N6 0Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.3.3 Neurological: Benzodiazepines and related drugsSources of age-standardized variationAll three categories of cost-drivers (volume of treatment purchased, the types of drug chosen, and prices paid) were important drivers of variation in spending on benzodiazepines across the provinces.Aft er adjusting for population age, residents in Ontario, Saskatchewan, and British Columbia purchased signifi cantly fewer benzodiazepines than other Canadians.A lower-cost mix of benzodiazepines (and related drugs) tended to be prescribed in Ontario and especially Quebec than in the rest of Canada.Residents of the Atlantic provinces tended to pay lower unit prices for particular brands of benzodiazepine drugs than other Canadians. Also related to price savings (or lack thereof), residents of Ontario and Quebec received generics less oft en than other Canadians.Population age and provincial spendingBecause spending on benzodiazepines is concentrated among older adults, diff erences in the age of provincial populations alone would cause relatively signifi cant variations in benzodiazepine spending per capita.Age-standardization alone would predict that per capita spending on benzodiazepines in Alberta would be 11.9% below the national average. In contrast, age-standardization would predict benzodiazepine spending per resident of New Brunswick to be 7.7% above the national average.Aft er fi gures were adjusted for diff erences in population age, spending on benzodiazepines deviated by more than 5% from the national average in all provinces except British Columbia.Age-standardized spending on benzodiazepines was approximately 62% above the national average in New Brunswick, and nearly 30% below the national average in Saskatchewan.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $7.5 $8.5 $5.3 $8.0 $6.0 $9.1 $12.7 $8.8 $9.7 $8.6Total variation from national average -0.2% 12.4% -29.2% 6.2% -20.5% 21.3% 69.6% 16.9% 29.0% 15.1% Variation predicted by population age 3.2% -11.9% 0.2% -2.9% -1.7% 5.3% 7.7% 6.7% 4.4% 6.7%Age-standardized variation -3.4% 24.3% -29.4% 9.1% -18.7% 16.0% 61.9% 10.2% 24.6% 8.4% Prescription volume -22.1% -16.1% -37.7% -16.0% -29.9% 53.6% 51.2% -9.3% 1.1% 2.7% Prescription size 1.7% 17.9% -3.6% 16.1% 13.7% -31.5% 17.6% 35.3% 34.2% 17.5%Volume effects -20.4% 1.8% -41.3% 0.1% -16.2% 22.1% 68.8% 26.0% 35.3% 20.1% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 16.0% 28.6% 13.5% 14.4% -4.2% -16.0% 6.3% 2.4% 11.3% 3.1%Therapeutic choice effects 16.0% 28.6% 13.5% 14.4% -4.2% -16.0% 6.3% 2.4% 11.3% 3.1% Prices paid 4.8% -0.4% 4.2% 2.6% -2.8% 7.7% -5.9% -10.1% -15.2% -8.9% Generic use -3.7% -5.7% -5.8% -7.9% 4.5% 2.2% -7.3% -8.0% -6.7% -5.9%Price effects 1.0% -6.1% -1.6% -5.3% 1.7% 9.9% -13.2% -18.2% -22.0% -14.8%Table 3.3A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H6 1-20%+2%-41%+20%0%-16%+22%+69%+35%+26%+16%+29%+14%+3%+14%-4%-16%+6%+11%+2%+1%-6%-2%-15%-5%+2%+10%-13%-22%-18%BritishColumbia-3%NewBrunswick+62%NovaScotia+10%Newfoundlandand Labrador+8%Prince Edward I.+25%Alberta+24%Saskatchewan-29%Manitoba+9% Quebec+16%Ontario-19%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 3.3E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 3.3D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N6 2Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.3.3 Neurological: Benzodiazepines and related drugsTh e most rapid growth in infl ation-adjusted and age-standardized benzodiazepine spending per capita was observed in Manitoba (5.1% per year).Decreased volume of benzodiazepines purchased from 1998 to 2007 was observed (aft er adjusting for population aging and general infl ation) in all provinces except Manitoba.Where observed, declines in age-standardized benzodiazepine use were off set by selection of more costly benzodiazepines and increases in the unit prices paid for particular brands.On an age-standardized and infl ation-adjusted per capita basis, Manitoba experienced a slight increase in the use of benzodiazepines, a shift toward more costly benzodiazepines (and related drugs), and a rise in the price of particular brands of benzodiazepine drug between 1998 and 2007.Pace of change, 1998–2007Th ere was very little in the way of increased retail spending on benzodiazepines per Canadian aft er accounting for the eff ects of general infl ation.Infl ation-adjusted spending on benzodiazepines grew by only 11.9% over the entire 1998 to 2007 decade. Several other drug classes experienced that much or more sales growth every year during the same period.Sources of changePopulation aging contributed between 0.6% and 1.5% per year toward the annual growth of per capita retail spending on benzodiazepines in Canadian provinces from 1998 to 2007.Infl ation-adjusted and age-standardized spending on benzodiazepines remained constant or fell in the Atlantic provinces and Quebec between 1998 and 2007.Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $6.7 $6.3 $6.6 $4.1 $4.6 $5.4 $8.8 $12.4 $9.4 $7.7Per capita spending in 2007 $7.5 $7.5 $8.5 $5.3 $8.0 $6.0 $9.1 $12.7 $8.8 $8.9 Average annual rate of change 1.1% 1.7% 2.5% 2.5% 5.7% 1.1% 0.3% 0.3% -0.7% 1.5% Rate of change due to population aging 0.9% 1.0% 1.0% 0.7% 0.6% 0.8% 1.3% 1.3% 1.2% 1.5%Age-standardized rate of change 0.2% 0.7% 1.6% 1.8% 5.1% 0.3% -0.9% -1.0% -1.8% 0.0% Prescription volume -2.1% -2.5% -1.7% -1.3% -0.3% -2.5% -1.4% -3.1% -4.3% -3.4% Prescription size -0.6% 0.2% 1.0% -0.1% 0.7% -0.5% -2.0% 0.0% 1.1% 1.4%Volume effects -2.7% -2.3% -0.7% -1.4% 0.4% -3.0% -3.4% -3.2% -3.2% -2.0% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 1.3% 1.1% 1.5% 2.0% 1.8% 1.8% 0.7% 1.1% 0.9% 1.2%Therapeutic choice effects 1.3% 1.1% 1.5% 2.0% 1.8% 1.8% 0.7% 1.1% 0.9% 1.2% Prices paid 1.6% 1.7% 0.8% 1.0% 2.4% 1.2% 1.7% 1.2% 0.5% 0.6% Generic use 0.0% 0.2% -0.1% 0.1% 0.5% 0.3% 0.1% -0.1% 0.0% 0.2%Price effects 1.6% 1.9% 0.7% 1.2% 2.9% 1.5% 1.8% 1.1% 0.5% 0.8%Table 3.3B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H6 3Note: All fi gures are expressed in the equivalent of year 2007 dollars.-2%-1%-1%-2%0%-3%-3%-3%-3%+1%+2%+2%+1%+2%+2%+1%+1%+1%+2%+1%+1%+1%+3%+1%+2%+1%+1%BritishColumbia+1%NewBrunswick-1%NovaScotia-2%Newfoundlandand LabradorandPrince Edward I.0%Alberta+2%Saskatchewan+2%Manitoba+5% Quebec-1%Ontario0%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 3.3G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 3.3F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N6 4Levels of spending across Canada and age groups3.4 Neurological: Gabapentin, pregabalin, topiramateSpending in CanadaCanadians spent an average of $7.30 on gabapentin, pregabalin, and topiramate in 2007. Th ese drugs, which may reduce certain kinds of seizures or symptoms of neuropathic pain, represent the fourth largest neurological drug class and fi ft eenth largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Spending on gabapentin, pregabalin, and topiramate is relatively concentrated among older adults. In 2007, Canadians aged 65 and older spent an average of $17.30 on gabapentin, pregabalin, and topiramate. Canadians aged 45–64 spent an average of $12.75 on gabapentin, pregabalin, and topiramate.Because of the size of the population of Canadians aged 45–64, this group accounted for 48% of all gabapentin, pregabalin, and topiramate sales in Canada in 2007.Th ere were insuffi cient purchases of gabapentin, pregabalin, and topiramate by persons aged 19 and under to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$0NLNSNBQCONMBSKBC AB PE$10$0$10NLNS PENBQCONMBSKBC ABCanada overall$0$10NLNSNBQCONMBSKBC AB PE$20NLPENSNBQCONMBSKBC AB$10$0NLPENSNBQCONMBSKBC AB$0$10$20$30Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 3.4A» Per capita spending in Canada by age group, 2007Figure 3.4B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$411,740,792 people45-64 years$138,936,632 people65+$174,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H6 5Per capita spending in Canada: $7.30Drugs in this therapeutic categoryGabapentin• Pregabalin• Topiramate• Common goals of therapyReduce certain kinds of seizures • (gabapentin, topiramate)Reduce neuropathic pain (pregabalin)• Prevent migraine headaches (topiramate)• Examples of indicated conditionsEpilepsy• Nerve pain caused by diabetes mellitus• Spending in provincesTh e age gradients for per capita spending on gabapentin, pregabalin, and topiramate were relatively steep in British Columbia, Quebec, and Prince Edward Island.In Nova Scotia and Newfoundland & Labrador, spending on gabapentin, pregabalin, and topiramate per person aged 45–64 was slightly greater than spending per person aged 65 and older.Interprovincial variations in age-specifi c spending levels were considerable in this therapeutic category. Average retail spending on gabapentin, pregabalin, and topiramate per person age 65 and older ranged from $5.20 in Newfoundland & Labrador to $26.60 in Quebec. Average spending per person aged 45–64 varied almost as much in proportionate terms—from $6.30 in Newfoundland & Labrador to $17.90 in Quebec.Provincial formulary coverageMost provinces provided either restricted or unrestricted coverage for two of the three drugs in this class (gabapentin, pregabalin, or topiramate). Only one was listed on the formulary for New Brunswick.Weighted by national sales volumes, the two drugs covered by most provinces accounted for 81% of the entire Canadian market for gabapentin, pregabalin, and topiramate.Figure 3.4C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 3 drugsPercent of $0.2 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N6 6Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.3.4 Neurological: Gabapentin, pregabalin, topiramatein Quebec, and 56.3% below the national average in Newfoundland & Labrador.Sources of age-standardized variationVolume of treatment purchased was by far the most important determinant of interprovincial variation in retail spending on gabapentin, pregabalin, and topiramate.Aft er adjusting for population age, residents of Ontario and Newfoundland & Labrador purchased signifi cantly less gabapentin, pregabalin, and topiramate than other Canadians.Residents of the western provinces tended to purchase much lower-cost drugs (–10.2% to –15.4%) from within this class relative to other Canadians.Diff erences in use of generic drugs also contributed to interprovincial variations in spending on gabapentin, pregabalin, and topiramate. Residents in Quebec, in particular, used generics in this class less oft en than other Canadians.Population age and provincial spendingBecause spending on gabapentin, pregabalin, and topiramate is concentrated among older adults, interprovincial diff erences in population age would cause moderate variation in related spending per capita.Based on age-standardization alone, predicted spending per Albertan on gabapentin, pregabalin, and topiramate would be 8.9% below the national average. Similarly, predicted per capita spending in provinces east of Ontario would be from 3.0% to 5.7% above the national average due to population age alone. Actual interprovincial variation in per capita spending on gabapentin, pregabalin, and topiramate in 2007 was far greater than population age structures would predict. Th is therapeutic category had among the highest levels of age-standardized spending variation observed in this atlas. Age-standardized spending on gabapentin, pregabalin, and topiramate was 44.3% above the national average BC AB SK MB ON QC NB NS PE NLPer capita spending in province $8.5 $7.0 $6.3 $5.9 $5.0 $10.9 $7.2 $8.2 $8.3 $3.5Total variation from national average 16.2% -3.7% -13.7% -19.4% -30.7% 49.6% -1.2% 13.1% 13.8% -51.9% Variation predicted by population age 3.2% -8.9% -1.8% -2.9% -1.5% 5.3% 5.2% 5.7% 3.0% 4.5%Age-standardized variation 13.1% 5.2% -11.9% -16.6% -29.2% 44.3% -6.4% 7.4% 10.8% -56.3% Prescription volume 11.9% -6.2% -7.7% -21.6% -52.9% 76.8% -50.6% -51.5% -37.2% -85.5% Prescription size 15.5% 27.0% 19.0% 17.9% 26.5% -47.8% 41.8% 56.8% 36.3% 19.1%Volume effects 27.4% 20.8% 11.3% -3.7% -26.5% 29.0% -8.7% 5.3% -0.9% -66.3% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix -10.2% -11.9% -15.4% -11.7% -1.2% 6.6% 1.4% 5.3% 7.1% 7.9%Therapeutic choice effects -10.2% -11.9% -15.4% -11.7% -1.2% 6.6% 1.4% 5.3% 7.1% 7.9% Prices paid -1.2% -1.0% 0.2% 1.8% -0.7% 2.9% 3.0% -1.6% 3.7% 3.0% Generic use -2.9% -2.7% -7.9% -3.0% -0.9% 5.8% -2.1% -1.6% 0.9% -0.9%Price effects -4.1% -3.7% -7.7% -1.2% -1.5% 8.7% 0.9% -3.3% 4.6% 2.1%Table 3.4A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H6 7+27%+21%+11%-66%-4%-26%+29%-9%-1%+5%-10%-12%-15%+8%-12%-1%+7%+1%+7%+5%-4%-4%-8%+2%-1%-2%+9%+1%+5%-3%BritishColumbia+13%NewBrunswick-6%NovaScotia+7%Newfoundlandand Labrador-56%Prince Edward I.+11%Alberta+5%Saskatchewan-12%Manitoba-17% Quebec+44%Ontario-29%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 3.4E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 3.4D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N6 8Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.3.4 Neurological: Gabapentin, pregabalin, topiramateVirtually all of the growth in age-standardized and infl ation-adjusted spending per capita on gabapentin, pregabalin, and topiramate resulted from increased use of these drugs between 1998 and 2007.In most provinces, changes in the mix of gabapentin, pregabalin, and topiramate selected between 1998 and 2007 contributed modestly (under 2% per year) to growth in age-standardized, infl ation-adjusted spending in this category. Changes in therapeutic choices drove spending in Nova Scotia up by a more notable 2.7% per year. In contrast, Manitoba experienced a shift toward less expensive choices in this category, reducing costs by an average annual rate of 0.2%.Increased availability and use of generics produced savings valued at an average annual rate of more than 4% per year in all provinces except Quebec. Generic savings in Quebec averaged an annual rate of 2.6%.Pace of change, 1998–2007Infl ation-adjusted retail spending on gabapentin, pregabalin, and topiramate per Canadian grew more than 1,100% between 1998 and 2007, or 28.9% per year.Sources of changeTh e eff ects of population aging alone account for a relatively modest amount of gabapentin, pregabalin, and topiramate spending growth in all provinces from 1998 to 2007. Aging contributed between 0.7% and 1.4% to annual growth rates in the provinces, the lowest of which was 25.9% per year.From 1998 to 2007, age-standardized spending per capita on gabapentin, pregabalin, and topiramate grew most rapidly in Quebec (33.3% per year aft er adjusting for general infl ation). Infl ation-adjusted and age-standardized gabapentin, pregabalin, and topiramate spending per capita grew least rapidly in British Columbia (24.8% per year).Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $0.6 $0.8 $0.6 $0.6 $0.4 $0.5 $0.6 $0.7 $0.6 $0.3Per capita spending in 2007 $7.3 $8.5 $7.0 $6.3 $5.9 $5.0 $10.9 $7.2 $8.2 $4.5 Average annual rate of change 28.9% 25.9% 27.1% 26.4% 29.6% 26.2% 34.6% 26.8% 29.8% 32.4% Rate of change due to population aging 1.0% 1.1% 1.1% 0.9% 0.7% 0.8% 1.3% 1.3% 1.3% 1.4%Age-standardized rate of change 27.9% 24.8% 26.1% 25.4% 28.9% 25.4% 33.3% 25.5% 28.6% 31.0% Prescription volume 31.6% 27.5% 28.5% 29.4% 31.4% 28.0% 38.1% 27.0% 27.4% 31.1% Prescription size -1.3% -0.5% 1.6% 0.3% -0.2% -0.2% -4.1% 1.5% 2.4% 1.6%Volume effects 30.3% 27.0% 30.1% 29.7% 31.3% 27.8% 33.9% 28.4% 29.8% 32.8% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 1.2% 1.8% 0.6% 1.2% -0.2% 1.7% 1.6% 1.5% 2.7% 1.8%Therapeutic choice effects 1.2% 1.8% 0.6% 1.2% -0.2% 1.7% 1.6% 1.5% 2.7% 1.8% Prices paid 0.4% 0.3% 0.3% 0.9% 1.8% 0.4% 0.3% 0.1% 0.2% 0.5% Generic use -4.0% -4.3% -4.9% -6.3% -4.0% -4.5% -2.6% -4.6% -4.1% -4.1%Price effects -3.6% -4.0% -4.6% -5.4% -2.2% -4.1% -2.2% -4.5% -3.9% -3.6%Table 3.4B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H6 9Note: All fi gures are expressed in the equivalent of year 2007 dollars.+27%+30%+30%+33%+31%+28%+34%+28%+30%+2%+1%+1%+2%0%+2%+2%+2%+3%-4%-5%-5%-4%-2%-4%-2%-4%-4%BritishColumbia+25%NewBrunswick+25%NovaScotia+29%Newfoundlandand LabradorandPrince Edward I.+31%Alberta+26%Saskatchewan+25%Manitoba+29% Quebec+33%Ontario+25%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 3.4G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 3.4F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N7 0Levels of spending across Canada and age groups3.5 Neurological: Psychostimulants and atomoxetineSpending in CanadaPsychostimulants and atomoxetine (hereaft er referred to as psychostimulants), used primarily to reduce symptoms of attention defi cit hyperactivity disorder (ADHD), are the fi ft h largest neurological drug class and the seventeenth largest therapeutic category of prescription drugs in terms of overall retail spending in Canada.Canadians spent approximately $5.50 per capita on retail purchases of prescription psychostimulants in 2007, for a total of approximately $180 million.Spending on psychostimulants is highly concentrated among children. In 2007, $17.70 was spent on retail purchases of psychostimulants per Canadian child aged 19 and under. Children account for 76% of spending on drugs within this therapeutic category.Th ere were insuffi cient purchases of psychostimulants by persons age 65 and older to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)NLPENSNBQCONMBSKBC AB$0$10$0$10NLNS PENBQCONMBSKBC ABCanada overall$0NLNSNBQCONMBSKBC AB PE$20$30$10$0$10NLNSNBQCONMBSKBC AB PENLPENSNBQCONMBSKBC AB$10$0Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 3.5A» Per capita spending in Canada by age group, 2007Figure 3.5B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$187,776,058 people20-44 years$211,740,792 people45-64 years$28,936,632 people65+$04,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H7 1Per capita spending in Canada: $5.50Drugs in this therapeutic categoryMethylphenidate• Amphetamines• Atomoxetine• Common goal of therapyReduce symptoms of attention defi cit • hyperactivity disorder (ADHD)Example of an indicated conditionAttention defi cit hyperactivity disorder • (ADHD)Spending in provincesSpending on psychostimulants was highly concentrated among children in every province, with average spending per person aged 19 and under approximately 10 times the average spending per person in other age groups. Although psychostimulant spending was focused on children in all provinces, the level of spending per child (and per adult) varied dramatically across provinces.Average retail spending on psychostimulants per child ranged from $9.30 in British Columbia to $25.80 in Quebec.Provincial formulary coverageSeveral of the formularies analyzed pertained to seniors’ drug plans (in provinces with such programs). Despite that limitation, all provincial formularies listed (with or without restrictions) two or three of the fi ve types of psychostimulant drugs that had more than $1,000 in national sales.Weighted by national sales volumes, the drugs covered in each province accounted for 72% or more of the entire Canadian retail market for psychostimulants.Figure 3.5C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 5 drugsPercent of $0.1 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N7 2Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.3.5 Neurological: Psychostimulants and atomoxetineSources of age-standardized variationInterprovincial diff erences in age-standardized retail spending on psychostimulants were largely driven by diff erences in the volume of these drugs purchased within the provinces.Aft er adjusting for population age, residents in Western Canada (most notably British Columbia) and Newfoundland & Labrador purchased signifi cantly fewer psychostimulants than the national average. Residents of Quebec, Nova Scotia, and Prince Edward Island purchased signifi cantly more psychostimulants than the national average.Th erapeutic choice eff ects contributed to provincial variations in age-adjusted per capita spending on psychostimulants. Notably, residents of Saskatchewan and Newfoundland & Labrador purchased a much less costly mix of psychostimulants than residents of other provinces.Population age and provincial spendingEven though spending on psychostimulants is almost entirely concentrated among children, diff erences in the age of provincial populations would still predict modest interprovincial variations in related spending per capita. Th is is because provinces diff er in the share of the population aged 19 and under.Because of the proportions of children within their populations, Alberta, Saskatchewan, and Manitoba would be expected to have levels of per capita psychostimulant spending from 5.3% to 6.9% above the national average.In contrast, Quebec, New Brunswick, Nova Scotia, and Newfoundland & Labrador would be expected to have per capita psychostimulant spending levels from 5.3% to 5.9% below the national average, because they have relatively fewer children among their populations.Age-standardized variations in per capita spending on psychostimulants were among the highest observed in the therapeutic categories included in this atlas.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $3.3 $5.6 $3.7 $4.3 $5.8 $6.6 $5.1 $6.9 $7.2 $3.3Total variation from national average -40.2% 1.9% -31.8% -21.0% 4.9% 21.1% -7.7% 25.4% 31.2% -40.3% Variation predicted by population age -3.1% 6.6% 5.3% 6.9% 1.8% -5.3% -5.6% -5.9% 1.3% -5.6%Age-standardized variation -37.1% -4.7% -37.1% -27.9% 3.1% 26.4% -2.2% 31.3% 30.0% -34.7% Prescription volume -33.5% -12.1% -16.0% -26.0% -16.5% 52.0% 8.1% -0.9% 25.4% -7.3% Prescription size 3.4% 3.1% -1.3% 8.4% 15.1% -25.8% -7.4% 38.0% 1.3% -3.7%Volume effects -30.1% -9.0% -17.3% -17.6% -1.4% 26.2% 0.7% 37.1% 26.7% -11.0% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix -5.3% 4.7% -21.6% -7.5% 2.9% 2.5% -6.9% 0.4% 2.1% -21.8%Therapeutic choice effects -5.3% 4.7% -21.6% -7.5% 2.9% 2.5% -6.9% 0.4% 2.1% -21.8% Prices paid -2.1% -0.5% 0.9% -1.9% 1.7% -2.4% 4.7% -5.9% -0.1% -0.4% Generic use 0.5% 0.0% 0.9% -0.9% -0.1% 0.1% -0.7% -0.3% 1.2% -1.5%Price effects -1.6% -0.4% 1.8% -2.8% 1.6% -2.3% 4.1% -6.2% 1.1% -1.9%Table 3.5A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H7 3-30%-9%-17%-11%-18%-1%+26%+1%+27%+37%-5%+5%-22%-22%-8%+3%+3%-7%+2%0%-2%0%+2%-2%-3%+2%-2%+4%+1%-6%BritishColumbia-37%NewBrunswick-2%NovaScotia+31%Newfoundlandand Labrador-35%Prince Edward I.+30%Alberta-5%Saskatchewan-37%Manitoba-28% Quebec+26%Ontario+3%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 3.5E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 3.5D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N7 4Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.3.5 Neurological: Psychostimulants and atomoxetineFrom 1998 to 2007, age-standardized spending per capita on psychostimulants grew most rapidly in Quebec (23.9% per year aft er adjusting for general infl ation). Age-standardized psychostimulant spending per capita grew least rapidly in Saskatchewan (6.4% per year aft er adjusting for general infl ation).Growth in age-standardized spending per capita on psychostimulants was driven by increased volume of purchases and by the use of more costly drugs within this therapeutic class. Only Saskatchewan experienced negligible growth in the volume of psychostimulant purchases. All provinces saw a dramatic rise in the average cost of treatment (increasing at rates from 5.4% to 11.3% per year) as a result of changes in the types of psychostimulants prescribed between 1998 and 2007.Pace of change, 1998–2007Infl ation-adjusted retail spending on psychostimulants per Canadian grew by a total of 365% between 1998 and 2007.Between 1998 and 2007, the rate of growth in spending on psychostimulants varied from 5.6% per year in Saskatchewan to 22.7% in Quebec.Sources of changeBecause spending on psychostimulants is concentrated in children, and because children represent a shrinking proportion of the populations of all provinces, population aging actually slowed growth in spending on this category of medicines between 1998 and 2007. Across provinces, the shrinking cohorts of children slowed psychostimulant spending growth by between –0.6% and –1.7% per year between 1998 and 2007.Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $1.2 $1.0 $1.7 $2.2 $0.8 $1.2 $0.9 $1.5 $1.5 $1.1Per capita spending in 2007 $5.5 $3.3 $5.6 $3.7 $4.3 $5.8 $6.6 $5.1 $6.9 $4.1 Average annual rate of change 16.6% 12.7% 12.9% 5.6% 18.1% 16.7% 22.7% 13.2% 16.3% 14.2% Rate of change due to population aging -0.9% -0.8% -0.8% -0.8% -0.6% -0.7% -1.2% -1.2% -1.2% -1.7%Age-standardized rate of change 17.5% 13.5% 13.7% 6.4% 18.7% 17.4% 23.9% 14.4% 17.5% 15.9% Prescription volume 7.6% 5.8% 3.2% 0.7% 9.0% 6.8% 12.7% 3.0% 6.3% 7.3% Prescription size -0.6% -1.5% 0.1% -0.6% -0.1% -0.7% 0.2% 0.7% 0.1% -0.2%Volume effects 7.0% 4.4% 3.3% 0.2% 8.9% 6.1% 13.0% 3.7% 6.4% 7.1% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 9.7% 6.9% 8.6% 5.4% 9.0% 10.7% 11.3% 10.5% 10.0% 8.4%Therapeutic choice effects 9.7% 6.9% 8.6% 5.4% 9.0% 10.7% 11.3% 10.5% 10.0% 8.4% Prices paid 1.2% 2.2% 2.1% 1.1% 1.2% 1.2% 0.1% 0.8% 1.5% 1.4% Generic use -0.4% 0.0% -0.3% -0.3% -0.4% -0.6% -0.5% -0.6% -0.4% -1.0%Price effects 0.8% 2.2% 1.8% 0.9% 0.8% 0.6% -0.4% 0.2% 1.1% 0.4%Table 3.5B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H7 5Note: All fi gures are expressed in the equivalent of year 2007 dollars.+4%+3%0%+7%+9%+6%+13%+4%+6%+7%+9%+5%+8%+9%+11%+11%+10%+10%+2%+2%+1%0%+1%+1%0%0%+1%BritishColumbia+13%NewBrunswick+14%NovaScotia+17%Newfoundlandand LabradorandPrince Edward I.+16%Alberta+14%Saskatchewan+6%Manitoba+19% Quebec+24%Ontario+17%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 3.5G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 3.5F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N7 6Levels of spending across Canada and age groups3.6 Neurological: Cholinesterase inhibitorsSpending in CanadaCholinesterase inhibitors, prescribed with the intent to reduce symptoms of dementia, are the sixth largest neurological drug class and eighteenth largest therapeutic category of prescription drugs in terms of overall retail spending in Canada.Canadians spent approximately $4.90 per capita on these drugs in 2007, for a total of $162 million.Cholinesterase inhibitors are eff ectively used only by the elderly. In 2007, Canadians aged 65 and older spent an average of $36.80 on cholinesterase inhibitors.Th ere were insuffi cient purchases of cholinesterase inhibitors by persons under age 65 to generate reliable age- and province-specifi c estimates of spending per capita for those age groups. (Total fi gures for this therapeutic category exclude estimates for the censored age categories.)$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PENLPENSNBQCONMBSKBC AB$10$0$0$10NLNS PENBQCONMBSKBC ABCanada overall$10NLPENSNBQCONMBSKBC AB$0$20$30$40$50Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 3.6A» Per capita spending in Canada by age group, 2007Figure 3.6B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$011,740,792 people45-64 years$08,936,632 people65+$374,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H7 7Per capita spending in Canada: $4.90Drugs in this therapeutic categoryDonepezil• Rivastigmine• Galantamine• Common goal of therapyReduce symptoms of dementia• Example of an indicated conditionAlzheimer’s disease• Spending in provincesTh e age gradient in spending on this category of medicine is a single step: from zero spending among the non-elderly to signifi cant spending among the elderly.While some Canadians under age 65 purchased cholinesterase inhibitors in 2007, the numbers were too low to produce reliable estimates of age- and province-specifi c estimates. Across the provinces in 2007, average retail spending on cholinesterase inhibitors per person age 65 and older varied from $18.60 in Saskatchewan to $48.00 in Ontario.Provincial formulary coverageAll provinces except British Columbia and Newfoundland & Labrador provided restricted coverage for the three diff erent types of cholinesterase inhibitors that had more than $1,000 in national sales. No province provided unrestricted coverage for these drugs.Expenditure weighting does not aff ect this analysis, as provinces listed either all or none of the three types drugs in this category.Figure 3.6C» Percentage of drugs and their market value listed on provincial formulariesRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 3 drugsPercent of $0.2 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N7 8Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.3.6 Neurological: Cholinesterase inhibitorsSources of age-standardized variationDiff erences in the volume of treatment purchased by elderly residents explained virtually all variation in age-standardized spending per capita on cholinesterase inhibitors.Aft er adjusting for population age, residents of Western Canada purchased signifi cantly fewer cholinesterase inhibitors than other Canadians. Residents of Ontario purchased signifi cantly more than other Canadians.Very little regional variation in costs resulted from diff erences in therapeutic choices made within the category of cholinesterase inhibitors.Residents of Saskatchewan, New Brunswick, and Prince Edward Island paid higher unit prices for cholinesterase inhibitors. Th is is surprising, since prescription length tended to be longer in these provinces (thereby reducing pharmacists’ fees paid per unit).Population age and provincial spendingBecause age-specifi c estimates of spending on cholinesterase inhibitors are found for elderly populations only, diff erences in the age of provincial populations alone would explain signifi cant variations in spending per capita in this therapeutic category.Age-standardization alone would predict that per capita spending on cholinesterase inhibitors in Alberta would be 20.8% below the national average. In contrast, age-standardization would predict cholinesterase inhibitors spending per Nova Scotian to be 11.0% above the national average.Aft er fi gures were adjusted for diff erences in population age, spending on cholinesterase inhibitors ranged from 40% below the national average in British Columbia, Saskatchewan, and Manitoba to 30% above the national average in Ontario.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $3.1 $3.2 $2.8 $2.9 $6.3 $5.0 $5.0 $6.3 $5.8 $3.5Total variation from national average -37.6% -34.2% -43.9% -41.7% 27.9% 1.2% 1.9% 27.6% 16.8% -30.1% Variation predicted by population age 3.8% -20.8% 7.7% 0.6% -2.3% 6.6% 7.6% 11.0% 8.2% 3.1%Age-standardized variation -41.5% -13.4% -51.6% -42.3% 30.2% -5.4% -5.6% 16.6% 8.6% -33.2% Prescription volume -55.4% -75.6% -88.0% -85.3% 28.6% 31.2% -66.6% -53.2% -46.0% -81.6% Prescription size 14.6% 61.0% 32.3% 42.0% 0.7% -34.1% 57.4% 68.7% 47.6% 45.8%Volume effects -40.8% -14.5% -55.7% -43.3% 29.3% -2.9% -9.1% 15.5% 1.6% -35.8% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix -0.1% 0.2% 0.1% 0.0% 0.1% -0.2% 0.2% 0.7% 1.9% 0.5%Therapeutic choice effects -0.1% 0.2% 0.1% 0.0% 0.1% -0.2% 0.2% 0.7% 1.9% 0.5% Prices paid -0.6% 0.9% 4.0% 1.0% 0.8% -2.3% 3.3% 0.5% 5.1% 2.1% Generic use 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Price effects -0.6% 0.9% 4.0% 1.0% 0.8% -2.3% 3.3% 0.5% 5.1% 2.1%Table 3.6A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H7 9-41%-15%-56%-36%-43%+29%-3%-9%+2%+15%0%0%0%+1%0%0%0%0%+2%+1%-1%+1%+4%+2%+1%+1%-2%+3%+5%0%BritishColumbia-41%NewBrunswick-6%NovaScotia+17%Newfoundlandand Labrador-33%Prince Edward I.+9%Alberta-13%Saskatchewan-52%Manitoba-42% Quebec-5%Ontario+30%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 3.6E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 3.6D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N8 0Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.3.6 Neurological: Cholinesterase inhibitorsTh e fi nancial impact of age-standardized growth in the volume of cholinesterase inhibitor purchases was greatest in Ontario and Quebec, at 26% or more per year,.For all provinces, the cost impact of therapeutic choice eff ects, price changes, and generic availability within the cholinesterase inhibitors category were modest by comparison to trends related to the volume of purchases in this category. Pace of change, 1998–2007Infl ation-adjusted retail spending on cholinesterase inhibitors per Canadian grew from about $0.60 per capita in 1998 to $4.90 in 2007. Th e total change over this period was 714%.Sources of changeWhile aging of the population contributed up to 2.2% per year toward growth in infl ation-adjusted and age-standardized spending on cholinesterase inhibitors, age-standardized spending growth was far greater: from 12.1% to 25.0% per year across provinces.As with the spending variations across provinces, infl ation-adjusted and age-standardized cholinesterase inhibitor spending trends between 1998 and 2007 were driven almost exclusively by volume of purchases.Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $0.6 $0.7 $0.4 $0.9 $0.8 $0.6 $0.5 $0.6 $0.7 $0.5Per capita spending in 2007 $4.9 $3.1 $3.2 $2.8 $2.9 $6.3 $5.0 $5.0 $6.3 $4.0 Average annual rate of change 23.3% 15.9% 22.7% 12.3% 14.1% 25.7% 26.0% 23.2% 24.8% 23.8% Rate of change due to population aging 0.9% 1.1% 0.6% 0.2% 0.0% 0.7% 1.6% 1.3% 1.3% 2.1%Age-standardized rate of change 22.4% 14.8% 22.0% 12.1% 14.1% 25.0% 24.4% 21.8% 23.5% 21.7% Prescription volume 28.1% 18.0% 18.4% 11.6% 11.1% 32.6% 32.6% 20.9% 22.2% 21.2% Prescription size -4.7% -3.1% 2.1% -0.2% 1.0% -6.3% -6.7% 0.9% 1.0% 0.2%Volume effects 23.3% 14.9% 20.5% 11.4% 12.1% 26.3% 26.0% 21.8% 23.2% 21.4% Therapeutic mix -1.7% -1.0% -1.8% -2.6% -1.0% -2.0% -1.2% -1.8% -1.3% -1.1% Drug mix 0.5% 0.6% 2.6% 2.8% 1.4% 0.4% -0.2% 1.9% 1.6% 1.1%Therapeutic choice effects -1.3% -0.4% 0.8% 0.2% 0.4% -1.6% -1.5% 0.1% 0.3% -0.1% Prices paid 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Generic use 0.3% 0.4% 0.7% 0.5% 1.6% 0.3% -0.1% -0.1% 0.0% 0.4%Price effects 0.3% 0.4% 0.7% 0.5% 1.6% 0.3% -0.1% -0.1% 0.0% 0.4%Table 3.6B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H8 1Note: All fi gures are expressed in the equivalent of year 2007 dollars.+15%+21%+11%+21%+12%+26%+26%+22%+23%0%+1%0%0%0%-2%-1%0%0%0%+1%+1%0%+2%0%0%0%0%BritishColumbia+15%NewBrunswick+22%NovaScotia+23%Newfoundlandand LabradorandPrince Edward I.+22%Alberta+22%Saskatchewan+12%Manitoba+14% Quebec+24%Ontario+25%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 3.6G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 3.6F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N8 2Levels of spending across Canada and age groups3.7 Neurological: Drugs for Parkinson’s diseaseSpending in CanadaDrugs used to reduce the symptoms of Parkinson’s disease are the last in the neurological class and the smallest therapeutic category studied in this atlas.Canadians spent approximately $2.60 per capita on these drugs in 2007, for a total of $86 million.Spending on drugs for Parkinson’s disease is concentrated only among older adults, particularly those aged 65 and older.In 2007, Canadians aged 45–64 spent an average of $2.50 each on drugs for Parkinson’s disease. Canadians aged 65 and older spent an average of $14.40 and accounted for 74% of all sales of drugs for Parkinson’s disease in Canada.Th ere were insuffi cient purchases of drugs for Parkinson’s disease by persons under age 45 to generate reliable age- and province-specifi c estimates of spending per capita for those age groups. (Total fi gures for this therapeutic category exclude estimates for the censored age categories.)$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNS PENBQCONMBSKBC ABCanada overall$0$10NLPENSNBQCONMBSKBC AB$10$20NLPENSNBQCONMBSKBC AB$0Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 3.7A» Per capita spending in Canada by age group, 2007Figure 3.7B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$011,740,792 people45-64 years$38,936,632 people65+$144,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H8 3Per capita spending in Canada: $2.60Drugs in this therapeutic categoryLevodopa/carbidopa• Dopamine agonists (e.g. ropinarole)• Other dopaminergic agents (e.g. • entacapone)Common goal of therapyReduce symptoms of Parkinson’s disease• Example of an indicated conditionParkinson’s disease• Spending in provincesAs measured by coeffi cient of variation (the ratio of the standard deviation over the mean), age-specifi c variation in spending on drugs for Parkinson’s disease was the lowest of all therapeutic categories studied in this atlas.Although age-specifi c levels of spending per capita on drugs for Parkinson’s disease were relatively comparable across provinces, provinces with relatively high spending among persons aged 65 and older had relatively low spending on persons aged 45–64.Average retail spending on drugs for Parkinson’s disease per person aged 45–64 ranged from $2.25 in Ontario to $3.79 in Manitoba. Average spending per person aged 65 and older ranged from $12.10 in Manitoba to $15.00 in Ontario.Provincial formulary coverageProvinces provided unrestricted or restricted coverage for eight of the 10 diff erent types of drug for Parkinson’s disease that had more than $1,000 in national sales.Weighted by national sales volumes, the drugs covered in each province accounted for almost all of the Canadian market for Parkinson’s drugs. (Drugs not listed had very small sales relative to leading drugs in this class.)Figure 3.7C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 10 drugsPercent of $0.1 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N8 4Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.3.7 Neurological: Drugs for Parkinson’s diseaseon drugs for Parkinson’s disease was 8.7% above the national average in Quebec and close to or below the national average in all other provinces.Sources of age-standardized variationA variety of factors explain the diff erences between Quebec and the rest of Canada in terms of age-standardized spending per capita on drugs for Parkinson’s disease in 2007.Aft er adjusting for population age, residents of Quebec purchased surprisingly fewer drugs for Parkinson’s disease than other Canadians.However, when residents of Quebec purchased drugs for Parkinson’s disease, they tended to receive expensive options from within this therapeutic category, they paid higher unit prices for particular brands, and they used generic alternatives less oft en.In 2007, prices of Parkinson’s drugs were lower in Ontario than all other provinces.Population age and provincial spendingBecause spending on drugs for Parkinson’s disease is concentrated among older adults, diff erences in the age of provincial populations alone would cause relatively signifi cant variations in spending per capita in this therapeutic category.Age-standardization alone would predict that per capita spending on drugs for Parkinson’s disease in Alberta would be 17.4% below the national average. In contrast, age-standardization would predict that per capita spending on drugs for Parkinson’s disease in Nova Scotia would be 9.0% above the national average.Aft er fi gures were adjusted for diff erences in population age, spending on drugs for Parkinson’s disease deviated by less than any other therapeutic category studied.Observed interprovincial variations were predominantly between Quebec and the rest of Canada. In 2007, age-standardized spending per capita BC AB SK MB ON QC NB NS PE NLPer capita spending in province $2.7 $1.9 $2.4 $2.6 $2.6 $3.0 $2.5 $2.6 $2.8 $2.5Total variation from national average 3.5% -27.3% -6.8% -0.3% -2.4% 15.5% -3.3% -2.4% 5.8% -5.2% Variation predicted by population age 4.4% -17.4% 5.6% -1.1% -2.3% 6.8% 7.6% 9.0% 7.1% 6.3%Age-standardized variation -1.0% -9.8% -12.4% 0.8% -0.1% 8.7% -10.8% -11.4% -1.3% -11.5% Prescription volume -22.3% -43.8% -8.7% -10.6% -1.8% 35.3% -38.4% -38.4% -14.1% -47.9% Prescription size 17.0% 36.7% 6.1% 13.6% 14.3% -43.4% 31.2% 34.2% 14.8% 33.7%Volume effects -5.4% -7.1% -2.6% 3.0% 12.5% -8.1% -7.2% -4.2% 0.7% -14.2% Therapeutic mix -5.1% 1.2% 0.5% 0.4% -3.0% 4.0% -0.8% -0.5% -2.7% 0.5% Drug mix 6.1% -1.8% -12.0% -5.0% -3.6% 4.0% -2.3% -7.0% -2.1% -6.9%Therapeutic choice effects 1.0% -0.6% -11.5% -4.6% -6.6% 8.0% -3.1% -7.4% -4.8% -6.4% Prices paid 1.3% 1.1% 7.1% 6.6% -2.6% 2.5% 4.4% 2.2% 7.4% 5.9% Generic use 2.2% -3.2% -5.4% -4.2% -3.4% 6.3% -5.0% -2.0% -4.5% 3.3%Price effects 3.4% -2.2% 1.7% 2.4% -6.0% 8.7% -0.5% 0.3% 2.8% 9.1%Table 3.7A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H8 5-5%-7%-3%-14%+3%+13%-8%-7%+1%-4%+1%-1%-11%-6%-5%-7%+8%-3%-5%-7%+3%-2%+2%+9%+2%-6%+9%-1%+3%0%BritishColumbia-1%NewBrunswick-11%NovaScotia-11%Newfoundlandand Labrador-11%Prince Edward I.-1%Alberta-10%Saskatchewan-12%Manitoba+1% Quebec+9%Ontario0%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 3.7E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 3.7D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N8 6Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.3.7 Neurological: Drugs for Parkinson’s diseaseGrowing volumes of prescriptions purchased from 1998 to 2007 contributed 2.8% and 3.2% per year in Quebec and Manitoba respectively to the annual growth in spending on drugs for Parkinson’s disease. In other provinces, changes in the use of drugs for Parkinson’s disease caused spending to fall or rise very modestly.Across provinces, changes in the types of drugs for Parkinson’s disease selected between 1998 and 2007 contributed from 0.6% to 1.9% per year to growth in age-standardized, infl ation-adjusted spending per capita.Increased availability and use of generic drugs for Parkinson’s disease between 1998 and 2007 resulted in savings ranging between –1.0% and –1.8% per year in the provinces. Th e prices paid for particular brands of drugs for Parkinson’s disease were relatively stable in most provinces. Pace of change, 1998–2007Infl ation-adjusted retail spending on drugs for Parkinson’s disease per Canadian grew by only 19.3% between 1998 and 2007. Th ese changes in spending amounted to an annual rate of growth equal to 1.8%, one of the slowest growth rates among the therapeutic categories studied in this atlas.Sources of changePopulation aging contributed between 0.5% and 1.7% toward the annual growth of per capita retail spending on drugs for Parkinson’s disease in Canadian provinces from 1998 to 2007.Infl ation-adjusted and age-standardized spending per capita on drugs for Parkinson’s disease actually fell in fi ve provinces. Age-standardized spending per capita on drugs for Parkinson’s disease grew most rapidly in Quebec (4.0% per year aft er adjusting for general infl ation). Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $2.2 $3.0 $1.7 $2.7 $1.9 $2.2 $1.8 $2.2 $2.6 $2.4Per capita spending in 2007 $2.6 $2.7 $1.9 $2.4 $2.6 $2.6 $3.0 $2.5 $2.6 $2.6 Average annual rate of change 1.8% -0.9% 0.9% -0.9% 3.2% 1.3% 5.5% 1.5% -0.1% 0.7% Rate of change due to population aging 1.0% 1.1% 0.9% 0.6% 0.5% 0.7% 1.5% 1.4% 1.4% 1.7%Age-standardized rate of change 0.8% -2.1% -0.1% -1.5% 2.8% 0.6% 4.0% 0.1% -1.5% -1.0% Prescription volume 3.2% -0.4% -2.0% -0.5% 2.9% 4.7% 5.8% -1.6% -2.1% -2.3% Prescription size -2.1% -1.3% 1.7% -0.4% 0.2% -3.3% -3.0% 1.4% 1.1% 1.8%Volume effects 1.1% -1.8% -0.4% -0.9% 3.2% 1.4% 2.8% -0.2% -1.0% -0.5% Therapeutic mix 0.0% 0.0% 0.3% 0.2% -0.2% -0.4% 0.3% 0.5% 0.1% 0.3% Drug mix 1.0% 1.1% 1.6% 0.6% 1.2% 1.1% 1.4% 1.0% 0.7% 1.1%Therapeutic choice effects 1.0% 1.0% 1.9% 0.8% 1.1% 0.6% 1.8% 1.5% 0.8% 1.3% Prices paid 0.1% 0.2% 0.1% -0.1% -0.4% -0.1% 0.5% 0.1% -0.1% 0.0% Generic use -1.4% -1.6% -1.7% -1.3% -1.1% -1.3% -1.0% -1.3% -1.2% -1.8%Price effects -1.2% -1.4% -1.5% -1.4% -1.5% -1.5% -0.5% -1.2% -1.3% -1.8%Table 3.7B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H8 7Note: All fi gures are expressed in the equivalent of year 2007 dollars.-2%0%-1%0%+3%+1%+3%0%-1%+1%+2%+1%+1%+1%+1%+2%+2%+1%-1%-2%-1%-2%-1%-1%-1%-1%-1%BritishColumbia-2%NewBrunswick0%NovaScotia-1%Newfoundlandand LabradorandPrince Edward I.-1%Alberta0%Saskatchewan-2%Manitoba+3% Quebec+4%Ontario+1%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 3.7G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 3.7F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N8 8Levels of spending across Canada and age groupsSpending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$1511,740,792 people45-64 years$598,936,632 people65+$1584,417,8054 Acid-reducing drugs$0NLNSNBQCONMBSKBC AB PE$20$40$0$20NLNS PENBQCONMBSKBC AB$40$60Canada overallNLNSNBQCONMBSKBC AB PE$0$20$40NLPENSNBQCONMBSKBC AB$0$20$40$60$100$80NLPENSNBQCONMBSKBC AB$0$20$40$60$100$120$140$160$180$80Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 4A» Per capita spending in Canada by age group, 2007Figure 4B» Per capita spending by province and age group, 2007Spending in CanadaSpending on drugs used to prevent ulcers or reduce the risk of damage to the esophagus resulting from acid refl ux (acid-reducing drugs) are the third largest therapeutic category of prescription drugs in terms of retail spending in Canada.Canadians spent approximately $42.70 per capita on these drugs in 2007, for a total of $1.4 billion (7.4% of all prescription drug spending in Canada).Th ere is a positive age gradient for per capita spending on acid-reducing drugs; however, these medicines are used by adults of all ages. In 2007, Canadians aged 65 and over spent an average of $158 on acid-reducing drugs. Canadians aged 45–64 spent an average of $59 each and accounted for 38% of all acid-reducing drug sales in Canada.Th ere were insuffi cient purchases of acid-reducing drugs by persons aged 19 and under to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H8 9Per capita spending in Canada: $42.70Drugs in this therapeutic categoryHistamine (2) receptor antagonists (e.g. • ranitidine)Proton pump inhibitors (e.g. omeprazole)• Common goal of therapyTreat and prevent the risk of ulcers and • damage to esophagus due to acid refl uxExamples of indicated conditionsAcid refl ux• Peptic ulcer• 0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 9 drugsPercent of $1.4 billionSpending in provincesTh e age gradient for spending on acid-reducing drugs was relatively steep in Ontario and Quebec, where spending per person aged 65 and older was 3.7 times or more that of all ages. Th e age gradient was fl atter in Nova Scotia and Newfoundland & Labrador, where spending by elderly residents was only 2.4 times or less the overall provincial average.In relative terms, age-specifi c spending levels varied across provinces the most for persons aged 20–44. Average retail spending on acid-reducing drugs in this age group ranged from $11.50 in British Columbia to $29.00 in Nova Scotia (a highest-to-lowest ratio of 2.53).Average spending per person in the age groups of persons 45–64 and 65 and older varied nearly as much in proportional terms (with highest-to-lowest ratios of 2.26 and 2.0, respectively).Provincial formulary coverageProvinces provided restricted or unrestricted coverage for six or more of the nine diff erent types of acid-reducing drugs that had more than $1,000 in national sales. Restricted listings were used in all provinces except Alberta and Quebec.Weighted by national sales volumes, the drugs covered in each province accounted for 84% or more of the Canadian market in acid-reducing drugs. (Drugs not listed had very small sales relative to leading drugs in this class.)Figure 4C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not coveredListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N9 0Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.4 Acid-reducing drugsSources of age-standardized variationVolume of treatment purchased was the most important cost-driver for most provinces that deviated signifi cantly from national average age-standardized retail spending on acid-reducing drugs.Aft er adjusting for population age, residents of Quebec purchased signifi cantly more acid-reducing drugs than did other Canadians. Th erapeutic choice eff ects also contributed to interprovincial variations in spending on acid-reducing drugs. Residents of Quebec and Alberta tended to receive a more expensive mix of drugs from within this therapeutic category than all other Canadians.As with other categories, prices paid per unit of particular brands of drugs in some provinces may have been infl uenced by the average length of prescriptions. Shorter prescriptions result in higher levels of pharmacists’ fees paid per unit of drug received.Population age and provincial spendingBecause spending on acid-reducing drugs is relatively concentrated among older adults, diff erences in the age of provincial populations alone would cause some interprovincial variations in spending per capita.Age-standardization alone would predict that per capita spending on acid-reducing drugs in Alberta would be 12.6% below the national average. In contrast, age-standardization would predict spending on acid-reducing drugs per Nova Scotian to be 7.7% above the national average.Aft er fi gures were adjusted for diff erences in population age, spending on acid-reducing drugs deviated by more than 5% from the national average in all provinces except Ontario.Age-standardized spending on acid-reducing drugs was approximately 30.9% above the national average in Nova Scotia, and 32.6% below the national average in British Columbia.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $30.1 $40.0 $35.3 $30.1 $43.0 $49.7 $54.6 $59.3 $54.1 $52.4Total variation from national average -29.7% -6.5% -17.4% -29.5% 0.7% 16.2% 27.8% 38.6% 26.5% 22.5% Variation predicted by population age 2.9% -12.6% 0.9% -2.0% -2.0% 5.5% 6.9% 7.7% 4.8% 7.0%Age-standardized variation -32.6% 6.1% -18.3% -27.5% 2.7% 10.7% 20.9% 30.9% 21.7% 15.6% Prescription volume -37.3% -29.8% 1.2% -22.1% -11.6% 41.8% -4.4% 8.6% 14.4% 14.6% Prescription size 16.0% 30.9% -8.5% 5.2% 21.8% -44.9% 36.4% 43.6% 18.6% 21.1%Volume effects -21.3% 1.2% -7.4% -16.9% 10.2% -3.1% 32.0% 52.2% 33.0% 35.7% Therapeutic mix -2.5% 3.6% -8.0% -3.6% -1.7% 5.7% -13.5% -16.0% -19.1% -18.8% Drug mix -8.7% 3.0% -6.2% -7.3% -4.2% 4.2% -2.3% -2.8% 0.8% -4.4%Therapeutic choice effects -11.2% 6.6% -14.2% -10.9% -5.8% 9.8% -15.9% -18.8% -18.2% -23.2% Prices paid -1.2% -0.8% 4.6% 2.0% -1.2% 3.0% 3.9% -3.2% 3.0% 1.2% Generic use 1.1% -0.9% -1.4% -1.8% -0.5% 1.0% 0.8% 0.8% 3.9% 1.8%Price effects -0.1% -1.7% 3.3% 0.3% -1.6% 4.0% 4.8% -2.5% 6.9% 3.0%Table 4A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H9 1-21%+1%-7%+36%-17%+10%-3%+32%+33%+52%-11%+7%-14%-23%-11%-6%+10%-16%-18%-19%0%-2%+3%+3%0%-2%+4%+5%+7%-2%BritishColumbia-33%NewBrunswick+21%NovaScotia+31%Newfoundlandand Labrador+16%Prince Edward I.+22%Alberta+6%Saskatchewan-18%Manitoba-27% Quebec+11%Ontario+3%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 4E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 4D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N9 2Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.4 Acid-reducing drugsMost of the growth in spending per capita on acid-reducing drugs between 1998 and 2007 was a result of increased volumes of prescriptions purchased. Aft er adjusting for population aging and general infl ation, increased prescribing of acid-reducing drugs caused spending per capita to rise by between 3.0% and 7.2% per year in the provinces.Th erapeutic choice eff ects also had a signifi cant impact on costs over time. Changes in the types of acid-reducing drugs selected between 1998 and 2007 contributed more than 2.1% per year to growth in age-standardized, infl ation-adjusted spending on acid-reducing drugs per capita.Increased availability and use of generic acid-reducing drugs between 1998 and 2007 resulted in savings ranging between 0.7% and 2.1% per year in the provinces. Th e average prices paid for particular brands of acid-reducing drugs were essentially unchanged over this period. Pace of change, 1998–2007Infl ation-adjusted retail spending on acid-reducing drugs per Canadian nearly doubled between 1998 and 2007. Per capita spending in this category grew at an infl ation-adjusted average rate of 6.6% per year over the period.Acid-reducing drugs accounted for 8% of the total increase in prescription drug spending in Canada between 1998 and 2007.Sources of changePopulation aging contributed between 0.6% and 1.6% to the annual growth of per capita retail spending on acid-reducing drugs in the provinces from 1998 to 2007.Infl ation-adjusted, age-standardized spending per capita on acid-reducing drugs grew most rapidly in Saskatchewan (8.5% per year) and least rapidly in Ontario (3.8% per year).Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $22.5 $16.1 $20.3 $14.4 $13.3 $27.5 $19.7 $24.5 $32.2 $26.6Per capita spending in 2007 $42.7 $30.1 $40.0 $35.3 $30.1 $43.0 $49.7 $54.6 $59.3 $52.7 Average annual rate of change 6.6% 6.5% 7.0% 9.4% 8.5% 4.6% 9.7% 8.4% 6.3% 7.1% Rate of change due to population aging 1.0% 1.1% 1.0% 0.9% 0.6% 0.8% 1.4% 1.3% 1.3% 1.6%Age-standardized rate of change 5.6% 5.3% 6.0% 8.5% 7.9% 3.8% 8.3% 7.0% 5.0% 5.5% Prescription volume 4.7% 3.6% 2.3% 4.8% 4.9% 3.5% 8.3% 0.9% 0.5% 0.6% Prescription size 0.5% 0.6% 2.8% 0.5% 1.9% 0.3% -1.2% 3.2% 2.5% 3.0%Volume effects 5.1% 4.1% 5.2% 5.4% 6.8% 3.8% 7.2% 4.1% 3.0% 3.6% Therapeutic mix 3.1% 4.0% 2.9% 4.7% 2.8% 3.3% 2.6% 4.0% 3.4% 2.7% Drug mix -0.9% -1.8% 0.0% -0.9% -0.4% -1.2% -0.2% 0.5% -0.1% 0.1%Therapeutic choice effects 2.2% 2.2% 3.0% 3.8% 2.4% 2.1% 2.4% 4.4% 3.4% 2.8% Prices paid 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Generic use -1.7% -1.0% -2.1% -0.7% -1.4% -2.0% -1.2% -1.5% -1.4% -0.9%Price effects -1.7% -1.0% -2.1% -0.7% -1.4% -2.0% -1.2% -1.5% -1.4% -0.9%Table 4B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H9 3Note: All fi gures are expressed in the equivalent of year 2007 dollars.+4%+5%+5%+4%+7%+4%+7%+4%+3%+2%+3%+4%+3%+2%+2%+2%+4%+3%-1%-2%-1%-1%-1%-2%-1%-1%-1%BritishColumbia+5%NewBrunswick+7%NovaScotia+5%Newfoundlandand LabradorandPrince Edward I.+6%Alberta+6%Saskatchewan+8%Manitoba+8% Quebec+8%Ontario+4%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 4G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 4F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N9 4Levels of spending across Canada and age groups5 Inhaled drugs for respiratory conditionsSpending in CanadaInhaled drugs used to manage the symptoms of respiratory conditions (hereaft er referred to as respiratory drugs) constitute the fi ft h largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Canadians spent approximately $27 per capita on these drugs in 2007, for a total of $888 million (4.7% of all prescription drug spending in Canada).While per capita spending on respiratory drugs is much higher among the elderly, these medicines are used relatively frequently by Canadians of all ages. Canadians aged 65 and over spent more on respiratory drugs than other age categories (an average of $81.50 per capita) and accounted for the largest share (41%) of all respiratory drug sales in Canada in 2007. However, Canadians aged 45–64 spent an average of $29.40 on respiratory drugs, accounting for 17% of spending in this therapeutic category, while Canadians under age 45 spent an average of $13.60 per capita and accounted for 30% of spending.NLPENSNBQCONMBSKBC AB$0$20$40$60$80$0NLNS PENBQCONMBSKBC AB$20Canada overall$0NLNSNBQCONMBSKBC AB PE$20$0NLNSNBQCONMBSKBC AB PE$20$20NLPENSNBQCONMBSKBC AB$0Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 5A» Per capita spending in Canada by age group, 2007Figure 5B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$147,776,058 people20-44 years$1411,740,792 people45-64 years$298,936,632 people65+$824,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H9 5Per capita spending in Canada: $27.00Drugs in this therapeutic categoryInhaled adrenergics (e.g. salbutamol, • salmeterol)Inhaled glucocorticoids (e.g. fl uticasone)• Inhaled anticholinergics (e.g. ipratropium)• Combinations (e.g. salmeterol/fl uticasone)• Common goal of therapyReduce symptons of respiratory conditions• Examples of indicated conditionsAsthma• Chronic obstructive lung disease• Spending in provincesTh e extent to which respiratory drug spending varied across age groups diff ered across provinces. Th e ratio of spending on respiratory drugs per person aged 65 and older to spending per person under age 65 was 4.8 in Quebec. Th is ratio was 4.2 in New Brunswick, 4.1 in British Columba, and 3.5 or less in all other provinces.Interprovincial variations in respiratory drug spending within age groups were highest at the ends of the age spectrum: among children and the elderly.Average retail spending on respiratory drugs per person aged 19 and under ranged from $7.20 in British Columbia to over $17 in Prince Edward Island and Newfoundland & Labrador.Average spending per person aged 65 and over varied nearly as much in proportional terms: from $48.70 in British Columbia to $93.90 in Quebec.Provincial formulary coverageProvinces provided restricted or unrestricted coverage for 12 or more of the 15 diff erent types of respiratory drugs that had more than $1,000 in national sales.Weighted by national sales volumes, the drugs covered in each province accounted for over 90% of the Canadian market for respiratory drugs.Drugs covered with restrictions in many provinces were ones that had signifi cant national sales.Figure 5C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 15 drugsPercent of $0.8 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N9 6Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.5 Inhaled drugs for respiratory conditionsSources of age-standardized variationVolume of treatment purchased was the most important cost-driver for most provinces that deviated signifi cantly from national average age-standardized retail spending on respiratory drugs.Aft er adjusting for population age, residents in Western Canada purchased signifi cantly fewer respiratory drugs than did other Canadians. Residents of Atlantic Canada tended to purchase types of respiratory drugs that were signifi cantly less expensive than those purchased by other Canadians.As with other categories, prices paid per unit of particular brands of drug in some provinces may have been infl uenced by the average length of prescriptions. Shorter prescriptions result in higher levels of pharmacists’ fees paid per unit of drug received.(Note: Analyses of changes in spending over time were not done for this category because 1998 data were not available for injectable and inhaled medicines.)Population age and provincial spendingAlthough spending on respiratory drugs occurs among all age groups in Canada, interprovincial diff erences in population ages would nevertheless predict higher per capita spending in some provinces.Per capita spending in Alberta would be expected to be 7% below the national average on the basis of population age alone. Similarly, age-standardization alone would predict that per capita spending on respiratory drugs in New Brunswick and Nova Scotia would be 4% or more above the national average.Aft er fi gures were adjusted for diff erences in population age, spending on respiratory drugs deviated by more than 5% from the national average in all provinces except New Brunswick, Nova Scotia, and Prince Edward Island.Age-standardized spending on respiratory drugs was approximately 7.8% above the national average in Quebec, and more than 30% below the national average in British Columbia.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $17.1 $22.5 $21.3 $20.2 $24.4 $30.1 $28.5 $29.4 $26.8 $24.4Total variation from national average -36.6% -16.8% -21.3% -25.4% -9.7% 11.4% 5.5% 8.7% -0.7% -9.7% Variation predicted by population age 1.7% -7.0% 1.9% -0.5% -1.0% 3.6% 4.0% 4.5% 3.2% 2.7%Age-standardized variation -38.4% -9.7% -23.2% -24.9% -8.7% 7.8% 1.5% 4.2% -3.9% -12.4% Prescription volume -37.8% -22.5% -11.7% -12.5% -12.6% 26.0% 14.7% 18.4% 16.3% -1.0% Prescription size 6.0% 9.1% -9.3% -2.0% 3.7% -14.4% 6.8% 3.4% -7.2% 5.1%Volume effects -31.8% -13.4% -21.0% -14.5% -9.0% 11.6% 21.5% 21.8% 9.1% 4.1% Therapeutic mix -2.5% 3.1% 3.0% -3.3% 2.4% 0.0% -14.1% -4.3% -10.9% -2.0% Drug mix -3.9% -1.3% -9.6% -8.5% -3.1% -0.7% -6.8% -12.4% -4.5% -13.6%Therapeutic choice effects -6.5% 1.8% -6.6% -11.8% -0.6% -0.7% -20.9% -16.7% -15.4% -15.6% Prices paid -0.2% 1.5% 4.2% 1.3% 0.7% -2.5% 1.6% -0.4% 1.8% -0.4% Generic use 0.1% 0.3% 0.2% 0.0% 0.2% -0.5% -0.7% -0.4% 0.6% -0.6%Price effects -0.1% 1.9% 4.4% 1.3% 1.0% -3.0% 0.9% -0.8% 2.4% -0.9%Table 5A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H9 7-32%-13%-21%+4%-14%-9%+12%+22%+9%+22%-6%+2%-7%-16%-12%-1%-1%-21%-15%-17%0%+2%+4%-1%+1%+1%-3%+1%+2%-1%BritishColumbia-38%NewBrunswick+1%NovaScotia+4%Newfoundlandand Labrador-12%Prince Edward I.-4%Alberta-10%Saskatchewan-23%Manitoba-25% Quebec+8%Ontario-9%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 5E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 5D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N9 8Levels of spending across Canada and age groups6.1 Analgesics: Opioid drugsSpending in CanadaCanadians spent an average of $14.80 per capita on opioid drugs in 2007, for a total of $485 million (2.6% of all prescription drug spending in Canada). Th is is the ninth largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Canadian adults of all ages purchased opioid drugs in 2007, with average spending slightly higher among Canadians aged 45–64 than among those aged 65 and over.In 2007, Canadians aged 65 and over spent an average of $26.10 on opioid drugs. Canadians aged 45–64 spent an average of $26.90 and accounted for 50% of all opioid drug sales in Canada.Th ere were insuffi cient purchases of opioid drugs by persons aged 19 and under to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20$20NLPENSNBQCONMBSKBC AB$30$10$0$10NLPENSNBQCONMBSKBC AB$0$20$30$0$10NLNS PENBQCONMBSKBC AB$20Canada overallAges 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 6.1A» Per capita spending in Canada by age group, 2007Figure 6.1B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$1111,740,792 people45-64 years$278,936,632 people65+$264,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H9 9Per capita spending in Canada: $14.80Drugs in this therapeutic categoryOpioids (e.g. morphine)• Common goal of therapyReduce symptoms of pain• Examples of indicated conditionsPost-surgical pain• Cancer pain• Spending in provincesTh e age gradient for spending on opioid drugs was steeper in British Columbia and Quebec than in other provinces. Th e ratio of opioid spending per person aged 65 and older to spending per person under age 65 was 2.0 nationally. Th is ratio was 2.6 in Quebec, 2.3 in British Columbia, and 1.5 or less in the Atlantic provinces.Across provinces, age-specifi c spending on opioid drugs was relatively varied for all adult age groups.Age-specifi c spending on opioid drugs was highest in Ontario for all age groups.Average retail spending on opioid drugs per person aged 20–44 ranged from $6.60 to $14.60, while spending ranged from $16.90 to $35.10 per person in the 45–64 age group and from $13.40 to $31.90 per person in the 65 and older age group.Provincial formulary coverageProvinces provided restricted or unrestricted coverage for nine or more of the 14 diff erent types of opioid drugs that had more than $1,000 in national sales.Weighted by national sales volumes, the opioid drugs covered in each province accounted for 91% or more of the entire Canadian retail market for opioids. Drugs covered with restrictions in many provinces had signifi cant national sales.Figure 6.1C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 14 drugsPercent of $0.6 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 0 0Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.6.1 Analgesics: Opioid drugsSources of age-standardized variationInterprovincial variation in age-standardized per capita spending on opioid drugs was primarily a function of both the volume and type of drug received from this therapeutic category. Residents of Alberta, Ontario, and Newfoundland & Labrador purchased signifi cantly more opioid drugs on an age-standardized basis than did residents in other provinces.When fi lling opioid prescriptions, residents of Manitoba, Ontario, and New Brunswick tended to receive signifi cantly more expensive types of opioid drug than did residents of other provinces.Residents in western provinces were more likely to use generic opioids than other Canadians.As with other categories, prices paid per unit of particular brands of drugs in some provinces may have been infl uenced by the average length of prescriptions. Population age and provincial spendingAlthough Canadian adults of all ages purchased opioid drugs in 2007, interprovincial diff erences in population age predict some variations in spending per capita because more is spent on opioids among older adult populations (those aged 45 and older).Based on population age alone, per capita opioid spending in Alberta would be expected to be 6.8% below the national average, whereas per capita spending in New Brunswick, Nova Scotia, and Newfoundland & Labrador would be expected to be more than 4% above the national average.Signifi cant interprovincial diff erences in spending on opioid drugs remained aft er adjusting for diff erences in population age.Age-standardized spending on opioids ranged from 37.7% below the national average in Prince Edward Island to 28.8% above the national average in Ontario.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $11.1 $15.2 $12.2 $10.9 $18.7 $11.1 $15.1 $14.9 $9.4 $13.8Total variation from national average -25.0% 3.2% -17.7% -25.9% 27.0% -24.7% 2.5% 1.1% -36.4% -6.5% Variation predicted by population age 2.3% -6.8% -2.6% -3.1% -1.8% 3.3% 4.6% 4.9% 1.3% 5.8%Age-standardized variation -27.3% 10.1% -15.1% -22.8% 28.8% -28.0% -2.1% -3.7% -37.7% -12.2% Prescription volume -12.1% 6.4% -27.9% -51.4% -3.2% 15.7% -12.0% -22.2% -22.5% 26.7% Prescription size -1.1% 9.8% 13.7% 7.7% 12.8% -26.8% -0.7% 24.6% 4.6% -3.1%Volume effects -13.2% 16.2% -14.3% -43.7% 9.5% -11.2% -12.8% 2.3% -17.9% 23.6% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix -9.1% -3.5% -2.0% 19.3% 21.1% -23.0% 5.2% -7.0% -24.5% -42.2%Therapeutic choice effects -9.1% -3.5% -2.0% 19.3% 21.1% -23.0% 5.2% -7.0% -24.5% -42.2% Prices paid -0.1% 0.1% 4.9% 1.8% -2.1% 4.5% 5.9% 0.9% 3.5% 7.2% Generic use -4.9% -2.7% -3.8% -0.2% 0.2% 1.7% -0.4% 0.0% 1.1% -0.8%Price effects -5.0% -2.6% 1.1% 1.5% -1.9% 6.1% 5.5% 0.9% 4.7% 6.4%Table 6.1A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 0 1-13%+16%-14%+24%-44%+10%-11%-13%-18%+2%-9%-4%-2%-42%+19%+21%-23%+5%-24%-7%-5%-3%+1%+6%+2%-2%+6%+5%+5%+1%BritishColumbia-27%NewBrunswick-2%NovaScotia-4%Newfoundlandand Labrador-12%Prince Edward I.-38%Alberta+10%Saskatchewan-15%Manitoba-23% Quebec-28%Ontario+29%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 6.1E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 6.1D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 0 2Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.6.1 Analgesics: Opioid drugsSaskatchewan (12.0% per year) and least rapidly in British Columbia (4.6% per year).Increased volumes of opioid purchases between 1998 and 2007 contributed to Saskatchewan and Manitoba’s relatively rapid growth in infl ation-adjusted and age-standardized opioid drug spending per capita.Nationally, the change in type of opioid drugs that were being used from 1998 to 2007 caused a signifi cant increase (3.4% per year) in infl ation-adjusted and age-standardized spending in this category. Across provinces, these trends contributed from 1.8% to 4.9% per year to infl ation-adjusted and age-standardized opioid drug spending per capita.Prices of particular opioid drugs increased between 1998 and 2007, off set only in part by savings generated by the use of available generics. Pace of change, 1998–2007Infl ation-adjusted retail spending on opioid drugs per Canadian more than doubled between 1998 and 2007, from $7.00 to $14.80 (in 2007 dollars).From 1998 to 2007, the average annual rate of growth for per capita retail spending on opioid drugs was signifi cantly higher in Saskatchewan (13.0%) and Manitoba (10.8%) than in the country as a whole (7.8%)Sources of changeBecause the age gradient in opioid drug spending is not very steep aft er age 45, population aging contributed a relatively modest amount (between 0.7% and 1.2%) to the annual growth of per capita retail spending on opioid drugs in the provinces from 1998 to 2007.Infl ation-adjusted and age-standardized spending per capita on opioid drugs grew most rapidly in Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $7.0 $6.4 $8.4 $3.6 $3.9 $8.1 $5.8 $7.6 $8.4 $6.9Per capita spending in 2007 $14.8 $11.1 $15.2 $12.2 $10.9 $18.7 $11.1 $15.1 $14.9 $12.9 Average annual rate of change 7.8% 5.6% 6.1% 13.0% 10.8% 8.7% 6.7% 7.1% 5.9% 6.4% Rate of change due to population aging 0.8% 1.0% 1.0% 1.0% 0.7% 0.7% 1.0% 1.1% 1.2% 1.2%Age-standardized rate of change 7.0% 4.6% 5.1% 12.0% 10.1% 8.0% 5.7% 6.0% 4.6% 5.2% Prescription volume 2.4% 1.3% -0.1% 8.0% 3.5% 2.4% 3.0% 1.5% 0.2% -0.4% Prescription size 0.2% -0.5% -0.1% 1.7% 1.2% 0.4% -0.5% 0.2% 2.0% 2.1%Volume effects 2.7% 0.7% -0.2% 9.7% 4.8% 2.8% 2.5% 1.7% 2.2% 1.7% Therapeutic mix -3.4% -2.8% -2.0% -2.2% -3.4% -3.8% -3.1% -2.6% -1.6% -1.7% Drug mix 6.8% 6.3% 6.9% 4.7% 6.1% 8.0% 4.9% 6.4% 4.7% 5.4%Therapeutic choice effects 3.4% 3.5% 4.9% 2.5% 2.8% 4.2% 1.8% 3.8% 3.1% 3.6% Prices paid 1.1% 0.8% 0.6% 0.9% 2.1% 1.0% 1.6% 1.1% 0.9% 1.1% Generic use -0.1% -0.5% -0.2% -1.2% 0.4% 0.0% -0.1% -0.7% -1.6% -1.3%Price effects 0.9% 0.4% 0.5% -0.2% 2.5% 1.0% 1.5% 0.4% -0.7% -0.2%Table 6.1B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 0 3Note: All fi gures are expressed in the equivalent of year 2007 dollars.+1%0%+10%+2%+5%+3%+2%+2%+2%+3%+5%+2%+4%+3%+4%+2%+4%+3%0%0%0%0%+3%+1%+1%0%-1%BritishColumbia+5%NewBrunswick+6%NovaScotia+5%Newfoundlandand LabradorandPrince Edward I.+5%Alberta+5%Saskatchewan+12%Manitoba+10% Quebec+6%Ontario+8%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 6.1G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 6.1F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 0 4Levels of spending across Canada and age groups6.2 Analgesics: Nonsteroidal anti-infl ammatory drugs Spending in CanadaIncluding COX-2 selective agents, nonsteroidal anti-infl ammatory drugs (hereaft er referred to as NSAIDs) comprise the 10th largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Canadians spent approximately $11.90 per capita on these drugs in 2007, for a total of $390 million.NSAIDs are largely used by adults only, with average spending per capita increasing steadily with age.Per capita retail spending on NSAIDs in 2007 was highest among Canadians aged 65 and older ($30.80), but Canadians aged 45–64 accounted for a larger share (47% versus 35%) of all NSAIDs sales in Canada. Retail spending on NSAIDs per Canadian aged 45–64 was $20.40 in 2007.Th ere were insuffi cient purchases of NSAIDs by persons aged 19 and under to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$0$10NLNS PENBQCONMBSKBC AB$20Canada overall$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20NLPENSNBQCONMBSKBC AB$30$10$0$10NLPENSNBQCONMBSKBC AB$0$20$30$40Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 6.2A» Per capita spending in Canada by age group, 2007Figure 6.2B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$611,740,792 people45-64 years$208,936,632 people65+$314,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 0 5Per capita spending in Canada: $11.90Drugs in this therapeutic categoryCyclooxgenase-2 (COX-2) inhibitors brand • (e.g. celecoxib)COX-2 inhibitors generic (diclofenac, • etodolac, meloxicam)Older NSAIDS (e.g. naproxen)• Common goal of therapyReduce symptoms of pain or infl ammation• Examples of indicated conditionsOsteoarthritis• Rheumatoid arthritis• Spending in provincesTh e age gradient for per capita spending on NSAIDs was steepest in Ontario.Th e ratio of NSAID spending per person aged 65 and older to spending per person under age 65 ranged from 2.6 in British Columbia to 4.2 in Ontario. Nationally, this ratio was 3.5.For all age groups, per capita retail spending on NSAIDs was highest in New Brunswick and lowest in British Columbia.Interprovincial diff erences in age-specifi c spending per capita were greatest among seniors, with spending per person aged 65 and older ranging from $16.10 in British Columbia to $38.10 in New Brunswick.Provincial formulary coverageProvinces provided restricted or unrestricted coverage for between 12 and 17 of the 19 diff erent types of NSAIDs that had more than $1,000 in national sales.Weighted by national sales volumes, the drugs covered in each province accounted for almost all of the Canadian market. NSAIDs covered with restrictions in some provinces were those that had signifi cant national sales, whereas those not listed on some formularies were ones with small national sales volumes.Figure 6.2C» Percent of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 19 drugsPercent of $0.4 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 0 6Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.6.2 Analgesics: Nonsteroidal anti-infl ammatory drugs Age-standardized spending on NSAIDs was 30.8% above the national average in New Brunswick, and 38.1% below the national average in British Columbia.Sources of age-standardized variationVolume of treatment purchased was the most important cost-driver for most provinces that deviated signifi cantly from the national average age-standardized retail spending on NSAIDs.Aft er adjusting for population age, residents of Quebec purchased fewer NSAIDs than did other Canadians, but tended to receive more costly treatments from within this category and pay higher unit prices for NSAIDs purchased.Aft er adjusting for population age, compared to other Canadians, residents of British Columbia purchased fewer NSAIDs, received less costly types of NSAIDs, received generic NSAIDs more frequently, and paid slightly lower unit prices for NSAIDs purchased.Population age and provincial spendingBecause spending on NSAIDs is relatively concentrated among older adults, diff erences in the age of provincial populations alone would cause moderate variations in spending per capita in this therapeutic category.Age-standardization alone would predict that per capita spending on NSAIDs in Alberta would be 10.4% below the national average. In contrast, age-standardization would predict spending on NSAIDs to be 6.5% or more above the national average in New Brunswick, Nova Scotia, and Newfoundland & Labrador.Aft er fi gures were adjusted for diff erences in population age, spending on NSAIDs deviated by more than 8% from the national average in British Columbia, Ontario, New Brunswick, Nova Scotia, and Prince Edward Island.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $7.6 $11.8 $12.2 $11.3 $12.8 $12.1 $16.3 $13.7 $13.6 $12.6Total variation from national average -35.7% -0.9% 2.4% -5.0% 7.9% 2.2% 37.5% 15.0% 14.6% 6.0% Variation predicted by population age 2.4% -10.4% -0.8% -2.9% -2.0% 4.3% 6.7% 6.5% 3.7% 6.7%Age-standardized variation -38.1% 9.5% 3.2% -2.1% 9.9% -2.1% 30.8% 8.5% 10.9% -0.7% Prescription volume -29.8% -10.9% 12.5% -4.7% -0.3% 20.3% 5.9% -11.9% 7.4% -10.8% Prescription size 7.2% 21.6% -9.4% 5.8% 14.8% -36.5% 29.8% 28.2% 15.5% 8.8%Volume effects -22.6% 10.7% 3.2% 1.1% 14.5% -16.3% 35.7% 16.4% 23.0% -1.9% Therapeutic mix -8.1% -3.5% -4.1% -4.4% -2.8% 6.5% -0.7% -2.0% -8.5% -2.6% Drug mix -4.8% 3.0% 4.7% 1.7% 0.0% -0.3% -2.1% -0.8% -5.8% 4.9%Therapeutic choice effects -12.9% -0.5% 0.6% -2.7% -2.8% 6.2% -2.8% -2.8% -14.3% 2.3% Prices paid -0.9% -0.1% 4.3% 1.8% -2.7% 6.2% -0.9% -4.8% 0.6% 0.1% Generic use -1.8% -0.7% -4.9% -2.3% 0.8% 1.8% -1.3% -0.2% 1.6% -1.1%Price effects -2.6% -0.8% -0.6% -0.5% -1.8% 8.0% -2.2% -5.0% 2.3% -1.0%Table 6.2A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 0 7-23%+11%+3%-2%+1%+15%-16%+36%+23%+16%-13%0%+1%+2%-3%-3%+6%-3%-14%-3%-3%-1%-1%-1%-1%-2%+8%-2%+2%-5%BritishColumbia-38%NewBrunswick+31%NovaScotia+9%Newfoundlandand Labrador-1%Prince Edward I.+11%Alberta+9%Saskatchewan+3%Manitoba-2% Quebec-2%Ontario+10%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 6.2E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 6.2D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 0 8Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.6.2 Analgesics: Nonsteroidal anti-infl ammatory drugs Aft er adjusting for population aging and general infl ation, falling NSAID use caused spending per capita to fall by at least 0.3% per year in all provinces.Th ere was a shift toward use of more costly drug classes within this therapeutic category (specifi cally toward COX-2 selective NSAIDs). Th is increased infl ation-adjusted and age-standardized per capita NSAID spending by an annual rate of 1.7% or more in all provinces.Increased availability and use of generic NSAIDs between 1998 and 2007 resulted in savings ranging between 0.6% and 1.1% per year in the provinces. Th e prices paid for particular brands of NSAIDs increased slightly. Pace of change, 1998–2007Infl ation-adjusted retail spending on NSAIDs per Canadian grew by a total of only 3.7% between 1998 and 2007. Th is growth is the net eff ect of an expansion followed by contraction, likely caused by high-profi le withdrawals from this class.Sources of changePopulation aging contributed between 0.7% and 1.5% to the annual growth of per capita retail spending on NSAIDs in the provinces from 1998 to 2007.Aft er adjusting for the eff ects of population age and general infl ation, NSAID spending per Canadian actually declined at an annualized rate of 0.6% between 1998 and 2007.Th e net change in spending per capita between 1998 and 2007 was a result of falling volumes of NSAID purchases combined with a trend toward the use of more expensive options from within class.Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $11.4 $7.4 $12.1 $10.9 $9.7 $13.3 $10.1 $13.9 $13.6 $14.3Per capita spending in 2007 $11.9 $7.6 $11.8 $12.2 $11.3 $12.8 $12.1 $16.3 $13.7 $12.8 Average annual rate of change 0.4% 0.4% -0.3% 1.1% 1.6% -0.4% 1.9% 1.6% 0.0% -1.1% Rate of change due to population aging 0.9% 1.0% 1.1% 0.9% 0.7% 0.8% 1.1% 1.3% 1.3% 1.5%Age-standardized rate of change -0.6% -0.6% -1.4% 0.2% 0.9% -1.2% 0.8% 0.3% -1.3% -2.5% Prescription volume -2.3% -2.6% -4.5% -1.5% -2.5% -2.0% -1.2% -3.3% -4.2% -5.7% Prescription size 0.2% -0.2% 0.8% -0.2% 0.5% 0.1% 0.9% 0.6% 0.7% 0.8%Volume effects -2.1% -2.9% -3.7% -1.7% -2.0% -1.9% -0.3% -2.7% -3.4% -4.9% Therapeutic mix 2.0% 1.8% 2.6% 1.9% 2.2% 2.1% 2.0% 3.4% 2.5% 2.5% Drug mix 0.2% 0.6% 0.5% 0.9% 0.7% -0.4% -0.2% 0.4% 0.4% 0.5%Therapeutic choice effects 2.2% 2.5% 3.1% 2.8% 2.9% 1.7% 1.8% 3.8% 2.9% 3.1% Prices paid 0.3% 0.5% 0.2% 0.1% 0.6% 0.2% 0.3% 0.2% 0.0% 0.1% Generic use -1.0% -0.8% -1.0% -1.0% -0.6% -1.1% -1.0% -1.0% -0.8% -0.8%Price effects -0.7% -0.3% -0.8% -0.9% 0.0% -0.9% -0.7% -0.8% -0.8% -0.7%Table 6.2B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 0 9Note: All fi gures are expressed in the equivalent of year 2007 dollars.-3%-4%-2%-5%-2%-2%0%-3%-3%+2%+3%+3%+3%+3%+2%+2%+4%+3%0%-1%-1%-1%0%-1%-1%-1%-1%BritishColumbia-1%NewBrunswick0%NovaScotia-1%Newfoundlandand LabradorandPrince Edward I.-3%Alberta-1%Saskatchewan0%Manitoba+1% Quebec+1%Ontario-1%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 6.2G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 6.2F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 1 0Levels of spending across Canada and age groups7.1 Diabetes: Oral drugsSpending in CanadaOral medications used to control blood sugar in persons with diabetes mellitus are the eighth largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Canadians spent approximately $17.10 per capita on these drugs in 2007, for a total of $563 million.Because these medicines are typically used for Type 2 diabetes, spending on oral diabetes drugs is concentrated among older adults.In 2007, the average amounts of retail spending on oral diabetes drugs per Canadian aged 20–44, 45–64, and 65 and older were $2.88, $27.96, and $63.25, respectively. Persons age 65 and older accounted for 50% of overall spending on oral diabetes drugs in Canada.Th ere were insuffi cient purchases of oral diabetes drugs by persons aged 19 and under to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$0$20NLNSNBQCONMBSKBC AB PENLPENSNBQCONMBSKBC AB$0$20$40$60$0$20NLNS PENBQCONMBSKBC ABCanada overall$20$0NLNSNBQCONMBSKBC AB PE$20$40NLPENSNBQCONMBSKBC AB$0Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 7.1A» Per capita spending in Canada by age group, 2007Figure 7.1B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$311,740,792 people45-64 years$288,936,632 people65+$634,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 1 1Per capita spending in Canada: $17.10Drugs in this therapeutic categoryMetformin• Sulphonylureas (e.g. glyburide)• Glitazones (e.g. rosiglitazone)• Meglitinides (e.g. repaglinide)• Acarbose• Common goal of therapyControl amount of glucose (sugar) in blood• Example of an indicated conditionDiabetes mellitus• Spending in provincesTh e age gradient for spending on oral diabetes drugs was steepest in Quebec.Th e ratio of spending on oral diabetes drugs per person aged 65 and older to spending per person under age 65 was 6.6 in Quebec, 6.5 in British Columbia, and 6.4 in Ontario. Th is ratio was greater than 4.6 in all other provinces.In all age groups, average per capita spending on oral diabetes drugs was lowest in British Columbia and highest in New Brunswick.Average spending per person aged 45–64 varied from $17.80 to $36.70 across provinces. Average spending per person aged 65 and older varied less in proportional terms: from $43.20 to $73.30.Provincial formulary coverageProvinces provided coverage for between four and nine of the 13 diff erent types of oral diabetes drugs that had more than $1,000 in national sales. Two types of oral diabetes drug were not covered by any province.Th e drugs covered in each province accounted for 78% to 90% of the entire Canadian retail market for oral diabetes drugs. Drugs on which many provinces placed coverage restrictions were those that accounted for nearly half of the oral diabetes drug market in Canada.Figure 7.1C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 13 drugsPercent of $0.5 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 1 2Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.7.1 Diabetes: Oral drugsof cost-drivers: volume eff ects, therapeutic choice eff ects, and price eff ects. Aft er adjusting for population age, residents in British Columbia, Saskatchewan, and Prince Edward Island purchased signifi cantly fewer oral diabetes drugs than did other Canadians.Residents of Alberta, Saskatchewan, and New Brunswick were much more likely to purchase higher-cost drugs from within the therapeutic category of oral diabetes drugs.Residents of Quebec paid much higher prices per unit of particular brands of oral diabetes drugs. Th is may have been infl uenced by the much shorter average length of prescriptions in Quebec. Shorter prescriptions result in higher levels of pharmacists’ fees paid per unit of drug received.Population age and provincial spendingInterprovincial diff erences in population ages alone would be suffi cient to generate considerable variation in per capita retail spending on oral diabetes drugs.Age-standardization alone would predict that per capita spending on oral diabetes drugs in Alberta would be 15.0% below the national average. In contrast, age-standardization would predict spending on oral diabetes drugs per capita to be 8% or more above the national average in New Brunswick, Nova Scotia, and Newfoundland & Labrador.Age-standardized spending on oral diabetes drugs was 25.2% above the national average in New Brunswick, and more than 34.3% below the national average in British Columbia.Sources of age-standardized variationVariations in age-standardized per capita spending on oral diabetes drugs were driven by all three categories BC AB SK MB ON QC NB NS PE NLPer capita spending in province $11.8 $17.4 $15.3 $15.9 $16.9 $19.9 $22.8 $19.5 $13.1 $19.6Total variation from national average -31.2% 1.6% -10.4% -6.8% -1.4% 16.4% 33.3% 14.2% -23.7% 14.2% Variation predicted by population age 3.1% -15.0% 1.4% -2.3% -2.3% 6.1% 8.1% 8.3% 4.7% 8.0%Age-standardized variation -34.3% 16.7% -11.8% -4.5% 0.9% 10.3% 25.2% 5.9% -28.5% 6.2% Prescription volume -43.7% -41.8% -21.9% -8.8% -21.2% 59.2% -29.1% -28.4% -51.2% -8.3% Prescription size 20.3% 38.0% 1.8% 3.3% 26.3% -55.1% 32.2% 31.8% 30.0% 16.1%Volume effects -23.5% -3.8% -20.2% -5.5% 5.1% 4.1% 3.1% 3.4% -21.2% 7.8% Therapeutic mix -8.8% 18.4% 19.1% -3.4% 1.9% -3.9% 18.1% -0.1% -2.8% -2.7% Drug mix 0.4% 5.0% -0.9% -0.3% -2.8% 0.0% 3.8% 6.5% 2.3% 2.2%Therapeutic choice effects -8.5% 23.5% 18.2% -3.7% -0.9% -3.9% 21.9% 6.4% -0.5% -0.5% Prices paid -2.4% -2.6% 3.1% 5.3% -3.0% 7.7% 0.9% -3.8% -5.8% -0.8% Generic use 0.0% -0.4% -13.0% -0.6% -0.3% 2.4% -0.8% -0.1% -0.9% -0.3%Price effects -2.4% -3.0% -9.9% 4.7% -3.3% 10.1% 0.1% -3.9% -6.7% -1.0%Table 7.1A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 1 3-23%-4%-20%+8%-6%+5%+4%+3%-21%+3%-8%+23%+18%-1%-4%-1%-4%+22%-1%+6%-2%-3%-10%-1%+5%-3%+10%0%-7%-4%BritishColumbia-34%NewBrunswick+25%NovaScotia+6%Newfoundlandand Labrador+6%Prince Edward I.-28%Alberta+17%Saskatchewan-12%Manitoba-5% Quebec+10%Ontario-1%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 7.1E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 7.1D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 1 4Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.7.1 Diabetes: Oral drugsOral diabetes drugs are one of the therapeutic categories for which changes in the type of drug chosen was the primary driver of age-standardized, infl ation-adjusted spending between 1998 and 2007. Across provinces, changes in the types of oral diabetes drugs selected between 1998 and 2007 contributed from 5.2% to 10.9% per year to growth in age-standardized, infl ation-adjusted spending on oral diabetes drugs per capita.Th e only province for which therapeutic choices were not dominant cost-drivers was Manitoba, where changes in age-standardized volumes of treatment contributed more to spending growth.Increased availability and use of generic oral diabetes drugs between 1998 and 2007 resulted in modest savings in all provinces except Manitoba. Pace of change, 1998–2007Infl ation-adjusted retail spending on oral diabetes drugs per Canadian grew by a total of 259% between 1998 and 2007. Th is translated into an infl ation-adjusted annual growth rate of 13.6%.Because of the relative size and growth of spending in this category, oral diabetes drugs accounted for 5% of the total increase in prescription drug spending in Canada between 1998 and 2007.Sources of changePopulation aging contributed between 0.9% and 2.0% to the annual growth of per capita retail spending on oral diabetes drugs in Canadian provinces from 1998 to 2007.Infl ation-adjusted and age-standardized spending per capita on oral diabetes drugs grew most rapidly in Manitoba (17.0% per year) and least rapidly in Nova Scotia (9.6% per year).Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $4.8 $3.7 $4.1 $3.3 $3.1 $4.5 $6.4 $4.8 $6.8 $4.5Per capita spending in 2007 $17.1 $11.8 $17.4 $15.3 $15.9 $16.9 $19.9 $22.8 $19.5 $18.2 Average annual rate of change 13.6% 12.4% 15.5% 16.7% 17.9% 14.2% 12.1% 16.8% 11.2% 15.1% Rate of change due to population aging 1.2% 1.4% 1.3% 1.2% 0.9% 1.0% 1.6% 1.7% 1.6% 2.0%Age-standardized rate of change 12.4% 11.0% 14.2% 15.5% 17.0% 13.2% 10.5% 15.2% 9.6% 13.0% Prescription volume 5.8% 6.2% 4.9% 6.9% 7.5% 5.5% 6.5% 2.9% 1.0% 2.3% Prescription size -0.3% -1.4% 1.4% 0.7% 0.7% -0.2% -1.7% 2.1% 2.2% 3.9%Volume effects 5.5% 4.8% 6.3% 7.6% 8.2% 5.3% 4.8% 4.9% 3.3% 6.2% Therapeutic mix 6.2% 4.8% 7.6% 8.2% 6.0% 7.4% 4.5% 9.3% 5.8% 6.5% Drug mix 0.8% 0.9% 0.9% 0.6% 1.0% 0.7% 0.7% 1.7% 1.8% 1.7%Therapeutic choice effects 7.0% 5.6% 8.5% 8.9% 7.0% 8.2% 5.2% 10.9% 7.6% 8.1% Prices paid 0.4% 0.8% -0.2% 2.4% 1.7% 0.1% 0.5% -0.3% -0.5% -0.9% Generic use -0.5% -0.2% -0.5% -3.4% 0.1% -0.5% -0.1% -0.4% -0.8% -0.5%Price effects -0.1% 0.6% -0.6% -0.9% 1.8% -0.3% 0.4% -0.7% -1.3% -1.3%Table 7.1B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 1 5Note: All fi gures are expressed in the equivalent of year 2007 dollars.+5%+6%+8%+6%+8%+5%+5%+5%+3%+6%+8%+9%+8%+7%+8%+5%+11%+8%+1%-1%-1%-1%+2%0%0%-1%-1%BritishColumbia+11%NewBrunswick+15%NovaScotia+10%Newfoundlandand LabradorandPrince Edward I.+13%Alberta+14%Saskatchewan+16%Manitoba+17% Quebec+10%Ontario+13%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 7.1G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 7.1F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 1 6Levels of spending across Canada and age groups7.2 Diabetes: InsulinsSpending in CanadaInsulins used to control blood sugar in persons with diabetes mellitus are the 16th largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Canadians spent approximately $6.90 per capita on these drugs in 2007, for a total of $226 million.Insulins are used by Canadians of all ages, although the average cost per capita increases steadily across age groups. In 2007, the average amount spent on insulins per Canadian aged 19 and under was $2.40, with the average amount spent per person increasing to a peak of $14.10 per person aged 65 and older.Although average spending was lower among younger populations, younger cohorts are larger than older ones. Th erefore, adults aged 20–44 accounted for nearly as much of the total national retail spending on insulins in 2007 as seniors did (24% versus 28%), and adults aged 45–64 accounted for the largest share (40%).$0$10NLNS PENBQCONMBSKBC AB$20Canada overall$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20NLPENSNBQCONMBSKBC AB$10$0$10NLPENSNBQCONMBSKBC AB$0$20$30Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 7.2A» Per capita spending in Canada by age group, 2007Figure7.2B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$27,776,058 people20-44 years$511,740,792 people45-64 years$108,936,632 people65+$144,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 1 7Per capita spending in Canada: $6.90Drugs in this therapeutic categoryInsulins (e.g. insulin aspart)• Common goal of therapyControl amount of glucose (sugar) in blood• Example of an indicated conditionDiabetes mellitus• Spending in provincesTh e age gradient for spending on insulins was steepest in Ontario and least steep in Manitoba. Th e ratio of spending on insulins per person aged 65 and older to spending per person under age 65 was 2.8 in Ontario and 1.7 in Manitoba. Th is ratio ranged from 2.2 to 2.6 in all other provinces.In all age groups, average per capita retail spending on insulins was highest in Prince Edward Island.Across provinces, spending on insulins varied the most in age groups at each end of spectrum. Average spending per person aged 19 and under ranged from $1.80 to $5.80, and average spending per person aged 65 and over ranged from $7.80 to $28.20.Provincial formulary coverageProvinces provided restricted or unrestricted coverage for between fi ve and eight of the 10 diff erent types of insulins that had more than $1,000 in national sales. Two types of insulins were not listed on any of the formularies studied. Th e drugs covered in each province accounted for 78% or more of the entire Canadian retail market for insulins. Drugs for which some provinces placed restrictions on coverage accounted for approximately a third of the national retail market for insulins.Figure 7.2C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 10 drugsPercent of $0.1 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 1 8Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.7.2 Diabetes: InsulinsSources of age-standardized variationTh e extreme variation in age-standardized spending on insulins across Canada was largely driven by variations in the volume of insulins purchased.Aft er adjusting for population age, residents of Eastern Canada purchased signifi cantly more insulins than did other Canadians.Residents of Ontario and Prince Edward Island tended to receive more costly insulins than did other Canadians.Residents of Prince Edward Island paid much more than other Canadians per unit of insulins, which may have been because of the size of prescriptions fi lled. Shorter prescriptions result in higher levels of pharmacists’ fees paid per unit of drug received.(Note: Analyses of changes in spending over time were not done for this category because 1998 data were not available for injectable and inhaled medicines.)Population age and provincial spendingBecause insulins are used by Canadians of all ages, interprovincial diff erences in population age will explain only modest variation in spending within this therapeutic category. Based on age-standardization alone, it would be expected that retail insulin spending per capita in Alberta would be 5.9% below the national average. Similarly, spending per capita in New Brunswick, Nova Scotia, and Newfoundland & Labrador would be expected to exceed the national average by 5% or more as a result of population age diff erences alone.Aft er fi gures were adjusted for diff erences in population age, there remained considerable interprovincial diff erences in spending on insulins.Age-standardized spending on insulins in Prince Edward Island and in Newfoundland & Labrador was roughly double the national average.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $5.4 $5.6 $7.4 $5.1 $6.9 $6.9 $10.8 $12.5 $14.7 $14.1Total variation from national average -22.0% -18.8% 7.2% -26.6% 0.1% -0.3% 57.0% 81.0% 113.4% 104.7% Variation predicted by population age 1.8% -5.9% -0.7% -1.6% -1.3% 2.9% 5.0% 5.7% 3.3% 5.8%Age-standardized variation -23.8% -12.9% 8.0% -25.1% 1.4% -3.2% 52.1% 75.3% 110.2% 98.9% Prescription volume -21.7% -12.4% 37.1% -8.9% -23.2% 24.9% 33.5% 60.6% 107.6% 93.2% Prescription size 0.0% -2.0% -16.5% -11.3% 16.8% -19.2% 10.6% 16.3% -22.4% 2.4%Volume effects -21.6% -14.5% 20.6% -20.2% -6.4% 5.7% 44.2% 76.9% 85.1% 95.5% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 0.9% 0.5% -6.8% -4.2% 4.5% -2.9% 0.3% -6.9% 9.1% -8.8%Therapeutic choice effects 0.9% 0.5% -6.8% -4.2% 4.5% -2.9% 0.3% -6.9% 9.1% -8.8% Prices paid -2.9% 0.9% -5.1% -0.4% 3.2% -6.2% 8.1% 5.4% 17.1% 12.5% Generic use -0.2% 0.1% -0.7% -0.2% 0.1% 0.1% -0.5% -0.1% -1.1% -0.4%Price effects -3.0% 1.0% -5.8% -0.6% 3.4% -6.1% 7.6% 5.3% 16.0% 12.1%Table 7.2A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 1 9-22%-14%+21%+96%-20%-6%+6%+44%+85%+77%+1%+1%-7%-9%-4%+4%-3%0%+9%-7%-3%+1%-6%+12%-1%+3%-6%+8%+16%+5%BritishColumbia-24%NewBrunswick+52%NovaScotia+75%Newfoundlandand Labrador+99%Prince Edward I.+110%Alberta-13%Saskatchewan+8%Manitoba-25% Quebec-3%Ontario1%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 7.2E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 7.2D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 2 0Levels of spending across Canada and age groups8 Oral antibioticsSpending in CanadaOral antibiotic drugs constituted the sixth largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Canadians spent approximately $20.20 per capita on these drugs in 2007, for a total of $665 million.Canadians of all ages fi ll prescriptions for antibiotics, and average spending on these medicines does not increase as dramatically with age as it does in other leading therapeutic categories of medicine. In 2007, spending on antibiotics per Canadian aged 20-44 ($18.70) was slightly lower than the average across all age groups, yet they accounted for the largest age-specifi c share of total spending on antibiotics (33%). $0NLNS PENBQCONMBSKBC AB$20 Canada overall$0NLNSNBQCONMBSKBC AB PE$20$0NLNSNBQCONMBSKBC AB PE$20$20NLPENSNBQCONMBSKBC AB$0NLPENSNBQCONMBSKBC AB$0$20$40Ages 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 8A» Per capita spending in Canada by age group, 2007Figure 8B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$167,776,058 people20-44 years$1911,740,792 people45-64 years$228,936,632 people65+$284,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 2 1Per capita spending in Canada: $20.20Drugs in this therapeutic categoryPenicillins (e.g. amoxicillin)• Sulfa drugs (e.g. trimethoprim/• sulfamethoxazole)Tetracyclines (e.g. doxycycline)• Cephalexin, erythromycin, clindamycin, • metronidazole, nitrofurantoinAmoxicillin/clavulanate• Fluroquinolones (e.g. ciprofl oxacin)• Macrolides (e.g. azithromycin)• 2nd and 3rd generation cephalosporins • (e.g. cefuroxime)Linezolid, vancomycin• Common goal of therapyTreat bacterial infections• Examples of indicated conditionsPneumonia• Bladder infection• Spending in provincesAge gradients for spending on antibiotics were relatively consistent across provinces.Th e ratio of spending on antibiotics per person aged 65 and older to spending per person under age 65 ranged from 1.3 (in Manitoba and Quebec) to 1.6 (in Ontario, Prince Edward Island, and Newfoundland & Labrador).Interprovincial variations in age-specifi c spending were greatest among children and seniors. In all age groups, spending per capita was highest in Newfoundland & Labrador and lowest in either British Columbia or Quebec.Across provinces, average retail spending on antibiotics per person aged 19 and under ranged from $11.70 to $23.20. Average spending per person aged 65 and older ranged from $21.90 to $42.90.Provincial formulary coverageProvinces provided restricted or unrestricted coverage for between 27 and 33 of the 39 diff erent types of antibiotics that had more than $1,000 in national sales. Four of these drugs were not listed on any of the formularies studied.Weighted by national sales volumes, the antibiotics covered in each province accounted for 73% to 87% of the Canadian retail market for antibiotics. Drugs covered with restrictions in some provinces were those that had signifi cant national sales.Figure 8C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 39 drugsPercent of $0.7 billionOlderNewerListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 2 2Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.8 Oral antibioticsAft er adjusting for population age, residents in British Columbia and Quebec purchased signifi cantly fewer antibiotics than did other Canadians.Th erapeutic choice eff ects also had a considerable impact on interprovincial diff erences in age-standardized retail spending on antibiotics. Residents of Saskatchewan and Manitoba tended to use lower-cost antibiotics than other Canadians, whereas residents of Quebec used higher-cost options from within this therapeutic category.Interprovincial diff erences in use of generics and unit prices within the antibiotics category were relatively modest when compared to variations in the volume and type of antibiotics used.Population age and provincial spendingInterprovincial diff erences in population age had minimal impacts on expected per capita spending on oral antibiotic drugs. Th is is because these medicines are used by Canadians of all ages, without a dramatic age gradient in average spending levels.Age-standardization alone would predict interprovincial variations in per capita spending on antibiotics to be less than 3%. Age-standardized variations in per capita spending on antibiotics are nevertheless signifi cant.Age-standardized spending on antibiotics was approximately 45% above the national average in Newfoundland & Labrador, and 12% below the national average in British Columbia.Sources of age-standardized variationVolume of treatment purchased was the primary driver of observed interprovincial variations in age-standardized retail spending on antibiotics.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $17.8 $20.9 $18.5 $19.6 $21.8 $18.1 $21.2 $21.9 $21.7 $29.7Total variation from national average -11.9% 3.4% -8.6% -3.2% 7.7% -10.7% 4.6% 8.4% 7.5% 46.7% Variation predicted by population age 0.7% -2.2% -0.2% -0.5% -0.4% 0.6% 1.0% 1.2% 0.9% 1.3%Age-standardized variation -12.6% 5.6% -8.4% -2.7% 8.1% -11.3% 3.5% 7.2% 6.6% 45.4% Prescription volume -5.3% 8.8% 19.8% 7.6% 6.5% -21.6% 2.6% 11.0% 17.1% 47.2% Prescription size -1.0% 1.0% -1.3% 1.2% 2.2% -4.4% 4.2% 1.7% 1.9% 10.2%Volume effects -6.3% 9.8% 18.5% 8.8% 8.7% -26.0% 6.8% 12.7% 19.0% 57.3% Therapeutic mix -4.6% -2.6% -16.0% -7.6% 0.9% 7.3% 1.0% -3.4% -2.3% -1.8% Drug mix -1.5% 0.7% -6.7% -5.9% -1.9% 5.1% -3.8% -1.9% -8.0% -4.2%Therapeutic choice effects -6.1% -1.9% -22.7% -13.4% -1.1% 12.4% -2.8% -5.3% -10.3% -6.0% Prices paid 0.6% -1.7% -1.0% 2.4% 0.3% 0.8% 0.1% -0.2% -1.5% -5.5% Generic use -0.8% -0.6% -3.1% -0.5% 0.1% 1.5% -0.6% 0.0% -0.5% -0.4%Price effects -0.1% -2.3% -4.2% 1.9% 0.4% 2.3% -0.5% -0.2% -2.1% -5.9%Table 8A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 2 3-6%+10%+18%+57%+9%+9%-26%+7%+19%+13%-6%-2%-23%-6%-13%-1%+12%-3%-10%-5%0%-2%-4%-6%+2%0%+2%0%-2%0%BritishColumbia-13%NewBrunswick+4%NovaScotia+7%Newfoundlandand Labrador+45%Prince Edward I.+7%Alberta+6%Saskatchewan-8%Manitoba-3% Quebec-11%Ontario+8%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 8E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 8D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 2 4Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.8 Oral antibioticsAcross provinces, declining volumes of antibiotic prescriptions purchased from 1998 to 2007 were suffi cient to drive costs down by –3.0% to –5.0% per year, aft er adjusting for population aging and general infl ation.Th e cost impact of declining use of antibiotics was off set, in part, by a shift toward the use of more costly antibiotics between 1998 and 2007. Across provinces, selecting more costly antibiotics resulted in an upward pressure of between 2.1% and 5.6% per year on age-standardized and infl ation-adjusted spending per capita.Increased availability and use of generic antibiotics between 1998 and 2007 resulted in savings ranging between –.07% and –1.3% per year in the provinces. Th e prices paid for particular brands of antibiotics increased slightly in all provinces. Pace of change, 1998–2007In contrast to most other leading therapeutic categories, infl ation-adjusted retail spending on antibiotics per Canadian fell by an average annual rate of –1.2% between 1998 and 2007.Antibiotic spending fell most rapidly in New Brunswick (–2.0% per year in infl ation-adjusted terms).Sources of changePopulation aging would have cause per capita retail spending on antibiotics in the provinces to rise by between 0.2% and 0.5% per year from 1998 to 2007. However, other factors drove age-adjusted spending per capita downward over this period in all provinces except British Columbia and Manitoba.Declining age-standardized and infl ation-adjusted spending on antibiotics in Canada was largely a result of reduced volumes of antibiotics purchased. Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $22.7 $17.1 $22.8 $20.3 $16.0 $26.1 $21.3 $25.8 $23.0 $27.4Per capita spending in 2007 $20.2 $17.8 $20.9 $18.5 $19.6 $21.8 $18.1 $21.2 $21.9 $28.0 Average annual rate of change -1.2% 0.4% -0.9% -0.9% 2.0% -1.8% -1.7% -2.0% -0.5% 0.2% Rate of change due to population aging 0.3% 0.4% 0.4% 0.3% 0.2% 0.3% 0.3% 0.4% 0.4% 0.5%Age-standardized rate of change -1.5% 0.0% -1.2% -1.2% 1.8% -2.0% -2.0% -2.4% -0.9% -0.3% Prescription volume -4.0% -3.7% -4.0% -3.1% -4.8% -4.3% -3.7% -4.7% -3.1% -3.4% Prescription size -0.3% -0.2% 0.0% -0.1% -0.2% -0.3% -0.5% -0.3% 0.1% -0.2%Volume effects -4.3% -3.9% -4.0% -3.1% -4.9% -4.5% -4.2% -5.0% -3.0% -3.6% Therapeutic mix 2.1% 2.6% 1.9% 1.3% 4.1% 2.3% 1.1% 2.1% 1.5% 2.6% Drug mix 1.3% 1.5% 1.3% 0.8% 1.5% 1.2% 1.5% 1.2% 1.1% 1.1%Therapeutic choice effects 3.4% 4.0% 3.2% 2.1% 5.6% 3.5% 2.7% 3.3% 2.7% 3.7% Prices paid 0.6% 0.8% 0.6% 0.5% 1.9% 0.4% 0.5% 0.4% 0.3% 0.5% Generic use -1.1% -0.9% -1.0% -0.7% -0.7% -1.3% -0.9% -1.1% -0.9% -1.0%Price effects -0.6% -0.1% -0.4% -0.2% 1.2% -1.0% -0.4% -0.7% -0.6% -0.5%Table 8B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 2 5Note: All fi gures are expressed in the equivalent of year 2007 dollars.-4%-4%-3%-4%-5%-5%-4%-5%-3%+4%+3%+2%+4%+6%+3%+3%+3%+3%0%0%0%-1%+1%-1%0%-1%-1%BritishColumbia0%NewBrunswick-2%NovaScotia-1%Newfoundlandand LabradorandPrince Edward I.0%Alberta-1%Saskatchewan-1%Manitoba+2% Quebec-2%Ontario-2%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 8G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 8F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 2 6Levels of spending across Canada and age groups9 BisphosphonatesSpending in CanadaBisphosphonate drugs used to increase bone density are the 11th largest therapeutic category of prescription drugs in terms of overall retail spending in Canada. Canadians spent approximately $10.30 per capita on these drugs in 2007, for a total of $338 million.Spending on bisphosphonates is highly concentrated among older adults. Additionally, although the data used in this study are not sex stratifi ed, bisphosphonate use is highly concentrated among women. In 2007, Canadians aged 65 and older spent an average of $57.30 on bisphosphonates. Canadians aged 45–64 spent an average of $9.50 each and accounted for 25% of all bisphosphonates sales in Canada.Th ere were insuffi cient purchases of bisphosphonates by persons under age 45 to generate reliable age- and province-specifi c estimates of spending per capita for those age groups. (Total fi gures for this therapeutic category exclude estimates for the censored age categories.)$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20$0$10NLPENSNBQCONMBSKBC AB$10NLPENSNBQCONMBSKBC AB$0$20$30$40$50$60$70$0$10NLNS PENBQCONMBSKBC ABCanada overallAges 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 9A» Per capita spending in Canada by age group, 2007Figure 9B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$011,740,792 people45-64 years$98,936,632 people65+$574,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 2 7Per capita spending in Canada: $10.30Drugs in this therapeutic categoryAlendronate• Etidronate• Risedronate• Zoledronic acid• Common goal of therapyIncrease bone mineral density• Example of an indicated conditionOsteoporosis• Spending in provincesTh e age gradient for spending on bisphosphonates was steepest in Ontario.Th e ratio of spending on bisphosphonates per person aged 65 and older to spending per person aged 45–64 was 7.0 in Ontario. Th is ratio was 4.0 or less in Saskatchewan, Prince Edward Island, and Newfoundland & Labrador.Average retail spending on bisphosphonates per person aged 45–64 ranged from $4.00 in Manitoba to over $13.70 in Quebec.Average spending per person aged 65 and older varied nearly as much in proportional terms: from $25.50 in Newfoundland & Labrador to $70.30 in Quebec.Provincial formulary coverageProvinces provided unrestricted coverage for between one and four of the six diff erent types of bisphosphonates that had more than $1,000 in national sales. Provinces used restricted listings on a further one to four drugs in this class. Weighted by national sales, bisphosphonates covered in each province accounted for almost the entire Canadian market. Bisphosphonates covered with restrictions in most provinces were ones that had signifi cant national sales.Figure 9C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverageRestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 6 drugsPercent of $0.3 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 2 8Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.9 BisphosphonatesSources of age-standardized variationVolume of treatment purchased was the most important determinant of diff erences in age-standardized retail spending on bisphosphonates per resident in Ontario and Quebec versus the rest of Canada.Aft er adjusting for population age, residents in Ontario and Quebec purchased signifi cantly more bisphosphonates than did other Canadians.Additionally, residents of Ontario tended to receive more costly bisphosphonates than did other Canadians.As with other categories, prices paid per unit of particular brands of drugs in some provinces may have been infl uenced by the average length of prescriptions. Shorter prescriptions result in higher levels of pharmacists’ fees paid per unit of drug received.Population age and provincial spendingBecause spending on bisphosphonates is highly concentrated among older adults, diff erences in the age of provincial populations alone would cause relatively signifi cant variations in spending per capita in this therapeutic category.Diff erences in population age would predict that per capita spending on bisphosphonates would be 17.9% below the national average in Alberta and 8.2% above the national average in Nova Scotia.Th ere were signifi cant variations in age-standardized per capita spending on bisphosphonates. Th is stemmed largely from the fact that age-standardized per capita spending levels in Ontario and Quebec were 11.0% and 29.0% above the national average, respectively. Th us, comparisons to be made in this category are largely between Ontario and Quebec versus the rest of Canada.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $6.7 $7.7 $8.0 $4.6 $11.2 $14.0 $7.5 $8.3 $7.1 $6.2Total variation from national average -34.5% -24.9% -21.8% -54.9% 8.6% 36.4% -27.2% -19.3% -31.1% -40.2% Variation predicted by population age 3.6% -17.9% 4.9% -0.4% -2.4% 7.4% 6.6% 8.2% 5.6% 5.3%Age-standardized variation -38.1% -6.9% -26.7% -54.5% 11.0% 29.0% -33.8% -27.6% -36.8% -45.5% Prescription volume -47.6% -34.0% -8.4% -59.1% -12.0% 66.2% -55.4% -55.1% -48.6% -60.3% Prescription size 20.2% 41.6% -19.5% 11.8% 26.4% -47.7% 28.3% 33.0% 14.8% 22.3%Volume effects -27.4% 7.6% -27.9% -47.2% 14.4% 18.5% -27.1% -22.1% -33.8% -38.1% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix -10.1% -10.4% -5.3% -7.3% 3.3% -0.8% -5.8% -2.2% -8.4% -7.1%Therapeutic choice effects -10.1% -10.4% -5.3% -7.3% 3.3% -0.8% -5.8% -2.2% -8.4% -7.1% Prices paid 0.1% -0.5% 9.4% 3.6% -3.8% 5.4% 3.1% 0.1% 4.9% 2.6% Generic use -0.7% -3.7% -2.8% -3.5% -2.9% 6.0% -3.9% -3.3% 0.6% -2.9%Price effects -0.6% -4.2% 6.6% 0.0% -6.6% 11.4% -0.9% -3.3% 5.5% -0.4%Table 9A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 2 9-27%+8%-28%-38%-47%+14%+18%-27%-34%-22%-10%-10%-5%-7%-7%+3%-1%-6%-8%-2%-1%-4%+7%0%0%-7%+11%-1%+5%-3%BritishColumbia-38%NewBrunswick-34%NovaScotia-28%Newfoundlandand Labrador-45%Prince Edward I.-37%Alberta-7%Saskatchewan-27%Manitoba-55% Quebec+29%Ontario+11%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 9E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 9D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 3 0Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.9 Bisphosphonatesand general infl ation, increased prescribing of bisphosphonates caused spending per capita to rise by more than 11% per year in all provinces.Changes in the types of bisphosphonates selected between 1998 and 2007 have varying impacts on spending in the provinces. In some provinces, these changes put downward pressure on spending per capita—at a rate of up to –3.0% per year (in Quebec).Increased availability and use of generic bisphosphonates between 1998 and 2007 resulted in savings ranging between –0.2% and –2.6% per year in the provinces. Th e prices paid for particular brands of bisphosphonates were relatively stable over this period. Pace of change, 1998–2007Infl ation-adjusted retail spending on bisphosphonates per Canadian grew by a total of 374.8% between 1998 and 2007. Th is translated to an annual average growth rate of 16.9%.Sources of changePopulation aging contributed between 0.4% and 2.4% to the annual growth of per capita retail spending on bisphosphonates in the provinces from 1998 to 2007.Infl ation-adjusted and age-standardized spending per capita on bisphosphonates grew most rapidly in Prince Edward Island and Newfoundland & Labrador (19.2% per year) and least rapidly in Manitoba (11.4% per year).Growing volumes of prescriptions purchased from 1998 to 2007 were by far the major driver of age-standardized per capita spending on bisphosphonates in Canada. Aft er adjusting for population aging Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $2.2 $1.9 $2.2 $2.3 $1.5 $2.5 $2.2 $2.0 $1.5 $0.9Per capita spending in 2007 $10.3 $6.7 $7.7 $8.0 $4.6 $11.2 $14.0 $7.5 $8.3 $6.4 Average annual rate of change 16.9% 13.4% 13.3% 13.5% 11.8% 16.2% 20.4% 14.1% 18.7% 21.6% Rate of change due to population aging 1.2% 1.4% 1.1% 0.9% 0.4% 0.9% 1.7% 1.6% 1.6% 2.4%Age-standardized rate of change 15.7% 12.0% 12.2% 12.6% 11.4% 15.3% 18.7% 12.5% 17.1% 19.2% Prescription volume 18.0% 12.6% 10.5% 15.9% 13.3% 16.4% 23.5% 12.9% 16.1% 18.7% Prescription size -0.2% -0.8% 2.0% -0.7% 0.6% -0.2% -1.5% 0.4% 0.8% 2.4%Volume effects 17.8% 11.8% 12.5% 15.2% 13.8% 16.2% 21.9% 13.3% 17.0% 21.1% Therapeutic mix -0.1% 0.2% 0.0% 0.0% 0.0% 0.0% -0.1% -0.3% -0.1% 0.0% Drug mix -0.3% 1.4% 1.8% -1.0% -1.3% 1.7% -2.9% 1.1% 1.6% -0.2%Therapeutic choice effects -0.4% 1.6% 1.7% -1.0% -1.3% 1.7% -3.0% 0.9% 1.6% -0.3% Prices paid 0.1% 0.1% 0.0% 0.0% 0.0% 0.1% 0.0% 0.1% 0.0% -0.1% Generic use -1.8% -1.5% -2.0% -1.6% -1.1% -2.6% -0.2% -1.8% -1.4% -1.5%Price effects -1.7% -1.4% -2.0% -1.6% -1.1% -2.6% -0.2% -1.7% -1.4% -1.7%Table 9B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 3 1Note: All fi gures are expressed in the equivalent of year 2007 dollars.+12%+12%+15%+21%+14%+16%+22%+13%+17%+2%+2%-1%0%-1%+2%-3%+1%+2%-1%-2%-2%-2%-1%-3%0%-2%-1%BritishColumbia+12%NewBrunswick+13%NovaScotia+17%Newfoundlandand LabradorandPrince Edward I.+19%Alberta+12%Saskatchewan+13%Manitoba+11% Quebec+19%Ontario+15%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 9G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 9F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 3 2Levels of spending across Canada and age groups10 Hormonal contraceptivesSpending in CanadaCanadians spent an average of $10.10 per capita (or $20.20 per woman) on retail purchases of hormonal contraceptive drugs in 2007. Th is amounted to $332 million in retail spending.Hormonal contraceptives are, for the most part, used only by women of child-bearing age. As such, age-specifi c per capita spending peaks for the group aged 20–44.At $23 per capita (or $46 per woman) within it, the group of Canadians aged 20–44 accounted for 81% of all spending on hormonal contraceptives in Canada.Th ere were insuffi cient purchases of hormonal contraceptives by persons aged 65 and older to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$10NLPENSNBQCONMBSKBC AB$0$0$10NLNS PENBQCONMBSKBC ABCanada overall$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNSNBQCONMBSKBC AB PE$20$30$0$10NLPENSNBQCONMBSKBC ABAges 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 10A» Per capita spending in Canada by age group, 2007Figure 10B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$57,776,058 people20-44 years$2311,740,792 people45-64 years$38,936,632 people65+$04,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 3 3Per capita spending in Canada: $10.10Drugs in this therapeutic categoryHormonal contraceptives (e.g. desogestrel/ • ethinyl estradiol)Common goal of therapyPrevent pregnancy• Spending in provincesTh e age gradient (or age-specifi c spike for the group aged 20–44) for spending on hormonal contraceptives was comparable across provinces. Spending per capita in 2007 varied most across provinces within the 19 and under age group. In Manitoba, girls of this age received an average of $5.30 worth of hormonal contraceptives in 2007, whereas girls in Atlantic Canada received over $14.00 worth of hormonal contraceptives on average. Spending per woman in the age group with the highest use of hormonal contraceptives (aged 20–44) ranged from $37.20 in Manitoba to $61.90 in Nova Scotia.Provincial formulary coverageAlthough some of the formulary data used here came from seniors’ drug plans, all provinces provided unrestricted coverage for seven of the 12 types of hormonal contraceptives that had more than $1,000 in national sales. One type of hormonal contraceptive was not listed on any provincial formulary.Weighted by national retail spending levels, the hormonal contraceptives listed on provincial formularies accounted for 75% or more of the national market.Figure 10C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 12 drugsPercent of $0.3 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 3 4Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.10 Hormonal contraceptivesSources of age-standardized variationAge-standardized spending per capita on hormonal contraceptives varied considerably across provinces.Age-standardized hormonal contraceptive spending per capita was 30% or more above the national average in provinces from Quebec eastward. Conversely, age-standardized hormonal contraceptive spending per capita was below the national average in Ontario and the western provinces.Th e volume of hormonal contraceptive purchased was the biggest driver of interprovincial variation.Provincial diff erences in the types of hormonal contraceptive selected had minor cost impacts.Owing to diff erences in generic use in particular, the price of hormonal contraceptives purchased varied from province to province. Some of the price eff ects observed in this therapeutic category may stem from interprovincial diff erences in prescription length.Population age and provincial spendingSpending per capita on hormonal contraceptives ranged across provinces from $7.60 ($15.20 per woman) in Manitoba to $12.90 ($25.80 per woman) in Quebec.Because persons aged 20–44 accounted for such a dominant share of spending on hormonal contraceptives, interprovincial diff erences in population ages would predict that relatively young provincial populations would have higher spending per capita in this therapeutic category. Population age alone would predict that per capita spending on hormonal contraceptives in Alberta would be 7.4% above the national average. Population ages alone would also predict that hormonal contraceptive spending in the Atlantic provinces would be from 4.7% to 7.2% below the national average.BC AB SK MB ON QC NB NS PE NLPer capita spending in province $8.2 $9.9 $8.8 $7.6 $9.0 $12.9 $12.9 $12.9 $12.6 $11.2Total variation from national average -19.0% -1.9% -12.6% -25.0% -10.7% 27.7% 27.3% 27.4% 25.2% 11.0% Variation predicted by population age -0.5% 7.4% -5.4% -2.4% 1.2% -3.3% -4.7% -5.6% -7.2% -5.9%Age-standardized variation -18.4% -9.3% -7.3% -22.7% -11.9% 31.0% 31.9% 33.0% 32.4% 16.9% Prescription volume -45.8% -13.1% -23.3% -22.0% -41.7% 75.6% 10.4% 4.9% 37.7% 23.9% Prescription size 25.6% 12.8% 12.6% 3.8% 24.5% -40.7% 16.4% 25.7% -6.4% -12.0%Volume effects -20.2% -0.2% -10.7% -18.2% -17.2% 34.9% 26.8% 30.6% 31.3% 11.9% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 1.7% 1.1% 0.4% 0.4% 0.9% -1.5% -2.5% 2.1% -0.8% 3.1%Therapeutic choice effects 1.7% 1.1% 0.4% 0.4% 0.9% -1.5% -2.5% 2.1% -0.8% 3.1% Prices paid 0.0% -10.2% 3.1% -4.6% 4.3% -2.4% 7.8% 0.6% 2.1% 2.3% Generic use 0.0% 0.1% -0.1% -0.2% 0.1% 0.0% -0.2% -0.3% -0.3% -0.4%Price effects 0.1% -10.1% 3.0% -4.8% 4.4% -2.4% 7.6% 0.3% 1.8% 1.9%Table 10A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 3 5-20%0%-11%+12%-18%-17%+35%+27%+31%+31%+2%+1%0%+3%0%+1%-1%-2%-1%+2%0%-10%+3%+2%-5%+4%-2%+8%+2%0%BritishColumbia-18%NewBrunswick+32%NovaScotia+33%Newfoundlandand Labrador+17%Prince Edward I.+32%Alberta-9%Saskatchewan-7%Manitoba-23% Quebec+31%Ontario-12%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 10E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 10D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 3 6Change in infl ation-adjusted per capita spending, 1998–2007Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.10 Hormonal contraceptivesAge-standardized volumes of hormonal contraceptive purchases actually declined over the period in all provinces except Quebec.Th e use of more costly drugs from within the hormonal contraceptives category contributed to increased spending in all provinces between 1998 and 2007.Th e unit prices paid for particular brands of hormonal contraceptives increased in all provinces from 1998 to 2007.Pace of change, 1998–2007Aft er adjusting for the eff ect of general infl ation on the value of a dollar, spending per capita on hormonal contraceptives drugs was virtually unchanged from 1998 to 2007. Sources of changeBecause persons aged 20–44 accounted for such a large share of spending in this therapeutic category, population aging actually placed a downward pressure on hormonal contraceptives spending between 1998 and 2007.Age-standardized hormonal contraceptives spending per capita grew modestly in most provinces. Th e annual growth rate of age-standardized and infl ation-adjusted spending per capita ranged from –1.1% in Prince Edward Island to 2.0% in Quebec.Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $10.0 $7.9 $10.1 $8.4 $7.7 $9.1 $11.6 $14.7 $14.6 $14.7Per capita spending in 2007 $10.1 $8.2 $9.9 $8.8 $7.6 $9.0 $12.9 $12.9 $12.9 $11.5 Average annual rate of change 0.1% 0.3% -0.1% 0.5% -0.2% -0.1% 1.1% -1.3% -1.2% -2.4% Rate of change due to population aging -0.7% -0.8% -0.4% -0.6% -0.6% -0.6% -0.9% -1.1% -1.0% -1.3%Age-standardized rate of change 0.8% 1.1% 0.3% 1.2% 0.4% 0.5% 2.0% -0.2% -0.2% -1.1% Prescription volume -1.9% -0.7% -3.9% -0.3% -3.3% -3.3% 0.6% -4.9% -5.7% -5.5% Prescription size 1.6% 0.3% 2.8% 0.1% 1.3% 2.1% 0.6% 3.5% 4.4% 2.8%Volume effects -0.3% -0.5% -1.1% -0.2% -1.9% -1.2% 1.2% -1.3% -1.3% -2.7% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 0.3% 0.2% 0.8% 0.2% 1.0% 0.7% 0.5% 0.8% 0.9% 0.8%Therapeutic choice effects 0.3% 0.2% 0.8% 0.2% 1.0% 0.7% 0.5% 0.8% 0.9% 0.8% Prices paid 0.7% 1.3% 0.5% 1.2% 1.5% 0.9% 0.3% 0.5% 0.4% 0.9% Generic use 0.0% 0.0% 0.0% 0.0% -0.1% 0.1% 0.1% -0.2% -0.3% -0.1%Price effects 0.7% 1.4% 0.5% 1.2% 1.4% 0.9% 0.3% 0.3% 0.2% 0.8%Table 10B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 3 7Note: All fi gures are expressed in the equivalent of year 2007 dollars.0%-1%0%-3%-2%-1%+1%-1%-1%0%+1%0%+1%+1%+1%0%+1%+1%+1%+1%+1%+1%+1%+1%0%0%0%BritishColumbia+1%NewBrunswick0%NovaScotia0%Newfoundlandand LabradorandPrince Edward I.-1%Alberta0%Saskatchewan+1%Manitoba0% Quebec+2%Ontario0%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 10G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 10F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 3 8Levels of spending across Canada and age groups11 Drugs for erectile dysfunctionSpending in CanadaCanadians spent an average of $4.40 per capita (or $8.80 per man) on retail purchases of drugs to treat erectile dysfunction (hereaft er referred to as ED drugs) in 2007. Th is amounted to $154 million in retail spending.ED drugs are used almost exclusively by older adult men. Spending on ED drugs per Canadian man aged 20–44 was $3.30. Th is group accounted for a total of $20 million in spending, or 13% of all Canadian spending on ED drugs in 2007. Canadians men aged 45–64 spent an average of $20 each on ED drugs, accounting for a total of $90 million in spending (62% of the Canadian total). Spending per man aged 65 and older was $16.30, accounting for $36 million of spending (25% of the Canadian total).Th ere were insuffi cient purchases of ED drugs by persons aged 19 and under to generate reliable age- and province-specifi c estimates of spending per capita for that age group. (Total fi gures for this therapeutic category exclude estimates for the censored age category.)$0$10NLPENSNBQCONMBSKBC AB$10NLPENSNBQCONMBSKBC AB$0$0$10NLNSNBQCONMBSKBC AB PE$0$10NLNS PENBQCONMBSKBC ABCanada overall$10$0NLNSNBQCONMBSKBC AB PEAges 65+Ages 45–64Ages 20–44Ages 0–19All agesFigure 11A» Per capita spending in Canada by age group, 2007Figure 11B» Per capita spending by province and age group, 2007Spending per capita$80$60$40$200-19 yearsNumberof people$07,776,058 people20-44 years$211,740,792 people45-64 years$108,936,632 people65+$84,417,805U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 3 9Per capita spending in Canada: $4.40Drugs in this therapeutic categoryAlprostadil• Yohimbine• Sidenafi l• Tadalafi l• Vardenafi l• Common goal of therapyImprove ability to get or keep an erection• Example of an indicated conditionErectile dysfunction• Spending in provincesTh e age gradient for spending on ED drugs was steepest in Ontario and least steep in Nova Scotia.Th e ratio of average spending per person aged 65 and older to that of persons aged 45–64 ranged from 1.8 in Nova Scotia to 2.3 in Ontario.Spending per capita in 2007 varied across provinces the most among the 20–44 age group. Men aged 20–44 in Newfoundland & Labrador received an average of $1.70 worth of ED drugs in 2007, whereas men in this age group in British Columbia received $4.40 worth of ED drugs on average.Spending per man in the age group with the highest use of ED drugs (aged 45–64) ranged from $11.70 in Newfoundland & Labrador to $24.10 in Alberta.Provincial formulary coverageTh e formulary data used in this study came from seniors’ drug plans in many provinces and universal pharmacare programs in others. Only British Columbia and Newfoundland & Labrador listed any ED drugs (just one) as benefi ts under these pharmacare programs.Th e dominant drugs in the market for ED treatments in Canada were not listed on the provincial formularies studied.Figure 11C» Percentage of drugs and their market value listed on provincial formulariesUnrestricted coverage Not covered0%20%40%60%80%100%NLNSNBQCONMBSKBC AB0%20%40%60%80%100%NLNSNBQCONMBSKBC ABPercent of 5 drugsPercent of $0.1 billionListing status as of December 2006T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 4 0Sources of variation in spending across CanadaNote: Rows may not add up due to rounding.11 Drugs for erectile dysfunctiondrug spending per capita was roughly 20% or more below the national average in all other provinces.Th e volume of ED drugs purchased was the biggest driver of interprovincial variation. Residents of Alberta and British Columbia purchased 23.7% and 16.1% greater age-standardized volumes of ED drugs than the national average. Residents of Atlantic Canada purchased far fewer (–29.7% or more) ED drugs than the national average on an age-standardized basis.Provincial diff erences in the types of ED drugs selected had minor cost impacts.Th ere were no interprovincial diff erences in generic ED drug use. However, the prices paid per unit of ED drug purchased varied from province to province. Some of the price eff ects observed in this therapeutic category may stem from interprovincial diff erences in prescription length. Shorter prescriptions result in higher levels of pharmacists’ fees paid per unit of drug received.Population age and provincial spendingSpending per capita on ED drugs ranged across provinces from $2.80 ($5.60 per man) in Newfoundland & Labrador to $5.00 ($10.00 per man) in British Columbia.Because spending on ED drugs is concentrated among older men, interprovincial diff erences in population ages would predict moderate variation in spending per capita in this therapeutic category. Diff erences in population age alone would predict that per capita spending on ED drugs would be 10.2% below the national average in Alberta and from 3.3% to 6.7% above the national average in the Atlantic provinces.Sources of age-standardized variationAge-standardized spending per capita was signifi cantly (9.4% or more) above the national average in British Columbia, Alberta, and Ontario. Age-standardized ED BC AB SK MB ON QC NB NS PE NLPer capita spending in province $5.0 $4.8 $3.5 $3.1 $4.9 $3.8 $3.3 $3.0 $3.2 $2.8Total variation from national average 12.7% 8.3% -21.8% -30.1% 12.0% -13.3% -24.4% -32.3% -27.0% -36.9% Variation predicted by population age 3.2% -10.2% -2.2% -3.0% -2.4% 4.5% 5.6% 5.3% 3.3% 6.7%Age-standardized variation 9.4% 18.5% -19.6% -27.1% 14.4% -17.8% -29.9% -37.6% -30.2% -43.6% Prescription volume 4.8% 16.9% -9.5% -19.7% 0.3% 4.5% -29.5% -37.4% -23.4% -31.4% Prescription size 11.2% 6.8% -11.0% -2.3% 9.5% -20.7% -5.4% 0.3% -6.3% -12.4%Volume effects 16.1% 23.7% -20.4% -22.0% 9.8% -16.2% -34.9% -37.1% -29.7% -43.8% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix -0.2% -0.3% 0.1% -0.7% 0.3% -0.1% -0.4% 0.0% -1.2% -0.6%Therapeutic choice effects -0.2% -0.3% 0.1% -0.7% 0.3% -0.1% -0.4% 0.0% -1.2% -0.6% Prices paid -6.4% -4.9% 0.8% -4.3% 4.3% -1.4% 5.4% -0.5% 0.6% 0.8% Generic use 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Price effects -6.4% -4.9% 0.8% -4.3% 4.3% -1.4% 5.4% -0.5% 0.6% 0.8%Table 11A» Sources of variation between average per capita spending in Canada and per capita spending in the provinces, 2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 4 1+16%+24%-20%-44%-22%+10%-16%-35%-30%-37%0%0%0%-1%-1%0%0%0%-1%0%-6%-5%+1%+1%-4%+4%-1%+5%1%0%BritishColumbia+9%NewBrunswick-30%NovaScotia-38%Newfoundlandand Labrador-44%Prince Edward I.-30%Alberta+19%Saskatchewan-20%Manitoba-27% Quebec-18%Ontario+14%VolumeeffectsTherapeuticchoice effectsPrice effects 40% 30% 20% 10% 5%+ 0%+ 5%+ 10%+ 20%+ 30%+ 40%Percent variationfrom thenational averageFigure 11E» Sources of age-standardized variation from the national average per capita spending by province, 2007Figure 11D» Age-standardized variation from the national average per capita spending by province, 2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 4 2Notes: Rows may not add up due to rounding. PEI and NL are combined due to 1998 data source.Change in infl ation-adjusted per capita spending, 1998–200711 Drugs for erectile dysfunctioninfl ation-adjusted per capita retail spending on ED drugs in the provinces. Age-standardized and infl ation-adjusted retail spending per capita on ED drugs grew by more than 24% per year in all provinces. Growth in this therapeutic category was largely driven by rapid increases (ranging from 19.4% to 36.8% per year) in the age-standardized volumes of ED drugs purchased. With increased ED drug use between 1998 and 2007 also came increased use of newer, more costly options within this therapeutic category. Th ese trends contributed from 6.0% per year to 9.8% per year to increased spending across provinces.In comparison to other cost-drivers within this therapeutic category, price eff ects were not important determinants of changes in spending on ED drugs between 1998 and 2007.Pace of change, 1998–2007Growth in infl ation-adjusted per capita spending on ED drugs between 1998 and 2007 was faster than any other therapeutic category studied. Infl ation-adjusted spending on retail purchases of ED drugs per Canadian grew by nearly 3000% from 1998 to 2007: from approximately $4.7 million to $145.2 million in 2007 (both fi gures in 2007 dollars). Aft er adjusting for the eff ects of general infl ation on the value of a dollar, retail spending on ED drugs per capita grew at an annual average rate of 39.6% per year between 1998 and 2007. Th e most rapid growth was observed in Quebec (46.7%). Sources of changeBecause persons aged 45–64 accounted for such a large share of spending in this therapeutic category, population aging contributed from 1.3% per year (Manitoba) to 2.2% per year (Prince Edward Island and Newfoundland & Labrador) to annual growth in Canada BC AB SK MB ON QC NB NS PEI + NLPer capita spending in 1998 $0.2 $0.1 $0.1 $0.1 $0.1 $0.2 $0.1 $0.2 $0.2 $0.3Per capita spending in 2007 $4.4 $5.0 $4.8 $3.5 $3.1 $4.9 $3.8 $3.3 $3.0 $2.9 Average annual rate of change 39.6% 43.5% 42.0% 45.5% 38.0% 37.6% 46.7% 32.9% 31.8% 26.8% Rate of change due to population aging 1.5% 1.5% 1.6% 1.8% 1.3% 1.3% 1.7% 1.9% 1.8% 2.2%Age-standardized rate of change 38.1% 41.9% 40.3% 43.7% 36.7% 36.3% 45.0% 31.0% 29.9% 24.6% Prescription volume 30.3% 32.0% 30.6% 34.1% 26.5% 28.9% 37.7% 24.9% 22.9% 17.0% Prescription size 0.9% 1.0% 1.4% 0.6% 2.3% 0.9% -0.9% 0.4% 1.6% 2.4%Volume effects 31.2% 32.9% 31.9% 34.7% 28.9% 29.8% 36.8% 25.2% 24.5% 19.4% Therapeutic mix 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Drug mix 7.5% 9.2% 8.9% 9.8% 7.8% 7.1% 8.7% 6.0% 6.6% 6.9%Therapeutic choice effects 7.5% 9.2% 8.9% 9.8% 7.8% 7.1% 8.7% 6.0% 6.6% 6.9% Prices paid -0.1% 0.0% 0.2% -0.1% 0.6% -0.2% -0.1% 0.5% -0.5% -1.1% Generic use -0.5% -0.1% -0.6% -0.7% -0.5% -0.4% -0.4% -0.7% -0.6% -0.6%Price effects -0.7% -0.2% -0.5% -0.8% 0.1% -0.6% -0.5% -0.3% -1.2% -1.7%Table 11B» Magnitude and sources of change in infl ation-adjusted per capita spending in Canada and the provinces, 1998–2007U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 4 3Note: All fi gures are expressed in the equivalent of year 2007 dollars.+33%+32%+35%+19%+29%+30%+37%+25%+24%+9%+9%+10%+7%+8%+7%+9%+6%+7%0%0%-1%-2%0%-1%-1%0%-1%BritishColumbia+42%NewBrunswick+31%NovaScotia+30%Newfoundlandand LabradorandPrince Edward I.+25%Alberta+40%Saskatchewan+44%Manitoba+37% Quebec+45%Ontario+36%VolumeeffectsTherapeuticchoice effectsPrice effectsAverage annualrate of change19982007 5%+ 0%+ 5%+ 2.5% 2.5%+ 10%+ 15%+ 20%Figure 11G» Sources of change in age-standardized, infl ation-adjusted per capita spending by province, 1998–2007Figure 11F» Age-standardized average annual rate of change in infl ation-adjusted per capita spending by province, 1998–2007T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 4 4DemographicsCharacteristics of provincial populationsBritishColumbia14.1%NewBrunswick14.5%NovaScotia14.8%Newfoundlandand Labrador13.9%Prince Edward I.14.5%Alberta10.4%Saskatchewan14.9%Manitoba13.6% Quebec14.4%Ontario13.2% 12%13%14%11%Canada13.4%BritishColumbia85%NewBrunswick51%NovaScotia55%Newfoundlandand Labrador58%Prince Edward I.45%Alberta82%Saskatchewan65%Manitoba71% Quebec80%Ontario85%50%60%70%80%Canada80%Information about population demographics are included on this and the facing page. Th is information (and the reason for including it) includes:Population age: Th is is a potentially important • determinant of drug spending (and the focus of much of the analysis in this report).Urbanization rates: Health care access, as well as • certain patterns of medicine use, may be expected to diff er across urban and rural settings.AgePercentage of population aged 65 and olderStatistics Canada, 2007UrbanizationPercentage of population living in an urban area2006 Census, Statistics CanadaIncome and education: Socioeconomic status may • infl uence both the needs for and the ability to aff ord/access prescription medicines.Immigration rates: Attitudes toward and needs • for medicines may diff er among Canadians born abroad.U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 4 5BritishColumbia52,709NewBrunswick45,194NovaScotia46,605Newfoundlandand Labrador44,136Prince Edward I.46,553Alberta63,988Saskatchewan46,705Manitoba47,875 Quebec46,419Ontario60,455$50,000$55,000$60,000$45,000Canada53,634BritishColumbia24%NewBrunswick16%NovaScotia20%Newfoundlandand Labrador14%Prince Edward I.18%Alberta22%Saskatchewan17%Manitoba19% Quebec21%Ontario26%18%16%20%22%24%26%Canada23%BritishColumbia27%NewBrunswick4%NovaScotia5%Newfoundlandand Labrador2%Prince Edward I.4%Alberta16%Saskatchewan5%Manitoba13% Quebec11%Ontario28%10%5%15%20%25%Canada20%Household incomeMedian household income2006 Census, Statistics CanadaEducationPercentage of population aged 25 to 64 with a bachelor’s degree or higher2006 Census, Statistics CanadaImmigrationPercentage of population who is or has ever been a landed immigrant in Canada2006 Census, Statistics CanadaT H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 4 6Health behavioursCharacteristics of provincial populationsBritishColumbia54%NewBrunswick43%NovaScotia48%Newfoundlandand Labrador46%Prince Edward I.47%Alberta53%Saskatchewan46%Manitoba52% Quebec46%Ontario49%48%50%52%46%44%Canada49%BritishColumbia41%NewBrunswick56%NovaScotia55%Newfoundlandand Labrador60%Prince Edward I.57%Alberta51%Saskatchewan53%Manitoba53% Quebec47%Ontario49%48%52%56%44%Canada49%Physical activityPercentage of population aged 12 and over that is physically active or moderately activeCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaObese and/or overweightPercentage of population aged 18 and over that is obese and/or overweightCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaInformation about the health behaviours of provincial populations that may (or may not) explain some of the fi ndings in this atlas is included on this and the facing page. Th is information (and the reason for including it) includes:Physical activity: Regular exercise not only improves • health but is oft en used as part of non-medical prevention and/or management strategies for some diseases.Rates of obesity and overweight: Th is may be • correlated with needs for a number of categories of drug treatment.Smoking and binge drinking: Th ese are correlated • with health status.Immunization for infl uenza: Immunization is an • indicator of preventive health behaviours.U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 4 7at least once a month in the past yearCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaBinge drinkingPercentage of population aged 12 and over that report drinking 5 or more drinks BritishColumbia17.8%NewBrunswick23.3%NovaScotia24.4%Newfoundlandand Labrador25.3%Prince Edward I.21.5%Alberta21.9%Saskatchewan25.9%Manitoba22.4% Quebec25.1%Ontario20.6% 20%22%24%18%Canada21.9%BritishColumbia19%NewBrunswick27%NovaScotia29%Newfoundlandand Labrador32%Prince Edward I.28%Alberta24%Saskatchewan24%Manitoba25% Quebec21%Ontario21%24%28%32%20%Canada22%BritishColumbia30%NewBrunswick26%NovaScotia39%Newfoundlandand Labrador22%Prince Edward I.31%Alberta26%Saskatchewan25%Manitoba26% Quebec25%Ontario36%24%28%32%36%Canada30%SmokingPercentage of population aged 12 and over that smokeCanadian Community Health Survey Cycle 3.2 (2007), Statistics Canadaimmunization less than one year agoCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaInfl uenza immunizationPercentage of population aged 12 and over reporting having an infl uenzaT H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 4 8Health statusCharacteristics of provincial populationsBritishColumbia59%NewBrunswick55%NovaScotia57%Newfoundlandand Labrador62%Prince Edward I.59%Alberta63%Saskatchewan56%Manitoba60% Quebec59%Ontario60% 58%60%62%56%Canada60%BritishColumbia68%NewBrunswick67%NovaScotia71%Newfoundlandand Labrador75%Prince Edward I.72%Alberta75%Saskatchewan71%Manitoba72% Quebec75%Ontario73%68%70%72%74%Canada73%Self-reported health statusPercentage of population aged 12 and over reporting being in very good or excellent healthCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaSelf-reported mental health statusPercentage of population aged 12 and over reporting being in very good or excellent mental healthCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaInformation about the health status of provincial populations that may (or may not) explain some of the fi ndings in this atlas is included on this and the facing page. Th is information (and the reason for including it) includes:Overall health status: Th is is likely correlated with • needs for prescription drugs.Self-reported mental health status: A signifi cant • amount of pharmaceutical therapy targets mental health issues.In addition, three specifi c measures of self-reported health status are included to help quantify needs for certain types of drug treatment:Hypertension: Hypertension may be correlated with • overall cardiovascular health needs. Diabetes: Diabetes may be correlated with a variety • of health needs. Asthma: Asthma rates are a health indicator that • is sensitive to the burden of illness in younger populations.U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 4 9BritishColumbia14%NewBrunswick19%NovaScotia19%Newfoundlandand Labrador21%Prince Edward I.17%Alberta14%Saskatchewan17%Manitoba16% Quebec16%Ontario16%17%19%21%15%Canada16%BritishColumbia5.4%NewBrunswick7.4%NovaScotia6.8%Newfoundlandand Labrador8.8%Prince Edward I.5.6%Alberta4.5%Saskatchewan5.7%Manitoba5.0% Quebec5.9%Ontario6.1% 6%7%8%5%Canada5.8%BritishColumbia6.7%NewBrunswick8.7%NovaScotia10.8%Newfoundlandand Labrador5.2%Prince Edward I.8.9%Alberta8.9%Saskatchewan8.4%Manitoba7.2% Quebec8.1%Ontario8.1% 9%10%8%7%6%Canada8.0%HypertensionPercentage of population aged 12 and over reporting to have hypertensionCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaDiabetesPercentage of population aged 12 and over reporting to have diabetesCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaAsthmaPercentage of population aged 12 and over reporting to have asthmaCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaT H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 5 0Health care systemCharacteristics of provincial populationsBritishColumbia88%NewBrunswick92%NovaScotia94%Newfoundlandand Labrador88%Prince Edward I.88%Alberta82%Saskatchewan85%Manitoba85% Quebec74%Ontario91% 80%85%90%75%Canada85%BritishColumbia$4,713NewBrunswick$5,070NovaScotia$4,850Newfoundlandand Labrador$5,010Prince Edward I.$4,686Alberta$5,390Saskatchewan$5,179Manitoba$5,250 Quebec$4,371Ontario$4,975 $4,750$5,000$5,250$4,500Canada$4,867Access to a regular medical doctorPercentage of population aged 12 and over reporting having a regular medical doctorCanadian Community Health Survey Cycle 3.2 (2007), Statistics CanadaTotal spending on health carePer capita spending on health careCIHI*, 2007* The Canadian Institute for Health Information, Drug Expenditure in Canada, 1985–2007.Information about provincial health care systems and residents’ access to them are included on this and the facing page. Th is information (and the reason for including it) includes:Access to regular medical doctors: Access to primary • care may infl uence access to (and therefore use of and spending on) prescription drugs.Total spending on health care: Spending on • prescription drugs may reduce overall health costs.Pharmaceutical-specifi c information includes:Spending on prescription drugs relative to total • health care: Th e share of health care spending that goes to prescription drugs may refl ect regional spending trade-off s.Shares of prescription drug costs paid for by • government: Government subsidy may encourage use and spending. Spending on non-prescription drugs: Th ese • medicines can serve as substitutes for certain prescription-only drugs.U B C C E N T R E F O R H E A LT H S E R V I C E S A N D P O L I C Y R E S E A R C H1 5 1BritishColumbia11.2%NewBrunswick15.3%NovaScotia14.4%Newfoundlandand Labrador14.9%Prince Edward I.13.8%Alberta10.6%Saskatchewan12.4%Manitoba11.2% Quebec17.1%Ontario14.7% 13%15%17%11%Canada14.0%BritishColumbia46%NewBrunswick32%NovaScotia40%Newfoundlandand Labrador41%Prince Edward I.36%Alberta50%Saskatchewan52%Manitoba53% Quebec52%Ontario47% 40%45%50%35%Canada48%BritishColumbia$71NewBrunswick$71NovaScotia$80Newfoundlandand Labrador$56Prince Edward I.$78Alberta$81Saskatchewan$64Manitoba$66 Quebec$60Ontario$80$65$60$70$75$80Canada$73Government spending on prescription drugsPercentage of total spending on prescription drugs paid for by public drugs plansCIHI*, 2007Spending on non-prescription drugsPer capita spending on non-prescription drugsCIHI*, 2007Spending on prescription drugsPercentage of health care spending accounted for by prescription drugsCIHI*, 2007* The Canadian Institute for Health Information, Drug Expenditure in Canada, 1985–2007.T H E C A N A D I A N R X A T L A S , 2 N D E D I T I O N1 5 2Levels of spending across Canada and age groupsUBC Centre for Health Services and Policy ResearchThe University of British Columbia201-2206 East MallVancouver, B.C. Canada V6T 1Z3Tel: 604.822.4969Fax: 604.822.5690Email: enquire@chspr.ubc.cawww.chspr.ubc.caAdvancing world-class health services and policy research, training and data resources on issues that matter to Canadians
Book
Canada
eng
Unreviewed
Vancouver : University of British Columbia Library
Centre for Health Services and Policy Research (CHSPR)
Attribution-NonCommercial-NoDerivs 2.5 Canada
Faculty
Researcher
Graduate
Drugs -- Prices -- Canada
Drug utilization -- Canada
Drugs -- Prescribing -- Canada
The Canadian Rx atlas, 2nd edition
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