Access to Drugs for Cancer: Does Where You Live Matter?

Article excerpt

ABSTRACT

Background: Provincial governments are responsible for administering publicly-funded anti-cancer drug benefit programs in Canada. This study examines inter-provincial variations in not only the content of such programs, but also the policies/processes used when considering a new drug for coverage.

Methods: Pharmaceutical manufacturers and provincial /regional cancer boards were surveyed to identify the drugs covered by public drug benefit plans. Kappa coefficients were calculated to determine inter-provincial coverage variations. The comprehensiveness of availability of anti-cancer drugs across the country was also assessed. A semi-structured survey of all 10 provincial/regional cancer board pharmacy and therapeutics (P&T) committees was employed to examine decision-making policies/procedures. It included questions on committee composition and processes and on factors influencing decisions regarding the introduction of new drugs. Completed surveys were analyzed using qualitative and quantitative techniques.

Results: All cancer boards and 75% of manufacturers contacted provided information on drugs covered in each province. Where lists were obtained from both sources, there was full agreement on content. Kappa values calculated ranged from -0.403 to 0.594, indicating poor to moderate agreement on anti-cancer drug coverage between provinces. Only 7 of the 115 drugs were available in all 10 provinces. Regarding decision-making processes, while ratings for both the relative importance and use of factors involved in decision-making (clinical effectiveness, patient preference, etc.) were similar across provinces, those for the relative importance and use of different information types (clinical trials, expert opinion, etc.) varied.

Conclusion: Access to anti-cancer drugs clearly varies across the country. In part, this may be due to differences in the views of P&T committees on the usefulness of information they use in their deliberations.

MeSH Terms: Formularies; antineoplastic agents; Canada; decision-making

In Canada, there are a number of different "payers" for drugs provided through out-patient programs (i.e., where patients visit a health care facility for treatment without spending the night), which do not fall within the domain of the Canada Health Act. They may be broadly categorized into three groups: 1) government programs (e.g., drug formularies), 2) employer-sponsored benefit packages, and 3) "out-of-pocket" payment. This paper focusses on the first of these three (i.e., the publicly-funded programs). Government benefit programs are typically administered by individual provinces, each of which independently makes decisions around what drugs to provide and to whom based upon the recommendations of a local pharmacy and therapeutics (P & T) committee. Consequently, patient eligibility criteria, as well as the content and scope of the formularies (i.e., list of publicly covered drugs), themselves, vary among provinces, creating a level of inequity in nation-wide access to drugs that could ultimately lead to regional disparities in the health of the Canadian public as a whole.

To date, research examining formulary decision-making and the comparative comprehensiveness of publicly-funded drug coverage across provinces has been limited to analyses of eligibility, cost-sharing arrangements, drug expenditures, and access to out-patient drugs for qualifying sub-populations (e.g., seniors, children, or those receiving social assistance),1-5 none of which have included drugs for treating cancer. Such drugs play a critical role in the management of many types of cancer, often comprising patients' only therapeutic option. In recent years, the development of high-cost, innovative anti-cancer drugs that offer new hope for improved survival and/or quality of life has significantly increased, placing pressure on provincial cancer boards/agencies and their P&T committees to make them available to patients. …