Informatics.medicine.dal.ca

Parliamentary Committee on Health
Prescription Drugs - October 27, 2003
Speaker’s Notes:
Dr. David Zitner
Director, Medical Informatics
Faculty of Medicine, Dalhousie University
Dr. David Zitner
Director, Medical Informatics
Faculty of Medicine, Dalhousie University
5849 University Avenue
Halifax, Nova Scotia
(902) 494-3802
NECESSARY TREATMENT FOR ALL CANADIANS
Summary:
All Canadians should have access to necessary drugs. This will only be possible when we
identify and pay for only those drugs that are valuable and not for ones that are merely
useless or harmful. Once we’ve identified and stopped paying for harmful or useless
pills, it will still be necessary for wealthier Canadians to pay a portion of their own drug
costs while subsidizing those who cannot contribute at all.
Speaking notes:
Canadians spend billions on drug treatment yet, strange to tell, no one knows how many
people were helped or harmed by this massive ingestion of pharmaceuticals. When were
you last contacted by someone who wanted to know if a particular treatment helped or
hurt you? Even when your doctor checks on you, the information you give is not
routinely collected and stored to become part of our on-going knowledge about drugs.
Many Canadians benefit from drug treatments, yet some are harmed.
Therapeutic Gap:
Some people cannot afford needed treatment because they are poor. Some are prevented
from receiving appropriate and useful drugs because the are not covered by drug plans, or
their drug plan has barriers to their use, or because clinicians don’t recognize a drug is
necessary.
Therapeutic Excess:
On the other hand, communities, either as individuals or through insurance, pay large
amounts for drugs which are eventually shown to be harmful (e.g. Paxil for adolescent
depression which is associated with increases in suicidal thinking or Serzone which
is associated with death and disability from liver disease) or merely useless and
possibly harmful (e.g. Paxil and certain other SSRI drugs used for adult depression,
long-term hormone replacement therapy for women). 28% of admissions to US
hospitals of older people are from drug problems, most from complications of treatment
(Heath, British Medical Journal, October 11, 2003).
SUBSTANTIAL WASTE:
Insurers, including governments, pay large amounts for drugs that are bought but never
consumed. About 50% of drugs prescribed for chronic disease are not taken.
(Townsend, British Medical Journal, October 11, 2003) If this waste were eliminated
Canadians would have additional resources available to pay for useful care.
Improving our system through learning and adaptation requires information.
Unfortunately, we don’t bother to collect information about the activities and results of
care. So our health system is unable to behave as a system that adapts and learns.
Feedback is essential for learning. Since we can’t link the activities and results of care –
get feedback on our actions in prescribing drugs – it becomes difficult to distinguishvaluable from harmful or merely wasteful.
Catastrophic drug coverage with a deductible could reduce waste. A Rand study
showed that people who spend their own money are more likely to be cautious in the use
of health care resources, and except for the very poor, are not harmed. Even Tommy
Douglas, a founder of Medicare recommended that people pay for a portion of their care.
We recognize the harms that occur when health care cannibalizes from other valuable and
health-enhancing services including education, recreation and economic development.
Recent commentators including Romanow and Kirby have recommended comprehensive,
catastrophic drug coverage, with a deductible and subsidies for poor people, so that rich
and poor people could get the useful drugs they need.
Romanow and others remarked on the tragedies that befall people with limited resourcesand those without insurance protection from catastrophic drug costs. It is important thatall Canadians receive the drugs they need, so subsidies to cover deductible costs arenecessary to protect the weakest among us.
Superstitious Beliefs:
We know that Western societies have had superstitious beliefs about many treatments.
Treatments including blood letting, routine use of episiotomies and widespread use of
tranquilizers (such as the drug Miltown) were widely used in the past. Certain
antidepressants are commonly used now in the absence of clear evidence that the benefits
outweigh the harms.
Policy makers, health services administrators and patients grapple with the question ofwhat drugs to pay for, hoping to only pay for those that are likely to produce benefit, notharm. Without information about beneficial and adverse results such decisions aremerely groping in the dark. Often no one can accurately say how many people are helpedor harmed by a particular drug. Decisions about what drugs to pay for would be helpedby knowing numbers needed to treat and numbers needed to harm (perhaps on the druglabel or with the medication). We waste substantial amounts on unnecessary and harmfulcare, then have insufficient left over to insure that middle class and poor Canadians haveaccess to expensive, but costworthy drugs.
Curing a complex chaotic health care system:
Government as a regulator must insist that health adopt the quality practices from other
industries and provide appropriate information about the benefits and harms of care
including information about the numbers of people needed to treat in order to have a
benefit from a particular treatment, and the number of people who will be harmed by
particular treatments. Doing so would permit all of us to make rational choices about
drugs, including consumers, who ultimately pay some or all of the cost of medication.
1 “I think there is a value in having every family and every individual make some individual contribution [to the cost oftheir coverage under Medicare]. I think it has psychological value. I think it keeps the public aware of the cost andgives the people a sense of personal responsibility.” Tommy Douglas, October 13, 1961, Saskatchewan Legislature.

Source: http://informatics.medicine.dal.ca/files/Speaker%20Notes%20Oct%2027%2003.pdf