Evaluation of Patient Access to Diabetic Medication

Mitchell Levine, Kathryn Gaebel, Lisa Dolovich, Jarold Cosby, Janusz Kaczorowski, Sorin Segal, Jaques LeLorier

Background

Avandia (rosiglitazone) and Actos (pioglitazone) are a new generation of oral hypoglycemic medications (thiazolidinediones or TZDs) that are available to Ontario Drug Benefit (ODB) eligible patients meeting specific Section 8 reimbursement criteria.  Although the province of Quebec has similar reimbursement criteria to Ontario, there is greater use of the TZDs (Avandia or Actos) in Quebec than Ontario.  In Ontario, TZD accounted for approximately 1.8% of oral hypoglycemic drug claims through the ODB program.  Whereas, in Quebec TZDs represent 6.6% of oral hypoglycemic drug claims in the publicly funded drug programs (Brogan PharmaStat data).  There is very little known about the impact of the ODB Section 8 program pertaining to the issue of drug under-utilization. Thus, an important question that needs to be addressed regarding the ODB process is whether the Section 8 mechanism prevents some patients who would benefit from a TZD from receiving the drug.

Study Objectives

Using funding received from GlaxoSmithKline, this study evaluated the extent that type 2 diabetic patients who are beneficiaries of the Ontario Drug Benefit (ODB) program and who meet the eligibility criteria for thiazolidinedione (TZD) reimbursement are receiving a TZD oral hypoglycemic drug through the ODB’s Section 8 program.  This study also evaluated patient data regarding both eligibility and use of TZDs between the Ontario and Quebec drug benefit programs to determine if there are patient (and physician) characteristics that predict whether or not a diabetic patient will receive a TZD oral hypoglycaemic drug, under conditions meeting either appropriate or less than appropriate reimbursement criteria.

Methods

Type 2 diabetic patients, 68 years or older, were recruited from community pharmacies in Quebec and Ontario through the Pharmacy Medication Monitoring Program (PMMP).   Patients participated in a telephone interview that explored their medication use and medical history.  Family physicians, caring for these same patients, were asked to complete a short questionnaire to provide information from each patient’s medical chart.  The matrix of the patient’s “reimbursement eligibility” and “medication use” were analyzed using descriptive statistics.  Regression modelling was used to evaluate characteristics that are predictive of drug access and use.

Key Findings

The number of patients recruited in Ontario was 393. The number of eligible patients completing a telephone interview was 368 (94%) and the number of completed physician fax-back forms was 297 (81% of interviewed patients). There were 80 patients that would have been eligible for TZD reimbursement based upon the criteria for optimal use. Patients using a TZD were slightly younger and had a slightly greater body mass index than non-TZD users. There was no difference in sex or duration of diabetes. The socio-economic variables that were different between the two groups were a greater likelihood for a TZD user to be living with someone compared to the non-TZD users, and users were more likely to have a household income greater than $30,000.

The number of patients recruited in Quebec was 312. The number of eligible patients completing a telephone interview was 296 (95%) and the number of completed physician fax-back forms was 153 (52% of interviewed patients). There were 43 patients that would have been eligible for TZD reimbursement based upon the criteria for optimal use. Patients using a TZD were slightly younger, had a longer duration of diabetes and had a slightly greater body mass index than non-TZD users. There was no difference in sex. There were no differences in socio-economic variables between the two groups.

In Ontario 32% of TZD users met the eligibility criteria, and similar results (36%) were obtained in Quebec. The difference of 4% was not significant. In Ontario 18% of TZD non-users met the eligibility criteria while only 8% of Quebec non-users met TZD eligibility criteria, for a significant difference of 10%.

Future Implications

The ODB policy to limit TZD reimbursement (in comparison to Quebec) did not efficiently achieve its goals as it may have limited appropriate use, but was unlikely to provide additional limitations on inappropriate use. Alternative policies or interventions are required to achieve the goal of maximizing optimal use of TZDs.

Publications

1. Abushomar H, Gaebel K, Levine M. Evaluation of patient access to diabetic medication. CJCP. 2005; 12(1):e76. Abstract.
2. Jurcic J, Gaebel K, Levine M. Is there an association amongst current medication use, clinical lab values and quality of life scores in patients with type 2 diabetes? CJCP. 2005; 12(1):e84. Abstract.
3. Gaebel K, Cosby J, Abushomar H, Levine M. Physician perceptions and experiences with restrictive policies for patient access to diabetic medications. CJCP. 2005; 12(1):e91. Abstract.
4. Levine M. Impact of formulary policy on thiazolidinedione (TZD) use in the Ontario Drug Benefit (ODB) program. Clin Pharmacol Ther. 2005; 77(2):72. Abstract.

For further information about this study, please contact Dr. Mitchell Levine.