Lingyun Lu1, Harlan M Krumholz1, Jack V Tu1, Joseph S Ross1, Dennis T Ko1, Cynthia A Jackevicius2. 1. From the Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA (L.L., C.A.J.); Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA (L.L., C.A.J.); Department of Medicine, Section of Cardiovascular Medicine (H.M.K.) and Center for Outcomes Research and Evaluation, Yale New Haven Hospital (H.M.K., J.S.R.), Yale University School of Medicine, New Haven, CT; Department of Epidemiology and Public Health, Section of Health Policy and Administration, Yale University School of Medicine, New Haven, CT (H.M.K., J.S.R.); Robert Wood Johnson Clinical Scholars Program, New Haven, CT (H.M.K., J.S.R.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., D.T.K., C.A.J.); Department of Health Policy, Management and Evaluation, Faculty of Medicine (J.V.T., D.T.K., C.A.J.) and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre (J.V.T., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT (J.S.R.); and University Health Network, Toronto, Ontario, Canada (C.A.J.). 2. From the Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA (L.L., C.A.J.); Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA (L.L., C.A.J.); Department of Medicine, Section of Cardiovascular Medicine (H.M.K.) and Center for Outcomes Research and Evaluation, Yale New Haven Hospital (H.M.K., J.S.R.), Yale University School of Medicine, New Haven, CT; Department of Epidemiology and Public Health, Section of Health Policy and Administration, Yale University School of Medicine, New Haven, CT (H.M.K., J.S.R.); Robert Wood Johnson Clinical Scholars Program, New Haven, CT (H.M.K., J.S.R.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., D.T.K., C.A.J.); Department of Health Policy, Management and Evaluation, Faculty of Medicine (J.V.T., D.T.K., C.A.J.) and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre (J.V.T., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT (J.S.R.); and University Health Network, Toronto, Ontario, Canada (C.A.J.). cjackevicius@westernu.edu.
Abstract
BACKGROUND: Ezetimibe use has steadily increased in Canada during the past decade even in the absence of evidence demonstrating a beneficial effect on clinical outcomes. Among the 4 most populated provinces in Canada, there is a gradient in the restrictiveness of ezetimibe in public-funded formularies (most to least strict: British Columbia, Alberta, Quebec, and Ontario). The effect of formulary policy on the use of ezetimibe over time is unknown. METHODS AND RESULTS: We conducted a population-level cohort study using Intercontinental Marketing Services Health Canada's data from June 2003 to December 2012 to examine ezetimibe use in these 4 provinces to better understand the association between use and formulary restrictiveness. We found regional variations in the patterns of ezetimibe use. From June 2003 to December 2012, British Columbia (most restrictive) had the lowest monthly increasing rate from $261 to $21 926 ($190/100 000 population/mo), whereas Ontario (least restrictive) had the most rapid monthly increase from $223 to $74 030 ($ 647/100 000 population/mo), and Quebec from $130 to $59 690 ($522/100 000 population/mo) and Alberta from $356 to $ 37 604 ($327/100 000 population/mo) were intermediate (P<0.001). CONCLUSIONS: Ezetimibe use remains common, increasing during the past decade. Use steadily increased in provinces with the most lenient formularies. In contrast, use was lower, plateauing since 2008 in British Columbia and Alberta, which have more restrictive formularies. The gradient in ezetimibe use was related to variability in restrictiveness of the provincial formularies, illustrating the potential of a policy response gradient that may be used to more effectively manage medication use.
BACKGROUND:Ezetimibe use has steadily increased in Canada during the past decade even in the absence of evidence demonstrating a beneficial effect on clinical outcomes. Among the 4 most populated provinces in Canada, there is a gradient in the restrictiveness of ezetimibe in public-funded formularies (most to least strict: British Columbia, Alberta, Quebec, and Ontario). The effect of formulary policy on the use of ezetimibe over time is unknown. METHODS AND RESULTS: We conducted a population-level cohort study using Intercontinental Marketing Services Health Canada's data from June 2003 to December 2012 to examine ezetimibe use in these 4 provinces to better understand the association between use and formulary restrictiveness. We found regional variations in the patterns of ezetimibe use. From June 2003 to December 2012, British Columbia (most restrictive) had the lowest monthly increasing rate from $261 to $21 926 ($190/100 000 population/mo), whereas Ontario (least restrictive) had the most rapid monthly increase from $223 to $74 030 ($ 647/100 000 population/mo), and Quebec from $130 to $59 690 ($522/100 000 population/mo) and Alberta from $356 to $ 37 604 ($327/100 000 population/mo) were intermediate (P<0.001). CONCLUSIONS:Ezetimibe use remains common, increasing during the past decade. Use steadily increased in provinces with the most lenient formularies. In contrast, use was lower, plateauing since 2008 in British Columbia and Alberta, which have more restrictive formularies. The gradient in ezetimibe use was related to variability in restrictiveness of the provincial formularies, illustrating the potential of a policy response gradient that may be used to more effectively manage medication use.
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