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Affordability of medications: (re)discovering the obvious

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Friday, 17 August 2012
in CHNET-Works!

In an earlier posting, I mentioned research by Canada's Dennis Raphael, among others, on the difficulty of managing diabetes on a low income. The cost of a healthy diet is a major part of the problem; another is the cost of medications. In Ontario, prescription medications outside hospital are covered by public health insurance only for people over the age of 65 and for those on extremely low incomes. A new study by researchers at the University of Toronto (1) points out that this may be having a substantial impact on the health of people with diabetes.

We already knew that mortality among high-income Ontarians with diabetes has been declining faster than it has among those with low incomes, leading to a widening equity gap. Starting with a health records database including almost all Ontarians with diabetes and using median household incomes in the Statistics Canada dissemination area where they lived as a proxy for an individual's own income, the researchers found that the socioeconomic gradient for death, acute myocardial infarction (AMI) and stroke is substantially steeper among people under 65, who either pay out of pocket for their medications or rely on private insurance, than it is among those 65 and over whose prescription drugs are covered. "[A]s many as 5,000 deaths and nearly 2,700 AMIs or strokes could have been avoided among younger and middle-aged adults with diabetes if the gap between wealthier and poorer individuals had been identical to that seen among older groups. "

affordability-car-accident-If we could eliminate vehicle accidents as a cause of death in Ontario, wouldn’t we give it a shot?
Photo: Sean Whaley/Nevada News Bureau, reproduced under a
Creative Commons Licence 3.0.
To put that figure of 5,000 into perspective, that's the total number of people who died in Ontario motor vehicle accidents from 2002 through 2007, the years covered by the new study. If we could eliminate such accidents as a cause of death in this province, wouldn't we do it? And since the study looked only at the portion of the population with one disease, the overall toll of avoidable illness and death associated with lack of universal public insurance for prescription medications ("pharmacare") is almost certainly higher.

Lack of pharmacare kills, in other words. Nothing is especially new about this realization. The new study cites previous research on the problem of drug costs for diabetics ... and it's now been more than a decade since a landmark study by Robyn Tamblyn and colleagues showed that emergency department visits and hospital admissions increased, and use of essential medications decreased, after Québec introduced co-payments in its public drug coverage for senior citizens.

Pharmacare is not just an equity issue; it's also an efficiency issue. The market power available to a single public purchaser could be important tool for cost containment. Indeed an important analysis published in the fall of 2010, which appears to have sunk without a trace, suggested that the lack of pharmacare is one of the reasons that prescription drug costs in Canada have been growing faster than in most other OECD countries, and argued that national pharmacare would reduce drug costs by 11.7 – 42.8 percent relative to current practice.

Failing to provide public insurance coverage for prescription drugs outside hospitals doesn't save money. It simply means that fewer costs are borne by the public treasury, and more by private insurers or people who may not be able to pay out-of-pocket, sometimes with fatal consequences.

At least under the current national government, there seems no hope for a federally initiated program. Ontario is one of the few provinces that are probably large enough to go it alone; a consortium of smaller provinces could do the same. Until that happens, the avoidable illnesses and deaths will continue, and we who are concerned with equity should laugh hollowly at all official claims that health policy is evidence-based.

(1) Unfortunately, full text is not available for open access

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Manufacturing Diabetes

Posted by guest blogger Colleen Fuller
guest blogger Colleen Fuller
Colleen Fuller is co-founder and President of PharmaWatch (http://pharmawatchcan
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on Tuesday, 24 July 2012
in CHNET-Works!

One of the things that drives me crazy is how the drug industry, instead of manufacturing useful medicines for existing diseases, manufactures diseases or epidemics and then the drugs to treat them. This is exactly backwards, but it is something that is happening more and more frequently.

One example is "pre-diabetes." Canadians are being bombarded with dire warnings about the skyrocketing number of people with diabetes – an "economic tsunami" according to the pharma-friendly Canadian Diabetes Association. The term pre-diabetes is not new — in the early postwar years many thought that women who gave birth to "large babies" were likely to develop Type 2 diabetes later in life, and they were described as being pre-diabetic (and, in line with sexist medical thinking, irresponsible as well). By the mid-1960s the association between pregnancy and pre-diabetes seems to have morphed into a diagnosis of gestational diabetes among pregnant women. But today, we're being told that pre-diabetes is an epidemic among people on the verge of developing the real thing and the main reason, according to the popular narrative, is obesity and, well, irresponsible sloth.

So let's parse out this picture. In Canada, the CDA says there are 2.7 million people with diabetes, including Type 1 (about 10% of the total), Type 2 or gestational diabetes. The numbers of people with diabetes is increasing in each category. But there are six million who are diagnosed as being "pre-diabetic" — a term that refers to those who are assumed to be at risk for Type 2. So the number of people who may get diabetes is actually higher than those who actually have it. Unfortunately, all of these different types, including the haves and the may-gets, are conflated into a single figure of nine million people.

How do they arrive at these scary numbers? One way is with a test that measures blood glucose levels. In 1997, the American Diabetes Association lowered the threshold that was used to arrive at a diagnosis of Type 2 diabetes from a fasting blood sugar level of 7.8 mmol/L to one of 7.0 mmol/L, a change that added another 1.9 million Americans to the list of people with this condition. Despite doubts about the evidence to support this move — not to mention warnings about the high cost as well as psychological and emotional impact of such an approach — the new standard was soon applied in Canada as well.

That same year the ADA introduced a new test to determine whether people had what was described as Impaired Fasting Glucose (IFG), a tool it said would help clinicians predict who would progress to Type 2 diabetes. In other words, to help doctors diagnose people with "pre-diabetes". The threshold was initially established at between 6.1 and 6.9 mmol/L, but by 2003, that level had dropped to 5.6 mmol/L. The change in the threshold increased the number of Americans diagnosed with IFG/pre-diabetes from 3.2% of the population to 9.7%.

Again voices of doubt were heard around the world. While the European Diabetes Epidemiology Group saw value in determining IFG levels, it looked at the evidence and rejected the higher threshold. Equally important, the Europeans preferred the more descriptive term "non-diabetic hyperglycaemia", and urged the diabetes community to avoid the use of the term "pre-diabetes" when describing those with an impaired fasting glucose. The EDEG pointed out that many people who meet the threshold for non-diabetic hyperglycaemia revert to normal glucose levels in subsequent testing. In addition, they said, "there is no fixed state of pre-diabetes" and warned of the emergence of a "pandemic" if the lower thresholds were used.

The controversy over the ADA thresholds went viral, leading to heightened scrutiny of the evidence used to support not only the glucose cut-offs, but of all the various tests used to diagnose Type 2 and "pre-" diabetes. By the end of the last decade, studies were pushing the use of a test called Hemoglobin A1c (HbA1c) to diagnose Type 2 diabetes and today, for better or worse, this is the standard used internationally, along with the "diagnostic cut-point" of 6.5%. In 2010, the ADA recommended that the HbA1c be applied to diagnose "pre-diabetes" as well, at a threshold of 5.7%.

As a diagnostic tool, the A1c test has its champions and its critics, including those who argue that the much higher costs associated with it increases the burden on the health care system. In addition, usefulness in certain populations is limited. The CDA's new pharma-sponsored guidelines will be published in March 2013, and it's likely that they, too, will embrace the HbA1c to diagnose pre-diabetes regardless of the fact that this is not a medical condition. So not only is this controversial diagnostic tool being used in spite of its limited utility, it is being used to diagnose a disease that, according to the EGED, doesn't exist. We are, after all, in epidemic mode!

The diagnosis of pre-diabetes is bad news for patients and their families, most of whom have no idea about all the drama in the background. But it's also bad news for society as a whole because of the enormous costs associated with treating millions of people who do not have a medical condition. But for the pharmaceutical and diagnostic industries, it's a great turn of events — and there's little doubt that Big Pharma has influenced the lower thresholds that have been put in place.

One of the companies that is hoping to benefit from a diagnosis of "pre-diabetes" is Sanofi, one of the largest pharmaceutical companies in the world. It has just unveiled a study that says insulin glargine (brand name Lantus) can delay full-blown Type 2 diabetes in those diagnosed with being on the verge of having the real thing. It's no coincidence, of course, that glargine is a Sanofi product and one of the most expensive insulins on the market.

The emergence of "pre-diabetes", according to one marketing firm, "should be viewed as an opportunity for pharmaceutical companies and manufacturers of blood glucose meters and nutriceutical products" who can educate physicians about new treatments for the pre-disease. And it's a big market — a much bigger market than the one made up of people who already have diabetes.

One of the most aggravating myths is that Type 2 is a "lifestyle" disease, brought on by sloth, laziness and poor eating habits. But the truth is that being poor is more likely to lead to diabetes than lifestyle choices — the poorest people are 4.14 times more likely to have Type 2 diabetes than those in the highest income category. And poverty isn't something that can be treated with a drug or a medical device.

Canada needs a strategy to reduce the chances that people will develop Type 2 diabetes. Key elements of such a strategy would be poverty reduction, including among the elderly, single women, Aboriginal people and people of colour; increased public funding for education; job security; and a more equitable distribution of wealth across the population.

* This article was originally posted June 27, 2012 on PharmaWatch Canada. Thanks to guest blogger Colleen Fuller for permission to repost here.

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The diabetes crisis: health care not doing its part? *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Friday, 11 May 2012
in CHNET-Works!

I do not ordinarily write about the health care industry (and it is an industry). I decided to break this rule after reading a recent report in the Ottawa Citizen on a decision by the Champlain Local Health Integration Network (or LHIN, Ontario's version of a regional health authority) to hire two chiropodists to provide free foot care to diabetics – a service otherwise not covered by provincial health insurance, and therefore unaffordable for many. Lack of appropriate foot care was cited as one of the reasons for the region's high rate of hospitalization for diabetic foot infections, which sometimes lead to amputations.

Diabetes is not an equal-opportunity disabler. As noted in an earlier posting, a pronounced socioeconomic gradient exists in the prevalence of Type 2 diabetes, and limited incomes seriously compromise patients' ability to manage the disease effectively. This helps to explain why diabetes mortality has declined faster among higher-income patients in Ontario. But even aside from these important issues, which suggest at the very least a need to broaden insurance coverage, Ontario's health care system seems not to be doing its part. Province-wide, according to health ministry figures, as of late 2010 fewer than two out of five Ontarians with diabetes had received all three of the tests recommended for diabetes management – blood glucose every six months, cholesterol (LDL) every year, and retinal eye examination every two years – in the appropriate period. (Nationally, a clear socioeconomic gradient exists for receipt of these tests; it would be interesting to know whether the same is true in Ontario.) And a recent article by Tara Kiran and colleagues at the University of Toronto, based on Ontario Health Insurance Plan records, points out that the 2002 introduction of a new billing code specifically to reimburse physicians for diabetes management tasks had, by the end of 2008, led to only modest increases in monitoring.

This is part of a more general, Canada-wide picture. Jeffrey Turnbull, past president of the Canadian Medical Association, has pointed out that in one of the OECD's more expensive health care systems (although it's not one of the more expensive when only public spending is considered) chronic disease management is "woefully inadequate" and "Canada now ranks below Slovenia in terms of effectiveness and last or second last in terms of money spent" on health care. With specific reference to diabetes care, 2008 figures from the Commonwealth Fund show that Canada ranked far behind the Netherlands, New Zealand and the United Kingdom in the percentage of adults with diabetes who received appropriate monitoring.

Now, I am an outsider to most of the quotidian operations of health care institutions; I don't have ready answers. Health system managers seem to be proliferating, yet few signs can be found of the "new management systems and new accountabilities" that Dr. Turnbull called for. Surely it's not unreasonable to ask that health ministries and regional health authorities have routines in place to benchmark diabetes management, and myriad other health care processes, against the world's best and transform the way they do things to match the leaders' performance.

* Tara Kiran provided valuable help with research for this posting. All views expressed are exclusively my own.

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Life A.D. (After Drummond), Part 1

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 20 February 2012
in CHNET-Works!

As Ontario-based readers will know, on February 15 the Government of Ontario released a far-reaching report on reorganizing public service provision in an era of austerity. The report was the work of a small commission chaired by Don Drummond, a former public servant in the federal Department of Finance and subsequently chief economist for TD Bank. The other commission members were the President of Laurentian University (base salary $304,647 in 2010); the Vice-President for Communications and Community Engagement of the Centre for Addictions and Mental Health (base salary $245,352 in 2010); and the dean of the business school at the University of Western Ontario (base salary $405,000 in 2010). These figures are matters of public record, as they should be, and are available under the Province of Ontario's salary disclosure legislation. The point is that all members of the commission were, to put it mildly, isolated from many of the influences that limit other Ontarians' ability to lead healthy lives.

The report proposed that public spending on health care – the largest item in Ontario's budget, as in that of other provinces – should grow by 2.5 percent annually over the next several years, as compared with the recent trend of 6 percent annual growth. Slower growth was recommended for public education; just 0.5 percent for "social programs"; and spending reductions of 2.4 percent annually in all other programs. However, the 'how to' rather than the 'how much' aspects of the report's recommendations may ultimately be most significant, if implemented.

The report has already generated a flood of commentary, to which I don't propose to add right now. I'll be posting a longer analysis after my presentation at Public Health Ontario's PHO Rounds on March 2, the last part of which will deal briefly with life A.D. (After Drummond). Meanwhile, the Wellesley Institute has commented on the report's neglect of broader social determinants of health that affect the prevalence of and prognosis for conditions like diabetes (the topic of one of my earlier postings). And the Toronto Star's Thomas Walkom pointed out the bias introduced by the government's instructions to the commission not to consider tax increases, at a time when the fiscal capacity of Canadian governments has been drastically reduced, while allowing it to consider user fees that will have a disproportionate impact on low- and middle-income households.

Walkom also pointed out the lack of attention to the employment impacts of a plan to take billions of dollars out of the Ontario economy by way of public spending cuts – indicative of a broader trend in which employment has all but vanished from the public policy agenda except when governments want to trot out the 'job creation' benefits of handouts to one or another corporate client. He predicts that implementation of the Drummond recommendation would lead to an Ontario unemployment rate of 11 percent by 2018, "even without another global crisis". Abundant evidence shows that not only unemployment rates but also the conditions of employment – full-time and secure versus precarious, casualized or entirely informal – and their effects on working conditions are key social determinants of health, so this is a point of some importance. (An aside to readers: would a future posting expanding on this evidence be of any interest?)

As pointed out by (among others) economist Erin Weir of the United Steelworkers, there is quite a bit in the report that those of us committed to social justice can support. There is also quite a bit that might be compatible with a "health in all policies" agenda, and with advancing health equity. Where will the public health community be as debates about the report continue in the coming weeks? How prominently, if at all, will population health and health equity figure in the discussions? Does the public health community, however defined, have an organizational platform capable of rapid, critical and effective response to events in the broader public policy environment? If not, it's high time we did.

Diabetes in Canada: Parts of the story

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 04 January 2012
in CHNET-Works!

Shortly before this past Christmas, with minimal publicity, the Public Health Agency of Canada released a valuable collection of facts and figures on Diabetes in Canada. It points out (for instance) that in the decade after 1998/99, the prevalence of diabetes among Canadians increased by 70 percent (to 2.4 million), with a predicted increase in prevalence to 3.7 million by 2018/19. Further, "although only 3.1% of all deaths in Canada were attributed to diabetes in 2007, more than a quarter (29.9% of individuals who died had diabetes in 2008/09. Diabetes itself does not typically lead directly to death, but the complications associated with diabetes do." Thus, prevalence figures substantially understate its overall contribution to the burden of illness borne by Canadians; that contribution includes cardiovascular disease (the most frequent complication), eye disease, kidney disease, increased infection from minor injuries and a variety of other conditions.

Diabetes-posting-pic-1Healthy food choices: not always availableThe report's importance in drawing attention to the magnitude of the diabetes-related burden of illness is beyond question, yet its contribution to understanding that burden from a health equity perspective is limited. For the most part the authors adopt a conventional risk factor approach to the causes of diabetes, starting (predictably and non-controversially) with a description of overweight and obesity, and the contributions of limited physical activity and unhealthy eating. A list of self-reported barriers to physical activity is reproduced, as is a list of factors influencing food choices that includes nutritional knowledge, perceptions of healthy eating, media advertising and "lower socio-economic status and social inequity," which is not further explored.

The report's treatment of socioeconomic gradients is similarly descriptive, confined to gradients among adult Canadians across Canada, stated by income quintile and education level, in self-reported obesity, physical inactivity, inadequate fruit and vegetable consumption, and daily tobacco smoking. Curiously, data on socioeconomic gradients in actual prevalence of diabetes are not presented, although according to Canadian Community Health Survey data prevalence of Type 2 diabetes in the lowest household income group (income less than $15,000) is more than four times as high as in the highest income group (over $80,000). According to the authors of this last study, "individual risk behaviours do not explain a substantial part of the income association," suggesting "that the diabetes burden associated with poor health behaviours should be looked at through the lens of socioeconomic conditions."

Diabetes-map-1Age- and sex-adjusted diabetes prevalence per 100 persons of all ages, Toronto, 2001-02. Source: Booth GL, Creatore MI, Gozdyra P, Glazier RH. Diabetes in Toronto, Chapter 2: Patterns of Diabetes Prevalence, Complications and Risk Factors. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.


Diabetes-map-2Average annual household income, Toronto, 2000. Source: Creatore MI, Gozdyra P, Booth GL, Ross K, Glazier RH. Diabetes in Toronto, Chapter 3: Socioeconomic Status and Diabetes. Toronto: Institute for Clinical and Evaluative Sciences; 2007. Reproduced by permission.

Finer-grained examinations of how socioeconomic conditions affect the origin, management and prognosis of diabetes can be found in several places. The Toronto diabetes atlas project of the Institute for Clinical Evaluative Sciences produced a multi-volume mapping of diabetes prevalence and a range of neighbourhood characteristics; just two of the 140 maps generated by the project are shown here. To oversimplify a complex set of findings, the project found that higher-income neighbourhoods generally had lower prevalence of diabetes. Prevalence was especially high in low-income neighbourhoods outside the downtown core, with high proportions of recent immigrants and members of recent minority groups. These neighbourhoods tended to have lower population densities, poor walkability, limited access to public transit and long distances to stores selling fresh fruits and vegetables (the 'food desert' problem) and other so-called healthy resources like parks. Conversely, high incomes seemed to have a protective effect against diabetes, even in neighbourhoods where adverse outcomes would be expected based on place-related characteristics. "We noted a striking mismatch," the authors concluded, "between areas of Toronto where healthy resources were most needed and where they were located."

Diabetes-posting-pic-2Activity-friendly urban environments like this may be inaccessible to people in low-income neighourhoodsThere is also, as I have pointed out in previous postings, the simple arithmetic impossibility of eating a healthy diet for many people living on low incomes if they are also paying market prices for housing. Indeed, a series of interviews by York University's Dennis Raphael and colleagues (1) with people trying to manage diabetes in Toronto on incomes below Statistics Canada's Low-Income Cutoff (LICO) found food insecurity and inability to afford an adequate diet widespread "even with almost two-thirds [of participants] living in some form of government-assisted housing or shelter." Two recent articles (2,3) by Claudia Chaufan and colleagues similarly explore the interaction of low incomes, limited availability (and high local prices) of healthy food, high transportation costs and other variables like insecure employment in a Latino and immigrant neighbourhood in Northern California, concluding that structural factors limit the relevance of health and lifestyle education interventions – a point that should by now be familiar, but nevertheless merits continued repetition. One interview respondent summed up the range of problems: "You know, it's a full time job to be poor."

Variables like those identified in the Toronto and Northern California studies are not prominent in the PHAC report, beyond brief generic discussion of healthy food choices and of the built environment. New York-based researchers Rodrick and Deborah Wallace have eloquently compared individualized explanations of obesity that focus on imbalance between caloric intake and exercise to "the remark by US President Calvin Coolidge on the eve of the Great Depression that 'unemployment occurs when large numbers of people are out of work' ... and as Raphael pointed out in a holiday posting on his Social Determinants of Health listserv, the word "poverty" appears nowhere in the PHAC report. (I checked; it doesn't.) That report remains useful, yet at the same time shows how very much still needs to be done to integrate social justice and social determinants into the everyday worldview of public health professionals.


(1) Raphael D, Daiski I, Pilkington B, Bryant T, Dinca-Panaitescu D, Dinca-Panaitescu S. A toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics: the experiences of poor Canadians with Type 2 diabetes. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

(2) The Twin Epidemics of Poverty and Diabetes: Understanding Diabetes Disparities in a Low-Income Latino and Immigrant Neighborhood. Journal of Community Health 2011;36:1032-43, (full text unfortunately not available for open access).

(3) Chaufan C, Constantino S, Davis M. 'It's a full time job being poor': understanding barriers to diabetes prevention in immigrant communities in the USA. Critical Public Health 2011 [online publication] (full text unfortunately not available for open access).

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