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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Thursday, September 25, 2003

0905

The Vice-Chair (Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ))

0915

Ms. Leslie MacLean (Acting Director General, Non-Insured Health Benefits Program, First Nations and Inuit Health Branch, Department of Health)

0920

0925

0930

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

Ms. Susan Fletcher

0935

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Merrifield

Ms. Leslie MacLean

The Vice-Chair (Mr. Réal Ménard)

Mr. Gilbert Barrette (Témiscamingue, Lib.)

0940

Ms. Leslie MacLean

Mr. Gilbert Barrette

Ms. Leslie MacLean

Mr. Gilbert Barrette

Ms. Leslie MacLean

The Vice-Chair (Mr. Réal Ménard)

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.)

The Vice-Chair (Mr. Réal Ménard)

Mr. Stan Dromisky

Ms. Leslie MacLean

0945

Mr. Stan Dromisky

Ms. Leslie MacLean

Mr. Stan Dromisky

Ms. Leslie MacLean

Mr. Stan Dromisky

Ms. Leslie MacLean

Mr. Stan Dromisky

Ms. Leslie MacLean

0950

Mr. Stan Dromisky

Ms. Leslie MacLean

Mr. Stan Dromisky

The Vice-Chair (Mr. Réal Ménard)

Ms. Hélène Scherrer (Louis-Hébert, Lib.)

Ms. Leslie MacLean

Ms. Hélène Scherrer

Ms. Leslie MacLean

0955

Ms. Hélène Scherrer

Ms. Leslie MacLean

The Vice-Chair (Mr. Réal Ménard)

Mr. Rob Merrifield

Ms. Leslie MacLean

Mr. Rob Merrifield

Ms. Leslie MacLean

1000

Mr. Rob Merrifield

The Vice-Chair (Mr. Réal Ménard)

Ms. Carolyn Bennett (St. Paul's, Lib.)

Ms. Leslie MacLean

Ms. Carolyn Bennett

Ms. Leslie MacLean

Ms. Carolyn Bennett

Ms. Leslie MacLean

1005

Ms. Carolyn Bennett

Ms. Leslie MacLean

Ms. Carolyn Bennett

Ms. Leslie MacLean

The Vice-Chair (Mr. Réal Ménard)

1010

The Chair (Ms. Bonnie Brown (Oakville, Lib.))

Mr. Claude Rocan (Director General, Centre for Healthy Human Development, Population and Public Health Branch, Department of Health)

Mr. Felix Li (Director, Chronic Disease Control and Management Division, Office of Public Security, Centre for Emergency Preparedness and Response, Population and Public Health Branch, Department of Health)

1015

1020

Mr. Claude Rocan

Ms. Louise Plouffe (Manager, Knowledge Development, Division of Aging and Seniors, Department of Health)

1025

The Chair

Ms. Louise Plouffe

The Chair

Mr. Rob Merrifield

Mr. Claude Rocan

Mr. Rob Merrifield

Mr. Claude Rocan

Mr. Rob Merrifield

Ms. Louise Plouffe

Mr. Rob Merrifield

1030

Ms. Louise Plouffe

Mr. Rob Merrifield

Ms. Louise Plouffe

Mr. Rob Merrifield

Ms. Louise Plouffe

Mr. Rob Merrifield

Ms. Louise Plouffe

Mr. Rob Merrifield

Ms. Louise Plouffe

Mr. Rob Merrifield

Ms. Louise Plouffe

Mr. Rob Merrifield

The Chair

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.)

Mr. Claude Rocan

Mr. Jeannot Castonguay

Mr. Claude Rocan

Ms. Louise Plouffe

Mr. Claude Rocan

Mr. Jeannot Castonguay

1035

Mr. Claude Rocan

Mr. Jeannot Castonguay

Mr. Claude Rocan

Ms. Louise Plouffe

Mr. Jeannot Castonguay

Ms. Louise Plouffe

Mr. Jeannot Castonguay

Ms. Louise Plouffe

Mr. Claude Rocan

Mr. Jeannot Castonguay

Mr. Claude Rocan

Mr. Jeannot Castonguay

The Chair

Ms. Carolyn Bennett

1040

Ms. Louise Plouffe

Ms. Carolyn Bennett

Ms. Louise Plouffe

Ms. Carolyn Bennett

Mr. Felix Li

1045

Ms. Carolyn Bennett

Mr. Felix Li

Mr. Gilbert Barrette

Mr. Claude Rocan

Mr. Gilbert Barrette

Mr. Claude Rocan

Ms. Louise Plouffe

Mr. Gilbert Barrette

The Chair

Ms. Hélène Scherrer

1050

Mr. Claude Rocan

Ms. Hélène Scherrer

The Chair

Mr. Jeannot Castonguay

Mr. Claude Rocan

1055

Mr. Jeannot Castonguay

Mr. Claude Rocan

The Chair

CANADA

Standing Committee on Health

NUMBER 047

2nd SESSION

37th PARLIAMENT

EVIDENCE

Thursday, September 25, 2003

[Recorded by Electronic Apparatus]

¿ (0905)

[Translation]

The Vice-Chair (Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ)): I see we have a quorum. Good morning, everyone. We will get our meeting underway. Our witnesses this morning are from Health Canada. I do not know which of you would like to make the first presentation. You have the floor.

¿ (0915)

Ms. Leslie MacLean (Acting Director General, Non-Insured Health Benefits Program, First Nations and Inuit Health Branch, Department of Health): Thank you, Susan.

Good morning, and thank you for inviting us to appear before you. I will be making most of my remarks in English, but of course I will do my best to respond in French.

[English]

The non-insured health benefits program is one of the largest health programs in the country. It is the largest federal program of health to individuals, and I think we're fourth or fifth in size in the country. I thought it would be helpful for members to see the overall expenditures for the program, so as to realize, as my colleague Susan pointed out, we're spending the largest amount in pharmacy for this program. The next largest component is transportation, at $200 million, and then dental, which has already been the subject of study by this committee.

We thought it might be helpful in talking about this program to first talk to the common challenges in managing prescription drug costs that are faced by all drug programs here in Canada, by provinces, territories, or other federal jurisdictions, many of which are common in the international scene as well, as I'm sure you're already beginning to discover with your inquiry. So on the next page you have these common challenges in controlling prescription drug costs. If I could summarize them as a lay person, they are the number of people using your program and the service cost. There are two parts of how much the service costs. One is how much the individual prescription drugs cost, and then how much you are paying in professional fees, the service component of cost.

You'll see here clearly that internationally, more people are using drugs, and drugs are being used for more and more purposes, to shorten hospital stays, for outpatient treatments, and then there is the ongoing discovery of new drugs to treat illnesses that in the past we didn't have drugs for, like hepatitis C. But I think the hardest part of the common challenge list is that public programs are dealing with finite resources. In private health plans, as we know, there are a number of tools private plans use to control costs that are not generally used by public programs.

Before we talk about how we, as a program in non-insured, do our best to manage costs efficiently and deliver services effectively to people, it might be helpful to look at some of the unique challenges for the non-insured program. My colleague Susan has already spoken to the effect of the population growth, and that's one of the largest contributors to our increasing costs. I should point out that in our pharmacy program costs went up by more than 14 1/2% last year. So although we're constantly comparing ourselves with other jurisdictions and doing our best to work with our colleagues to learn from the ways they're managing costs, this is a very big challenge for us. Our population growth was one of the big contributors to that 14 1/2% increase. With our population base expanding at more than twice the rate of the rest of the population, clearly, the number of people eligible to use our program continues to grow.

The other large contributor, of course, is the fee component. We negotiated some new fees last year in a couple of our larger client populations, Alberta and Manitoba, if I've got that right. But some of the other factors that are unique to our program are our people and where they live. Very simply, we have quite a young population, and we've already talked about that disease burden. So even those with a chronic disease like diabetes may end up with an early onset in this first nations and Inuit population, and that has a corresponding effect on the drugs used to treat that condition. Half of the clients of this program live on reserve. As members of the committee would know, a large proportion of those communities are in rural or remote parts of Canada, where access is limited. So we have challenges that sometimes we have to overcome by paying, for example, to have drugs shipped into a nursing station or using mail order drugs. Those are all components.

The last thing I would point out that's a challenge for us is the reality that although we do our best to fix our prices and interchangeabilities for generics to the provincial and the territorial norm, we are working in 13 separate jurisdictions. So our challenge is to keep our formulary appropriate for the professional judgment of pharmacists in any jurisdiction.

So if you look at the range of factors that drive costs, clearly, it's very difficult for us as a program to control those drivers, very challenging to manage those costs. We have limited tools at our disposal to manage those factors. So how do we deliver the program?

¿ (0920)

[Translation]

How do we deliver the program? At the moment, pharmaceutical services are delivered throughout Canada by pharmacists who use an electronic system. We should make it clear that the potential client base is large—approximately 700,000 individuals—and almost 500,000 people use the program. That means that between 9 and 10 million transactions are carried out each year. Everything is done automatically, by electronic means.

[English]

So the challenge in that huge volume of business is maintaining our focus on health outcomes and on cost-effective drug therapies.

I want to also draw committee members' attention to the many things we pay for through the pharmacy program, and I have two sets of information for you. The next slide shows you that of the almost $300 million we spent on pharmacy goods last fiscal year about three-quarters was for actual prescription drugs, which I understand to be the focus of this committee. Another signification proportion, over 10%, went for over-the-counter medications, everything from aspirin to antihistamines. Another chunk was for medical supplies and equipment. Here I want to point out to committee members that the focus of this program is on health. For example, for diabetics we offer not just the insulin, but also the glucometers, the insulin testing kits. Those are all services covered by our pharmacy program.

I also thought, given the questions the committee has had, it would be helpful for you to see how those expenditures break out by class of medication. I know that medications in the central nervous system class have been of interest to the committee. You see that 30% of the drugs provided are for those, and you would be aware that covers the range of medications, antidepressants or antipsychotics to treat schizophrenia, but also other medications, like anticonvulsants for people with epilepsy, narcotics for people who have cancer or other kinds of chronic pain, anti-inflammatories, treatments for migraines. It's a very large class of medications. The only other drug class to which I would draw your attention is the hormone one, at 13%, which is for insulin and other products used to treat diabetes.

I would just point out to you the obvious connection between the nature of the population and the use of medications. Despite that, our understanding is that this is a relatively comparable profile for the age distribution of our client group, remembering again that it is a relatively young population, but that chronic onset happens a bit faster for some of those chronic conditions. We would look forward to any findings the committee could offer us in your examination of other drug programs.

You were also interested, we understood, in regional trends, so I'll take you to the next page, where we do show our per capita pharmacy expenditure. As you know, explaining regional differences in health programs is always very complex. There are a number of factors, such as provincial practice. There is obviously physician and pharmacist practice that contributes to that. We've already talked about the professional fees. Geography and isolation also drive costs.

I would draw your attention to Alberta and Quebec, which do have the highest per capita expenditures in our program. My understanding is that in those two regions it is principally related to the dispensing arrangements we have with pharmacists, how mark-ups are calculated in Alberta and how in Quebec prescriptions are dispensed in what are called dosettes, in controlled quantities, and those do drive costs for us.

The next slide, on program management, has a great deal of information, and there are two or three areas the committee may wish to come back to in questioning. We can expand at that time. Very simply, our goal in managing this very large and important program is to get the best efficiency and effectiveness we can to improve health for clients. That means we have a drug-benefit list of over 20,000 drugs that we review on an ongoing basis. Four times a year we publish changes to that. For example, we've just completed a quite thorough review of our over-the-counter medication area and added and subtracted some medications to maximize our cost-efficacy ratios and to make sure we're taking things off that could have a negative effect on people's safety. We're similarly looking at our whole range of prescription drugs with a similar focus, going back and requestioning our cost efficacy and making sure we have things on that contribute to people's health. We also will be benefiting from the new Canadian expert drug advisory committee that's being set up. That's one of the things I can come back and talk about later if that's of interest to members.

¿ (0925)

Clearly, a key challenge for us in managing the program is appropriate use of medication. We do that in two ways. Those millions of transactions a year are done in an electronic real time environment, which means that if there's an issue like a drug allergy, a drug interaction, or too frequent refill, the pharmacist will immediately receive a message. At that point, the pharmacist may talk to the client or the physician--in short, make sure they're using their professional judgment before dispensing. If they choose to dispense, they have to enter an override code and justify in a document why they have overridden the warning message in the system.

I know there were recommendations from both the Auditor General and the public accounts committee on how we monitor use. That's another area in which we'd welcome the opportunity to come back and update you in more detail. We're prepared to do that today, if you wish. I'm just flying through the presentation.

On how the program operates, we've spoken to its size. You should know we have a drug exception centre that performs two functions. It helps us control costs by challenging some of those drugs that are quite expensive, but it also limits access where we're concerned about potential side effects.

We have two different classes of things that go through the drug exception centre. There are limited-use benefit drugs, where the criteria are published as part of our drug benefit list. Those are things where we're concerned about quite serious potential for negative side effects, or quite expensive drugs, in which case we want to have a challenge function. We also have exceptions, and those are done on a case-by-case basis. I'm sure committee members are familiar with our annual report, which I think has been provided to you before. All the volume statistics and turnaround times on the work of the drug exception centre are in that. I'll be happy to speak to those, if you wish.

On provider relations, given that we're delivering this program through thousands of pharmacies, working well with the pharmacists is critical to effective and efficient delivery of the program. We're just setting up a joint working group with the Pharmacists Association on audits. We have ongoing negotiations and liaison with provincial and territorial pharmacy associations. Of course, subsequent to the Auditor General recommendations, we got Ernst & Young to help us design our audit program. We perform at least 80 audits a year. Again, that's all in the annual report for your information.

Obviously we can't deliver the program alone, so there's collaboration with other federal departments through, for example, the health care coordination initiative. That enables us to work with other federal departments to try to purchase collectively for those federal programs like veterans, national defence, or the RCMP. We also participate in a number of federal and provincial and territorial initiatives. I think people have already spoken to you about two new initiatives around improving information about the utilization of prescription drugs, and a best practices initiative.

The other thing on this page I would offer to come back to, at members' discretion, is the very detailed work we're just re-launching around drug utilization reviews. We're setting up an independent advisory committee, with first nations and Inuit representation, to guide our work in setting up the industry protocols on how we'll go back to profile data to make sure we're using drugs appropriately. For example, we don't want physicians to prescribe what are called second-line antibiotics, instead of beginning with the first-line antibiotics. Clearly, issues around antibiotic resistance are of concern to all populations using drugs.

When you're dealing with such a large health program, appropriately protecting people's personal health information is critical. When we appeared before you on another matter earlier in the spring, the issues around consent and protection of people's private health information were examined by you. You made a number of recommendations around the consent initiative, one of which was to extend the deadline.

As members of the committee are aware, the minister has extended the consent guidelines from September 1 to March 1. The key focus there is to give us the opportunity to continue the collaborative work with first nations and Inuit to address their concerns around the appropriate use of health information, the appropriate protection, and to make sure people are comfortable authorizing Health Canada to collect, use, and share their personal health information, in a very limited and constrained way, to effectively manage the program. As you know, patient safety remains a key concern for this program, and consent is important in our ability to help contribute to that.

In summary, managing this program and its effective and efficient delivery and containing costs remain big challenges for the program. We continue to have a focus on health. This is not a program that simply pays bills; it's meant to be a program that contributes to people's health. Despite that, we also need to live within our means.

Finally, for the branch as a whole, our emphasis remains on promotion and prevention initiatives as a way of controlling or even preventing prescription drug costs. We remain very keenly interested in all opportunities to work with our various stakeholders to deliver our programs effectively. We look forward to the committee's recommendations. As you go across the country, any advice and information you're able to gain on controlling regional variations will be helpful to us in our delivery.

Merci beaucoup.

¿ (0930)

[Translation]

The Vice-Chair (Mr. Réal Ménard): We will now move to the question and answer period. I will now give the floor to Mr. Merrifield, from the Canadian Alliance.

[English]

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you for coming in. You're actually in an interesting position because of having this pharmaceutical program nationally for a specific group of individuals. Hopefully, we can learn some things from you that perhaps can be applied across the country.

Before we get into that, can you give us an update on how you're doing with the consent and privacy issue we had some problems with, the dentists review this spring? Is that proceeding? Are you getting compliance or not?

Ms. Leslie MacLean: As members of the committee will remember, this was an initiative to help us catch up with other programs, in circumstances where people have signed forms when they applied for the program, either because they're an employee or because they've signed up with Sun Life or some other commercial company. As you will remember, at the time it was to make sure that clients knew that we were collecting their information to deliver the program and that we needed to share it to protect their safety.

We have been continuing to work; people have been continuing to sign forms. I think over 115,000 people have signed individual consent forms to the collection, use, and sharing of their health information on a very limited basis. We're continuing to work quite closely with the AFN, both at the national level with the secretariat and with regional first nations organizations across the country. Similarly, we've been working closely with the ITK and we're looking at working with their regional associations as well.

To sum up, we're continuing to work quite hard. The committee encouraged us to do our best to be flexible and to be clear with people about what we were up to and why, and we've been doing our best to make that happen.

Mr. Rob Merrifield: Okay.

What percentage are you at right now?

Ms. Leslie MacLean: If you think of our eligible client population, it's about 735,000. In any given year, of course, not all clients access our program. The pharmacy program is actually the program that's used by most people; it's used by almost 70% of people. So in any year about 465,000 people use that largest program. I would think we definitely need a few more hundred thousand people to have signed forms by March 1 to enable us to be able to continue to deliver service in that uninterrupted way. So we do have more work to do.

Mr. Rob Merrifield: You're much under 20% right now.

Ms. Leslie MacLean: Yes.

Mr. Rob Merrifield: Are you going to make it by March 1?

Ms. Leslie MacLean: We'll certainly do our best to do so, yes.

Mr. Rob Merrifield: Good luck.

Ms. Leslie MacLean: Thank you.

Mr. Rob Merrifield: Can you give us some stats on...? You said that prescription medication--maybe you went through this quickly enough that I didn't catch it quite right. I think you said 7% asked for help with regard to addiction to prescription medication. Is that the number you used?

Ms. Leslie MacLean: That's correct.

Mr. Rob Merrifield: You said that's comparable to the general population.

Ms. Leslie MacLean: I said 7% presented to our treatment centres because of difficulties with prescription medication. What I said was that that number of people with prescription drug issues is comparable in our population, I understand, to the general population.

Ms. Susan Fletcher: Can you speak to that--

¿ (0935)

Mr. Rob Merrifield: So those are the ones who are asking for help. It doesn't necessarily mean, in even the general population or the native population, that those are the only ones who have a problem.

Ms. Leslie MacLean: The study--I'll provide the researchers with a copy--was done in the year 2000 in British Columbia and looked at the utilization of acetaminophen with codeine and benzodiazepines, which are painkillers, in first nations populations and in non-first-nations populations.

There were some excessive users. However, their findings were that the use among first nations recipients of the program were within the same bounds as the non-first-nations populations in the study group. I will provide the coordinates of that to the researchers, so you can look at the study in more detail.

Mr. Rob Merrifield: It may not tell us much. We may have as significant a problem throughout the general population as we do in the native population.

Ms. Leslie MacLean: As I understand the study, quite frankly, that is the key finding, that there is not a disproportionate addiction issue in the first nations Inuit population as compared with that of the general Canadian population. But as you say, that does not mean there are not issues and concerns.

Mr. Rob Merrifield: Do you have any stats on how many deaths are attributed to addiction to medications?

Ms. Leslie MacLean: That was a question raised, I believe, in a previous public accounts committee, and it was, as I understand it, a recommendation of the Auditor General that we endeavour to track that. However, one of the principles of privacy is around the exchanging of information between jurisdictions. So very simply, we don't know how provinces or territories record deaths due to prescription drug use, nor is that information reported back to us.

I'm sorry to give you such a long way of saying that, despite those recommendations by the Auditor General. We did pursue that with our provincial counterparts to see if there were ways we could gather that information, and, very simply, our understanding of privacy legislation is that even if provinces or territories were tracking that in a systematic way, there are bars against them sharing that information with us.

[Translation]

The Vice-Chair (Mr. Réal Ménard): You have six minutes, Mr. Merrifield. You may ask one final question.

[English]

Mr. Rob Merrifield: Okay.

That's a real shame, because therein lies the whole rationale behind our study. We've talked to coroners who are telling us that maybe Mrs. Jones died because of suicide or had a car accident, but when you really look at the medications she was on, or look a little deeper, you find there was a significant problem with addiction to prescription medications.

You're saying that you can't follow up because of privacy. We're not asking for Mrs. Jones' name. We're looking for general stats so we know how severe a problem we have. It's really a shame. The Auditor General has instructed you to do this. How far along are you, and what are your timelines on getting that information?

Ms. Leslie MacLean: In responding to the question and to the Auditor General's recommendation, which, if I'm not mistaken, is from 1997, we did work with the provincial and territorial jurisdictions. I think one of the initiatives that's coming from the common drug review is the system that I think one of our colleagues from Health Canada talked to you about, the national prescription utilization drug information system. That should help provinces and territories become more consistent, I hope, in tracking this sort of information.

You're absolutely right that we have and can explore ways with our colleagues to get the information without breaching privacy. Our largest challenge, though, in my understanding, is that there is not consistency in terms of how that's actually reported or tracked at the provincial or territorial level.

So as you move across the country, if that could be one of the questions we could have advice or help with, we would welcome it.

[Translation]

The Vice-Chair (Mr. Réal Ménard): You have now had eight minutes, Mr. Merrifield. We will come back to you on the second round.

Please proceed, Mr. Barrette.

Mr. Gilbert Barrette (Témiscamingue, Lib.): Good morning.

I have a few brief questions for you. I'm very interested in the subject, because there are four reserves in my riding and people living off reserve as well. That may be similar to other parts of the country. Do you get complaints about the accessibility of these services from people eligible for them, either on reserve or off reserve?

¿ (0940)

Ms. Leslie MacLean: In some cases, access to the services can be tremendously difficult, particularly for people who live in remote areas, far from urban centres. However, it is very clear that our services are provided wherever the client lives, whether on reserve or off reserve. Sometimes there are problems with access, and that is why we occasionally have to use other approaches, such as delivering drugs by mail. We do our best, with the help of the pharmacists, to overcome these delivery problems, but they are a challenge everywhere.

Mr. Gilbert Barrette: Thank you.

I would now like to ask a question about drug use. I'm sure you have some studies on drug use by people living on and off reserve for the aboriginal first nations, or Inuit communities, but particularly the aboriginal community. I'm sure you have information as well comparing drug use by the aboriginal population and the non-aboriginal population living in the area around the reserve. I'm sure you have figures on that.

Ms. Leslie MacLean: No, because we do not check on the residence of individuals using our services. Consequently, since we do not keep the addresses of our clients, we have no way of determining whether the individual receiving the drug lives on a reserve or lives in Montreal. We have no way of making this type of comparison nor do we have any access to detailed data from the provinces or territories. Consequently, we cannot make the two comparisons you mention in your question, because of the way we keep our client data and the lack of information-sharing between the jurisdictions. Confidentiality must always be ensured, and as a result, we do not share data on individuals.

Mr. Gilbert Barrette: I have one last question. You seem to be saying that it would be difficult to determine whether there is a drug abuse or other problem in a particular community.

Ms. Leslie MacLean: You are right that it would be difficult to make such an analysis. Sometimes, we can do some analyses by service point. For example, as was mentioned earlier, we do careful audits, and when we see a trend such as a drop or an increase in drug use at one service point, namely a pharmacy, we can look into what is happening in this location. At the moment, however, we do not have the data we need to make an in-depth analysis comparing on and off reserve communities.

The Vice-Chair (Mr. Réal Ménard): You have the floor, Mr. Dromisky.

[English]

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.): Thank you very much, Mr. Chairman. I apologize for being late. I waited 45 minutes for a taxi. It never arrived, so the Minister of Health came and gave me a ride to the West Block. Isn't that nice? It was really nice. Thank you very much.

[Translation]

The Vice-Chair (Mr. Réal Ménard): That comes under provincial jurisdiction.

[English]

Mr. Stan Dromisky: Your presentation has been excellent so far, clear, distinct, and right on point.

Let's go back to the question of overloads. I'm wondering if there's any information regarding whether this is a regional problem. Is it more evident in some regions of the country than in other areas of the country? Is it more evident in certain provinces than in other provinces? I'm not too sure.

The practice of doctors in my area is that after two or three renewals of a prescribed drug, they insist that you come back to the clinic and be re-examined before you continue with your drugs. Is that a common practice across the country? Or is that in one province or two?

Can you respond to those two questions before I go on?

Ms. Leslie MacLean: Yes.

As you point out, the provision of services under this program is very complex, because individual physician prescribing practice is one part of that, and individual pharmacy dispensing practice is another part of that. When most of us go into our pharmacist, we are used to having that automatic check for allergies or drug interactions, that sort of thing.

We have in the electronic system that I talked about some norms established so that if someone suddenly seems to be getting a large quantity of a drug they will reach a checkpoint where they need to get prior approval for more of that particular drug. So you're right, physicians across the country are working to make sure they're verifying ongoing use. Of course, the colleges are a large part of supporting that work, as are the professional associations. Similarly, pharmacists are setting professional standards in their provinces or territories.

I apologize if I've been long-winded in answering, but, in short, that initiative should be taking place across the country. What we can do in our program is set those maximums so that if prescribers or pharmacists aren't perhaps up to date with the latest ways to check appropriateness, that's a way we can build a check into our system. At that point someone would have to come to our drug exception centre and get prior approval, because they're exceeding what would be a normal quantity of a drug over a normal period of time.

¿ (0945)

Mr. Stan Dromisky: All right.

I'm assuming something here in light of what you've said. If Mrs. A is taking drugs and she has six different doctors prescribing that same drug and the doctors don't know this is happening, do you know it's happening? Are you telling me that you have that information now about that one particular patient, but the doctors don't have it?

Ms. Leslie MacLean: You're right at the heart of a very important issue, the consent issue that we spoke to you about in April. Yes, we do have that information for any prescriptions that are paid for under our program. That's where the pharmacist would get that warning message I spoke to you about earlier, which would suggest many, many refills or too-soon refills.

That's where the professional judgment of the pharmacist comes in, to intervene and to try to find out what's going on, to see if someone has indeed lost their prescription or if they are indeed visiting multiple prescriptions.

That's also part of how we are not at liberty without client consent to share that information with pharmacists or physicians right now. It's one of the many reasons why we've been working hard to put the consent initiative in place. The legal advice we have is that we are not at liberty to share that information with the individual pharmacist or doctor until we have the client's consent to do that.

Mr. Stan Dromisky: Oh.

Ms. Leslie MacLean: That's a very important challenge for us as a program. We're limited to what we can do in the real-time electronic world: popping up a message that says “too soon refill”. That's the point at which the pharmacist's professionalism in talking to the client and talking to the prescribing doctor is very important.

Mr. Stan Dromisky: This next question contains information, Mr. Chairman. Some drugstores, when you get a prescription, will give you a printout listing the characteristics of the drug, what it should be doing, and then some of the things people should be aware of—allergies, or whatever kind of reaction they might get about which they should notify the doctor immediately. Is that a common practice? Is it legislated? I'm just wondering if it's happening all across the country.

Ms. Leslie MacLean: My understanding is that pharmacists' associations across the country are applying those industry standards around drug-to-drug interactions or allergies, tracking for clients who get prescriptions filled at their pharmacy.

Mr. Stan Dromisky: That's a fairly new practice in the history of this country; it's not something that has been going on for 20, 30, 40, or 50 years. I'm wondering if it's having an impact. Has it had any noticeable effect on the use of certain drugs within the country?

Ms. Leslie MacLean: I can't comment on that, but I wonder if that isn't actually something where the advent of technology has not helped us make enormous improvement. In the past, if one went into the pharmacy, your pharmacist would have the list of medications you were on and would be able to check for things like adverse drug reaction or allergies and things like that, because he or she would have your file. Now that we have technology, not only can that happen automatically because of the industry standards that are in their electronic filling system, but they're also able to, as you point out, provide that important education to all of us as consumers.

I can't comment on what effect it might be having on all of us as consumers. I know I always read my warnings—

¿ (0950)

Mr. Stan Dromisky: I do too.

Ms. Leslie MacLean: —and my assumption is that many others do as well.

Mr. Stan Dromisky: Thank you very much.

[Translation]

The Vice-Chair (Mr. Réal Ménard): You have the floor, Ms. Scherrer.

Ms. Hélène Scherrer (Louis-Hébert, Lib.): Thank you very much, Mr. Chairman.

I would like to come back to the three charts you presented to us this morning, which I find quite revealing. I would like you to comment on each of these charts, including the one on the per capita expenditures for the pharmacy program. I was wondering whether you could compare the figures, not for people living on and off reserve, but rather for members of first nations communities and other Canadians.

I know that some geographic factors have an impact on expenditures, but I would like to know whether the figures are comparable. I think the charts tell us a great deal about certain things. For example, the chart on the distribution of expenditures shows that prescription drugs are heavily used compared to over the counter medication. Is the same true in urban communities, or is there really a significant difference?

The same is true of drug expenditures by therapeutic class. Is there a significant difference between the figures for first nations communities and other Canadians?

Ms. Leslie MacLean: I will do my best to answer your questions. I would like to start by speaking about the expenditures by region, on page 17. When we look at expenditures by province and territory, we must always bear in mind that these comparisons are sometimes very limited. As we mentioned earlier, this population is relatively young. Consequently, comparing people covered by the programs in British Columbia and New Brunswick, for example, is rather like comparing apples and oranges.

I do not have this information with me today, but I think we can try to get it for committee members. If you prefer, this could be one of the things you look at as you travel across the country.

Ms. Hélène Scherrer: I would like you to answer another question. We see here that there is a breakdown by province as well. Since there are figures for each province, perhaps it would be possible to make a comparison. I would just like to know whether the first nation communities really have higher drug use than the rest of the population. When we look at the figures, the expenditure seems horrendous, but if we had a comparable figure for urban residents, we might find that the difference was not all that significant. If there really is a substantial difference between the provinces, we should perhaps be asking some questions about this.

The same is true of the other charts. Since we are trying to compare apples to apples, we can make some comparisons. In Quebec, where there are a number of off-reserve people, it might be possible to do a comparison, in light of the fact that in areas such as Mr. Barrette's riding, which is very remote, non-aboriginal people must have the same access problems. Consequently, it probably would be possible to make some comparisons.

This would be interesting because we often hear that drugs are overused, and that this is terrible and there is no check on this problem. Either there is not a significant difference, in which case we will allay many fears, or there really is a major difference, and then we will have to try to work with this problem. I would like you to tell me more about the other two charts, please.

Ms. Leslie MacLean: In answer to your colleague's question, the difference between rural and urban populations is also a difficult issue. Postal codes for areas where services are provided can be used, however, as was already mentioned, where drugs are concerned, many of our services to very isolated communities are provided by post. That is why comparisons may not be accurate. I will have to consult further and do more research in order to determine whether or not we can obtain valid data that will distinguish between urban and rural areas. We also need to determine whether or not we're comparing apples with apples, in the case of drug groupings.

From what I understand from the comparisons that have already been made, rates between classes are relatively normal for any one age group. However, as I already mentioned, our program is unique in that the population is very young, with chronic diseases beginning early on in life. This makes comparisons difficult. We would be quite happy to send you any comparative material if we have valid data.

¿ (0955)

Ms. Hélène Scherrer: Your graph displaying the use of prescription drugs by therapeutic class can certainly provide Health Canada with information on the type of problems that exist in individual communities.

For example, if problems related to the nervous system in first nations communities are becoming very costly, one can draw conclusions with respect to the causes. I would assume that Health Canada uses that information when it decides how it will invest, for example in prevention, health programs, areas that go beyond simple pharmaceutical concerns.

Ms. Leslie MacLean: As my colleague Susan already pointed out, the rate of accidents is very high. We need to take into account the pain that follows—this is also a factor. We would be happy to provide you with data if it is suitable for the purpose of making comparisons.

The Vice-Chair (Mr. Réal Ménard): Colleagues, it is already 10 o'clock and there are still two people who wish to speak. Shall we grant three minutes each or shall we move on to the next two witnesses? Given the importance of this issue, perhaps we could continue for another five or ten minutes. How do you wish to proceed?

We have two people who wish to speak : Mr. Merrifield and Ms. Bennett. We will continue for another 10 minutes; agreed?

[English]

Mr. Rob Merrifield: I just have a quick question.

I'm a little confused with the consent forms you're going after for privacy. My understanding in the spring was that the form was quite complex and detailed, and the objection was not so much concerning consent about where the information was going to be used as it was about the complexity and the detail of the information. What you are saying is that you have the information but don't have the consent to use it—that is what you just said—but in the spring the objection was to the kind of information that was being asked for. Can you explain what really is going on?

Ms. Leslie MacLean: Yes. There were a number of questions, as you rightly point out, around the form, and you're absolutely right that the form we have looks quite complicated; however, the information being sought was actually quite simple. I would describe it as nominative information. It was the name, the treaty or status number, the date of birth, and the address for the person.

The reason the form is quite long is as a result of the test pilot work we had done in I think 16 different sites across the country, where it was thought extremely important that the form detail all the kinds of information that would be collected—so that's one whole section of the form—all the uses to which the information might be put, and that's another whole section of the form, and then all the people with whom the information might be shared, which is yet another section of the form.

I would agree with you that the form we looked at together in April was quite long and complicated. It was because of Health Canada's desire to be completely transparent with the person signing the form: “This is the information collected; it will be shared only with these people, under these circumstances.” That's actually the heart of much of the work we've been doing with the AFN and the ITK and which we're beginning to do at a regional level: trying to respond to questions about whether we can make the form simpler and yet be completely up front about what is being sought and what people are authorizing us to do.

Mr. Rob Merrifield: Now, if by March 1, 2004, I come in and say this is inappropriate and I don't want my information going there, do you refuse service?

Ms. Leslie MacLean: It's important to remember that our clients remain eligible for service. Our goal with the consent initiative has been to maintain access, not to deny it. The choice the person would have at that point would be to acquire the service either by paying up front and getting reimbursed by us after the fact or by making any other arrangement he or she might with their service provider and then filling out a reimbursement form, where they would give us the consent to collect, use, and share the information for that specific transaction.

Our goal in the consent form we spoke about in the spring was, quite frankly, our effort to make it as easy as possible for the individual client to understand and agree to that collection of information on an ongoing basis. If people choose to do that on a transaction-by-transaction basis, clearly we will honour their preference.

À (1000)

Mr. Rob Merrifield: But in reality you're saying that--

[Translation]

The Vice-Chair (Mr. Réal Ménard): With your permission, Mr. Merrifield, we will now give Ms. Bennett the floor. It is already 10:05 and you have had four minutes.

Ms. Bennett.

[English]

Ms. Carolyn Bennett (St. Paul's, Lib.): Thanks very much.

When we were looking at optimal drug prescribing, there were organizations in those days like SureMed that tracked six million Canadians' prescriptions. Even with the identifier off they were able to track that there were people on uppers and downers at the same time, there were seniors who were getting things that shouldn't have been for seniors and kids getting things that shouldn't have been for kids.

We have an opportunity as the direct provider for aboriginal people in this country to be tracking and planning optimal prescribing. On the double doctoring thing, that's against the law. You can be charged for getting narcotics from two different doctors and not telling the doctors you're getting them.

I want to know, even with the identifiers off, are we tracking the prescribing and doing some sort of education? It is our responsibility to get these people the best health care that's possible. Are we tracking trends and stuff, not worrying about consent and not worrying about identifiers, just in terms of what the problems are so we can actually have an approach to go and fix it?

Ms. Leslie MacLean: There are two parts to that. One is the drug exception centre, where putting people through that prior approval hoop, which can cause paperwork for the pharmacist and/or the doctor, does enable us to do, if you like, that behaviour modification. If people are constantly prescribing, for example, second-line antibiotics instead of starting where they should, that's a way for us to control it at the start.

I talked about drug utilization review work, which we had stood down for some time. That's why we want to get that committee back doing that analysis that--you're absolutely right--can be done at the aggregate level. That way we can do provider education if we need to and work with colleges in a way that doesn't focus on individuals but focuses on general prescribing or dispensing trends.

Ms. Carolyn Bennett: But why is it only on the prior approval stuff? Even without prior approval you can follow trends.

Ms. Leslie MacLean: Yes, we can follow trends.

Ms. Carolyn Bennett: We're paying for it. That was the point of the insurance companies: they're paying for it. If we have people loaded up on Valium these days and then they go and break their hip, we know that's not good. Those people should come off the Valium.

My little goal would be that we should be doing what we preach. If this is the area we actually have direct responsibility for, what would it look like to you in terms of best practices if we could actually do this job properly? If we're not going to do it, why don't we just give it to the provinces to do?

Ms. Leslie MacLean: For me, if we were doing the full range of things we could be doing, we'd be doing one of the big components we're doing now, which is the electronic, real time, “hey, there's something funny with this prescription” warnings, and we'd be doing what we're doing in terms of following up when pharmacists just override those. That part we're doing.

The part where we need to improve, and this is where we sent out a call letter in August to restart this work, is in doing that analysis that can be done at the aggregate level--you're absolutely right--of taking industry standards around what is appropriate prescribing behaviour, analyzing to see if we have gaps, and acting to fill gaps.

As you know, there are two ways we can act to address gaps. One is on the general education and information level. The second part, where we have been blocked from sharing information, is on specific follow-ups where you see specific issues around specific individuals or you see an issue with a specific pharmacist or provider. We can complain to the regulatory body, and do, but at that point the regulatory body says they want individual client information so they can follow up and understand exactly what the problems are. That's the point at which our action is currently blocked.

What I would see in the ideal world of us monitoring and supporting appropriate use of drugs to improve and maintain people's health is that we would have an active program of monitoring that was appropriate to the culture of first nations and Inuit and that provided information so providers, prescribers, and clients were all working together to use the drugs in the most cost-effective manner.

À (1005)

Ms. Carolyn Bennett: How many providers do you report to the college a year?

Ms. Leslie MacLean: That I would have to follow up on. Our audit information is in here, but I don't have the number of specific providers with me today.

Ms. Carolyn Bennett: That is, ones who are reported to the college of physicians and surgeons in their province.

Ms. Leslie MacLean: I can come back, I believe, with a number on that.

[Translation]

The Vice-Chair (Mr. Réal Ménard): That wraps up our first presentation. Thank you to our witnesses. I will now suspend the meeting to give the second group time to come forward.

À (1005)

À (1010

À (1010)

[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Ladies and gentlemen, could we reconvene, please, because apparently we absolutely have to be finished at eleven. Our interpreters have to go somewhere else, and we think there might be another meeting anyway, so we should probably get going.

We have more officials from our department, including Mr. Rocan, Mr. Li, and Ms. Plouffe.

Whichever one of you is going to begin, please feel free. You have the floor.

Mr. Claude Rocan (Director General, Centre for Healthy Human Development, Population and Public Health Branch, Department of Health): Thank you.

Good morning. I'm Claude Rocan, the director general of the Centre for Healthy Human Development, located in the Population and Public Health Branch of Health Canada.

I'm here with Felix Li, who is the acting director in the chronic disease control and management division of the Centre for Chronic Disease Prevention and Control; and with Louise Plouffe, who is out of the room for a moment. She's manager with the division of aging and seniors.

Just to set the context briefly, the role of our branch with respect to health and aging is principally one of health promotion and disease prevention, so our focus is on the health of seniors as a population group, rather than the health system or health economic issues. In fact, this is very consistent with the work we do with other population groups, as well.

We have community-based programs related to children, and again, we take a population health approach to that—especially with emphasis on health promotion and disease prevention.

Having said that, we do work with non-government organizations, health professionals, and seniors organizations to promote safe medication use among seniors and better prescription practices. We do these primarily by supporting some extramural research activities, funding some community-based health promotion projects, and by developing information materials for seniors and health professionals.

I'll also mention in this context that the division of aging and seniors in my centre also supports a federal-provincial-territorial committee of ministers that looks at a broad range of seniors issues and that has, in the past, looked at medication issues and medication abuse in the case of the seniors population.

Now I'll pass it on to Felix, who will talk about patterns of chronic disease in Canada, with particular relevance for the population of seniors.

First of all, it's my pleasure to be able to present at this committee. As Claude mentioned, I'm with the Centre for Chronic Disease Prevention and Control. The mandate of our centre is to reduce the burden of chronic disease in Canada through the surveillance and monitoring of the trends of chronic disease, to assess the risks of chronic disease among the various sectors of the population, and to plan, implement, and evaluate prevention and control measures for the reduction of chronic disease in Canada. We also perform our work through health promotion.

In my presentation I would like to mention some of the relationships between prescription drug use and chronic disease in Canada and its trends. In 1998 Health Canada published a report called “Economic Burden of Illness in Canada”. I'm happy to leave a copy here, as required. It revealed the economic burden of illness in Canada in the year 1998.

For the relevance of this committee, the distribution of prescription drug expenditure in Canada by disease category is as follows: infectious disease about 10%; injuries about 2%; and non-infectious disease about 88%.

In the non-infectious disease area obviously most, if not all, of the chronic diseases are included, among which, the major drug expenditures are as follows. Chronic diseases such as heart disease represent about 20% of our drug expenditure as a whole, and around the 10% range are mental disorders, endocrine disorders, including diabetes, digestive system diseases, chronic lung diseases, and musculoskeletal diseases, meaning arthritis, osteoporosis, low back pain, rheumatism, and so on.

The major chronic diseases we have in Canada--namely, heart disease, cancer, diabetes, chronic lung disease, mental health, and musculoskeletal diseases--actually account for 50% of all drug expenditure in Canada on a year-to-year basis. I'm trying to paint a picture that most of the drug expenditures are related to chronic disease and therefore the trends and the patterns of chronic disease will have an important impact on the drug expenditure in Canada.

There is research that shows, number one, drug use increases with the number of chronic conditions a person has. For example, in the 1996-97 national population health survey, when we asked the question, “How many drugs have you used in the last two days?”, we noticed that for people with one chronic disease they used about one, and it goes steadily upwards rather linearly. When they have seven conditions, they take an average of four medications. It's quite clear to us that the more chronic conditions one has, the more numbers of drugs one uses.

The important thing to bear in mind is that the prevalence of chronic disease mostly increases with age. For example, cancer goes up with age, as we have assumed and is proven by statistics; heart disease increases with age; diabetes increases with age; chronic lung diseases, and arthritis, osteoporosis, and those musculoskeletal diseases increase with age.

When you have more chronic conditions we are seeing that you take more drugs, and when you are older you get more chronic diseases. So I guess the two combined would show that when you are older you take more drugs. That's more or less what we expected, but it has been shown repeatedly by the statistics. For example, in a survey we asked people, again, “How many drugs have you taken in the last two days?” For those under 65 years old, they would take 0.8 drugs on average, and for those over 65, it was 2.2. So we are seeing almost a threefold increase in the numbers of drugs used for those under 65 and over 65.

À (1015)

Another major factor that impacts on the issue of chronic disease and drug use is the aging Canadian population. As we are aware, the Canadian population is aging, like in most developed countries. For example, in 1980, 9% of the Canadian population was over 65 years old, amounting to 2.3 million. Right now we have 13% of our population over 65, 4.1 million in total. So we have seen it almost double from 1980 to now, and the trend is forecast to increase. We haven't seen a downturn. As far as projections go from Statistics Canada, we will still see an upturn in the next 20 years. After that they haven't come up with projections, but up to year 2026 we are still on the increasing trend.

Due to the efforts of public health and governments and the medical community, certain chronic diseases are decreasing in prevalence--for example, heart diseases, lung cancer among men, cervical cancer among women. In those we are seeing a decreasing trend, which is good news. There are certain chronic diseases that are increasing as well, such as diabetes, which is increasing in the Canadian population and in the aboriginal population.

We have two trends working against each other, in a way. We have certain chronic diseases coming down, but we have the aging population going up. Combining the two, all the projections we have seen indicate that the absolute number of people in the population having chronic diseases will go up because the force of the population growing in the aging population is much bigger than the reduction in chronic disease trends. Although the rates are decreasing, because of the size of the elderly population the absolute number is going to go up.

In conclusion, based on the various statistics we have seen and the monitoring of trends and the population trends, we came to the conclusion that the absolute number of people in Canada with chronic diseases is going to increase and it's going to increase in the future. Therefore, if existing conditions remain the same, the continuing trend of increasing prescription drug use and costs will be expected.

Thank you.

À (1020)

Mr. Claude Rocan: I'll next pass it on to Louise, who will talk about the health aspects of aging and their implications for drug prescription use and expand on some of the themes that Felix has raised.

Ms. Louise Plouffe (Manager, Knowledge Development, Division of Aging and Seniors, Department of Health): Thank you.

I won't repeat the statistics that Dr. Li has mentioned to you, but I will mention a few others that look at specifically the issue of aging in seniors.

Dr. Li mentioned the doubling of the population of seniors within the next 30 years, from 13% to about 23%. But I would like to point out that the fastest-growing age segment in the seniors population is the 85 plus. Their numbers will quadruple in the next half century; they'll go up from some 400,000 now to about 1.6 million by 2040.

Fortunately, seniors are healthier than before, but, as Dr. Li mentioned, chronic diseases and disabilities become more prevalent with increasing age. For what we call young seniors, between 65 and 74, eight in ten have at least one chronic condition; and for the 75-to-84 range, nine in ten have a least one chronic condition. As Dr. Li mentioned as well, the prevalence of multiple chronic conditions increases the older people get. If you have the fastest-growing age segment being 85 plus, you have a growing number of people with multiple chronic conditions. Arthritis and cardiovascular diseases are the most prevalent conditions.

Another point that deserves to be mentioned that often isn't is the prevalence of chronic pain. Chronic pain also increases with age. You can see that it is associated with arthritis as well, but not exclusively with arthritis. Take as a comparison point 15- to 24-year-olds: some 10% will report chronic pain; among seniors 65 to 74, 30% report chronic pain; and for seniors 75 plus, 35% report chronic pain. Not surprisingly, the prescription drug that is most frequently reported in response to the question “What prescription drugs are you taking?” is pain relievers. I haven't brought it with me, but I will share with the committee results from the national population health survey that indicate the proportion of seniors taking specific drugs for specific conditions, and by far and away pain relievers are the most commonly used.

Not surprisingly, seniors are the main users of prescription medications, and particularly several medications at the same time. They account for somewhere between 28% and 40% of all prescriptions. The 28% to 40% are different estimates based on different studies. The statistics I'm quoting are contained in the article I circulated to you by Dr. Robin Tamblyn and Dr. Robert Perrault, which I believe responds quite well to the questions the committee is asking, specifically with response to medication use of older adults. These are researchers who have done a systematic literature review that was funded in part by Health Canada. I think this article will be most enlightening for you.

Managing a complex medication regimen is difficult enough for anyone, but the difficulty may increase with age, as all of us do tend to become more forgetful as we get older. In addition to that, for a significant number of seniors low educational level and the presence of cognitive impairments may place them at even higher risk for unsafe drug use. The majority of today's seniors, more than 60%, have not completed high school. Fortunately, with each successive cohort, seniors or older people are becoming more and more educated, so that as a factor will diminish over time. But today's seniors have not had the benefit of advanced education. Literacy levels are among the lower ones in Canada for seniors.

À (1025)

In addition, dementia affects 8% of seniors over 65 and over one-third of seniors over 85. Another 16% have milder, but still clinically significant, cognitive impairments that impair memory and reasoning. That amounts to about one in four, 24%, of seniors who have some degree of cognitive impairment, from mild to severe but still clinically significant.

The Chair: I hope we have a certain chance to remain lucid.

Ms. Louise Plouffe: Research indicates that seniors' drug compliance problems consist mainly in not filling prescriptions and in inadvertent underuse or overuse, usually forgetting to take the drug or taking too much or too little at a time. It's been estimated by experts that suboptimal compliance accounts for 11% of hospital admissions for adverse drug reactions among seniors.

More problematic than unsafe medication use by seniors' compliance problems are inappropriate prescribing practices, which are said to account for anywhere between 19% to 36% of drug-related conditions. Inappropriate prescriptions are attributed to many factors, including multiple prescribing physicians, inadequate knowledge among doctors of appropriate drug dosages for seniors, potential side effects and contraindications, poor communication with older patients, and lack of knowledge about aging in older adults that are compounded by stereotypes about aging.

Lack of knowledge about older people and stereotypes may be responsible for the documented over-prescription of minor tranquilizers and under-prescription of drugs to treat cardiovascular disease.

Issues of drug costs related to aging are outside the scope of my work, but it is clear that improving safe medication use by seniors, and especially improving prescribing practices, will reduce the rate of hospital admissions for adverse drug reactions that are preventable.

Thank you.

The Chair: Thank you to all three.

We'll begin now with our questioning. Our first questioner is Mr. Merrifield.

Mr. Rob Merrifield: Thank you.

On seniors and pain, I was talking to a senior the other day, and he said, “You know, after the age of 60 pain takes on a completely new meaning”. That's probably true. I'm a long way from being there, but I understand that what you're saying is probably very true, that chronic pain causes more use of pharmaceutical products.

I'm a little concerned about the recommendation from Health Canada. Is 12 products, 12 different drugs, the maximum that you recommend an individual be prescribed at one time? Do you know that for seniors? Is that right or wrong?

Mr. Claude Rocan: That's not the sort of issue we would deal with in our part of the--

Mr. Rob Merrifield: You don't know. You haven't studied that.

Mr. Claude Rocan: No.

Mr. Rob Merrifield: You're obviously looking at mis-prescribing, because you're saying that up to 36% are being mis-prescribed. So what would deem a mis-prescription? Is it an adverse reaction? Is it too many different drugs in a body?

Ms. Louise Plouffe: It could be too many different.... It could be products that are incompatible, however many there are. It could be taking too much of a particular product or taking not enough.

I'm not a physician, but geriatric physicians I have spoken to will say that it's not uncommon, nor necessarily inappropriate, for a senior to be taking five medications at a time if they're properly managed.

Mr. Rob Merrifield: The reason that 12 came up is because in my past life, when I was sitting on a regional health authority, I think that was recommended within a seniors home. I'm not 100% sure about that, but I think it's where the number came from. They thought that if it got over 12 different products, it was inappropriate.

But some of the studies I've seen and some of the information I have indicated that individual seniors were on much more than that, and the drug misuse was causing a significant number of the problems due to its complications.

There are no studies there other than this 19% to 36%, that's what you're saying? If 36% is right, that's a third of our seniors who are in a situation where they're being mis-prescribed. Is that what you're really telling us?

À (1030)

Ms. Louise Plouffe: That's what the research studies seem to indicate, that there is a high level of problems related to inappropriate drug prescribing.

Mr. Rob Merrifield: Have you followed that back through to see if it was from one physician, or are seniors seeing more than one physician? Is that causing some of the problem?

Ms. Louise Plouffe: Yes, for seniors seeing more than one physician. If they have many problems, they may see their general practitioner but then may go to see a specialist for other problems, for other issues, and the different physicians may not know what the other has prescribed.

Mr. Rob Merrifield: If the medical records followed that patient, you'd have that information known from physician to physician. What alarms me a little is that a specialist could see someone, especially a senior, and not know what kind of medication he was on. That's really what you're saying is the problem.

Ms. Louise Plouffe: It can be a problem. There was a study done in New Brunswick and reported in the Canadian Medical Association Journal that found that there was a direct correlation between the number of patients a physician saw each day and the number of drugs prescribed.

Mr. Rob Merrifield: And the correlation is, the more they saw, the more the drugs?

Ms. Louise Plouffe: That's right: the more patients they saw, the more drugs they prescribed.

Mr. Rob Merrifield: Meaning that there isn't the time to be able to deal with the problem appropriately—

Ms. Louise Plouffe: That is the implication that's drawn.

Mr. Rob Merrifield: —so it's easier to get him out of the office by giving him a pill. Is that just the seniors, or is that right through—or would you know?

Ms. Louise Plouffe: I believe the study was of the number of patients seen.

Mr. Rob Merrifield: Okay. I don't have any more questions. I just know this is a serious problem and I think you've shared that. I hope as a committee we understand how severe the problem is here and look towards how we're going to fix it.

The Chair: Thank you, Mr. Merrifield.

Dr. Castonguay.

[Translation]

Mr. Jeannot Castonguay (Madawaska—Restigouche, Lib.): Thank you, Madam Chair. Thank you to our witnesses. That was an excellent presentation. Obviously, the longer one lives, the more one consumes, and the more one suffers from chronic diseases.

Has the increase in costs and, of course, the increase in drug use, provided savings elsewhere in the system? Do we have any information on this? It is felt that many patients who would have been hospitalized previously can now be kept out of the hospital thanks to the new drugs that are available. For example, people with chronic lung diseases used to suffer repeatedly from infections and were frequently hospitalized. Today, there is a greater attempt to keep them out of hospitals. Is there any comparative data that would demonstrate that within the health system, certain costs have changed in certain areas, but savings have been realized elsewhere? That is my first question.

My second question is this. The frequency of chronic diseases is said to increase with age. Are there any measures that can be taken to prevent these diseases as one ages? What is being done in that area?

Finally, I would like to raise the issue of educating people who are taking several drugs. As a consumer, I feel I have the responsibility to tell my doctor what medication I am using. What is being done to make people aware of the importance of doing that? Some people take up to six, seven, or even eight different drugs; it may be that four or five of those should be removed because of their side effects or their combined effects.

Mr. Claude Rocan: In answer to your first question, unfortunately we do not have the type of information you are requesting. We therefore cannot make the connections between the various parts of this system and how that might affect changes in the use of medication, etc.

Mr. Jeannot Castonguay: Does that information exist anywhere?

Mr. Claude Rocan: Personally, I could not say. Does anyone else know?

Ms. Louise Plouffe: No, that would probably fall under another directorate.

Mr. Claude Rocan: Yes. That information may exist somewhere else within the department, but we do not have it.

Mr. Jeannot Castonguay: Do you think it would be important to have that kind of information or do you think that it is a stupid question?

À (1035)

Mr. Claude Rocan: No, it is certainly not a stupid question, and no doubt that kind of information would be useful.

Mr. Jeannot Castonguay: Fine.

Mr. Claude Rocan: In terms of preventive measures, we are carrying out and encouraging certain strategies. One in particular deals with physical activity. In fact, we have a physical activity guide for seniors. This is a very important measure that we have taken. We are working on other strategies for disease prevention. I would ask Louise to give you some examples of this.

Ms. Louise Plouffe: We publish a lot of educational material for seniors, for service providers and for professionals in order to encourage a healthy lifestyle among aging people and seniors. Physical activity is very important but we also focus on healthy eating and injury prevention.

We have also emphasized the appropriate use of medication and what seniors can do in order to improve their consumption of that medication. We have worked with professional groups in order to improve pharmacists' and doctors' methods of managing and prescribing medication.

Mr. Jeannot Castonguay: Do we have any information on how effective these programs are? If you create these kinds of programs, it is important to get feedback in order to find out whether you have made the right investment and whether you are getting a return on your investment. Do you have any idea about that? Are you trying to find out whether our programs really work, or rather, on the contrary, do you create programs and simply hope for the best?

Ms. Louise Plouffe: When Health Canada decides to support a program or a community project, an evaluation estimate and a longer feasibility estimate, which assesses whether a project will survive the initial Health Canada funding, must be submitted for each project. Our funding is a catalyst which helps a project get started, but it is not meant to be funding for the longer term. The projects which are approved and funded are those which are feasible over the longer term and which are supported by the community.

Mr. Jeannot Castonguay: Is there evidence that this approach works?

Ms. Louise Plouffe: That is not part of my mandate, but some of my colleagues are more directly involved in evaluating and managing community funding programs.

Mr. Claude Rocan: There is a group of people within the department in charge of assessing and analyzing the results of the evaluations.

Mr. Jeannot Castonguay: Who is this group?

Mr. Claude Rocan: We can give you that information later, but I do not know the names of the people involved.

Mr. Jeannot Castonguay: Thank you.

[English]

The Chair: Ms. Bennett.

Ms. Carolyn Bennett: Thanks very much.

Obviously in focusing on seniors or on wellness there are two different facts you've given us that are related. One involves the lack of optimal therapy for chronic diseases, where I think a lot of people feel, whether it's for congestive heart failure or diabetes, that we end up with a huge economic burden and a huge number of unnecessary hospitalizations because these people aren't being optimally treated. I think the places that actually do this, whether it's a Sault Ste. Marie clinic or elsewhere, have shown huge savings on that.

The second thing you've said is that bad drug therapy, in terms of drug interactions—particularly in seniors—can actually account for 15% to 30% of admissions.

I'd like to know, what are the strategies for these two things? We've talked about specialized clinics for chronic diseases, but as the federal government we don't get to deliver heath care, so how do we help with both of these things?

The question I asked the other day that's even more relevant to seniors is whether by good prescribing we're also preventing hospitalizations and surgery—particularly in cardiac disease—all the time with the newer, better medication. By paying more on drugs, we may be saving money in hospitalizations and surgery and pacemakers and all kinds of things. Seeing that seniors are the most complex, is that analysis being done, and what are we doing, in the big picture of health reform, in forming the reform of our health care system based on these rather impressive facts?

À (1040)

Ms. Louise Plouffe: We have funded research. One of the major research programs that was funded under the seniors independence research program in the nineties was a program looking at prescription drug practices and ways to improve drug prescription. Dr. Robin Tamblyn and Dr. Robert Perrault are the authors of that article. So we have helped by promoting research in the area, and that research function has been taken over by the Canadian Institutes of Health Research.

Also, the federal, provincial, and territorial ministers responsible for seniors in the nineties explored the issue of safe medication use and developed a series of—guidelines might be too strong a word—advice to seniors and professionals to promote safer drug use and prescribing practices across jurisdictions.

Ms. Carolyn Bennett: Let's go to the seniors, please. I'm a big believer that if the patients know more.... These seniors have never been healthier in their lives. I came from a practice where the patients would come in and ask why I was giving them this instead of that.

What are we doing in terms of educating seniors? Because I think that's something the federal government can do, actually talk directly to Canadians about stuff. What do we do with seniors organizations, etc., to get them more knowledgeable about asking tougher questions of their practitioners--for example, why they're on all these things, or having them take in their brown paper bags, saying, do you know I'm taking all of these things, doctor?

Ms. Louise Plouffe: We have had and we do publish a lot of educational materials for seniors. One of the strategies, obviously, is to ask the right questions.

Ms. Carolyn Bennett: I think my issue is that we have all the research. How do we get the research into practice? Because the knowledge transfer around this.... My view is you can do all you want, but unless citizens and patients are pulling, we don't get there--and we're famous for little brochures that no one reads.

Mr. Felix Li: I would like to add a little to Louise's answer.

Yes, I agree 100% with you that appropriate treatment is the most important thing. It's more than money; it's the quality of life and health of the patients.

As Louise mentioned, we did some research, either in-house or outside. We have worked on the asthma treatment practices in the general population, and we are trying hard to include treatment statistics data in our Canadian cancer surveillance system so we can see where the appropriate treatments are and find ways to address that.

Getting to the action part, we have been working in the past and are continuing to work with professional organizations--physician groups--to establish clinical practice guidelines in the sense that we, the federal government, the provinces and territories, and professional organizations agree as a consensus that these are the optimal treatments for these patients, and we will work with the patients and the provinces and so on to implement them.

A book is something they may read, but they may not accept the infighting. So we have been working to implement those guidelines in the medical practices as well.

We have done asthma treatment guidelines, diabetes guidelines, and we are working on some of the cancer treatment guidelines.

Dr. Bennett mentioned that the patients have to be empowered to do that. We've done that in the past and we will continue to do so. For example, in asthma education, we focus on two groups, the health care providers and patients with asthma and their families. And it will be a common effort in our diabetes strategy to do the same, to empower and allow the patients and their families to take care of their own illness and be able to converse with their physicians on their requirements and so on.

So this is an ongoing way we are heading, and hopefully we'll be able to do more of it.

À (1045)

Ms. Carolyn Bennett: Even on the antibiotic treatment, it's “How come you gave me the $70 antibiotic when penicillin would do?” It seems to be that the more patients understand, the more you start to change practitioners' ways. Is that it?

Mr. Felix Li: Actually, that's one thing we've found in our asthma treatment surveillance as well, because the patient is very instrumental in effecting the appropriate.... To know what they should be getting and not getting is a good addition to the patient and physician. A healthy interaction between physician and patient would be beneficial to both.

[Translation]

Mr. Gilbert Barrette: Last week, we heard a presentation on prescriptions and costs. We heard that the effectiveness of a drug was not necessarily proportional to its costs and that new drugs were not necessarily better.

My question comes back to the one asked by my colleague Mr. Castonguay. How closely do you work with the provinces to assess the effectiveness of drugs when administered over a prolonged period in home care as opposed to a shorter hospital stay? I presume that this aspect of drug management is basically carried out by the provinces.

Mr. Claude Rocan: Unfortunately, that area is not the branch's responsibility. Therefore, we do not have that information. We work with the provinces. The subject was raised at the forum for federal, provincial and territorial ministers responsible for seniors, a meeting which brought together provincial and territorial representatives in June 2002. However, we cannot give you more specific information on the level of cooperation on specific issues, because that is the responsibility of other branches within the department.

Mr. Gilbert Barrette: Does that exist?

Mr. Claude Rocan: I could not tell you. We could try to get you the information, but I cannot give you a specific answer today.

Ms. Louise Plouffe: I think that area falls under the Strategic Policy Branch responsible for health care issues. The branch's officials could provide a more specific answer to your question because their work is focused on the health care system.

Mr. Gilbert Barrette: Fine.

[English]

The Chair: Madam Scherrer.

[Translation]

Ms. Hélène Scherrer: I would like to talk about the statistics you provided on life expectancy. We see that people are living much longer than they did in the past. If I look around me, particularly at my relatives, I see that not only are people living longer, but they are much more active, alive and involved in the community than they used to be. We no longer find grandparents sitting in their rocking chairs. We find them on golf courses and all sorts of other places. These days, these healthy older people are passing us on the bike paths.

I understand that we cannot control or even prevent some diseases that go with aging, such as senility or other such illnesses. Without in-depth research, it is impossible to anticipate these diseases through genetic means. However, prevention can be helpful in forecasting and perhaps even fighting certain diseases that affect the older population particularly. I am thinking of osteoarthrosis and rheumatism, for example. The incidence of diabetes is much higher than in the past, but this disease can be prevented with proper nutrition.

I would also like to talk about smoking. So many seniors are affected by the direct or indirect effects of smoking! Are we doing enough prevention work among people in their 50s, who want to enjoy their senior years? No one wants to live in a wheelchair until they are 80, 85 or 90. If people live that long, it is preferable for them to have a much better quality of life. In our prevention activities, do we try hard enough to explain the direct link between the food we eat and the chances of getting diabetes? Do we emphasize the importance of physical activity enough? Do we talk enough about smoking? In my opinion, we will never have too many such prevention activities. We have to tell people that at the moment, they are not suffering too much from second-hand smoke, but that as they age, they will suffer from it more. At the moment, health problems are dealt with by clinics and doctors. It seems that doctors are intent to deal with the diseases they see every day, but that there are no aggressive campaigns for people our age about things such as prostate cancer, arthritis, rheumatism or diabetes. We do not tell people enough that what they do today has a direct link on their quality of life at age 85.

À (1050)

Mr. Claude Rocan: In September 2002, the federal, provincial and territorial ministers of Health decided to implement a strategy to promote healthy lifestyles. In English, it is called the Healthy Living Strategy. We have been working on this strategy for more than a year, and the ministers of Health had an opportunity to discuss it again this month.

We want the strategy to be aggressive and to deal with subjects such as nutrition, physical activity, smoking and the relationship between weight and health. We are working with our provincial and territorial colleagues to establish this strategy and we are also trying to discuss it with various interest groups and the private sector so that we can develop other effective, positive approaches.

Ms. Hélène Scherrer: Thank you.

[English]

The Chair: Thank you.

We will have one last question from Dr. Castonguay.

I just want to remind the members that there is another very short meeting at 3:30 this afternoon in Room 269 West Block.

Dr. Castonguay.

[Translation]

Mr. Jeannot Castonguay: Thank you, Madam Chair.

You have been asked a few questions about what you do. You answered that information was circulating among groups of asthmatics and diabetics and that you were in contact with professional organizations. I believe that the most important thing is to talk to consumers. If we are talking about prevention, we must not wait until people have these diseases. We have to try to reach them earlier.

In nearly all communities, there are associations for seniors, which used to be called golden age clubs. That is how we need to reach people. Written information is fine, but if half the people do not know how to read and the other half are blind, you are not going to have an impact with written information. Instead, I think that you can talk to most of them.

You really need to get down to the grassroots level if you want to reach people. If we are talking about prevention in general, we are talking about education, and if we want long-term results, we need to start at the school level and give children proper information, so that they can make decisions, change their behaviours and also ask the right questions when they go to the doctor.

I would like to hear your reactions.

Mr. Claude Rocan: I think that you are absolutely right. In the strategy I was talking about, we involve groups representing seniors. Yesterday, in fact, there was a meeting that involved representatives of seniors' groups.

That is a very important component of our strategy. We want to be sure that we understand the circumstances and that we find ways of communicating effectively with all segments of the population. We talk a lot about schools in our strategy. We are working tirelessly to ensure that schools take steps to educate teachers and students.

À (1055)

Mr. Jeannot Castonguay: Are the provinces receptive to this approach?

Mr. Claude Rocan: Absolutely. They have been good partners from the outset.

[English]

The Chair: Thank you very much, Dr. Castonguay, and thank you to our witnesses today. It was a very clear presentation. We thank you very much for the work you do every day, but most particularly for the work you did this morning to assist us. Thank you so much.

The meeting is adjourned.