Can the Present Canadian Health Care System Provide Evidence-Based Pharmaceutical Care? Consideration of Two...

Canada is the only country with universal health care lacking universal pharmaceutical care (pharmacare). Currently, a minority portion of the population has drug coverage. Furthermore, there may be discordance between provincial plans of medications that are covered. We aimed to evaluate present systems for drug coverage and ability to provide evidence-based care according to Canadian cardiovascular (CV) guidelines.

The drug review process and formularies for provinces and territories were queried to evaluate concordance between guideline-recommended medications and present coverage. Two common cardiology scenarios, heart failure with reduced ejection fraction and antiplatelet drugs in acute coronary syndrome, were chosen as case studies because of recent Canadian-based CV practice guideline updates. Coverage criteria were extracted to assess for interprovincial variations and determine whether listing decisions are concordant with best evidence and guidelines.

Multiple organisations are involved in drug review. Despite Canada's Drug and Health Technology Agency (CADTH) recommendations, there are extensive interprovincial variations in listing decisions for CV drugs, with CADTH recommendations followed only 33% of the time. Among 24 CV drugs reviewed, 23% of listing decisions were discordant from guidelines and best evidence. Novel drugs disproportionately carried the highest discordance from evidence. No systematic process exists for formulary updates based on new evidence, changes in guidelines, or drug pricing.

Current Canadian drug review decisions are complex and coverage decisions vary widely, resulting in an inability to provide guideline-recommended CV evidence-based medicine. In developing future pharmacare programs, it is crucial to centralise the drug review process and integrate mechanisms to incorporate up-to-date evidence.