Highlights of this issue [CMAJ

Highlights of this issue

CMAJ 1999;161:233

Reference-based pricing

Initial impact

Evaluating reference-based pricing: initial findings and prospects [Education]

In 1995 British Columbia introduced a controversial reference-based pricing program, which limits reimbursement for a prescribed drug to the cost of the lowest priced product in a class of drugs deemed to be therapeutically equivalent. Lutchmie Narine and colleagues report that the initial impact of reference-based pricing in BC was an immediate and pronounced shift toward prescribing reference drugs, with a drop in annual expenditures for drugs in referenced categories from $42 million in the year before the introduction of the policy to $23.7 million the year after. The market share for the histamine-2 (H₂) antagonist reference drug, cimetidine, increased from 10.5% to 56.8%, and the total number of prescriptions for H₂ antagonists decreased by 5.2%. Drug expenditures have been reduced, but why has the total volume of drugs prescribed dropped?

Reference-based pricing

Equivalency challenged

Reference-based pricing of prescription drugs: exploring the equivalence of angiotensin-converting enzyme inhibitors [Evidence]

Evaluating the impact of reference-based pricing [Editorial]

Chantal Bourgault and colleagues challenge the assumption of therapeutic equivalency inherent in reference-based pricing by demonstrating that the rate of hospital admissions and visits to general practitioners (GPs) vary by the type of angiotensin-converting-enzyme inhibitor prescribed. The adjusted rate ratio of the number of visits to a GP for patients receiving enalapril relative to captopril was 0.84, and for those receiving lisinopril, it was 0.79. Do these ratios indicate differences in therapeutic effect? In an accompanying editorial Paul Grootendorst and Anne Holbrook suggest alternate explanations for these findings and emphasize the need for the ongoing evaluation of the policy to help delineate the impact of reference-based pricing.

The white-coat response in patients with hypertension

Prevalence and predictors of white-coat response in patients with treated hypertension [Evidence]

Withholding treatment in white-coat hypertension: wishful thinking [Editorial]

Mary MacDonald and colleagues studied the prevalence and determinants of a white-coat response in 103 patients with essential hypertension. The comparison of clinic blood pressure measurements with mean ambulatory readings revealed a striking difference between the sexes; 20% of the men and 54% of the women demonstrated a white-coat response. Logistic regression modelling showed that perceived level of stress and time since diagnosis of hypertension predicted a white-coat response among women. Depression was a weak predictor among men. In an accompanying editorial David Spence ponders what to do with this information.

Program successes

A shift toward palliated deaths

Edmonton Regional Palliative Care Program: impact on patterns of terminal cancer care [Education]

With the introduction of the Edmonton Regional Palliative Care Program in 1995 the percentage of cancer-related deaths in acute care settings dropped from 86% in 1992/93 to 49% in 1996/97, the number of inpatient days decreased by more than 70% and about 4 times as many patients saw a palliative care team. Eduardo Bruera and colleagues explain that this improved access of patients with terminal cancer to care can be attributed to 5 new elements in the palliative care program. Unfortunately, participation of Edmonton family physicians was relatively low at 35%. Symptom control, patient satisfaction and cost of care require further investigation.

Early discharge and newborn morbidity

Are we sending newborns home too early?

Higher neonatal morbidity after routine early hospital discharge: Are we sending newborns home too early? [Evidence]

Perhaps so. Michael Lock and Joel Ray assessed the impact of an early-discharge policy following uncomplicated vaginal delivery on the rate of hospital readmission among newborns. After the policy was implemented the mean hospital stay declined from 1.88 days (95% confidence interval [CI] 1.841.92) to 1.62 days (95% CI 1.561.67, p < 0.001), and the overall rate of hospital readmission among newborns rose from 6.7% to 11.7% (odds ratio 1.86, 95% CI 1.512.30). In the early-discharge cohort most infants (10.9%) were readmitted within 7 days after discharge, with jaundice and anatomic or metabolic concerns being the most frequent reasons. These findings lead one to question the optimal length of stay to minimize costs and still maintain quality of care.