CADTH 2015 Symposium

1. Collaboration Across the
Spectrum of Formularies in
Saskatchewan:
The RQHR Perspective
Wm. Semchuk, MSc,PharmD,FCSHP
Manager, Pharmacy Practice
Regina Qu’Appelle Health Region
April 13, 2015

2. 2
Speaker Disclosure and Perspective
– No relevant real or potential conflicts in
relation to this presentation to disclose
– Perspective provided as a member of the P
and T Committee of the Regina Qu’Appelle
Health Region, as well as a member of the
Drug Advisory Committee of Saskatchewan

3. 3
Health Authorities
in Saskatchewan
• Provincially in Sask,
13 Health Regions, 5
provincial hospitals, 6
Regional Hospitals, 9
District Hospitals
Formularies in Sask
• SPDP
• SCA
• Hospitals….
• Limited collaboration

4. Decision Making Process within RQHR
• Formulary requests generated by physician or pharmacist
• Review and Recommendation Process
• Completed by a pharmacist with expertise within the therapeutic area
• Consultation and discussion with the requesting Medical Department is
the norm
• CADTH review often but not universally considered
• Considerations include:
• Where the drug will be used:
• Only in hospital, predominantly in hospital, chronic oral conditions
largely used in outpatient setting
• Provincial Formulary Coverage major consideration for chronic oral
medications
• RQHR aligns with provincial coverage in the vast majority of cases
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5. Hospital Only Drugs (Usually short term, high
cost, ordered by Sub Specialists, eg. eltrombopag)
• Lack of clarity in alignment across the province for hospital only
drugs
• Many of these agents do not go for CADTH review in a time frame
that is consistent with requests for use
• Consideration is cost per patient per year
• Generally will require support by Medical Department, P and T and consideration
by Senior Management
• Case by case review may occur and consideration of cost of hospitalization is
important
• Often perceived as having a significant short term effect on patient outcome
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6. 6
Drugs Used Predominantly in the Hospital,
eg. LMWH (dalteparin, enoxaparin, tinzaparin
• Generally align with provincial formulary criteria
and coverage though formulary options may be
more restrictive
• Principle reason for restriction is to ensure
medication safety (agents that could create
confusion) and contract opportunities
• Challenge exist as patients are transferred
between health regions

7. Chronic Oral Medications
Provincial Formulary Coverage major consideration for
chronic oral medications:
• RQHR aligns with provincial coverage in the vast majority of
cases
• RQHR formulary generally much more restricted than
provincial formulary for oral medications carrying several
products within a class rather than the entire class
• Consideration for a late entry into the class for RQHR
addition is an estimated 10% market share or greater
• Rationale:
• Patient stabilization
• Patient’s experience and awareness
• Inventory
• Residents
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8. 8
Challenges that may Facilitate Enhanced
Collaboration in the Future
• Transfer of patients between Regions
• Transfer of patients into and out of Tertiary Care
Centers
• Tertiary Care Centers may send drug with patient as
they are transferred out to Regional Sites
• Tertiary Care Centers may serve as resource to
smaller regions

9. 9
Example of Interregional/Provincial
Collaboration
• Ticagrelor initially added to RQHR formulary approximately 6
months prior to provincial coverage
– Rationale: approximate 1% reduction in absolute mortality for ACS patients
– Concern: will use of agent in hospital, and lack of outpatient coverage lead to
nonadherence?
– Strategy: Initiate a local registry to assess outcomes
• When added to SPDP Formulary: Restrictive Coverage provided
• Provincial Cardiology Groups (RQHR and SDH) voice concern over
limitations of coverage
• Provincial ACS working group struck Sept 2013 which included
representatives from:
– Interventional Cardiology – Regina and Saskatoon
– Internal Medicine – Regina, Saskatoon, Yorkton, Prince Albert
– CV Surgeons – Regina
– Regina, Saskatoon Cardiology PharmDs

10. Example of Interregional/Provincial
Collaboration
• ACS Working group provided clinical perspective related to
the ACS data and the role of ticagrelor (and many other
agents)
• ACS Working group reviewed data, results of ACS registry
and discussed impact of different policies at tertiary care
and regional levels
• ACS working group developed a provincial ACS order set
• Discussion with Ministry of Health occurred following
completion of provincial ACS order set
• Provincial coverage for ticagrelor changed to align with
working group recommendations and moved from approved
indication to approved prescriber
• Educational roll out occurring
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11. Challenges and Opportunities
• Challenges:
• As the provision of care results in patient movement into and out of
hospital as well as between Health authorities, the impact of differing
policies, formularies and practices poses risk to best outcomes
• Differing expert opinions which contrast with policy can further lead to
confusion and frustration
• Opportunities:
• By aligning evidence review and applying a “clinical lens”, alignment
of practice becomes more likely
• By creating opportunity for policy makers to consult more easily with
clinicians the opportunity for alignment of practice becomes more
likely
• By ensuring that multiple health regions are included in the
consultation, the opportunity to influence each region to align practice
becomes more likely
• Alignment of practice should decrease challenges and errors as
patients transition through the health care setting
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12. Summary
• Collaboration is informal at present, however growing
recognition for need of collaboration
• Best patient care is dependent upon ensuring continuity in
coverage of agents across the spectrum of care
• Given the size of the province, working together is the best
solution
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