Ontario's Formulary Committee: How Recommendations Are Made

Background: In 1996, the provincial government in Ontario, Canada required pharmaceutical manufacturers seeking to list their products on the provincial formulary to provide a formal economic analysis documenting the products' cost effectiveness. The provincial formulary lists pharmaceutical products for which reimbursement is provided for residents on the Ontario Drug Benefit Program (ODB). Objective: To describe how listing decisions are made, and specifically the role of economic analysis in this process. Design: A qualitative case study approach was taken. Data were analysed using the pattern-matching technique. Data consisted of meeting transcripts and interviews with committee members, which were coded and weighted for analysis using the pattern-matching technique. Setting: Nine meetings of the Drug Quality and Therapeutics Committee (DQTC), which makes listing recommendations to the ODB, were observed. Participants: Seven individual committee members were interviewed. Results: Complex economic analyses (i.e. analyses more involved than a simple cost-consequence analysis) played a limited role. The clinical factor dominated the perception of costs. Generic and `me-too' products with no price premium did not require complex economic analyses. Poor quality analyses were not useful and the DQTC members' lack of in-depth knowledge of health economics influenced the extent to which analyses were discussed. The DQTC did discuss economic issues however, and often performed informal economic analyses to guide decisions. Conclusions: Complex economic analyses had an impact on provincial drug benefit decisions in a limited number of circumstances, principally for expensive innovative products. However, the committee did use some form of economic analysis to guide decisions in almost all cases, and therefore requesting economic analyses, even simple ones, from manufacturers seeking formulary listing is a useful healthcare policy.Formularies, Health economics, Pharmacoeconomics

Vitamin D and hypertension in pregnancy

Purpose: Vitamin D Deficiency is common, particularly in northern latitudes. We examined the association between vitamin D status and hypertension in late pregnancy. Methods: A case-control study was conducted during two time periods: September-October, 2008, and January-March, 2009, in women near term. A case was defined as having two or more documented blood pressure readings above 140/90 (either/or) at any time during pregnancy (n=78). Controls had at least two blood pressure readings, with none above 140/90 during pregnancy (n=109). Serum 25-hydroxyvitamin D (25(OH)D) was measured in all participants. Results: In the summer, 13% of controls and 29% of the cases had 25(OH) D levels < 50 nmol/L. During the winter, these numbers rose to 44% and 49% respectively. Both cases and controls were more likely to be vitamin D deficient in the winter (p=0.002). There was a negative correlation between BMI and 25(OH)D (r=-0.202, p=0.002). In univariate analysis, cases had lower 25(OH)D (p=0.046), but also higher body mass index, so that in multivariate analysis 25(OH)D status was no longer significant. There was no difference in mean oral daily vitamin D intake (dietary intake and supplements, 746 and 785 IU respectively). Controls gained less weight in pregnancy. There was a negative correlation between the highest blood pressure measured in pregnancy and 25(OH)D levels (r= -0.118; p=0.012). Conclusion: There is a high prevalence of vitamin D deficiency in pregnant women recruited in Saskatoon, Saskatchewan. Women with low circulating vitamin D concentrations are more likely to have hypertension

Dress and deportment of medical residents: Formal or informal?

Purpose: Health care workers, including physicians, have adopted more casual dress. The appearance of a physician may influence patients’ opinion of physician knowledge, competence and trustworthiness. We hypothesized that medical inpatients and outpatients would rate these attributes higher in residents who dressed and acted in a more formal manner. Methods: Prospective cohort included both inpatients and outpatients. One hundred thirty three patients, aged 62.3±16 years, 49% of whom were female, were surveyed. One of two male resident physicians approached each patient, ostensibly to obtain consent to a brief mini-mental status examination. The physician was dressed, and acted, either “formally” (F) or “informally” (I). Patients then completed a six item questionnaire, using a 5 point Likert scale, to assess their confidence in the resident. Total scores could be 6 to 30. Total scores were compared using one-way ANOVA. Results: Patients’ perceptions were high for both F and I: 25.5±3.1 vs. 24.1±3.0, respectively (p=0.013). This difference was driven by the “labcoat” question: patients generally preferred physicians to wear a labcoat (3.9±1.0 vs. 2.8±1.3, p < 0.0001). Responses to four of the other fivequestions were numerically, but not statistically, higher in F. There was no difference in preference between the tworesidents: 24.6±2.8 vs. 24.9±3.5, p=0.56. Conclusion: More formal dress and demeanor by residents leads to a modest, but significant, increase in patient perception of the resident’s value. Wearing a white lab coat, in particular, has a positive effect

Comparing health behaviours of internal medicine residents and medical students: An observational study

Purpose: During residency, many physicians find it difficult to maintain a healthy lifestyle; however, there is little objective data available. In this study, residents’ health behaviours and cardiovascular risk status were compared with those of medical students. Methods: Medical residents (n=55, postgraduate years 1 to 4) were compared with medical students (n=62, years 1-4). The main dependent variable was the average number of steps per day (assessed using a pedometer) at work and leisure over three days, during which subjects were not on call or post-call. In addition, all subjects completed a three day food log. Frequency of vigorous exercise was assessed by a single question. Body mass index (BMI), waist circumference, blood pressure, total and high-density lipoprotein cholesterol, smoking habits and random blood glucose were measured, and Framingham Risk Score coronary artery disease 10 year probabilities (FRS) were calculated. Results: Residents recorded 8344±3520 steps per day while students recorded 10703±3986 (p < 0.002). 35% of residents and 52% of students averaged more than 10,000 steps per day and senior residents took fewer steps than junior residents. Both groups frequently failed to achieve the recommended daily servings of fruits and vegetables; on average, 3.5±2.0 servings for residents and 5.4±2.2 for students (p < 0.0001). BMI and FRS were higher among the residents in comparison with the students. Conclusion: Medical residents at our institution appear less active and consume fewer servings of fruits and vegetables than undergraduate medical students. These differences are associated with higher BMI, waist circumference and cardiovascular risk