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Response from ADM Barbara Walman - June 13 2013

 Ministry of Health
Office of the Assistant Deputy Minister
Pharmaceutical Services                               
3-2, 1515 Blanshard Street
Victoria BC V8W 3C8 
Telephone: 250 952’  64
June 13 2013 
Mr. R.E. Sleath
Access for Sight-Impaired Consumers
75 - 6600 Lucas Rd
Richmond BC V7C 4T1 
Dear Mr. Sleath: 
Thank you for your letter of April 12, 2013, regarding treatment of age-related macular  degeneration (AMD) in British Columbia. I apologize for the delay in responding. 
BC’s AMD program is the most comprehensive in Canada provides retinal specialists and  patients access to three treatments: verteporfin (Visudyne), bevacizumab (Avastin®) and  ranibizumab (Lucentis). 
Numerous international and Canadian research publications have concluded that bevacizumab  has a similar efficacy and safety profile to ranibizurnab. Most jurisdictions around the world  fund bevacizumab as the standard of care. In Canada, bevacizumab is currently reimbursed by  Veteran Affairs, Nova Scotia, Manitoba, Yukon, New Brunswick and BC. In the United States,  many Medicare programs cover bevacizumab for AMD. Bevacizumab is also covered in Italy  and Germany. 
As we had shared with you at our meeting, the AMD program in BC is the only program that  includes a comprehensive quality assurance program to monitor the safety and effectiveness of  the treatments. The Ministry of Health works with retinal specialists in monitoring new clinical  evidence and also gathering data on the experience of patients in BC. BC is unique in being the  only jurisdiction in Canada that has the ability to track the effectiveness and safety of each  injection given to a patient covered by the Program. Since the beginning of the AMD 
Program, there have been an extremely low number of adverse reactions associated with  bevacizumab and ranibizumab. 
Because both bevacizumab and ranibizumab have similar efficacy and safety, retinal specialists  may choose to use either bevacizumab or ranibizumab for their patients, depending on the  clinical scenario. Regarding your letter’s claim that the AMD Program motivates doctors to use  the cheaper bevacizumab, with efficacy and safety of the drugs being similar, if there are no  other relevant clinical factors to prefer one drug over the other, then it is entirely appropriate that  specialists select the less expensive option. This prescribing pattern represents an appropriate  and accountable stewardship of limited health resources and not what you suggest as a  financial incentive. 
In answer to your question regarding the differences in remuneration for BC retinal specialists  participating in the AMD Program and specialists in other provinces, the AMD Program in BC  covers the cost of the drugs, and also reimburses retinal specialists a program management fee  for performing a range of functions. These functions include developing and maintaining  clinical practice guidelines, monitoring program safety and effectiveness and implementing a  plan for province wide access to specialist care including travel to regional centres not served by  a resident retinal specialist. 
In regards to the survey, I appreciate receiving your survey of people treated for AMD in BC.  However, I note several survey limitations which raise concerns about the validity of the  findings. The results do not indicate when a patient may have started therapy or whether they  were accompanied by a care provider when first treated. This is important to have accurate  results as information could have been provided by the physician to the patient at the start of  therapy. Further, it is interesting to note that some patients do not recall getting an injection at  all and many do not know what drug they are getting. 
However, I do recognize the challenges in completing such a survey in the elderly and  appreciate the suggested conclusion that most patients receiving these treatments perceive a  need for more information. We have shared the survey results with the Provincial Health  Services Authority who are managing the AMD Program on behalf of the province and have  asked them to review the findings with the participating specialists. It will be useful for the  retinal specialists to understand the perspectives of their patients regarding provision of  information about AMD and the available treatment options. 
barbara Walman
Assistant Deputy Minister
Pharmaceutical Services

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