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Response from Assistant Deputy Minister – 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