pital stays should be carefully monitored by the appropriate hospital committees and physicians should avoid, as far as possible, prolonged stays for reasons other than medical. The fact is that our entire system of medical education is largely hospitaloriented. The medical graduate, who is a product of a large hospital with sophisticated equipment and a wealth of medical and nursing staff, can be forgiven for feeling uneasy when plunged into a small community with a minimum of facilities. Apart from increasing demand for ever more sophisticated facilities, this syndrome has another unfortunate effect - it discourages many young physicians from practising in rural areas. I believe physicians should observe these basic rules for admitting patients to hospital: * At the time of admission to hospital, assess the probable outcome. Where appropriate, plan ahead for the possible transfer of that patient to more appropriate facilities outside the expensive conventional hospital. * Do not admit a patient to hospital for an elective condition on a Friday or Saturday when it is known that the necessary procedures will not be started until Monday or later. In the same way, patients should be discharged at the earliest date possible consistent with good medical and nursing practice. In this changing emphasis on the cost and nature of care and treatment, the physician can help by explaining to patients and relatives the planned substitution of less expensive alternatives to acute hospital care. Given a logical explanation, the public will accept the reduction in ratio of acute beds to the population if they are assured that less expensive alternatives such as home care, outpatient and day care, personal care facilities and extended care outside the acute hospital do not represent second-class medicine but a more realistic use of the taxpayer's money. The methods of paying for medical care need thorough examination. At
present there is some duplication of payment out of tax funds. For many fee-for-service items the rate is based on the assumption the work will be performed in the physician's office. An increasing volume of these procedures is being performed in hospitals. The provincial hospital plan pays for the necessary staff, supplies and overhead, yet the physician bills the provincial medical plan for the standard fee. I understand that Quebec tackled this problem in recently completed negotiations by providing for lower physician charges when the typical office service is provided in a hospital or in another government-financed facility. Personally, I don't agree with the often-heard argument that since the hospital or laboratory exists, it will cost money anyway, no matter how wisely or unwisely it is used. I believe that everyone in the health care professions should develop an attitude of value for money consistent with good medical care. All of us in health care are taxpayers, too. Since all of us are paying the bills as well as creating them, we have an urgent responsibility to control the soaring costs of health care in Canada. I'm pleased to say that in British Columbia the medical profession appears well aware of this mounting crisis in health care costs. At two recent meetings with the British Columbia Medical Association, physicians expressed their interest and concern in the very questions raised by the Canadian Medical Association Journal in this issue. The BC'MA is also actively encouraging its members to make patients aware of changes in lifestyle that in turn will reduce demands on health care services. If we take a global view of health, it isn't too much to ask the physician to make his patients aware of the risks of smoking, driving without seat belts, obesity and overindulging in alcohol. Again, we will be reducing demands on services. More important, we will be encouraging people to be healthier.
The physician and pharmacotherapy IAN HENDERSON, FRCS[C]
Costs to governments and the individual for comprehensive health care have been increasing substantially faster than recent annual increases in the gross national product. For 1975 the overall cost in Canada has been estimDr. Henderson, an Ottawa surgeon and professor of surgery, chairs the subcommittee on pharmacotherapy of the GMA.
ated to have been nearly $10 billion. Of this, $4.7 billion was for hospital care. The total amounted to $352 per capita. The consumption of medicines amounted to about $23 per capita. Examination of Canada's health care costs at 5-year intervals between 1960 and 1975 demonstrates that the costs for hospital services increased 6 times; physicians' services 4 times; dentists'
1048 GMA JOURNAL/MAY 7, 1977/VOL. 116
Pro-BanthTne for more than peptic ulcer INDICATIONS Pro-Banthine is indicated in peptic ulcer, functional gastrointestinal disturbances, ulcerative colitis, bi iary dyskinesia, chronic hypertrophic gastritis, pylorospasm, acute and chronic pancreatitis, hypermotility of the small intestine not associated with organic change, ileostomies, irritable colon syndrome, diverticulitis, ureteral and urinary bladder spasm, hyperhidrosis. CONTRAIND ICATIONS Glaucoma Obstructive disease of the gastrointestinal tract Obstructive uropathy due to prostatism Intestinal atony of elderly or debilitated patients Toxic megacolon complicating ulcerative colitis Hiatal hernia associated with reflux esophagitla Unstable cardiovascular adjustment in acute hemorrhage PRECAUTIONS Patients with severe cardiac disease should be given this medication with caution if even a slight increase in heart rate is undesirable. Fever and heat stroke may occur due to anhidrosis. Varying degrees of urinary hesitancy may occur in elderly patients with prostatic hyperlrophy. In such patients urinary retention may be avoided if they are advised to micturate at the time of taking the medication. A decrease in bronchial secretion may lead to inspissation by these secretions and formation of mucus plugs especially in the elderly or debilitated with chronic pulmonary disease. ADVERSE EFFECTS Varying degrees of drying of salivary secretions may occur as well as mydriasis and blurred vision. In addition the following adverse reactions have been reported: nervousness, drowsiness, dizziness, insomnia, headache, loss of the sense of taste, nausea, vomiting, constipation, impotence and allergic dermatitis. Some of these effects are dose related. DOSAGE AND ADMINISTRATION Oral: Dosage should be individualized Pro-Banthine tablets (7.5 mg and 15 mg): the usual adult dosage is 7.5 mg to 15 mg of propantheline bromide with meals and 15 mg to 30 mg at bedtime. Patients with severe manifestations may require increased dosage up to 30 mg four limes a day. Pro-Banthine P.A. (30 mg): the usual adult dosage is one tablet in the morning and one at night. Occasionally patients may require one tablet every 8 hours. Parenteral: Initial parenteral dose may be 30 mg or more every 6 hours intramuscularly or intravenously, depending on the condition for which it is administered and the requirements for prompt action. IM. solution - prepared by sterilizing the rubber cap with alcohol and injecting 1 ml of U.S.P. sterile waler for injection into the ampoule. IV. solution - recommended that the contents of the 30 mg ampoule be dissolved in 10 ml of U.S.P. sodium chloride injection. COMPOSITION AND AVAILABILITY Pro-Banthine 7.5 mg: each white, round, convex, sugar-coated tablet imprinted "Searle" on one side and '611" on the other contains 7.5 mg of propantheline bromide. In bottles of 100 tablets. Pro-Banthlne 15 mg: each peach-coloured, sugarcoated tablet imprinted "Searle" on one side and "601" on the other contains 15 mg of propantheline bromide. In bottles of 100, 1000 and 2500 tablets. Pro-Banthlne P.A. (Prolonged ActIng): the core of each capsule-shaped, compression-coated, peach-coloured tablet, impressed "Searle" on one side and "651" on the other contains 30 mg of propantheline bromide in the form of sustainedrelease beads, about half being released within one hour of ingestion and the remainder released slowly as earlier increments are metabolized. In bottles of 50 and 500 tablets. Pro-Banlhine VIALS: each vial contains 30 mg of propantheline bromide as a dry sterile powder for parenteral therapy following reconstitution. In boxes of 10 vials. Full prescribing information available on request or in OPS.
-'. Searle Pharmaceuticals Oakville, Ontario
services S times; and prescribed drugs by a factor of 5 times. Absolute figures reveal the relativity of costs for drugs (1975: $0.5 billion) as compared to hospital services (1975: $4.7 billion) and physicians' services (1975: $1.7 billion). None the less there has been, and continues to be, considerable concern over what seem to be steadily rising per capita expenditures on prescriptions and average prescription prices. In 1961, per capita expenditures on prescription drugs averaged $7.50, and by 1975 it was estimated that this had risen to $23 per capita. Average prescription prices (retail) rose, between 1964 and 1974, from $3.14 to $4.45, an increase of 42%. When these figures are compared in the light of inflation over that same period, the price may be calculated in constant dollars to have decreased by some 15%. It is logical to assume that increased expenditures on drugs today must be due to a greater number of prescriptions for a greater number of people. This indeed is the case in practice both outside and within hospitals. Universal health care plans for the increasing Canadian population have resulted in markedly increased accessibility to physicians and the ready availability of hospital care when necessary. Increased diagnostic skills and a growing belief in preventive medicine are resulting in the surfacing of more and more previously undiagnosed illnesses readily treatable with pharmacotherapy. Canadians may actually be undermedicated. Possibly not more than 25% of those with mild or moderate hypertension have been diagnosed, largely because the disease is often asymptomatic prior to a serious complication; perhaps one quarter of all diabetics are not under a therapeutic regimen; up to one third of all arthritics may not be receiving adequate drug therapy; a quarter of persons with VD are probably escaping drug treatment; and of those Canadians suffering from some form of mental or emotional illness, perhaps fewer than 35% are receiving adequate care. Similar statements are almost certainly justified for vaccinations and immunizations. More diagnoses
Increases in the number of diagnoses reached have resulted from increasingly sophisticated procedures and equipment and as a consequence of screening programs by medical and paramedical personnel. More persons are in the age groups that require the most treatment. All increase the numbers of prescriptions for all kinds of drugs. Whether these drugs are generic or brand in
products made it necessary to test different manufacturers' products for relative bioavailability and several other aspects of drug quality assessment. Out of these have emerged the concepts of drug interchangeability and low-cost substitution on the basis of official drug lists and formularies. Many provinces have introduced drug programs such as Ontario's PARCOST (prescription at reasonable cost), and Saskatchewan has introduced a "maximum allowable cost" program. More recently the federal government, in conjunction with several provinces, has initiated a central drug-purchasing program. Adaptation
m Canadians may be undermedicated
With all these innovations Canadian physicians have learned to live. They have at least partially adapted to the reality of an ever-increasing government presence in what has been one of the traditional freedoms of the practice of medicine. To contend repeatedly that drugs ordered by our prescriptions are costing us all too much is possibly to add insult to injury! Nevertheless, it has to be admitted that drug costs could be lowered by desirable changes in our medical practice without harming our patients' welfare. From my viewpoint as chairman of the pharmacy and therapeutics committee of a teaching hospital, I see where costs could be trimmed if: * Our hospital formulary systematically excluded duplicative preparations. * We accepted the concepts of both pharmaceutical interchangeability of products, and therapeutic interchangeability (cefazolin for cephalothin; cloxacillin for dicloxacillin - or vice versa). * Manufacturers' promotional campaigns were effectively countered by a continuing program of clinical pharmacology and therapeutics. * Prescribing were truly rational. In many countries there is a realization that drug therapy is often so irrational (incorrect choice of drug, wrong route of administration, the wrong dosage schedule for best results, use at inappropriate times with relationship to food, or use with other drugs with which it is incompatible or with which it interacts), that the intended benefits are never achieved, while the incidence of drug adverse reactions remains unacceptably high. There is a beginning acceptance in North America and Europe that dinical pharmacologists are very useful staff members of even medium-sized hospitals, in which they can raise the standards of drug prescribing by promoting a more rational use of all drugs
type, almost certainly there will be an increase in drug costs in the years ahead. An important aspect of drug use in the pattern of modern medical practice and treatment is the great change from inpatient to outpatient care, using pharmacotherapy at home to substitute for costly hospital stays. Indeed only the availability of newer and safer pharmaceutical products has made home care feasible and oftentimes preferable for patients who previously would have needed prolonged institutional nur-sing and other forms of nondrug therapy. There are certainly some instances where drugs are used in excess of requirements both in hospital and nonhospital practice, but the harmfulness of this is small indeed, compared to the damage that ensues from failure to use medications at proper dosages when needed. Nevertheless in recent years throughout Canada, a variety of programs have been introduced at federal and provincial government levels that have, as their primary goal, lower drug costs. These began in 1968 with the Patent, Trade Marks and Food and Drugs Act amendments, culminating the following year with Bill C-102, which permitted compulsory licensing to import drug products covered under process patents. It was this more than anything else that occasioned the recent profusion of generic products on the Canadian market. The large number of what were supposed to be "identical" CMA JOURNAL/MAY 7, 1977/VOL. 116 1051
0.05% emollient crea
lidemol® (fluocinonide)
Prescribing information Description: Lidemol (fluocinonide 0.05%) is an antiinflammatory, antipruritic and vasoconstrictor agent for topical use in the management of corticosteroid responsive dermatoses. Lidemol contains fluocinonide in a specially formulated emollient cream base. The formutation does not contain lanolin, parabens or phenolic compounds indications: Lidemol (fluocinonide 0.05%) is intended for topical use in the management of acute or chronic corticosteriod responsive dermatoses such as psoriasis, atopic dermatitis, seborrheic dermatitis, contact dermatitis, eczematous dermatitis, lichen planus, neurodermatitis, intertriginous psoriasis, nummular eczema, exfoliative dermatitis, pruritus ani et vulvae, lichen simplex chronicus, intertrigo, postanal surgery, otitis externa and stasis dermatitis. Lidemol is suitable when an emollient effect is desired. Contraindications: Topical corticosteroids are contraindicated in tuberculous, fungal and most viral lesions of the skin (including herpes simplex, vaccinia and varicella), untreated purulent bacterial infections, and also in individuals with a history of hypersensitivity to its components. This preparation is not for ophthalmic use. Warnings: The safety of topical corticosteroids during pregnancy or lactation has not been established. The potential benefit, if used during pregnancy or lactation, should be weighed against possible hazards to the fetus or the nursing infant. It is recommended that Lidemol not be used under occlusive dressings Precautions: Although side effects are not ordinarily encountered with topically applied corticosteroids, as with all drugs, a few patients may react unfavorably under certain conditions. Should sensitivity or idiosyncratic reactions occur, the agent should be discontinued and appropriate steps taken. In the presence of an infection, the use of an appropriate anti-fungal or antibacterial agent should be instituted. If a favorable response does not occur promptly, the corticosteroid cream should be discontinued until the infection has been adequately controlled. If extensive areas are treated, the possibility exists of increased systemic absorption and suitable precautions should be takenPatients should be advised to inform subsequent physicians of the prior use of corticosteroids. Causal factors should be eliminated whenever possible. It is recommended that rotation of sites of application and inl.rmittent therapy be considered. Adverse reactions: Side effects have been extremely rare and consist mainly of local burning, irritation and itching. When this occurs, the possibility of sensitization must be kept in mind. Skin atrophy, strise, hypertrichosis and adrenal suppression have been shown to occur with prolonged and indiscriminate use of topical corticosteroids, particularly under occlusion. Due to percutaneous absorption, similar phenomena could conceivably occur with prolonged and excessive use of Lidemol. Posterior subcapsular cataracts have been reported following the systemic use of corticosteroids. Dosage: Lidemot (f uoc inonide 0.05%) - is suitsble when an emollient effect is desired, in dry, scaly conditions, and on less severely inflamed surfaces, or where there is a tendency to fissuring and cracking, as in hand dermatoses. A small amount should be applied lightly to the affected skin area two to four times daily with gentle but thorough massage. Availabiiity: Lidemof (fluocinonide 0.05%) - 15 g and 45 g tubes. Product monograph available on request.
SYNTEX Syntex Ltd. Montr6al, Quebec
- which sometimes means less pre- best by community counselling services scribing. Clinical pharmacologists how- or psychiatric consultation rather than ever are in short supply, and thus clin- by prescribing nonspecific psychoactive icians in all specialties must begin to drugs for long periods. Only some take more interest in prescribing patients with angina should appropristandards as part of the medical audit ately receive p-blocking agents. function and as part of peer review of Whatever savings may accrue to drug utilization. our health care programs from listed There is a growing interest on the interchangeability of drugs, mandatory part of hospital pharmacists and clin- substitution by pharmacists or limitaical pharmacists in rational prescribing, tion of drug products by formularies, and we would thus do well to admit no factor will save as much as rational interested and constructively minded prescribing. pharmacist colleagues to our discusManufacturers' promotional camsions about therapy. paigns that attempt to change estabCertain areas of prescribing irration- lished prescribing practices should be ality raise costs enormously. By far the viewed with healthy scepticism. This is greatest is incorrect antibiotic usage. not the same thing as refusing to conPossibly no area of pharmacotherapy sider new drugs that really are a little needs more specific remedial education (and occasionally a lot) better than than this. A proper understanding of older ones, but simply to indicate that appropriate employment of anti-infec- claims of improvements or "breaktive agents necessitates a working throughs" require careful appraisal beknowledge of the constantly changing fore acceptance. field of microbiology as it applies to our particular patients, whether these A costly affitude be children, old-age pensioners, debilitated or immunosuppressed patients, or In an attempt to prove to ourselves, a mixture of all of them. The choice of or perhaps to our colleagues, that we an appropriate antibiotic, its adminis- are "with it", a recently promoted prodtration by the parenteral or oral route uct is seized upon in the belief that (with the parenteral always much more the manufacturer would not have reexpensive), correct time-and-dose sched- ceived a licence to market it unless uling according to basic pharmacokin- there were therapeutic advantages or etic data, all call for a modicum of decided improvements. Use of a cephstudy of information and daily con- alosporin instead of penicillin G or V sideration of cost-benefit. for an infection that responds equally well to both (but at very differing costs) is a good example of this costly atRoutine antibiotics titude. While there may be some small place In the absence of a truly Canadian for prophylactic antibiotic therapy, we drug publication providing critical recannot justify routine use of antibac- view of new drugs, and because only terial agents for viral diseases that just some physicians regularly receive exmight be followed by a bacterial in- cellent provincial information about fection, or the postoperative use of drugs, our hospital library committees antibiotics after surgical procedures should be encouraged to subscribe that rarely are complicated by infec- either to the US Medical Letter or tion. to the informative but less critical There is a host of other examples of INPHARMA bulletins. Many physiirrational prescribing. Insomnia is not cians find a book such as "Drugs of necessarily an indication for hypnotics; Choice" (1976-77) edited by Walter obesity is managed best without drugs Modell (C.V. Mosby Company, Saint (usually by nonmedical groups); and Louis) useful as a general guide for emotional problems may be managed rational use of drugs.
Qul est responsable de I'augmentation des coOts de Ia sante? CLAIRE LALONDE
Le grand d6bat de 1'heure dans le domaine de la sant6 est certainement celui des coiits des services. Ceux-ci occupent d6Ja une part importante du budget des gouvernements et semblent
1054 CMA JOURNAL/MAY 7, 1977/VOL. 116
devoir continuer . s'accroitre. Une .tude de la R.gie de 1'assurance-maladie du Quebec (RAMQ) rendue publique en f.vrier dernier a ouvert un autre chapitre . cette controverse; cette 6tude
present there is some duplication of payment out of tax funds. For many fee-for-service items the rate is based on the assumption the work will be performed in the physician's office. An increasing volume of these procedures is being performed in hospitals. The provincial hospital plan pays for the necessary staff, supplies and overhead, yet the physician bills the provincial medical plan for the standard fee. I understand that Quebec tackled this problem in recently completed negotiations by providing for lower physician charges when the typical office service is provided in a hospital or in another government-financed facility. Personally, I don't agree with the often-heard argument that since the hospital or laboratory exists, it will cost money anyway, no matter how wisely or unwisely it is used. I believe that everyone in the health care professions should develop an attitude of value for money consistent with good medical care. All of us in health care are taxpayers, too. Since all of us are paying the bills as well as creating them, we have an urgent responsibility to control the soaring costs of health care in Canada. I'm pleased to say that in British Columbia the medical profession appears well aware of this mounting crisis in health care costs. At two recent meetings with the British Columbia Medical Association, physicians expressed their interest and concern in the very questions raised by the Canadian Medical Association Journal in this issue. The BC'MA is also actively encouraging its members to make patients aware of changes in lifestyle that in turn will reduce demands on health care services. If we take a global view of health, it isn't too much to ask the physician to make his patients aware of the risks of smoking, driving without seat belts, obesity and overindulging in alcohol. Again, we will be reducing demands on services. More important, we will be encouraging people to be healthier.
The physician and pharmacotherapy IAN HENDERSON, FRCS[C]
Costs to governments and the individual for comprehensive health care have been increasing substantially faster than recent annual increases in the gross national product. For 1975 the overall cost in Canada has been estimDr. Henderson, an Ottawa surgeon and professor of surgery, chairs the subcommittee on pharmacotherapy of the GMA.
ated to have been nearly $10 billion. Of this, $4.7 billion was for hospital care. The total amounted to $352 per capita. The consumption of medicines amounted to about $23 per capita. Examination of Canada's health care costs at 5-year intervals between 1960 and 1975 demonstrates that the costs for hospital services increased 6 times; physicians' services 4 times; dentists'
1048 GMA JOURNAL/MAY 7, 1977/VOL. 116
Pro-BanthTne for more than peptic ulcer INDICATIONS Pro-Banthine is indicated in peptic ulcer, functional gastrointestinal disturbances, ulcerative colitis, bi iary dyskinesia, chronic hypertrophic gastritis, pylorospasm, acute and chronic pancreatitis, hypermotility of the small intestine not associated with organic change, ileostomies, irritable colon syndrome, diverticulitis, ureteral and urinary bladder spasm, hyperhidrosis. CONTRAIND ICATIONS Glaucoma Obstructive disease of the gastrointestinal tract Obstructive uropathy due to prostatism Intestinal atony of elderly or debilitated patients Toxic megacolon complicating ulcerative colitis Hiatal hernia associated with reflux esophagitla Unstable cardiovascular adjustment in acute hemorrhage PRECAUTIONS Patients with severe cardiac disease should be given this medication with caution if even a slight increase in heart rate is undesirable. Fever and heat stroke may occur due to anhidrosis. Varying degrees of urinary hesitancy may occur in elderly patients with prostatic hyperlrophy. In such patients urinary retention may be avoided if they are advised to micturate at the time of taking the medication. A decrease in bronchial secretion may lead to inspissation by these secretions and formation of mucus plugs especially in the elderly or debilitated with chronic pulmonary disease. ADVERSE EFFECTS Varying degrees of drying of salivary secretions may occur as well as mydriasis and blurred vision. In addition the following adverse reactions have been reported: nervousness, drowsiness, dizziness, insomnia, headache, loss of the sense of taste, nausea, vomiting, constipation, impotence and allergic dermatitis. Some of these effects are dose related. DOSAGE AND ADMINISTRATION Oral: Dosage should be individualized Pro-Banthine tablets (7.5 mg and 15 mg): the usual adult dosage is 7.5 mg to 15 mg of propantheline bromide with meals and 15 mg to 30 mg at bedtime. Patients with severe manifestations may require increased dosage up to 30 mg four limes a day. Pro-Banthine P.A. (30 mg): the usual adult dosage is one tablet in the morning and one at night. Occasionally patients may require one tablet every 8 hours. Parenteral: Initial parenteral dose may be 30 mg or more every 6 hours intramuscularly or intravenously, depending on the condition for which it is administered and the requirements for prompt action. IM. solution - prepared by sterilizing the rubber cap with alcohol and injecting 1 ml of U.S.P. sterile waler for injection into the ampoule. IV. solution - recommended that the contents of the 30 mg ampoule be dissolved in 10 ml of U.S.P. sodium chloride injection. COMPOSITION AND AVAILABILITY Pro-Banthine 7.5 mg: each white, round, convex, sugar-coated tablet imprinted "Searle" on one side and '611" on the other contains 7.5 mg of propantheline bromide. In bottles of 100 tablets. Pro-Banthlne 15 mg: each peach-coloured, sugarcoated tablet imprinted "Searle" on one side and "601" on the other contains 15 mg of propantheline bromide. In bottles of 100, 1000 and 2500 tablets. Pro-Banthlne P.A. (Prolonged ActIng): the core of each capsule-shaped, compression-coated, peach-coloured tablet, impressed "Searle" on one side and "651" on the other contains 30 mg of propantheline bromide in the form of sustainedrelease beads, about half being released within one hour of ingestion and the remainder released slowly as earlier increments are metabolized. In bottles of 50 and 500 tablets. Pro-Banlhine VIALS: each vial contains 30 mg of propantheline bromide as a dry sterile powder for parenteral therapy following reconstitution. In boxes of 10 vials. Full prescribing information available on request or in OPS.
-'. Searle Pharmaceuticals Oakville, Ontario
services S times; and prescribed drugs by a factor of 5 times. Absolute figures reveal the relativity of costs for drugs (1975: $0.5 billion) as compared to hospital services (1975: $4.7 billion) and physicians' services (1975: $1.7 billion). None the less there has been, and continues to be, considerable concern over what seem to be steadily rising per capita expenditures on prescriptions and average prescription prices. In 1961, per capita expenditures on prescription drugs averaged $7.50, and by 1975 it was estimated that this had risen to $23 per capita. Average prescription prices (retail) rose, between 1964 and 1974, from $3.14 to $4.45, an increase of 42%. When these figures are compared in the light of inflation over that same period, the price may be calculated in constant dollars to have decreased by some 15%. It is logical to assume that increased expenditures on drugs today must be due to a greater number of prescriptions for a greater number of people. This indeed is the case in practice both outside and within hospitals. Universal health care plans for the increasing Canadian population have resulted in markedly increased accessibility to physicians and the ready availability of hospital care when necessary. Increased diagnostic skills and a growing belief in preventive medicine are resulting in the surfacing of more and more previously undiagnosed illnesses readily treatable with pharmacotherapy. Canadians may actually be undermedicated. Possibly not more than 25% of those with mild or moderate hypertension have been diagnosed, largely because the disease is often asymptomatic prior to a serious complication; perhaps one quarter of all diabetics are not under a therapeutic regimen; up to one third of all arthritics may not be receiving adequate drug therapy; a quarter of persons with VD are probably escaping drug treatment; and of those Canadians suffering from some form of mental or emotional illness, perhaps fewer than 35% are receiving adequate care. Similar statements are almost certainly justified for vaccinations and immunizations. More diagnoses
Increases in the number of diagnoses reached have resulted from increasingly sophisticated procedures and equipment and as a consequence of screening programs by medical and paramedical personnel. More persons are in the age groups that require the most treatment. All increase the numbers of prescriptions for all kinds of drugs. Whether these drugs are generic or brand in
products made it necessary to test different manufacturers' products for relative bioavailability and several other aspects of drug quality assessment. Out of these have emerged the concepts of drug interchangeability and low-cost substitution on the basis of official drug lists and formularies. Many provinces have introduced drug programs such as Ontario's PARCOST (prescription at reasonable cost), and Saskatchewan has introduced a "maximum allowable cost" program. More recently the federal government, in conjunction with several provinces, has initiated a central drug-purchasing program. Adaptation
m Canadians may be undermedicated
With all these innovations Canadian physicians have learned to live. They have at least partially adapted to the reality of an ever-increasing government presence in what has been one of the traditional freedoms of the practice of medicine. To contend repeatedly that drugs ordered by our prescriptions are costing us all too much is possibly to add insult to injury! Nevertheless, it has to be admitted that drug costs could be lowered by desirable changes in our medical practice without harming our patients' welfare. From my viewpoint as chairman of the pharmacy and therapeutics committee of a teaching hospital, I see where costs could be trimmed if: * Our hospital formulary systematically excluded duplicative preparations. * We accepted the concepts of both pharmaceutical interchangeability of products, and therapeutic interchangeability (cefazolin for cephalothin; cloxacillin for dicloxacillin - or vice versa). * Manufacturers' promotional campaigns were effectively countered by a continuing program of clinical pharmacology and therapeutics. * Prescribing were truly rational. In many countries there is a realization that drug therapy is often so irrational (incorrect choice of drug, wrong route of administration, the wrong dosage schedule for best results, use at inappropriate times with relationship to food, or use with other drugs with which it is incompatible or with which it interacts), that the intended benefits are never achieved, while the incidence of drug adverse reactions remains unacceptably high. There is a beginning acceptance in North America and Europe that dinical pharmacologists are very useful staff members of even medium-sized hospitals, in which they can raise the standards of drug prescribing by promoting a more rational use of all drugs
type, almost certainly there will be an increase in drug costs in the years ahead. An important aspect of drug use in the pattern of modern medical practice and treatment is the great change from inpatient to outpatient care, using pharmacotherapy at home to substitute for costly hospital stays. Indeed only the availability of newer and safer pharmaceutical products has made home care feasible and oftentimes preferable for patients who previously would have needed prolonged institutional nur-sing and other forms of nondrug therapy. There are certainly some instances where drugs are used in excess of requirements both in hospital and nonhospital practice, but the harmfulness of this is small indeed, compared to the damage that ensues from failure to use medications at proper dosages when needed. Nevertheless in recent years throughout Canada, a variety of programs have been introduced at federal and provincial government levels that have, as their primary goal, lower drug costs. These began in 1968 with the Patent, Trade Marks and Food and Drugs Act amendments, culminating the following year with Bill C-102, which permitted compulsory licensing to import drug products covered under process patents. It was this more than anything else that occasioned the recent profusion of generic products on the Canadian market. The large number of what were supposed to be "identical" CMA JOURNAL/MAY 7, 1977/VOL. 116 1051
0.05% emollient crea
lidemol® (fluocinonide)
Prescribing information Description: Lidemol (fluocinonide 0.05%) is an antiinflammatory, antipruritic and vasoconstrictor agent for topical use in the management of corticosteroid responsive dermatoses. Lidemol contains fluocinonide in a specially formulated emollient cream base. The formutation does not contain lanolin, parabens or phenolic compounds indications: Lidemol (fluocinonide 0.05%) is intended for topical use in the management of acute or chronic corticosteriod responsive dermatoses such as psoriasis, atopic dermatitis, seborrheic dermatitis, contact dermatitis, eczematous dermatitis, lichen planus, neurodermatitis, intertriginous psoriasis, nummular eczema, exfoliative dermatitis, pruritus ani et vulvae, lichen simplex chronicus, intertrigo, postanal surgery, otitis externa and stasis dermatitis. Lidemol is suitable when an emollient effect is desired. Contraindications: Topical corticosteroids are contraindicated in tuberculous, fungal and most viral lesions of the skin (including herpes simplex, vaccinia and varicella), untreated purulent bacterial infections, and also in individuals with a history of hypersensitivity to its components. This preparation is not for ophthalmic use. Warnings: The safety of topical corticosteroids during pregnancy or lactation has not been established. The potential benefit, if used during pregnancy or lactation, should be weighed against possible hazards to the fetus or the nursing infant. It is recommended that Lidemol not be used under occlusive dressings Precautions: Although side effects are not ordinarily encountered with topically applied corticosteroids, as with all drugs, a few patients may react unfavorably under certain conditions. Should sensitivity or idiosyncratic reactions occur, the agent should be discontinued and appropriate steps taken. In the presence of an infection, the use of an appropriate anti-fungal or antibacterial agent should be instituted. If a favorable response does not occur promptly, the corticosteroid cream should be discontinued until the infection has been adequately controlled. If extensive areas are treated, the possibility exists of increased systemic absorption and suitable precautions should be takenPatients should be advised to inform subsequent physicians of the prior use of corticosteroids. Causal factors should be eliminated whenever possible. It is recommended that rotation of sites of application and inl.rmittent therapy be considered. Adverse reactions: Side effects have been extremely rare and consist mainly of local burning, irritation and itching. When this occurs, the possibility of sensitization must be kept in mind. Skin atrophy, strise, hypertrichosis and adrenal suppression have been shown to occur with prolonged and indiscriminate use of topical corticosteroids, particularly under occlusion. Due to percutaneous absorption, similar phenomena could conceivably occur with prolonged and excessive use of Lidemol. Posterior subcapsular cataracts have been reported following the systemic use of corticosteroids. Dosage: Lidemot (f uoc inonide 0.05%) - is suitsble when an emollient effect is desired, in dry, scaly conditions, and on less severely inflamed surfaces, or where there is a tendency to fissuring and cracking, as in hand dermatoses. A small amount should be applied lightly to the affected skin area two to four times daily with gentle but thorough massage. Availabiiity: Lidemof (fluocinonide 0.05%) - 15 g and 45 g tubes. Product monograph available on request.
SYNTEX Syntex Ltd. Montr6al, Quebec
- which sometimes means less pre- best by community counselling services scribing. Clinical pharmacologists how- or psychiatric consultation rather than ever are in short supply, and thus clin- by prescribing nonspecific psychoactive icians in all specialties must begin to drugs for long periods. Only some take more interest in prescribing patients with angina should appropristandards as part of the medical audit ately receive p-blocking agents. function and as part of peer review of Whatever savings may accrue to drug utilization. our health care programs from listed There is a growing interest on the interchangeability of drugs, mandatory part of hospital pharmacists and clin- substitution by pharmacists or limitaical pharmacists in rational prescribing, tion of drug products by formularies, and we would thus do well to admit no factor will save as much as rational interested and constructively minded prescribing. pharmacist colleagues to our discusManufacturers' promotional camsions about therapy. paigns that attempt to change estabCertain areas of prescribing irration- lished prescribing practices should be ality raise costs enormously. By far the viewed with healthy scepticism. This is greatest is incorrect antibiotic usage. not the same thing as refusing to conPossibly no area of pharmacotherapy sider new drugs that really are a little needs more specific remedial education (and occasionally a lot) better than than this. A proper understanding of older ones, but simply to indicate that appropriate employment of anti-infec- claims of improvements or "breaktive agents necessitates a working throughs" require careful appraisal beknowledge of the constantly changing fore acceptance. field of microbiology as it applies to our particular patients, whether these A costly affitude be children, old-age pensioners, debilitated or immunosuppressed patients, or In an attempt to prove to ourselves, a mixture of all of them. The choice of or perhaps to our colleagues, that we an appropriate antibiotic, its adminis- are "with it", a recently promoted prodtration by the parenteral or oral route uct is seized upon in the belief that (with the parenteral always much more the manufacturer would not have reexpensive), correct time-and-dose sched- ceived a licence to market it unless uling according to basic pharmacokin- there were therapeutic advantages or etic data, all call for a modicum of decided improvements. Use of a cephstudy of information and daily con- alosporin instead of penicillin G or V sideration of cost-benefit. for an infection that responds equally well to both (but at very differing costs) is a good example of this costly atRoutine antibiotics titude. While there may be some small place In the absence of a truly Canadian for prophylactic antibiotic therapy, we drug publication providing critical recannot justify routine use of antibac- view of new drugs, and because only terial agents for viral diseases that just some physicians regularly receive exmight be followed by a bacterial in- cellent provincial information about fection, or the postoperative use of drugs, our hospital library committees antibiotics after surgical procedures should be encouraged to subscribe that rarely are complicated by infec- either to the US Medical Letter or tion. to the informative but less critical There is a host of other examples of INPHARMA bulletins. Many physiirrational prescribing. Insomnia is not cians find a book such as "Drugs of necessarily an indication for hypnotics; Choice" (1976-77) edited by Walter obesity is managed best without drugs Modell (C.V. Mosby Company, Saint (usually by nonmedical groups); and Louis) useful as a general guide for emotional problems may be managed rational use of drugs.
Qul est responsable de I'augmentation des coOts de Ia sante? CLAIRE LALONDE
Le grand d6bat de 1'heure dans le domaine de la sant6 est certainement celui des coiits des services. Ceux-ci occupent d6Ja une part importante du budget des gouvernements et semblent
1054 CMA JOURNAL/MAY 7, 1977/VOL. 116
devoir continuer . s'accroitre. Une .tude de la R.gie de 1'assurance-maladie du Quebec (RAMQ) rendue publique en f.vrier dernier a ouvert un autre chapitre . cette controverse; cette 6tude
