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Background: Potentially inappropriate medications (PIMs) are medications whereby the harms may outweigh the benefits for a given individual. Although overprescribed to older adults, their direct costs on the healthcare system are poorly described., Methods: This was a cross-sectional study of the cost of PIMs for Canadians aged 65 and older, using adapted criteria from the American Geriatrics Society. We examined prescription claims information from the National Prescription Drug Utilization Information System in 2021 and compared these with 2013. The overall levels of inflation-adjusted total annual expenditure on PIMs, average cost per quarterly exposure, and average quarterly exposures to PIMs were calculated in CAD$., Results: Exposure to most categories of PIMs decreased, aside from gabapentinoids, proton pump inhibitors, and antipsychotics, all of which increased. Canadians spent $1 billion on PIMs in 2021, a 33.6% reduction compared with 2013 ($1.5 billion). In 2021, the largest annual expenditures were on proton pump inhibitors ($211 million) and gabapentinoids ($126 million). The quarterly amount spent on PIMs per person exposed decreased from $95 to $57. In terms of mean cost per person, opioids and antipsychotics were highest ($138 and $118 per exposure). Some cost savings may have occurred secondary to an observed decline of 16.4% in the quarterly rate of exposure to PIMs (from 7301 per 10,000 in 2013 to 6106 per 10,000 in 2021)., Conclusions: While expenditures on PIMs have declined in Canada, the overall cost remains high. Prescribing of some seriously harmful classes of PIMs has increased and so directed, scalable interventions are needed., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Competing Interests: Intérêts concurrents :: Steven Morgan déclare avoir reçu en 2018 un financement de Santé Canada pour des articles de recherche documentaire à l’intention du Conseil consultatif sur la mise en œuvre d’un régime national d’assurance médicaments par le gouvernement, indépendamment des travaux soumis. Matthew Herder déclare avoir reçu des subventions des Instituts de recherche en santé du Canada et de l’Agence de santé publique du Canada et avoir été membre du conseil d’administration du Conseil d’examen du prix des médicaments brevetés, indépendamment des travaux soumis.

Competing Interests: Competing interests:: Steven Morgan reports receiving funding, in 2018, from Health Canada for background research papers for the Advisory Council on the Implementation of National Pharmacare, outside the submitted work. Matthew Herder reports receiving grants from the Canadian Institutes of Health Research and the Public Health Agency of Canada, and has held a role as a board member of the Patented Medicine Prices Review Board, all outside the submitted work.

Background: The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use)., Methods: We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted., Results: From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy., Conclusion: Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs., Competing Interests: Declaration of competing interest MC has no real or perceived conflicts of interest; SM has no real or perceived conflicts of interest; CG has no real or perceived conflicts of interest; CAS discloses funding from Pfizer Canada (project: A Quality Improvement Project to Address lower urinary tract symptoms by pharmacists in the community, $109,000.00); JLS has no real or perceived conflicts of interest; CT has no real or perceived conflicts of interest; JPT has no real or perceived conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Importance: Few interventions are proven to reduce total health care costs, and addressing cost-related nonadherence has the potential to do so., Objective: To determine the effect of eliminating out-of-pocket medication fees on total health care costs., Design, Setting, and Participants: This secondary analysis of a multicenter randomized clinical trial using a prespecified outcome took place across 9 primary care sites in Ontario, Canada (6 in Toronto and 3 in rural areas), where health care services are generally publicly funded. Adult patients (≥18 years old) reporting cost-related nonadherence to medicines in the past 12 months were recruited between June 1, 2016, and April 28, 2017, and followed up until April 28, 2020. Data analysis was completed in 2021., Interventions: Access to a comprehensive list of 128 medicines commonly prescribed in ambulatory care with no out-of-pocket costs for 3 years vs usual medicine access., Main Outcome and Measures: Total publicly funded health care costs over 3 years, including costs of hospitalizations. Health care costs were determined using administrative data from Ontario's single-payer health care system, and all costs are reported in Canadian dollars with adjustments for inflation., Results: A total of 747 participants from 9 primary care sites were included in the analysis (mean [SD] age, 51 [14] years; 421 [56.4%] female). Free medicine distribution was associated with a lower median total health care spending over 3 years of $1641 (95% CI, $454-$2792; P = .006). Mean total spending was $4465 (95% CI, -$944 to $9874) lower over the 3-year period., Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, eliminating out-of-pocket medication expenses for patients with cost-related nonadherence in primary care was associated with lower health care spending over 3 years. These findings suggest that eliminating out-of-pocket medication costs for patients could reduce overall costs of health care., Trial Registration: ClinicalTrials.gov Identifier: NCT02744963.

Introduction: Standardized patient (SP) methodology has been used in health professional education to help students develop communication, deeper diagnostic reasoning, and critical thinking skills. Few examples demonstrate the use of SPs to practice difficult conversations with pediatric caregivers in the pediatric dentistry literature. The objective of this educational activity was to describe the implementation of three SPs in a pediatric dentistry course for second-year dental students., Methods: We developed three SP encounters covering interactions with caregivers of an infant with severe early childhood caries, an adolescent on the path to gender affirmation, and a child with autism and dental caries whose caregiver was resistant to fluoride- and silver-containing dental materials. We describe the case design process, rubric construction and calibration, student debriefing, and pandemic modifications. We evaluated the effectiveness of the implementation by thematic analysis of student reflections following each encounter using a qualitative descriptive framework., Results: Eighty-three students completed each encounter. Qualitative analysis showed that students preferred a more realistic encounter by having a child or other distraction present. Students relied on different elements of motivational interviewing depending on the objective of each encounter and the age of the patient. Overall, the SP encounters were well received by students and faculty as an alternative or supplement to traditional student evaluation methods., Discussion: We noted a number of lessons learned about implementing SP methodology in pediatric dental education. With these experiences now in place, future evaluations should measure student performance in the SP encounters against student performance during clinical care., (© 2022 Meyer et al.)

Background: Adherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted., Methods and Findings: We randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI -0.25 to 0.79, p = 0.302), systolic blood pressure (-3.9; 95% CI -9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI -0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports., Conclusions: In this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years., Trial Registration: ClinicalTrials.gov NCT02744963., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: PJ serves as unpaid member of steering group or executive committee of trials funded by Abbott Vascular, Astra Zeneca, Biotronik, Biosensors, St. Jude Medical, Terumo and The Medicines Company, has received research grants to the institution from Appili Therapeutics, Astra Zeneca, Biotronik, Biosensors International, Eli Lilly, The Medicines Company, and honoraria to the institution for participation in advisory boards and/or consulting from Amgen, Ava and Fresenius, but has not received personal payments by any pharmaceutical company or device manufacturer. MRL has consulted for Health Canada, the Hospital Employees’ Union, the Conference Board of Canada, and provided expert witness testimony for the Attorney General of Canada. MM has received honoraria for serving as a member of an Advisory Board for NovoNordisk.

Marine Protected Areas (MPAs) are increasingly established globally as a spatial management tool to aid in conservation and fisheries management objectives. Assessing whether MPAs are having the desired effects on populations requires effective monitoring programs. A cornerstone of an effective monitoring program is an assessment of the statistical power of sampling designs to detect changes when they occur. We present a novel approach to power assessment that combines spatial point process models, integral projection models (IPMs) and sampling simulations to assess the power of different sample designs across a network of MPAs. We focus on the use of remotely operated vehicle (ROV) video cameras as the sampling method, though the results could be extended to other sampling methods. We use empirical data from baseline surveys of an example indicator fish species across three MPAs in California, USA as a case study. Spatial models simulated time series of spatial distributions across sites that accounted for the effects of environmental covariates, while IPMs simulated expected trends over time in abundances and sizes of fish. We tested the power of different levels of sampling effort (i.e., the number of 500-m ROV transects) and temporal replication (every 1-3 yr) to detect expected post-MPA changes in fish abundance and biomass. We found that changes in biomass are detectable earlier than changes in abundance. We also found that detectability of MPA effects was higher in sites with higher initial densities. Increasing the sampling effort had a greater effect than increasing sampling frequency on the time taken to achieve high power. High power was best achieved by combining data from multiple sites. Our approach provides a powerful tool to explore the interaction between sampling effort, spatial distributions, population dynamics, and metrics for detecting change in previously fished populations., (© 2020 by the Ecological Society of America.)

Evolutionary responses to opposing directions of natural selection include trade-offs, where the phenotype balances selective forces, and compensation, where other traits reduce the impact of one selective force. Zooplankton pigmentation protects from ultraviolet radiation (UVR) but attracts visual predators. This trade-off is understudied in the ocean where planktonic larvae in surface waters face ubiquitous UVR and visual predation threats. We tested whether crab larvae can behaviorally reduce UVR risk through downward swimming or expansion of photoprotective chromatophores. Then we examined whether more pigmented larvae are more heavily predated by silverside fish under natural sunlight in the tropics in three UVR treatments (visible light, visible + UVA, visible + UVA + UVB). Lastly, we tested the behavioral chromatophore response of larvae to predation threats in two light treatments. Armases ricordi avoided surface waters after exposure to sunlight with UVR. Armases ricordi, Armases americanum, and Eurypanopeus sp. consistently expanded chromatophores in UVR or visible light, while Mithraculus sculptus and Mithraculus coryphe showed no response. Fish preferred pigmented larvae on sunnier days in visible light lacking UVR. Lastly, both M. coryphe and M. sculptus unexpectedly expanded chromatophores in fish cues, but responses were inconsistent over trials and across light treatments. The more consistent larval responses to UVR than to predator cues and the lack of predator preferences in natural light conditions suggest that UVR may have a stronger influence on pigmentation than predation. This study improves our understanding of planktonic adaptation to countervailing selection caused by visual predation and exposure to UVR.

Background: Because not all medicines are equally safe, effective, and affordable, health systems often use formularies to define explicitly which medicines will be included and excluded from coverage., Objective: We sought to synthesize methods and findings from published studies of formulary variation across health systems in high-income countries., Methods: We conducted a systematic review of peer-reviewed research papers published from 2000 to 2017, inclusively. Because of the heterogeneous nature of the literature, we used an inductive approach to summarize methods and findings., Results: Nine studies met our study inclusion criteria. Included studies used a variety of methods for selecting medicines for analysis, for measuring coverage levels, and for measuring concordance between formularies. Studies assessing variations in coverage of all licensed medicines and found lower rates of cross-national coverage variation than studies of coverage for selected specialty drugs and indications. The one study that focused on coverage of high-volume medicines found the most complete and consistent levels of formulary listings across countries., Conclusion: Although published studies contain interesting findings that likely have prompted discussions about their policy implications, the literature can be improved with greater transparency concerning the overarching objective of work in this area and more rigor concerning the selection, analysis, and reporting of data., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests:We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed.

Importance: Nonadherence to treatment with medicines is common globally, even for life-saving treatments. Cost is one important barrier to access, and only some jurisdictions provide medicines at no charge to patients., Objective: To determine whether providing essential medicines at no charge to outpatients who reported not being able to afford medicines improves adherence., Design, Setting, and Participants: A multicenter, unblinded, parallel, 2-group, superiority, outcomes assessor-blinded, individually randomized clinical trial conducted at 9 primary care sites in Ontario, Canada, enrolled 786 patients between June 1, 2016, and April 28, 2017, who reported cost-related nonadherence. Follow-up occurred at 12 months. The primary analysis was performed using an intention-to-treat principle., Interventions: Patients were randomly allocated to receive free medicines on a list of essential medicines in addition to otherwise usual care (n = 395) or usual medicine access and usual care (n = 391)., Main Outcomes and Measures: The primary outcome was adherence to treatment with all medicines that were appropriately prescribed for 1 year. Secondary outcomes were hemoglobin A1c level, blood pressure, and low-density lipoprotein cholesterol levels 1 year after randomization in participants taking corresponding medicines., Results: Among the 786 participants analyzed (439 women and 347 men; mean [SD] age, 51.7 [14.3] years), 764 completed the trial. Adherence to treatment with all medicines was higher in those randomized to receive free distribution (151 of 395 [38.2%]) compared with usual access (104 of 391 [26.6%]; difference, 11.6%; 95% CI, 4.9%-18.4%). Control of type 1 and 2 diabetes was not significantly improved by free distribution (hemoglobin A1c, -0.38%; 95% CI, -0.76% to 0.00%), systolic blood pressure was reduced (-7.2 mm Hg; 95% CI, -11.7 to -2.8 mm Hg), and low-density lipoprotein cholesterol levels were not affected (-2.3 mg/dL; 95% CI, -14.7 to 10.0 mg/dL)., Conclusions and Relevance: The distribution of essential medicines at no charge for 1 year increased adherence to treatment with medicines and improved some, but not other, disease-specific surrogate health outcomes. These findings could help inform changes to medicine access policies such as publicly funding essential medicines., Trial Registration: ClinicalTrials.gov identifier: NCT02744963.

Toxic chemicals within and adsorbed to microplastics (0.05-5 mm) have the potential to biomagnify in food webs. However, microplastic concentrations in highly productive, coastal habitats are not well understood. Therefore, we quantified the presence of microplastics in a benthic community and surrounding environment of a remote marine reserve on the open coast of California, USA. Concentrations of microplastic particles in seawater were 36.59 plastics/L and in sediments were 0.227 ± 0.135 plastics/g. Densities of microplastics on the surfaces of two morphologically distinct species of macroalgae were 2.34 ± 2.19 plastics/g (Pelvetiopsis limitata) and 8.65 ± 6.44 plastics/g (Endocladia muricata). Densities were highest in the herbivorous snail, Tegula funebralis, at 9.91 ± 6.31 plastics/g, potentially due to bioaccumulation. This study highlights the need for further investigations of the prevalence and potential harm of microplastics in benthic communities at remote locations as well as human population centers., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Competing Interests: Competing interests: Kai Yeung is a research scientist at Kaiser Permanente Washington Health Research Institute, a nonproprietary, public-interest research centre in Washington State. Steven Morgan has received funding from the Government of Canada for research in support of the Advisory Council on the Implementation of National Pharmacare.

Plankton live under the countervailing selective pressures of predation and ultraviolet radiation (UVR). In lakes, zooplankton are transparent reducing visibility to predatory fishes but are pigmented in the absence of fishes, hypothetically reducing UVR damage. In the sea, planktivorous fishes are widespread, so plankton typically are transparent and ascend to productive surface waters at night to forage and descend during the day to reduce visibility to predators. However, larvae of some species face the unique constraint of traveling in surface currents in the daytime during migrations between adult and larval habitats. We would expect these larvae to be transparent since companion studies demonstrated increased predation risk of pigmented larvae under strong sunlight. Paradoxically, larvae range from being darkly to lightly pigmented. We hypothesize that some larvae are more heavily pigmented to reduce UVR damage, while other species travelling in subsurface currents with low UVR might be more transparent. Linking larval morphology to depth-dependent selective pressures would add a key element to help improve predictions of larval vertical distributions, which are important for simulating larval transport trajectories. We quantitatively tested the hypothesis that selection may have favored photoprotective pigmentation for larvae in the predominantly transparent plankton community while testing the differential effects of UVA and UVB radiation. We measured larval pigmentation of 12 species of crabs and exposed them to visible light only, visible + UVA, or visible + UVA + UVB in the tropics. Controlling for phylogeny, more pigmented species survived UVR better than less pigmented species, especially on sunnier days, though intraspecific comparisons for four species were equivocal. Most species died even from UVA exposure, which has long been regarded as relatively harmless despite penetrating deeper underwater than UVB. Thus, we demonstrate with a phylogenetically controlled analysis that crab larvae are pigmented in the predominantly transparent planktonic community to protect from UVR, improving our understanding of the selective forces acting on animal coloration and the factors determining planktonic distributions, survival, and dispersal. This linkage of morphology with susceptibility will be important for developing mechanistic models of environmental stress responses to better predict larval dispersal in current and future climates., (© 2019 by the Ecological Society of America.)

Competing Interests: Competing interests: Steven Morgan reports receiving personal fees for pharmaceutical policy research work for the Government of Canada, outside the submitted work. No other competing interests were declared.

Background: Out-of-pocket drug costs lead many Canadians to engage in cost-related nonadherence to prescription medications, but our understanding of other consequences such as borrowing money remains incomplete. In this descriptive study, we sought to quantify the frequency of borrowing to pay for prescription drugs in Canada and characteristics of Canadians who borrowed money for this purpose., Methods: In partnership with Statistics Canada, we designed and administered a cross-sectional rapid-response module in the Canadian Community Health Survey administered by telephone to Canadians aged 12 years or more between January and June 2016. We restricted our analyses to participants who responded to the question regarding borrowing money to pay for prescription drugs and used logistic regression to identify characteristics associated with borrowing., Results: A total of 28 091 Canadians responded to the survey (overall response rate 61.8%). The weighted proportion of respondents who reported having borrowed money to pay for prescription drugs in the previous year was 2.5% (95% confidence interval 2.2%-2.8%), an estimated 731 000 Canadians. The odds of borrowing were higher among younger adults, people in poor health and people lacking prescription drug insurance. Other factors associated with increased adjusted odds of borrowing were having 2 or more chronic conditions, low household income and higher out-of-pocket prescription drug costs., Interpretation: Many Canadians reported borrowing money to pay for out-of-pocket prescription drug costs, and borrowing was more prevalent among already vulnerable groups that also report other compensatory behaviours to address challenges in paying for prescription drugs. Future research should investigate policy responses intended to increase equity in access to prescription drugs., Competing Interests: Competing interests: Michael Law has consulted for Health Canada and has acted as an expert witness for the Attorney General of Canada. Anne Holbrook is a therapeutics expert and drug policy consultant for the Ontario public drug programs, the Canadian Agency for Drugs and Technologies in Health and Hamilton hospitals. No other competing interests were declared., (Copyright 2018, Joule Inc. or its licensors.)

Background: Canadians have long been proud of their universal health insurance system, which publicly funds the cost of physician visits and hospitalizations at the point of care. Prescription drugs however, have been subject to a patchwork of public and private coverage which is frequently inefficient and creates access barriers to necessary medicine for many Canadians., Methods: A narrative review was undertaken to understand the important economic, policy and political considerations regarding implementation of universal prescription drug access in Canada (pan-Canadian pharmacare). PubMed, SCOPUS and google scholar were searched for relevant citations. Citation trails were followed for additional information sources. Published books, public reports, press releases, policy papers, government webpages and other forms of gray literature were collected from iterative internet searches to provide a complete view of the current state on this topic., Main Findings: Regarding health economics, all five of the reviewed pharmacare simulation models have shown reductions in annual prescription drug expenditure. However, differing policy and cost assumptions have resulted in a wide range of cost-saving estimates between models. In terms of policy, a single-payer, 'first-dollar' coverage model, using a minimum national formulary, is the model most frequently advocated by the academic community, healthcare professions and many public and patient groups. In contrast, a multi-payer, catastrophic 'last-dollar' coverage model, more similar to the current "patchwork" state of public and private coverage, is preferred by industry drug manufacturers and private health insurance companies. Primary concerns from the detractors of universal, single-payer, 'first-dollar' coverage are the financing required for its implementation and the access barriers that may be created for certain patient populations that are not majorly present in the current public-private payer mix., Conclusion: Canada patiently awaits to see how the issue of prescription drug coverage will be resolved through the work of the Advisory Council on the Implementation of National Pharmacare. The overarching and ongoing discourse on policy and program implementation may be construed as a political debate informed by divergent public and private interests., Competing Interests: Not Applicable.Not Applicable.JB has served as Vice-President of Pharmacists Manitoba (professional advocacy body).Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Objective: We sought to estimate size and sources of differences in per capita expenditures on primary care medications in the US versus ten comparable countries combined: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom., Methods: Using market research data on year 2015 volumes and sales of medicines, we measure total per capita expenditures on six categories of primary care prescription drugs: hypertension treatments, pain medications, lipid lowing medicines, non-insulin diabetes treatments, gastrointestinal preparations, and antidepressants. We quantified the contributions of five drivers of the observed differences in per capita expenditures., Results: We estimated that the US spent 203% more per capita on primary care pharmaceuticals than did the ten comparable countries. Despite the difference in spending levels, on average, Americans actually purchased 12% fewer days of related therapies than residents of the comparator countries. Most of the observed difference in expenditures was due to higher transaction prices of medicines and the use of a more expensive mix of medicines in the US., Conclusions: If utilization patterns and pharmaceutical prices in the US were similar to those in the 10 comparator countries combined, total spending on primary care pharmaceuticals would fall by 30% or more. Such evidence on the level and drivers of US pharmaceutical expenditures should inform policies in this sector., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: Nav Persaud reports research funding from the Canadian Institutes of Health Research and the Ontario Strategy for Patient-Oriented Research (SPOR) Support Unit, outside of the submitted work. No other competing interests were declared.

Background: Many Canadians face substantial out-of-pocket charges for prescription drugs. Prior work suggests that this causes some patients to not take their medications as prescribed; however, we have little understanding of whether charges for prescription medicines lead patients to forego basic needs or to use more health care services. Our study aimed to quantify the consequences of patient charges for medicines in Canada., Methods: As part of the 2016 Canadian Community Health Survey, we designed and fielded cross-sectional questions to 28 091 Canadians regarding prescription drug affordability, consequent use of health care services and trade-offs with other expenditures. We calculated weighted population estimates and proportions, and used logistic regression to determine which patient characteristics were associated with these behaviours., Results: Overall, 5.5% (95% confidence interval 5.1%-6.0%) of Canadians reported being unable to afford 1 or more drugs in the prior year, representing 8.2% of those with at least 1 prescription. Drugs for mental health conditions were the most commonly reported drug class for cost-related nonadherence. About 303 000 Canadians had additional doctor visits, about 93 000 sought care in the emergency department, and about 26 000 were admitted to hospital at the population level. Many Canadians forewent basic needs such as food (about 730 000 people), heat (about 238 000) and other health care expenses (about 239 000) because of drug costs. These outcomes were more common among females, younger adults, Aboriginal peoples, those with poorer health status, those lacking drug insurance and those with lower income., Interpretation: Out-of-pocket charges for medicines for Canadians are associated with foregoing prescription drugs and other necessities as well as use of additional health care services. Changes to protect vulnerable populations from drug costs might reduce these negative outcomes., Competing Interests: Competing interests: Michael Law has consulted for Health Canada and has acted as an expert witness for the Attorney General of Canada. No other competing interests were declared., (Copyright 2018, Joule Inc. or its licensors.)

Plankton are transported onshore, providing subsidies of food and new recruits to surf-zone and intertidal communities. The transport of plankton to the surf zone is influenced by wind, wave, and tidal forcing, and whether they enter the surf zone depends on alongshore variation in surf-zone hydrodynamics caused by the interaction of breaking waves with coastal morphology. Areas with gently sloping shores and wide surf zones typically have orders-of-magnitude-higher concentrations of plankton in the surf zone and dense larval settlement in intertidal communities because of the presence of bathymetric rip currents, which are absent in areas with steep shores and narrow surf zones. These striking differences in subsidies have profound consequences; areas with greater subsidies support more productive surf-zone communities and possibly more productive rocky intertidal communities. Recognition of the importance of spatial subsidies for rocky community dynamics has recently advanced ecological theory, and incorporating surf-zone hydrodynamics would be an especially fruitful line of investigation.

Background: Erectile dysfunction (ED) can be a sentinel marker for future cardiovascular disease and has been described as providing a "window of curability" for men to receive targeted cardiovascular risk assessment., Aim: To determine whether the prescription of phosphodiesterase type 5 inhibitors (PDE5is) for ED leads to the detection and treatment of previously undiagnosed cardiometabolic risk factors., Methods: We performed a retrospective population-based cohort study of residents of British Columbia, Canada using linked health care databases from 2004 to 2011. An individual-level time series analysis with switching replications was used to determine changes in drug use for hypertension, hypercholesterolemia, and diabetes in men 40 to 59 years old. The observation window for each patient was 720 days before and 360 days after the index date., Outcomes: The primary outcome was changes in prescriptions for antihypertensive, statin, and oral antidiabetic drugs, with secondary outcomes being laboratory tests for plasma cholesterol and glucose., Results: 5,858 men 40 to 59 years old newly prescribed a PDE5i were included in the analysis. We found a sudden increase in prescriptions for antihypertensive drugs (40 per 1,000; P < .001), statins (10 per 1,000; P = .001), and antidiabetic drugs (17 per 1,000; P = .002) in the 90 days after a new prescription for a PDE5i. For hypercholesterolemia and diabetes, most of this change was observed in men with relevant screening tests performed in the 30 days after their PDE5i prescription. Only 15% and 17% of men who did not have a screening test for cholesterol and glucose, respectively, in the year before their PDE5i prescription went on to have one in the subsequent 30 days., Clinical Implications: The paucity of screening tests observed in our study after PDE5i prescriptions suggests that physicians should be educated on the recommended screening guidelines for men newly diagnosed with ED., Strengths and Limitations: The number of men who were ordered a laboratory test or written a prescription but chose not to complete or fill it, respectively, is unknown., Conclusion: Treatment for ED with PDE5is can be a trigger or "gateway drug" for the early detection and treatment of cardiometabolic risk factors provided physicians perform the requisite screening investigations. Skeldon SC, Cheng L, Morgan SG, et al. Erectile Dysfunction Medications and Treatment for Cardiometabolic Risk Factors: A Pharmacoepidemiologic Study. J Sex Med 2017;14:1597-1605., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Many patients report skipping doses, splitting pills, or not filling prescriptions due to out-of-pocket costs-a phenomenon known as cost-related non-adherence (CRNA). This study investigated CRNA from the patient's perspective, and, to our knowledge, is the first study to undertake a qualitative investigation of CRNA specifically. We report the results from 35 semi-structured interviews conducted in 2014-15 with adults in four Canadian cities across two provinces. We used framework analysis to develop a CRNA typology to characterize major factors in patients' CRNA decisions. Our typology identifies four major components: (1) the insurance reason driving the drug cost, (2) the individual's overall financial flexibility, (3) the burden of drug cost on the individual's budget, and (4) the importance of the drug from the individual's perspective. The first two components set the context for CRNA and the final two components are the drivers for the CRNA decision. We also found four major patterns in CRNA experiences: (1) CRNA in individuals with low financial flexibility occurred for all levels of drug importance and all but the lowest level of cost burden; (2) CRNA for high importance drugs only occurred when the drug cost had a high burden on an individual's budget; (3) CRNA in individuals with more financial flexibility primarily occurred in drugs with medium importance but high or very high cost burdens; and (4) CRNA for low importance drugs occurred at almost all levels of drug cost burden. Our study furthers the understanding of how numerous factors such as income, insurance, and individual preferences combine and interact to influence CRNA and suggests that policy interventions must be multi-faceted or encourage significant insurance redesign to reduce CRNA., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: In 2011, Manitoba implemented a province-wide program of physician detailing and free sampling for generic atorvastatin to increase use of this generic statin. We examined the impact of this unique combined program of detailing and sampling for generic atorvastatin on the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin., Methods: We conducted a retrospective study of Manitoba insurance claims data for all continuously enrolled patients who filled one or more prescriptions for a statin between 2008 and 2013. Data were linked to physician-level data on the number of detailing visits and sample provision. We used interrupted time series analyses to assess policy-related changes in the use and cost of statin medicines, market share of generic atorvastatin, the choice of starting statin for new users, and switching from a branded statin to generic atorvastatin., Results: The detailing program reached 31% (651/2103) of physicians who prescribed a statin during the study period. Collectively, these physicians prescribed 61% of statins dispensed in the province. Free sample cards were provided to 61% (394/651) of the detailed physicians. The program did not change the level or trend in the overall statin use rate and the total cost of statins or increase the number of patients switching from another branded statin to generic atorvastatin. We found the program had a small impact on atorvastatin's market share of new prescriptions, with a level increase of 2.6%., Conclusions: Though physician detailers were skilled at targeting high-prescribing physicians, a combined program of detailing visits and sample provision for generic atorvastatin did not lower overall statin costs or lead to switching from branded statins to the generic. The preceding introduction of generic atorvastatin appeared sufficient to modify prescribing patterns and decrease costs.

Competing Interests: Competing interests: Marc-André Gagnon reports a grant from Health Canada and personal fees from Prescrire International and from the Canadian Association of Pharmacy in Oncology, all outside the submitted work. No other competing interests were declared.

Background: Advances in pharmaceuticals offer improved health outcomes for a wide range of illnesses, yet medicines are often inaccessible for many patients worldwide. One potential barrier to making medicines available to all is the cost of product registration, the fees for regulatory review and licensing for the sale of medicines beyond the cost of clinical trials, if needed., Methods and Findings: We performed a cross-sectional analysis of pharmaceutical registration fees in low-, middle-, and high-income countries. We collected data on market authorization fees for new chemical entities and for generic drugs in 95 countries. We calculated measures of registration fee size relative to population, gross domestic product (GDP), and total health spending in each country. Each of the 95 countries had a fee for registering new chemical entities. On average, the ratio of registration fees to GDP was highest in Europe and North America and lowest in South and Central America. Across individual countries, the level of registration fees was positively correlated with GDP and total health spending, with relatively few outliers., Discussion: We find that, generally speaking, the regulatory fees charged by medicines regulatory authorities are roughly proportional to the market size in their jurisdictions. The data therefore do not support the hypothesis that regulatory fees are a barrier to market entry in most countries.

Background: Benzodiazepines and benzodiazepine-like sedatives (zopiclone, zolpidem and zaleplon) are commonly prescribed to treat anxiety and insomnia but are contraindicated for chronic use. We sought to study the persistence, over multiple years, of chronic use of benzodiazepines and benzodiazepine-like sedatives among community-dwelling adults in British Columbia, Canada., Methods: This is a retrospective analysis of linked health data for adults aged 50 to 69 in 2004 who resided in British Columbia, Canada, between 2004 and 2013. We assigned subjects to one of four groups according to the total number of days of benzodiazepines and benzodiazepine-like sedatives that they were dispensed from retail pharmacies in each observation year. We estimated logistic regression models to measure associations between the odds of chronic sedative use and explanatory variables. We computed transition probability matrices that depict likelihood of changes in sedative utilization levels across years., Results: Nearly one in ten (9.4%) community-dwelling older adults in British Columbia filled prescriptions with more than 90 days' worth of benzodiazepines or benzodiazepine-like sedatives in 2013. The odds of such chronic sedative use were higher for people who were older, had lower income, were sicker, or lived in rural communities; odds were lower for people with Chinese or South Asian surnames and for men who were married. Controlling for other factors, chronic users of sedatives in 2008 were 15 times more likely than non-users of sedatives in 2008 to be chronic sedative users in 2013 (OR = 14.73; 95% CI = [14.24, 15.24]). Approximately two out of every five older British Columbians who were chronic sedative users in 2013 had been chronic users of sedatives 10 years prior. Two out of every three chronic sedative users in 2004 were either chronic users (57%) or dead (16%) by 2013., Interpretation: Chronic use of sedatives is prevalent and persistent among older adults in British Columbia. The persistence of chronic sedative use between when patients were 50 to 59 years old and when they were 60 to 69 years old suggests that earlier interventions to curb chronic sedative use may be warranted even if patients do not experience significant risks until later ages.

Background: Managing expenditures on pharmaceuticals is important for health systems to sustain universal access to necessary medicines. We sought to estimate the size and sources of differences in expenditures on primary care medications among high-income countries with universal health care systems., Methods: We compared data on the 2015 volume and cost per day of primary care prescription drug therapies purchased in 10 high-income countries with various systems of universal health care coverage (7 from Europe, in addition to Australia, Canada and New Zealand). We measured total per capita expenditure on 6 categories of primary care prescription drugs: hypertension treatments, pain medications, lipid-lowering medicines, noninsulin diabetes treatments, gastrointestinal preparations and antidepressants. We quantified the contributions of 5 drivers of the observed differences in per capita expenditures., Results: Across countries, the average annual per capita expenditure on the primary care medicines studied varied by more than 600%: from $23 in New Zealand to $171 in Switzerland. The volume of therapies purchased varied by 41%: from 198 days per capita in Norway to 279 days per capita in Germany. Most of the differences in average expenditures per capita were driven by a combination of differences in the average mix of drugs selected within therapeutic categories and differences in the prices paid for medicines prescribed., Interpretation: Significant international differences in average expenditures on primary care medications are driven primarily by factors that contribute to the average daily cost of therapy, rather than differences in the volume of therapy used. Average expenditures were lower among single-payer financing systems that appeared to promote lower prices and the selection of lower-cost treatment options., Competing Interests: Competing interests: None declared., (© 2017 Canadian Medical Association or its licensors.)

Background: With the launch of very highly priced therapies and sudden price increases of generics, pressures on health systems have drastically increased., Objectives: We aimed to elicit opinions of key decision makers responsible for national assessment and funding decisions on their experiences to adapt to these new realities., Methods/setting: Through interviews with decision makers of pharmaceutical assessment and/or funding agencies, we describe the challenges systems are currently facing, systems' responses and systems' characteristics facilitating or hindering responses to changes and overarching topics for the future., Results: Among the most common challenges are increased funding pressures, increased uncertainty and lack of transparency in decision-making. Systems' responses include utilization management, changing of assessment processes, stakeholder engagement and a focus on outcomes and on coordinated negotiations. Integrated delivery systems, fixed health care budgets and geographic and historical characteristics facilitate or sometimes hinder responses to change. Future policy emphasis lays on expanding data structures, managing the exit of drugs funded early, and implementing processes for communications with patients and the public., Conclusions: Going forward emphasis has to be given to structured communications with all stakeholders with a specific emphasis on the broader public and patients about financial limits and priority setting in health care., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Institutional payers for pharmaceuticals worldwide appear to be increasingly negotiating confidential discounts off of the official list price of pharmaceuticals purchased in the community setting. We conducted an anonymous survey about experiences with and attitudes toward confidential discounts on patented pharmaceuticals in a sample of high-income countries. Confidential price discounts are now common among the ten health systems that participated in our study, though some had only recently begun to use these pricing arrangements on a routine basis. Several health systems had used a wide variety of discounting schemes in the past two years. The most frequent discount received by participating health systems was between 20% and 29% of official list prices; however, six participants reported their health system received one or more discount over the past two years that was valued at 60% or more of the list prices. On average, participants reported that confidential discounts were more common, complex, and significant for specialty pharmaceuticals than for primary care pharmaceuticals. Participants had a more favorable view of the impact of confidential discount schemes on their health systems than on the global marketplace. Overall, the frequency, complexity, and scale of confidential discounts being routinely negotiated suggest that the list prices for medicines bear limited resemblance to what many institutional payers actually pay., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To examine variation in pharmaceutical spending and patient characteristics across prescription drug user groups., Data Sources: British Columbia's population-based linked administrative health and sociodemographic databases (N = 3,460,763)., Study Design: We classified individuals into empirically derived prescription drug user groups based on pharmaceutical spending patterns outside hospitals from 2007 to 2011. We examined variation in patient characteristics, mortality, and health services usage and applied hierarchical clustering to determine patterns of concurrent drug use identifying high-cost patients., Principal Findings: Approximately 1 in 20 British Columbians had persistently high prescription costs for 5 consecutive years, accounting for 42 percent of 2011 province-wide pharmaceutical spending. Less than 1 percent of the population experienced discrete episodes of high prescription costs; an additional 2.8 percent transitioned to or from high-cost episodes of unknown duration. Persistent high-cost users were more likely to concurrently use multiple chronic medications; episodic and transitory users spent more on specialized medicines, including outpatient cancer drugs. Cluster analyses revealed heterogeneity in concurrent medicine use within high-cost groups., Conclusions: Whether low, moderate, or high, costs of prescription drugs for most individuals are persistent over time. Policies controlling high-cost use should focus on reducing polypharmacy and encouraging price competition in drug classes used by ordinary and high-cost users alike., (© 2016 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust.)

Recent mass mortalities of two predatory sea star species provided an unprecedented opportunity to test the effect of predators on rocky intertidal prey. Mass mortalities provide insight that manipulative experiments cannot because they alter ecosystems on a larger scale, for longer time periods, and remove both organisms and their cues from the environment. We examined shifts in population size structure, vertical zonation, and use of emersed refuge habitats outside tidepools by the abundant herbivorous black turban snail Tegula funebralis, both before and after the successive mortalities of two predatory sea stars. The small cryptic predator Leptasterias spp. suffered a localized but extreme mortality event in November 2010, followed by two mass mortalities of the keystone predator Pisaster ochraceus in August 2011 and autumn 2013. After the local extinction of Leptasterias, the population size of Tegula more than doubled. Also, since Leptasterias primarily inhabited only mid to low intertidal tidepools at this site, small and medium sized snails (which are preferred by Leptasterias) shifted lower in the intertidal and into tidepools after the mortality of Leptasterias. After the mortality of Pisaster in August 2011, large snails did not shift lower in the intertidal zone despite being preferred by Pisaster. Small and medium sized snails became denser in the higher zone and outside tidepools, which was not likely due to Pisaster mortality. Previous studies concluded that Pisaster maintained vertical size gradients of snails, but our data implicate the overlooked predator Leptasterias as the primary cause. This natural experiment indicated that (1) predators exert top-down control over prey population sizes and lower limits, (2) vertical zonation of prey are dynamic and controlled in part by prey behavior, and (3) predators exert the strongest effects on more vulnerable individuals, which typically inhabit stressful habitats higher on the shore or outside tidepools to avoid predation. Because the mass mortalities of two predators drastically reduced both the predation pressure and the chemical cues of predators in the environment, we were able to investigate both the effects of predators on prey populations and the effects on mobile prey behavior., (© 2016 by the Ecological Society of America.)

Background: In recent years, some provinces have implemented income-based catastrophic drug coverage in an effort to provide universal drug coverage while limiting government liability for the escalating costs of medicines needed for an aging population. We sought to examine the effects of income-based deductibles under British Columbia's Fair PharmaCare system on older patients' use of cardiovascular medicines in 2013, 10 years after the province's policy change., Methods: Using linked administrative databases, we studied rates of hypertension and cholesterol medication used by 2 cohorts of older, married women who had different levels of public drug subsidy based solely on their spouses' ages. We compare measures of 2013 medication use by study cohorts using statistical models that controlled for age, general health status, indicators of need for specific drug classes, ethnicity, rural residence and household income., Results: Among members of our study cohorts, the odds of filling cardiovascular prescriptions in 2013 were influenced by patient age, general health status, drug-specific diagnoses, ethnicity, place of residence and household income. For women with household incomes less than $50 000 (42% of our study population), having preferential public drug coverage by way of spousal age was associated with a 15% increase in the adjusted odds of filling 1 or more prescription for hypertension treatment (adjusted odds ratio [OR] 1.15, 95% confidence interval [CI] 1.06 to 1.24) and a 13% increase in the adjusted odds of filling 1 or more prescription for cholesterol treatments (adjusted OR 1.13, 95% CI 1.06 to 1.21). There were no statistically significant effects on the number of days of therapy purchased per user of these cardiovascular medicines., Interpretation: We have found that the level of income-based deductibles under catastrophic drug benefi t plans can affect the use of cardiovascular drug treatments, even long after deductibles are put in place. These results add to the body of evidence in support of the idea that public drug coverage design can affect access to necessary medications., Competing Interests: Competing interests: None declared.

Background: Chronic use of benzodiazepines and benzodiazepine-like sedatives (z-drugs) presents substantial risks to people of all ages. We sought to assess trends in long-term sedative use among community-dwelling adults in British Columbia., Methods: Using population-based linked administrative databases, we examined longitudinal trends in age-standardized rates of sedative use among different age groups of community-dwelling adults (age ≥ 18 yr), from 2004 to 2013. For each calendar year, we classified adults as nonusers, short-term users, or long-term users of sedatives based on their patterns of sedative dispensation. For calendar year 2013, we applied cross-sectional analysis and estimated logistic regression models to identify health and socioeconomic risk factors associated with long-term sedative use., Results: More than half (53.4%) of long-term users of sedatives in British Columbia are between ages 18 and 64 years (young and middle-aged adults). From 2004 to 2013, long-term sedative use remained stable among adults more than 65 years of age (older adults) and increased slightly among young and middle-aged adults. Although the use of benzodiazepines decreased during the study period, the trend was offset by equal or greater increases in long-term use of z-drugs. Being an older adult, sick, poor and single were associated with increased odds of long-term sedative use., Interpretation: Despite efforts to stem such patterns of medication use, long-term use of sedatives increased in British Columbia between 2004 and 2013. This increase was driven largely by increased use among middle-aged adults. Future deprescribing efforts that target adults of all ages may help curb this trend., Competing Interests: Competing interests: None declared.

Background: Canada's universal health care system does not include universal coverage of prescription drugs. We sought to estimate the effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada., Methods: We used administrative and market research data to estimate the 2015 shares of the volume and cost of prescriptions filled in the community setting that were for 117 drugs on a model list of essential medicines for Canada. We compared prices of these essential medicines in Canada with prices in the United States, Sweden and New Zealand. We estimated the cost of adding universal public drug coverage of these essential medicines based on anticipated effects on medication use and pricing., Results: The 117 essential medicines on the model list accounted for 44% of all prescriptions and 30% of total prescription drug expenditures in 2015. Average prices of generic essential medicines were 47% lower in the US, 60% lower in Sweden and 84% lower in New Zealand; brand-name drugs were priced 43% lower in the US. Estimated savings from universal public coverage of these essential medicines was $4.27 billion per year (range $2.72 billion to $5.83 billion; 28% reduction) for patients and private drug plan sponsors, at an incremental government cost of $1.23 billion per year (range $373 million to $1.98 billion; 11% reduction)., Interpretation: Our analysis showed that adding universal public coverage of essential medicines to the existing public drug plans in Canada could address most of Canadians' pharmaceutical needs and save billions of dollars annually. Doing so may be a pragmatic step forward while more comprehensive pharmacare reforms are planned., (© 2017 Canadian Medical Association or its licensors.)

Objectives: To assess the effects of costs on access to medicines in 11 developed countries offering different levels of prescription drug coverage for their populations., Design: Cross-sectional study of data from the Commonwealth Fund 2014 International Health Policy Survey of Older Adults., Setting: Telephone survey conducted in 11 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the USA., Participants: 22 532 adults aged 55 and older and living in the community in studied countries., Primary Outcome Measure: Self-reported cost-related non-adherence (CRNA) in the form of either not filling a prescription or skipping doses within the last 12 months because of out-of-pocket costs., Results: Estimated prevalence of CRNA among all older adults varied from <3% in the France, Norway, Sweden, Switzerland and the UK to 16.8% in the USA. Canada had the second highest national prevalence of CRNA (8.3%), followed by Australia (6.8%). Older adults in the USA were approximately six times more likely to report CRNA than older adults in the UK (adjusted OR=6.09; 95% CI 3.60 to 10.20). Older adults in Australia and Canada were also statistically significantly more likely to report CRNA than older adults in the UK. Across most countries, the prevalence of CRNA was higher among lower income residents and lower among residents over age 65., Conclusions: Observed differences in national prevalence of CRNA appear to follow lines of availability of prescription drug coverage and the extent of direct patient charges for prescriptions under available drug plans., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: We aimed to calculate trends in incidence and prevalence rates of long-term opioid use for non-cancer pain, as well as to describe the characteristics of long-term opioid users and their patterns of opioid use., Methods: We used population-based linked health care and socio-demographic administrative data for British Columbia (BC) between 2005 and 2012. We included individuals who had at least one episode of long-term opioid use during the study period and who were not cancer or palliative care patients., Results: Long-term users comprised only 10% of all individuals prescribed opioids for non-cancer pain, but accounted for 64% of all opioid prescriptions and 87% of all morphine equivalents dispensed in BC during this period. While the incidence rate did not significantly change, the prevalence rate increased by 27% for men and 22% for women. In 2012, there were 3.80 (3.72-3.88) new long-term opioid users per 1,000 men and 4.42 (4.34-4.51) new users per 1,000 women. At the same time, there were 18.3 (95% CI 18.1-18.5) existing long-term users per 1,000 men and 21.7 users (95% CI 21.5-21.9) per 1,000 women. Overall, 2.4% of BC residents were long-term users of prescription opioids in 2012. Most long-term users had one continuous episode of use spanning multiple years. Almost two thirds took opioids every other day or more frequently., Conclusion: There is a growing population of long-term opioid users for non-cancer pain in BC, with higher incidence and prevalence rates observed among women than among men.

Canada's universal public healthcare system is unique among developed countries insofar as it does not include universal coverage of prescription drugs. Universal, public coverage of prescription drugs has been recommended by major national commissions in Canada dating back to the 1960s. It has not, however, been implemented. In this article, we extend research on the failure of early proposals for universal drug coverage in Canada to explain failures of calls for reform over the past 20 years. We describe the confluence of barriers to reform stemming from Canadian policy institutions, ideas held by federal policy-makers, and electoral incentives for necessary reforms. Though universal "pharmacare" is once again on the policy agenda in Canada, arguably at higher levels of policy discourse than ever before, the frequently recommended option of universal, public coverage of prescription drugs remains unlikely to be implemented without political leadership necessary to overcome these policy barriers., (© 2016 The Canadian College of Health Leaders.)

Larvae of intertidal species develop at sea and must return to adult habitats to replenish populations. Similarly, nutrients, detritus and plankton provide important subsidies spurring growth and reproduction of macroalgae and filter-feeding invertebrates that form the foundation of intertidal communities. Together, these factors determine the density and intensity of interactions among community members. We hypothesized that spatial variation in surfzone hydrodynamics affects the delivery of plankton subsidies. We compared entire zooplankton communities inside and outside the surf zone daily while monitoring physical conditions for one month each at two shores with different surfzone characteristics. Opposite cross-shore distributions of larvae and other zooplankters occurred at the two sites: zooplankton was much more abundant inside the mildly sloping dissipative surf zone (DSZ) with rip currents and was more abundant outside the steep reflective surf zone (RSZ). Biophysical numerical simulations demonstrated that zooplankters were concentrated in rip channels of the DSZ and were mostly unable to enter the RSZ, indicating the hydrodynamic processes behind the observed spatial variation of zooplankters in the surf zone. Differences in the concentration of larvae and other zooplankters between the inner shelf and surf zone may be an underappreciated, key determinant of spatial variation in inshore communities., (© 2016 The Author(s).)

Purpose: The aim of this study is to examine the relationship between domperidone (commonly used off-label for lactation stimulation), ventricular arrhythmia and all-cause mortality during the postpartum period., Methods: This is a retrospective, population-based cohort study of all women with a live birth between 1 January 2002 and 31 December 2011 in British Columbia, Canada. Cox proportional hazards models, yielding hazard ratios (HRs), were used to estimate the risk of hospitalization for ventricular arrhythmia associated with domperidone exposure within six months postpartum., Results: The study population consisted of 225 532 women with 320 351 live births. There was only one death during the six-month postpartum period among the study population, and thus we did not perform any analyses of all-cause mortality. We identified 21 hospitalizations for ventricular arrhythmia. Adjusting for age, smoking and prior history of ventricular arrhythmia and cardiovascular disease, the risk of ventricular arrhythmia hospitalization was approximately double among those exposed to domperidone, but the results were not statistically significant (HR = 2.25, 95%CI 0.84-6.01). Adjustment for body mass index in the 74% of women for whom it was known further reduced the association (HR = 1.69, 95%CI 0.48-5.96)., Conclusions: We found a possible association between exposure to domperidone and hospitalization for ventricular arrhythmia among a cohort of women who have recently given birth. Future studies are needed to confirm this association. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Seamounts have generally been identified as locations that can promote elevated productivity, biomass and predator biodiversity. These properties attract seamount-associated fisheries where elevated harvests can be obtained relative to surrounding areas. There exists large variation in the geological and oceanographic environment among the thousands of locations that fall within the broad definition of seamount. Global seamount surveys have revealed that not all seamounts are hotspots of biodiversity, and there remains a strong need to understand the mechanisms that underlie variation in species richness observed. We examined the process of fish species assembly at El Bajo Espiritu Santo (EBES) seamount in the Gulf of California over a five-year study period. To effectively quantify the relative abundance of fast-moving and schooling fishes in a 'blue water' habitat, we developed a simplified underwater visual census (UVC) methodology and analysis framework suitable for this setting and applicable to future studies in similar environments. We found correlations between seasonally changing community structure and variability in oceanographic conditions. Individual species responses to thermal habitat at EBES revealed three distinct assemblages, a 'fall assemblage' tracking warmer overall temperature, a 'spring assemblage' correlated with cooler temperature, and a 'year-round assemblage' with no significant response to temperature. Species richness was greatest in spring, when cool and warm water masses stratified the water column and a greater number of species from all three assemblages co-occurred. We discuss our findings in the context of potential mechanisms that could account for predator biodiversity at shallow seamounts., Competing Interests: The authors declare that they have no competing interests.

Recent syntheses on the evolutionary causes of dispersal have focused on dispersal as a direct adaptation, but many traits that influence dispersal have other functions, raising the question: when is dispersal 'for' dispersal? We review and critically evaluate the ecological causes of selection on traits that give rise to dispersal in marine and terrestrial organisms. In the sea, passive dispersal is relatively easy and specific morphological, behavioural, and physiological adaptations for dispersal are rare. Instead, there may often be selection to limit dispersal. On land, dispersal is relatively difficult without specific adaptations, which are relatively common. Although selection for dispersal is expected in both systems and traits leading to dispersal are often linked to fitness, systems may differ in the extent to which dispersal in nature arises from direct selection for dispersal or as a by-product of selection on traits with other functions. Our analysis highlights incompleteness of theories that assume a simple and direct relationship between dispersal and fitness, not just insofar as they ignore a vast array of taxa in the marine realm, but also because they may be missing critically important effects of traits influencing dispersal in all realms., (© 2015 Cambridge Philosophical Society.)

Canada needs a national strategy to fulfill its obligation to ensure universal access to necessary healthcare, including prescription drugs. A 2004 attempt at a national strategy for pharmaceutical policy failed because it lacked clear vision, logical planning and commitment from federal and provincial governments. The result of uncoordinated pharmaceutical policies in Canada has been more than a decade of poor system performance. In this essay, we present a framework for a renewed national strategy for pharmaceutical policy. Building on published research and international frameworks, we propose that pharmaceutical policies of federal, provincial and territorial governments be coordinated around a core health-focused goal. We strongly suggest policy actions be taken on four core objectives that are necessary to support the overarching health goal. If implemented, the proposed strategy would offer clear benefits to all Canadians who use medicines, federal and provincial governments and to the economy as a whole. We therefore argue that political leadership is now needed to articulate and implement such a plan on behalf of Canadians., (Copyright © 2016 Longwoods Publishing.)

Increasing rates of prescription opioid-related death are well documented in Ontario (ON) but little is known about prescription opioid-related harms in other Canadian provinces. Using administrative mortality data from 2004 to 2013, we found that rates of prescription opioid-related death in British Columbia (BC) were higher but more stable than published rates for ON over the same period. Methadone was involved in approximately 25% of the prescription opioid-related deaths in BC. The majority of prescription opioid-related deaths among men and women were unintentional. Men had higher overall rates of prescription opioid-related deaths in BC; women had lower rates of prescription opioid-related deaths but a larger proportion of them were suicides. Efforts to reduce prescription opioid-related deaths must consider sex differences in patterns of prescription opioid use and associated harms., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: to measure sex differences in the risk of receiving potentially inappropriate prescription drugs and to examine what are the factors that contribute to these differences., Design: a retrospective cohort study., Setting: community setting of British Columbia, Canada., Participants: residents of British Columbia aged 65 and older (n = 660,679)., Measurements: we measured 2013 period prevalence of prescription dispensations satisfying the American Geriatrics Society's 2012 version of the Beers Criteria for potentially inappropriate medication use in older adults. We used logistic regressions to test for associations between this outcome and a number of clinical and socioeconomic factors., Results: a larger share of women (31%) than of men (26%) filled one or more potentially inappropriate prescription in the community. The odds of receiving potentially inappropriate prescriptions are associated with several clinical and socioeconomic factors. After controlling for those factors, community-dwelling women were at 16% higher odds of receiving a potentially inappropriate prescription than men (adjusted odds ratio = 1.16, 95% confidence interval = 1.12-1.21). Much of this sex difference stemmed from women's increased odds of receiving potentially inappropriate prescriptions for benzodiazepines and other hypnotics, for tertiary tricyclic antidepressants and for non-selective NSAIDs., Conclusion: there are significant sex differences in older adults' risk of receiving a potentially inappropriate prescription as a result of complex intersections between gender and other social constructs. Appropriate responses will therefore require changes in the information, norms and expectations of both prescribers and patients., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.)