Peer-Reviewed Article

Canadian Trends in Estimated Pharmaceutical Drug Purchases and Projections: 2023

This article has been peer reviewed.

Authors: Mina Tadrous, Pooyeh Graili, Kaleen N. Hayes, Heather L. Neville, Joanne Houlihan, Fiona Clement, Jason R. Guertin, Michael R. Law, Tara Gomes

Abstract

Background: Comprehensive data identifying trends in the pharmaceutical market are limited. Last year, our group presented the first forecast. We report the first annual update of estimated pharmaceutical drug purchases in Canada. The goal is to identify factors that may influence future spending to support public and private decision-makers in predicting the growth of national drug purchases.

Methods: We conducted a time series analysis of annual estimated pharmaceutical drug purchases across Canada between 2001 and 2021 using IQVIA’s Canadian Drugstore and Hospital Purchases Audit. We calculated total estimated pharmaceutical drug purchases and relative percentage change annually, stratified by sector (retail and hospital), and forecast annual spending to 2023. We also assessed recent drug approvals, policies, or legislation that may influence drug spending.

Results: Total drug purchases for 2021 were approximately $35.4 billion, 8.3% higher than in 2020 (7.3% growth in the retail sector; 12.4% growth in the hospital sector). Overall, total spending for the top 25 drugs accounted for 31.2% and 52.3% of total spending in the retail and hospital sectors, respectively. Spending has grown over the past 2 decades, with an annual average growth of 5.4% and 7.4% for the retail and hospital sectors, respectively. The forecast for the retail sector is continued moderate levels of growth in drug spending (7% to 8% annually), with higher rates of growth (12% to 13% annually) in the hospital setting.

Interpretation: We project continued growth in overall drug purchases across the entire Canadian market. New approvals of specialty and oncology drugs and generic formulations of the top 25 drugs are expected to influence drug purchases in 2022–2023. If no action is taken to curb sustained growth in pharmaceutical spending in Canada, costs may necessitate a shift in spending from other public budgets or to private industry and directly to patients. The opportunity cost of continued increased spending on pharmaceuticals must be considered.

Introduction

Total public health care spending in Canada was forecasted by CIHI to reach more than $308 billion in 2021, representing 12.7% of the country’s gross domestic product.¹ Public spending on prescription drugs was expected to account for 6.9% ($16.5 billion) of national public health care purchases — a $1.1 billion increase compared with the 2020 projections.¹ Public drug spending accounted for 44% of total drug spending in Canada in 2020.¹

In 2021, our group published the first of what we aim to be an annual report highlighting spending on drugs in Canada.² We found that between 2001 and 2020 drug spending increased on average by 5.3% annually in the retail sector and by 7.1% annually in the hospital sector, and we projected that spending was likely to continue increasing until at least 2023.² Although drug spending has been historically driven by medications for chronic conditions, our results highlighted that biologics and biosimilars had become the key contributors to drug spending.² Furthermore, based on the available information about novel treatments approved by Health Canada and the US FDA combined with the historical growth in spending,^2-7 we projected that drug spending for the years 2021 to 2023 would increase by 3% to 4% annually in the retail sector and by 7% to 8% annually in the hospital sector.²

Budget planning for drug spending is an annual process and requires forecasting of potential growth. We aim to conduct this analysis annually to help inform decision-makers and formulary managers in developing their annual budgets and strategies. Approvals for novel pharmaceutical technologies with the potential to change budget trajectories are expected in the coming years; therefore, an annual update of both the spending forecast and a Horizon Scan are needed. External and independent assessments of drug spending across the country can help support public and private decision-makers better anticipate how various factors could influence drug spending as novel technologies driving spending are expected to continue. In this first update of our planned annual report, we present trends and forecasts of retail and in-hospital estimated pharmaceutical drug purchases across Canada. We also provide a Horizon Scan looking at new innovative drugs that could potentially change the spending trajectory.

Methods

Drug Purchases and Projection

We conducted a retrospective time series analysis of annual estimated pharmaceutical drug purchases (i.e., drug purchases) across Canada between January 1, 2001, and December 31, 2021, using IQVIA’s Canadian Drugstore and Hospital (CDH) Purchases Audit. These data estimate purchasing costs and unit volumes of all pharmaceutical products purchased by the Canadian retail and hospital sectors.⁸ This audit is derived from a sample of outlets within these sectors (more than one-third of retail and 86% of hospital sectors) in each province and territory, which are projected to represent total pharmaceutical purchasing at the national level using proprietary methods. We included all pharmaceutical purchasing of all dosage forms and formulations over the study period. Purchasing may be made through a wholesaler or directly from the manufacturer, and therefore may include mark-ups, but does not capture discounts and rebates. Although CDH projections will not capture any subsequent rebates or volume discounts credited to the outlets afterward, it does reflect all up-front discounts for each specific invoice. Due to the aggregated nature of the data provided, research ethics board approval was not required.

We describe total estimated pharmaceutical drug purchases across Canada annually (using calendar years) over the study period, stratified by sector (retail versus hospital). We calculated the annual growth in purchases as the relative percentage change from the previous year. We used exponential smoothing models, applying Holt’s method, to forecast annual estimated pharmaceutical drug purchases in 2022 and 2023. Costs were reported as nominal annual costs, and nominal costs were used for projection models. In a sensitivity analysis, we inflated annual costs before 2021 to 2021 values using the all-items consumer price indexes.⁹ Finally, we identified the 25 medications with the highest total purchases in the calendar year 2021 in the retail and hospital sectors separately.

Horizon Scan

An Environmental Scan of global and national drug spending and pipeline reports was conducted to identify therapeutic classes with potentially major impacts on pharmaceutical spending.^10-13 All medications approved by Health Canada in 2021 and the first quarter of 2022, as well as generic drugs and biosimilars currently under review, were assessed for anticipated budget impacts.¹⁴ New drug approvals by the US FDA in 2021 and the first quarter of 2022 were also reviewed to identify drugs that may soon enter the Canadian market.¹⁵

Drugs with potential high impact on future spending (via upward pressure or downward pressure) were flagged based on the following criteria: disease prevalence, current medication use and availability in the therapeutic area, anticipated cost, and public plan reimbursement recommendations by CADTH. Based on the list of drugs with the highest potential for impact on the Canadian market, the authors made a consensus recommendation on whether the projected spending might be more likely on the high, middle, or low end of the projected confidence interval (CI) range estimated from the forecast analysis for the next 2 years.

Results

Trends in Canadian drug purchases from 2001 to 2021 in the retail and hospital sectors are presented in Figure 1 and Figure 2, respectively. Graphs that include values accounting for inflation can be found in Appendix 1 (Figure 4 and Figure 5).

Overall Spending

In 2021, total drug purchases in Canada grew 8.3%, reaching $35.4 billion (versus $32.7 billion in 2020). This was higher than our previous forecasted rate of 4.2%. The retail sector accounted for 84.5% of drug purchases in 2021 ($29.9 billion), and the hospital sector accounted for 15.5% ($5.5 billion). Retail and hospital purchases in 2021 increased from 2020 by 7.3% and 12.4%, respectively. The rates in both sectors were also higher than our forecasted rates of 6.9% and 3.8%, respectively. Figure 3 illustrates the trends in the annual change in purchases across both sectors.

Retail and Hospital Spending

In the retail sector, total drug purchases increased by 184%, from $10.5 billion in 2001 to $29.9 billion in 2021. In the hospital sector, total drug purchases grew 309% from $1.3 billion in 2001 to $5.5 billion in 2021. Among retail purchases, the average annual growth was higher in earlier years (6.7% between 2001 and 2011) compared with 2012 onward (4.1% between 2012 and 2021); 2011 was the only year with a decrease in annual purchases (−2.9%). Over the entire period (2001 to 2021), the average annual growth was 5.4% and 7.4% for the retail and hospital sectors, respectively.

In the hospital sector, the average annual growth was similar to the retail environment between 2001 and 2011 (6.5%) but grew quicker between 2012 and 2021 (8.4%); there was no year with a reported decrease in annual spending. The drug purchases for hospital-administered drugs grew 12.7%, 18.4%, 6.9%, and 12.4% in 2018, 2019, 2020, and 2021, respectively. In comparison, drug purchases in the retail sector experienced a smaller growth of 3.4%, 5.2%, 3.8%, and 7.3% in 2018, 2019, 2020, and 2021, respectively.

Figure 1: Total Estimated Pharmaceutical Drug Purchases in Canada for the Retail Sector From 2001 to 2021

Note: The grey zone illustrates forecasted purchases in the retail sector (solid line) with 95% confidence interval estimates (dashed lines) for 2022 and 2023.

Source: This figure is based on information licensed from IQVIA: Canadian Drugstore and Hospital Purchases Audit for 2001 to 2021 estimates of real-world activity. All rights reserved.

Figure 2: Total Estimated Pharmaceutical Drug Purchases in Canada for the Hospital Sector From 2001 to 2021

Note: The grey zone illustrates forecasted purchases in the hospital sector (solid line) with 95% confidence interval estimates (dashed lines) for 2022 and 2023.

Source: This figure is based on information licensed from IQVIA: Canadian Drugstore and Hospital Purchases Audit for 2001 to 2021 estimates of real-world activity. All rights reserved.

Drug Expenditure Forecast for 2022 and 2023

We forecast a yearly increase (all sectors combined) in drug purchases of 6.2% in 2022 and 5.9% in 2023 (Figure 3). We project that purchases for hospital-administered drugs will increase annually by 9.4% and 8.8% for 2022 and 2023, respectively; in the retail setting, purchases will increase between 5.6% and 5.3% annually for 2022 and 2023, respectively. When considered in absolute costs, we forecast an increase of $33.2 billion (95% CI, $30.7 billion to $35.8 billion) for retail purchases and $6.5 billion (95% CI, $6.0 billion to $7.0 billion) for hospital purchases by 2023 (Figure 1 and Figure 2).

Figure 3: Annual Growth in Estimated Pharmaceutical Drug Purchases From the Previous Year (2002 to 2021) for the Retail and Hospital Sectors

Note: Blue bars represent the retail sector and orange bars represent the hospital sector. The grey zone illustrates forecasted annual growth for 2022 and 2023.

Source: This figure is based on information licensed from IQVIA: Canadian Drugstore and Hospital Purchases Audit for 2001 to 2021 estimates of real-world activity. All rights reserved.

Top 25 Drugs by Overall Purchases in 2021

Table 1 provides the top 25 drugs by purchases in retail and hospital settings across the country for the year 2021. In terms of purchases, infliximab ($1.3 billion), adalimumab ($979 million), and ustekinumab ($636.3 million) were the top 3 drugs in the retail setting, whereas pembrolizumab ($518.8 million), daratumumab ($254.2 million), and nivolumab ($245.7 million) were the top 3 drugs in the hospital setting. Overall, total purchases for the top 25 drugs in both markets in 2021 accounted for $12.2 billion ($9.3 billion and $2.9 billion in the retail and hospital sectors, respectively), which accounted for 31.2% and 52.3% of total spending in each sector, respectively. Only 3 drugs were in the top 25 of both lists: a vascular endothelial growth factor-A (VEGF-A) antagonist (aflibercept: number 4 in retail spending and number 17 in hospital spending) and 2 kinase inhibitors (ibrutinib: number 13 in retail spending and number 7 in hospital spending; palbociclib: number 24 in retail spending and number 10 in hospital spending).

Table 1: Top 25 Drugs by Purchases in Retail and Hospital Settings for the Calendar Year 2021 and Trends Compared With 2020

Note: The drugs with a dash are new entries to the top 25 drugs in 2021.

Source: This table is based on information licensed from IQVIA: Canadian Drugstore and Hospital Purchases Audit for 2001 to 2021 estimates of real-world activity. All rights reserved.

Horizon Scan

Fifteen global reports were reviewed to determine trends for drug spending in Canada (Appendix 1, Table 3). In Table 2, we present the drugs that are anticipated to have the most impact on drug purchases in 2022 and 2023. Here, we summarize major themes for new and upcoming therapies in Canada. We first highlight treatments we believe will have the largest impact on increased spending (“upward pressure”) then discuss potential mitigating factors (“downward pressure”). A complete list of drug approvals for Health Canada and the US FDA in 2021 and the first quarter of 2022 are presented in Table 4, and Table 5, respectively. The FDA approved 50 novel drugs in 2021 compared with 53 in 2020.⁷ Health Canada approved 78 drugs in 2021 compared with 84 new drugs in 2020, of which 40 were novel drugs.¹⁶

Table 2: Selected Drugs and Biologicals That Received Health Canada and/or FDA Approval in 2021 and Early 2022 and Are Expected to Affect Drug Spending

ALS = amyotrophic lateral sclerosis; AML = acute myeloid leukemia; CAR = chimeric antigen receptor; CGRP = calcitonin gene-related peptide; CML = chronic myelogenous leukemia; DPP-4 = dipeptidyl peptidase-4; GLP-1 = glucagon-like peptide-1; MS = multiple sclerosis; NA = not applicable; SGLT2 = sodium-glucose cotransporter-2; SMA = spinal muscular atrophy; VTE = venous thromboembolism.

Potential for Upward Pressure

In oncology, chimeric antigen receptor (CAR) T-cell therapies are anticipated to make the largest impact on spending. A new CAR T-cell therapy was recently approved for the treatment of mantle cell lymphoma, and another is under review by Health Canada for multiple myeloma, a relatively common cancer. Daratumumab (Darzalex) is the number 2 ranked drug in the hospital sector, and purchases have increased over the past 2 years. It will likely impact spending even more in coming years because it has now been approved for additional indications of multiple myeloma and amyloidosis therapy.

Certain therapeutic areas are likely to increase spending due to the prevalence of these conditions in the Canadian population. Drugs for migraine treatment continue to increase drug spending as the new calcitonin gene-related peptide inhibitors take over a higher market share for the prevention of chronic migraine. Lasmiditan (Reyvow), a first-in-class medication indicated for acute treatment of migraine that was approved by the FDA in 2019, is not yet under review by Health Canada. Semaglutide (Wegovy), the number 5 ranked drug in the retail sector, has been approved for chronic weight management in adults and is currently under review by CADTH for this indication. Liraglutide (Saxenda) has an expanded indication for weight management in adolescents 12 years and older; however, CADTH did not recommend reimbursement by public plans. New medications for multiple sclerosis continue to be approved, such as ofatumumab (a once-monthly injection) and ponesimod, both of which are expected to increase the cost of treatment overall. Of note, ocrelizumab, which is a treatment for multiple sclerosis that is infused every 6 months, is a new addition to the top 25 in retail spending this year. Finally, aducanumab (Aduhelm) received FDA approval for the treatment of Alzheimer disease in 2021. Approximately 76,000 Canadians are diagnosed with dementia each year,¹⁷ and aducanumab costs approximately US$28,000 annually. The medication is presently under review by Health Canada, but it remains unclear whether it will be approved and funded in Canada.

For rare diseases, the increasing number of therapies with high price tags are expected to drive costs, particularly in diseases that previously had no or few treatment options available. Notable examples include sodium phenylbutyrate and ursodoxicoltaurine for amyotrophic lateral sclerosis and risdiplam for spinal muscular atrophy. In addition, elexacaftor, ivacaftor, and tezacaftor (Trikafta) was approved in 2021 for cystic fibrosis and received a positive recommendation for reimbursement by CADTH for adults and adolescents aged 12 years and older. Trikafta received an expanded indication for pediatric patients aged 6 years and older in 2022 and another positive recommendation to reimburse by CADTH, indicating continued growth for this product.

Potential for Downward Pressure

A limited number of approved or upcoming generic medications and biosimilars have been identified as having the potential to exert downward pressure on drug spending. In oncology, 2 new generic medications have been approved for multiple myeloma (carfilzomib and pomalidomide) and are expected to have an impact. Generic ibrutinib may impact both retail (ranked number 13) and hospital (ranked number 7) spending, but savings will be partially blunted by the expected replacement with a new kinase inhibitor, zanubrutinib. Among medications for diabetes, insulin aspart and lispro have new biosimilar market entries to join Trurapi (insulin aspart biosimilar for NovoRapid) and Admelog (insulin lispro biosimilar for Humalog), which could lead to reduced spending on insulin.¹⁸ Furthermore, several generic drugs in the sodium-glucose cotransporter-2 (SGLT2) inhibitor, dipeptidyl peptidase-4 (DPP-4) inhibitor, and glucagon-like peptide-1 (GLP-1) receptor agonist classes are under review and expected to significantly decrease costs for diabetes treatment overall. Although several generic antiretroviral products for HIV are also under review, it is anticipated the abacavir, dolutegravir, and lamivudine combination will exert the highest impact because it is 1 of the recommended initial therapies in HIV treatment guidelines.¹⁹ Based on market share, generic apixaban (number 6 in retail spending) for venous thromboembolism and generic tofacitinib for immune diseases such as rheumatoid arthritis and ulcerative colitis will likely reduce costs. Finally, the first market entry for a ranibizumab biosimilar (number 8) and the availability of several adalimumab biosimilars (number 2) are expected to decrease spending substantially in the retail sector.²⁰

Interpretation

Spending on pharmaceuticals has grown considerably over the past 2 decades in Canada, leading to a total market size of more than $35 billion in 2021. In 2021, the annual growth compared to the previous year in spending reached 7.3% for retail drug purchases and 12.4% for hospital drug purchases, far surpassing growth rates seen the year prior and our previous forecast in 2021. This is particularly apparent in the retail sector where the annual growth in spending between 2020 and 2021 was higher than has been observed for the past decade. This expansion is likely driven by new product approvals, higher market entry prices for new drugs, and growing utilization. Thus, we anticipate continued increases in the retail sector combined with accelerated growth in the hospital sector, leading to projected total annual drug purchases nearing $40 billion by 2023. Importantly, the anticipated growth in the number of new therapies and associated costs will continue to put pressure on constrained government budgets across the country, leading to a need for strategies that balance access to novel therapeutics against limited resources.

It is expected that the pressure from growth in the available therapies identified in the pipeline are likely to continue to affect the degree of change in spending in the coming years. We did note fewer approvals in comparison to 2021, which was a record-breaking year. Overall, we believe the growth in spending will be on the lower end of the predicted range in the outpatient retail setting due to the introduction of new generics or biosimilar formulations for several top 25 therapies, including adalimumab, ranibizumab, 2 direct oral anticoagulants, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, and insulin biosimilars. However, much of the effect of biosimilars will depend on their uptake in Canada. Presently, most Canadian provincial public drug plans require biologic-naive patients to initiate a biosimilar formulation, and half of these drug plans have introduced mandatory non-medical biosimilar switching policies over the past several years.²¹ If a large province, such as Ontario, implemented similar policies, we anticipate this would have a large effect on total national spending projections. Finally, despite this downward pressure, diabetes therapies have particular potential to be “blockbuster” retail pharmacy drugs due to the high prevalence of diabetes and the expanded scope of many diabetes drugs to include weight loss. Therefore, it will be important to monitor the ongoing use of these medications to ensure appropriate use and manage spending.²²

Importantly, the validity of our projections remains uncertain since they were mostly based on data collected before the COVID-19 pandemic. This also explains why our current projections for 2023 are higher than our previous forecast. The pandemic has substantially impacted health care across the country, including drug spending. For example, at the time of publishing our first report, only 1 treatment, remdesivir, was approved by Health Canada and the FDA for a COVID-19 indication but spending on this drug had yet to occur. Since then, many treatments, including a series of COVID-19 vaccines, were not only developed but are approved and being used across the country. Spending on these new treatments may dramatically increase drug spending across Canada, maybe even beyond the upper bound of our projections for 2022 and 2023. However, other factors directly and indirectly related to the COVID-19 pandemic may have the opposite impact. The second, third, fourth, and fifth waves of COVID-19 have caused various levels of delayed treatments within hospitals across the country and have led to reduced screening of chronic conditions and cancers, potentially reducing the use of health care resources, including pharmaceuticals, at least in the short-term. We did observe that 16 of the top 25 drugs experienced expansion in their total purchases compared with last years’ report in 2020.

Our analysis has limitations that warrant discussion. First, we do not have information on the rebates that manufacturers provide to public and private drug plans or hospital purchasers because these contracts are kept confidential. These discounts can be sizable — for example, pan-Canadian Pharmaceutical Alliance (pCPA) negotiations yielded $1.24billion in savings in 2017–2018.²³ However, our results still represent the total purchases in the current drug system, and we do not anticipate major differences in the proportion of rebates to total purchases in recent years. The purchase prices do account for up-front discounts. Rebates are also re-invested to pay for future drug spending and thus are paid forward in spending. Additionally, rising prices have important consequences on patient co-pays depending on payment method and plan structure.²⁴ Second, our data had no information on payers (i.e., public insurance, private insurance, or out-of-pocket) and thus only characterizes global spending in Canada and the future impact for all payers.

Conclusion

Overall pharmaceutical drug purchases in Canada for 2021 were higher than our predicted increases in our previous report. This was for both the retail and hospital sectors and was caused by the combined impact of higher utilization and higher prices for new therapies. Because the nature of drugs is driving the change, there is a continued need for rigorous assessment and price negotiation by public payers to ensure these investments represent good value for money. We project continued growth in overall drug purchases across the entire Canadian market. Specifically, the forecast for the retail sector is continued moderate levels of growth in drug spending (7% to 8% annually), with higher rates of growth (12% to 13% annually) in the hospital setting.

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Appendix 1: Additional Figures and Tables

Note that this appendix has not been copy-edited.

Figure 4: Total Estimated Pharmaceutical Drug Purchases in Canada for the Retail Sector From 2001 to 2021

Note: The grey zone illustrates forecasted purchases in the retail sector (solid line) with 95% confidence interval estimates (dashed lines) for 2022 and 2023. Blue line with circles = non–inflated-adjusted purchases; orange line with triangles = inflated-adjusted purchases.

Source: This figure is based on information licensed from IQVIA: Canadian Drugstore and Hospital Purchases Audit for the period of 2001 to 2021 estimates of real-world activity. All rights reserved.

Figure 5: Total Estimated Pharmaceutical Drug Purchases in Canada for the Hospital Sector From 2001 to 2021

Note: The grey zone illustrates forecasted purchases in the hospital sector (solid line) with 95% confidence interval estimates (dashed lines) for the years 2022 and 2023. Red line with circles = non–inflated-adjusted purchases; light blue line with triangles = inflated-adjusted purchases.

Source: This figure is based on information licensed from IQVIA: Canadian Drugstore and Hospital Purchases Audit for the period of 2001 to 2021 estimates of real-world activity. All rights reserved.

Table 3: Fifteen Global Reports Reviewed to Determine Trends for Drug Spending in Canada

Table 4: Health Canada Drug Approvals Between January 1, 2021, and March 31, 2022

Table 5: FDA Drug Approvals Between January 1, 2021, and March 31, 2022

Appendix 2: Author Information

Corresponding Author

Mina Tadrous

Leslie Dan Faculty of Pharmacy, University of Toronto

144 College St., Toronto, Ontario

mina.tadrous@utoronto.ca

Author Information

Mina Tadrous, PharmD, PhD;^1-3 Pooyeh Graili, MD, MPH, MBE;² Kaleen N. Hayes, PharmD;⁴ Heather L. Neville, BSc Pharm, MSc;⁵ Joanne Houlihan, BSc Pharm;⁶ Fiona Clement, PhD;^7,8 Jason R. Guertin, PhD;^9,10 Michael R. Law, PhD;¹¹ Tara Gomes, PhD;^2,3,12

¹Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada

²Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada

³ICES, Toronto, Ontario, Canada

⁴Brown University, Providence, Rhode Island, US

⁵Queen Elizabeth II Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada

⁶Nova Scotia Cancer Care Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada

⁷Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

⁸O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada

⁹Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada

¹⁰Department of Social and Preventive Medicine, Université Laval, Québec, Canada

¹¹Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada

¹²Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada

Author Disclosures

Dr. Gomes received salary support through a Canada Research Chair in Drug Policy Research and Evaluation and grant funding from the Ontario Ministry of Health. Dr. Law received salary support through a Canada Research Chair in Access to Medicines. Dr. Law has consulted for Health Canada, the Health Employees’ Union, the Conference Board of Canada, and provided expert witness testimony for the Attorney General of Canada and the Federation of Post-secondary Educators. Dr. Guertin holds a research career award from the Fonds de recherche du Québec – Santé (FRQS). Dr. Guertin has consulted for the Institut national d’excellence en santé et services sociaux (INESSS). Dr. Tadrous has consulted for CADTH and Green Shield Canada. Ms. Neville is a member of the CADTH Canadian Drug Expert Committee. Ms. Houlihan is a member of the Provincial Advisory Committee for CADTH. Dr. Tadrous reported consulting fees from CADTH and Green Shield Canada and funding from the Ontario Ministry of Health.

Acknowledgements

All authors were involved in the design, interpretation of results, writing, conceptualization of recommendations, and revision of the manuscript. MT was involved in the implementation of the study and had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. MT is the guarantor of the content of the manuscript, including the data and analysis.

The statements, findings, conclusions, views, and opinions contained and expressed in the report are based in part on data obtained under license from IQVIA, Canada Inc. concerning the following information service(s): IQVIA’s Canadian Drugstore and Hospital Purchases Audit, data period January 1, 2001, and December 31, 2021. All rights reserved. The statements, findings, conclusions, views, and opinions expressed herein are not necessarily those of IQVIA Canada Inc. or any of its affiliated or subsidiary entities.