1. Clinical Epidemiology Study Who benefits? How do we know? B Lynn Beattie MD FRCPC Professor Emeritus Div Geri Med, Dept Med, UBC Medical Director UBCH CARD

2. Low-income subset of the cohort from the Utilization and Cost Study Policy begins Low-income people* ChEI use No use: Historical Controls *On MSP premium subsidy

3. 70% increase among poor a) Impact on Low-income Cohort (n = 24,253) …vs 30% increase in all BC

4. Rate of contacts with physicians: Low-income cohort vs all of BC Low Income: Policy cohort Historical control All BC: Policy cohort Historical control No impact BC linked data for 2006-2009

5. Rate of entry to long-term or palliative care: Low-income vs all of BC Low Income: Policy cohort Historical control No impact BC linked data for 2006-2009

6. Rate of hospitalizations: Low-income cohort vs all of BC Low Income: Policy cohort Historical control No impact BC linked data for 2006-2009

7. b) Special Authority data: Changes in Clinical Measures New users of ChEI (naïve) Continuing users (non-naïve) Problem: No SMMSE data collected before policy.

8. Initial Special Authority Form

9. Renewal Special Authority Form – Overall Patient Assessment Rating OPAR

10. Change in SMMSE scores over 6 mo SMMSE Change First SMMSE Low scorers, who score below 10 at 6 months, do not submit SA forms High scorers cannot score much higher Naïve: new users of ChEIs (n = 1094) Middle of graph is relatively free of bias

11. Change in SMMSE scores over 6 mo SMMSE Change First SMMSE Low scorers, who score below 10 at 6 months, do not submit SA forms High scorers cannot score much higher Non-naïve: Continuing users (n = 1584) Middle of graph is relatively free of bias

12. Changes in SMMSE scores naïve continuing SMMSE Change + 0.28 - 0.22 Difference : + 0.5 (95% CI: 0.3-0.7) SMMSE Change Naïve improved by half a point more than Non-Naive.

13. Change in GDS by first SMMSE naïve continuing Difference:0.05 (95% CI: 0.0-0.09) GDS Change + 0.03 - 0.03 GDS Change Naïve achieved 5% of a GDS point more than Non-Naïve

14. OPAR compared by first SMMSE naïve continuing Difference: 0.23 (95% CI: 0.15- 0.33) OPAR 0.49 0.26 OPAR Naive achieved a quarter of a point more on OPAR than Non-Naive

15. Conclusions In real-world usage of ChEIs, there is evidence of clinical improvement, based on measurements by frontline physicians. This is consistent with the pivotal trials, most of which were 6 months RCTs. Value of OPAR will be looked at further. We look forward to the evidence on longer- term effects of ChEIs.