Ontario Public Drug Programs
5700 Yonge Street, 3rd Floor
Toronto ON M2M 4K5
Please send completed submission and/or any additional relevant information to the Ontario Public Drug Programs,
Patient Evidence Submission, 5700 Yonge Street, 3rd Floor, Toronto ON M2M 4K5, fax to 416 327-8123 or
email to PatientSubmission.OPDP@ontario.ca.
Drug and Indication
Patient Advocacy Group
The author and the patient group must declare any potential conflicts of interest that may influence or have the appearance of influencing the
information submitted. Examples of conflicts of interest include, but are not limited to, financial support from the pharmaceutical industry (such as educational/research grants, honoraria, gifts, and salary), as well as affiliations or personal/commercial relationships with drug
manufacturers or other interest groups.
What symptoms and problems do patients have as a result of the disease/condition? How does the condition affect day-to-day life? For
example, are there activities that patients are not able to do as a result of the condition?
Treatment outcomes that matter most to patients
What are the most important aspects of the condition that patients would like to see addressed by treatments?
In terms of treatment efficacy and side effects, what are patients getting from the existing treatments and what would patients like new
treatments to do differently?
Are there other practical implications to be considered in determining the value of a treatment? For example, how do treatments impact
patients’ or caregivers’ daily routine or lifestyle?
In addition to the drug cost, are there other financial implications to patients or caregivers (e.g. traveling cost, time away from work, drug
disposal issues, drug administration supplies)?
Information from patients who have used this drug
For patients who have used this drug as part of a clinical trial or from a manufacturer’s compassionate supply or have purchased it through other
means (private insurance or paid out of pocket).
What positive and negative impacts does the drug have on the condition?
Which symptoms is the drug best or worst at treating (advantages and disadvantages)?
What difference does the drug make to patients’ long-term health and wellbeing?
What are the side effects of the drug, which ones are patients prepared to put up with, and which ones do they find unacceptable?
How does the drug compared with other available treatments in terms of efficacy, side effects and other practical implications (e.g. administration, time, costs)?
I declare that I am the sole author of this submission and confirm that no other parties had input into the submission.
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