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BMJ No 7122 Volume 315 Letters Saturday 13 December 1997 Use of statins See Editorial by Muldoon p 1554 Glasgow has already produced strategy for treatment Editor Freemantle et al are correct in emphasising that costs and benefits must be linked when new treatments are considered, but they then go on to ignore this advice.(1) They make the all too common error of emphasising mortality benefits while excluding the impact of treatment on morbidity. This is looking at only one side of the cost effectiveness equation, where effectiveness reflects mortality benefits and costs avoided reflect the impact of treatment on morbidity. Yes, 4S (Scandinavian simvastatin survival study) tells us that we may need to treat 30 patients for five years to prevent one death, but the picture looks completely different when it is realised that 16 admissions to hospital for myocardial infarction, six admissions for angina, 1.5 admissions for heart failure, two strokes or transient ischaemic attacks, and nine revascularisation procedures will also be avoided.(2) Indeed, a total of 34 fewer admissions for cardiovascular reasons and 347 fewer hospital bed days can be expected.(2) Not surprisingly, therefore, cholesterol lowering treatment is likely to be cost effective in a population similar to that in 4S. Freemantle et al are wrong in stating that no formal information on cost effectiveness is available. There are at least three published economic analyses of 4S, and the estimated incremental cost effectiveness ratio is around £5,000-10,000 per life year gained in Britain.(3) We have supported this conclusion in an unpublished analysis, estimating that the direct incremental cost of treatment is £2,083 per patient over 10 years (that is, £208 a year or 57p a day). Similar, detailed, analyses of the benefits and costs of primary prevention are widely available.(4) Health boards such as Glasgow have already produced a strategy and accompanying guidelines to target and treat cost effectively, in an evidence based way, those patients who have most to gain from cholesterol lowering treatment.(5) J McMurray Consultant cardiologist MRC Clinical Research Initiative in Heart Failure, University of Glasgow, Glasgow G12 8QQ A McGuire Professor of health economics M Raikou Research fellow Department of Economics, City University, London EC1V 0HB C Morrison Consultant in public health Scottish MONICA Project, Royal Infirmary, Glasgow G31 2ER References 1 Freemantle N, Barbour R, Johnson R, Marchment M, Kennedy A. The use of statins: a case of misleading priorities? BMJ 1997;315:826-8. (4 October.) 2 Pedersen T R, Kjekshus J, Berg K, Olsson A G, Wilhelmsen L, Wedel H, et al. Cholesterol-lowering and the use of health-care resources: results of the Scandinavian simvastatin survival study (4S). Circulation 1996;94:63. 3 Jonsson B, Johannesson M, Kjekshus J, Olsson A G, Pedersen T R, Wedel H. Cost-effectiveness of cholesterol-lowering-results from the Scandinavian simvastatin survival study (4S). Eur Heart J 1996;17:1001-7. 4 Caro J, Klittich W, McGuire A, Norrie J, Ford I, McMurray J, et al. The cost effectiveness of preventinig initial coronary events with pravastatin: results of the west of Scotland coronary preention study economic analysis. Atherosclerosis 1997;134:46. 5 Morrison C, McMurray J. Lipid-lowering strategies for thee prevention of coronary heart disease. Clin Sci 1997;92:431. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline