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BMJ No 7122 Volume 315 Letters Saturday 13 December 1997
Use of statinsSee Editorial by Muldoon p 1554Health authorities must work with clinicians to target statinsEditorWe agree with some of Freemantle et al's views on the use of statins, but the authors seem to be more concerned with the financial implications of using statins than with the cost effective treatment of coronary heart disease.(1) They assert that the Standing Medical Advisory Committee's report(2) ignores cost effectiveness and that enthusiasts for cholesterol lowering drugs `may do more harm than good through making savings in more cost effective areas,' but they fail to provide evidence in support of their claims. Indeed, available estimates suggest that the cost effectiveness of using statins, both in secondary prevention of coronary heart disease and in primary prevention in those at high risk, is reasonable in comparison with that of alternative methods of treating coronary heart diseases and other claims on available resources (table).
The population impact of use of statins is likely to be much greater than that of coronary artery surgery.(4) Waiting time pressures for coronary artery surgery have encouraged an increase in provision, although increasing use of statins may have had more impact on health. The authors do not consider the other beneficial effects of statins-for example, on non-fatal coronary heart disease events or stroke. Our experience suggests that general practitioners, rather than being 'overwhelmed by the size of the proposed change,' are keen to implement evidence based approaches to prescribing in coronary heart disease. The challenge for health authorities is to work with clinicians to target the use of statins to those at high risk. In Dudley, because of a combination of a district-wide clinical audit process facilitated by the local medical audit advisory group, guidelines, and intervention by the prescribing adviser, 85% of patients with a history of myocardial infarction are now receiving low dose aspirin. A similar approach will be adopted to target use of statins, initially in secondary prevention. Finally, we share concern that advice to implement the advisory committee's document in the absence of additional resources may be seen as 'passing the buck.' A recent survey that we did of district prescribing committees showed considerable similarity in the main prescribing challenges facing health authorities(5); this illustrates the desirability of a national approach in important therapeutic areas. We therefore welcome the national approach adopted in the advisory committee's guidance and trust that the size of annual increases in prescribing allocations to health authorities will fully reflect this national priority. Andrew P Wakeman
Medical adviser
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 Standing Medical Advisory Committee. The use of
statins. London: Department of Health, 1997. (11061 HCD Aug 97
(04).)
3 Working Group on Acute Purchasing. Statin therapy/HMG coA
reductase inhibitor treatment in the prevention of coronary heart
disease. Sheffield: Trent Institute for Health Services
Research, University of Sheffield, 1996.
4 European Coronary Surgery Study Group. Long term results of
prospective randomised study of coronary artery bypass surgery in
stable angina pectoris. Lancet 1982;241:1173-80.
5 Wakeman A P, Leach R H. Joint prescribing committees:
characteristics, progress and effectiveness. Health
Trends (in press).
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