Letters

Secondary prevention in coronary heart disease

Cost effectiveness of treatment must be borne in mind

Payment for chronic disease management should include coronary heart disease

Cost effectiveness of treatment must be borne in mind

EDITORCampbell et al surveyed the true rates of treatment with various forms of secondary prophylaxis in patients with coronary heart disease, at least in those general practices that participated.¹ The authors do not consider the utilitarian argument that it is best to do the greatest good for the greatest number. The figure shows the number of lives saved per £100 000 spent on drugs for secondary prevention, based on the approximate number of patient years of treatment needed to save one life. If "all bad things" are considered² then aspirin (after the first five weeks)³ and simvastatin⁴ will both prevent about one bad thing for every 30-40 years of patient use, but £100 000 of aspirin (half a 300 mg tablet a day) will prevent about 1300 events, while £100 000 of simvastatin (20 mg a day) will prevent only eight.

View larger version (6K): [in this window] [in a new window]   Areas of squares represent number of lives saved by spending £100 000 on each of four drugs after myocardial infarction. A: soluble aspirin 150 mg daily in first five weeks; B: soluble aspirin 150 mg daily long term; C: atenolol 50 mg daily; D: simvastatin 20 mg daily.

I do not argue that we should abandon secondary prevention with lipid lowering agents, but we should concentrate on doing the easy and most cost effective things well. By these criteria, aspirin, then  blocking drugs and angiotensin converting enzyme inhibitors, in suitable cases are orders of magnitude more important than statins.

R E Ferner, Director.  .
West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH

1. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. BMJ 1998; 316: 1430-1434[Abstract/Free Full Text]. (9 May.)
2. Moore A, McQuay H, Muir Gray JA. Statins. Bandolier 1998; 47: 2-4.
3. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy. I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994; 308: 81-106[Abstract/Free Full Text].
4. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian simvastatin survival study (4S). Lancet 1994; 344: 1383-1389[Medline].

Payment for chronic disease management should include coronary heart disease

EDITORCampbell et al have confirmed that secondary prevention of coronary heart disease in Scotland is inadequate but have gone on to show that the situation can be improved by proper organisation within general practice.¹

When the banding system of health promotion in general practice was abolished the requirement for general practitioners to provide coronary secondary prevention was also abolished; the long term care of diabetic and asthmatic patients, however, was ensured by separate payments for chronic disease management for these conditions. Local medical committees were charged with setting up health promotion committees, to which all general practitioners had to submit their own protocols for health promotion, which might include coronary disease. No guidance was given about what these protocols should cover or how they should be structured. No way of monitoring their performance or outcomes has ever been proposed.

The Coronary Prevention Group has been lobbying the BMA's General Practitioners Committee to negotiate for the inclusion of coronary disease in the specific payment scheme for chronic disease management. There are four justifications for this approach: secondary prevention of coronary disease is effective²; secondary prevention of coronary disease in general practice is far more cost effective than primary prevention³; secondary prevention is not currently being provided adequately in the United Kingdom ^{4 5} ; and paying general practitioners to provide secondary prevention is likely to improve that provision. Plenty of evidence supports the first three of these justifications, but the Coronary Prevention Group was unable to find any evidence to support its belief that paying general practitioners to perform chronic disease management was effective. Campbell et al have now provided that evidence.

The Coronary Prevention Group strongly believes that improved secondary prevention of coronary disease would best be served by general practitioners' representatives negotiating with the government for coronary heart disease to be included in the payment scheme for chronic disease management, funded by new money. We would encourage all general practitioners to lobby their representatives on the General Practitioners Committee for this to happen.

Hugh J N Bethell, Chairman, secondary prevention and rehabilitation committee. 
Coronary Prevention Group, London WC1E 7DB

1. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair J. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998; 316: 1434-1437[Abstract/Free Full Text]. (9 May.)
2. O'Connor G, Buring J, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger Jr RS, et al. An overview of randomised trials of rehabilitation with exercise after myocardial infarction. Circulation 1989; 80: 234-244[Abstract/Free Full Text].
3. Hunink MGM, Goldman L, Tosteson ANA, Mittleman MA, Goldman PA, Williams LW, et al. The recent decline in mortality from coronary heart disease, 1980-1990. The effect of secular trends in risk factors and treatment. JAMA 1997; 277: 535-542[Abstract].
4. Bowker TJ, Clayton TC, Ingham J, McLennan NR, Hobson HL, Pyke SD, et al. A British Cardiac Society survey of the potential for secondary prevention of coronary disease: ASPIRE (action on secondary prevention through intervention to reduce events). Heart 1996; 75: 334-342[Abstract/Free Full Text].
5. McCallum AK, Wincup PH, Morris RW, Thomson A, Walker M, Ebrahim S. Aspirin use in middle-aged men with cardiovascular disease: are opportunities being missed? Br J Gen Pract 1997; 47: 417-421[Medline].