Threshold is £37 000 per QALY

EDITOR—Although I agree with most of Law's and Wald's conclusions with regard to risk factors, I cannot agree that, as a result, treatment thresholds do not exist.1 With regard to the risk of coronary heart disease, the recent joint British recommendations recommend starting treatment of high blood pressure at an absolute 10 year risk of coronary heart disease of 15%, and of a high lipid ratio at 30%.2 Neither these recommendations nor those of the Standing Medical Advisory Committee explain why these particular thresholds have been set. (Neither do they mention when treatment should be stopped.) But could or should it have something to do with cost? I think that, despite the article's title, Law and Wald acknowledge this implicitly by saying that people at high risk should be targeted.

There have been several published cost effectiveness analyses of lipid lowering drugs. The report from Pickin et al puts the cost per (presumably good quality) year of life gained of treating coronary heart disease risk above 3% per year at £8200, which they describe as of comparable cost effectiveness to many treatments in wide use.3 They say, however, that treatment below this level is unlikely to be affordable. The de facto threshold currently being used by the National Institute of Clinical Excellence is considerably higher—about £37 000 per QALY.

Ethical questions such as the value the NHS and other health systems should place on preventive rather than immediately lifesaving care remain largely undiscussed. Perhaps that is why so many authors overlook that resources are scarce and so thresholds must always exist. Isn't it time that this collective blind spot was removed?

Hypothesis is dangerous nonsense

EDITOR—Law and Wald …