NICE guidelines could put 12 million UK adults on statinsBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3674 (Published 01 August 2017) Cite this as: BMJ 2017;358:j3674
Almost all men over 60 and all women over 75 in England qualify for statin prescriptions under guidelines adopted by the National Institute for Health and Care Excellence (NICE) in 2014, a new analysis shows.1
Some 11.8 million people in England—37% of adults aged 30 to 84—exceed the threshold set by NICE for prescribing statins, the authors found. They said that most of these patients (9.8 million) are healthy, with no history of cardiovascular events, and are eligible for treatment simply because they exceed the risk threshold set by NICE: a 10% risk of experiencing such an event in the next 10 years.
Even some people with no risk factors at all are part of this group by virtue of their age. Nearly all men exceed the 10% threshold by age 65, and all women do so by age 70, even if they are non-smokers of normal weight with low cholesterol and no family history of heart disease, because the tool used for calculating risk (QRISK2) puts a high premium on age.
On average, 200 patients per GP are potentially eligible for statins but not currently getting them, said the study authors, led by Peter Ueda of the Karolinska Institute in Stockholm, Sweden, who worked as a postdoctoral researcher at Harvard University, USA, while conducting the analysis. Together with coauthors at Harvard and from Australia, he wrote in the British Journal of General Practice that, even if the statins are deemed cost effective, other costs need to be included.1
“Implementation of the guidelines should be considered in the context of opportunity costs for primary care and its available resources, in particular given the high and increasing workload facing GPs in England,” the team concluded.
Helen Stokes-Lampard, chair of the Royal College of General Practitioners, said, “We agree that the workload implications for GPs and our teams with so many people being potentially eligible for statin therapy is enormous, so this must be matched with appropriate resources.
“We need to get the risk scores right. If we find that all men over 60 and all women over 75 are going to be eligible for statins with new risk scoring, regardless of any other risk factor, then it should ring alarm bells—because it is not clear that every 60 year old man or 75 year old woman is going to benefit from statin therapy.”
Azeem Majeed, professor of primary care at Imperial College London, said that NHS England had not discussed how this additional GP workload would be met.
“The assumption is that the workload will be picked up by primary care teams without any additional allocation of funding,” he said. “In theory, there should be some net savings to the NHS because an increase in the use of statins should lead to a reduction in CVD [cardiovascular disease] events in the people being treated. However, none of these savings are likely to be made available in primary care budgets.
“I think that one lesson from this is that NICE also needs to consider whether the NHS has the capacity to deliver its guidance. Otherwise, NICE will increasingly be seen by clinicians as an ‘ivory tower’ institution that is detached from the realities of NHS clinical practice.”
Mark Baker, director of NICE’s centre for guidelines, said that the risk scores reflected the fact that heart disease and stroke are largely age related and that, although those scores do make people eligible for statins, alternatives are available.
“To make progress in the battle against heart disease and stroke, we must encourage exercise, improve our diets still further, stop smoking, and where appropriate offer statins to people at risk,” said Baker. “People, including older people, should not take statins instead of making the lifestyle adjustments that those at risk of cardiovascular disease need to make—such as stopping smoking, being more active, drinking less alcohol, eating more healthily, and losing weight.”
The 2014 guideline was controversial when first announced,2 and many doctors criticised its “mass medication” implications. NICE did not deny that it would mean many millions more people having statins prescribed; but Ueda said that, despite this, the implications have not been subject to much investigation.
The new study aimed to remedy this by using data from the Health Survey for England to estimate just how many patients could be drawn in. But in practice, the team said, nothing like this many will ever take statins: only 31% of eligible people actually complied with a 2008 guideline that set a 20% risk.