While I agree entirely with most of Professors Law's and Wald's
conclusions with regard to risk factors, I cannot agree that, as a result,
treatment thresholds do not exist.
With regard to CHD risk factors, the recent Joint British
recommendations (1) recommend starting treatment of high blood pressure at
an absolute ten year CHD risk of 15%, and of a high lipid ratio at 30%.
Strangely, neither these recommendations, not those of the Standing
Medical Advisory Committee explain why these particular thresholds have
been set. (Nor 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, Professors Law and Wald acknowledge this implicitly
by stating that people at high risk should be targeted.
There have been a number of published cost-effectiveness analyses of
lipid-lowering drugs. The report from Pickin et al (2)puts the cost per
(presumably good quality) year of life gained of treating CHD risk above
3% per year at £8,200, which they describe as "as cost effective as many
treatments in wide use". On the other hand they state that treatment below
this level is unlikely to be affordable". However the de facto threshold
currently being used by the National Institute of Clinical Excellence is
considerably higher- about £37K per QALY.
Ethical questions such as the value the NHS, and other health
systems, should place on preventative 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?
No competing interests
References
(1) British Cardiac Society et al. Joint British recommenadtions on
prevention of CHD in clinical practice. Heart 1998; 80(supplement 2):S1-
S29.
(2) Pickin DM, McCabe CJ, Ramsay LE et al. Cost effectiveness of HMG-CoA
reductase inhibitor (statin) treatment related to the risk of CHD and cost
of drug treatment. Heart 1999; 82: 325-332.
Rapid Response:
Is The Threshold is £37K Per QALY?
While I agree entirely with most of Professors Law's and Wald's
conclusions with regard to risk factors, I cannot agree that, as a result,
treatment thresholds do not exist.
With regard to CHD risk factors, the recent Joint British
recommendations (1) recommend starting treatment of high blood pressure at
an absolute ten year CHD risk of 15%, and of a high lipid ratio at 30%.
Strangely, neither these recommendations, not those of the Standing
Medical Advisory Committee explain why these particular thresholds have
been set. (Nor 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, Professors Law and Wald acknowledge this implicitly
by stating that people at high risk should be targeted.
There have been a number of published cost-effectiveness analyses of
lipid-lowering drugs. The report from Pickin et al (2)puts the cost per
(presumably good quality) year of life gained of treating CHD risk above
3% per year at £8,200, which they describe as "as cost effective as many
treatments in wide use". On the other hand they state that treatment below
this level is unlikely to be affordable". However the de facto threshold
currently being used by the National Institute of Clinical Excellence is
considerably higher- about £37K per QALY.
Ethical questions such as the value the NHS, and other health
systems, should place on preventative 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?
No competing interests
References
(1) British Cardiac Society et al. Joint British recommenadtions on
prevention of CHD in clinical practice. Heart 1998; 80(supplement 2):S1-
S29.
(2) Pickin DM, McCabe CJ, Ramsay LE et al. Cost effectiveness of HMG-CoA
reductase inhibitor (statin) treatment related to the risk of CHD and cost
of drug treatment. Heart 1999; 82: 325-332.
Competing interests: No competing interests