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Letters

Cost effective strategies for reducing coronary risk in primary care

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7004.573 (Published 26 August 1995) Cite this as: BMJ 1995;311:573
  1. Peter Winocour
  1. Consultant physician Queen Elizabeth II Hospital, Welwyn Garden City, Hertfordshire AL7 4HQ

    EDITOR,--The implication of K Field and colleagues' paper seems to be that the cost of screening in cardiovascular prevention is high in primary care, particularly when the screening is not targeted at high risk patients.1 I agree with this but disagree with the model used in the paper to assess the cost effectiveness of reducing coronary risk. I think that the message to purchasers that we should use lipid lowering treatment only in patients with cholesterol concentrations above 9.5 mmol/l is dangerous. This is reminiscent of the nonsensical recommendation made by the Scottish Home and Health Department some years ago for a cut off of 10 mmol/l.

    It is naive to estimate benefits simply on the basis of total cholesterol concentration, particularly when examining a population of women. Up to a quarter of women aged 35 or more have a high high density lipoprotein cholesterol concentration, but many of these women have a low attributable cardiovascular risk on the basis of their non-high density lipoprotein cholesterol concentrations. This explains why the cost effectiveness was less evident in women in Field and colleagues' paper and may have tended to skew the data.

    We should be moving away from simple reliance on absolute numerical values of cholesterol. We should assess people's absolute risk on the basis of other metabolic measurements, such as glucose, triglyceride, and high density lipoprotein cholesterol concentrations, as well as information on blood pressure, smoking, family history, and established cardiovascular disease. I await the misguided moves of commissioners of health care with trepidation.

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