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Effectiveness and efficiency of different guidelines on statin treatment for preventing deaths from coronary heart disease: modelling study

BMJ 2006; 332 doi: (Published 15 June 2006) Cite this as: BMJ 2006;332:1419
  1. Douglas G Manuel, scientist (doug.manuel{at},
  2. Kelvin Kwong, graduate student1,
  3. Peter Tanuseputro, research coordinator1,
  4. Jenny Lim, research coordinator1,
  5. Cameron A Mustard, president and senior scientist2,
  6. Geoffrey M Anderson, professor3,
  7. Sten Ardal, director4,
  8. David A Alter, scientist1,
  9. Andreas Laupacis, chief executive officer1
  1. 1 Institute for Clinical Evaluative Sciences G106-2075 Bayview Avenue, Toronto, Ontario M4N 3M5 (Note to Author: We give only one address per author)
  2. 2 Institute for Work and Health, Toronto
  3. 3 Department of Health Policy, Management and Evaluation, University of Toronto
  4. 4 Central East Health Information Partnership, Toronto
  1. Correspondence to: D G Manuel
  • Accepted 1 April 2006


Objective To examine the potential effectiveness and efficiency of different guidelines for statin treatment to reduce deaths from coronary heart disease in the Canadian population.

Design Modelled outcomes of screening and treatment recommendations of six national or international guidelines—from Canada, Australia, New Zealand, the United States, joint British societies, and European societies.

Setting Canada.

Data sources Details for 6760 men and women aged 20-74 years from the Canadian Heart Health Survey (weighted sample of 12 300 000 people) that included physical measurements including a lipid profile.

Main outcome measures The number of people recommended for treatment with statins, the potential number of deaths from coronary heart disease avoided, and the number needed to treat to avoid one coronary heart disease death with five years of statin treatment if the recommendations from each guideline were fully implemented.

Results When applied to the Canadian population, the Australian and British guidelines were the most effective, potentially avoiding the most deaths over five years (> 15 000 deaths). The New Zealand guideline was the most efficient, potentially avoiding almost as many deaths (14 700) while recommending treatment to the fewest number of people (12.9% of people v 17.3% with the Australian and British guidelines). If their “optional” recommendations are included, the US guidelines recommended treating about twice as many people as the New Zealand guidelines (24.5% of the population, an additional 1.4 million people) with almost no increase in the number of deaths avoided.

Conclusions By focusing recommendations on people with the highest risk of coronary heart disease, the Canadian, US, and European societies guidelines could improve either their effectiveness (in terms of hundreds of avoided deaths) or efficiency (in terms of thousands of fewer people recommended treatment) in the Canadian population.


  • Contributors DGM, GMA, CAM, and DAA conceived of and designed the study. DGM obtained the data. DGM, PT, JL, and KK analysed and interpreted the data. DGM, KK, DAA, SA, JL, CAM, and AL wrote the manuscript, and all authors critically revised it. DGM, PT, JL, and KK performed the statistical analysis and provided administrative, technical, or material support. DGM is guarantor for the study.

  • Funding Support for this project was received from the Canadian Population Health Initiative. The Institute for Clinical Evaluative Sciences is supported in part by a grant from the Ontario Ministry of Health. However, the results, conclusions, and opinions expressed are those of the authors alone.

  • Competing interests None declared

  • Ethical approval From Sunnybrook and Women's College Health Sciences Centre and privacy impact assessment from the Institute for Clinical Evaluative Sciences.

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