Azeem Majeed: Three obstacles to increasing the use of statins for the primary prevention of cardiovascular disease
20 May, 14 | by BMJ
Statistics from the OECD show that the per person use of statins in the UK is the highest in Europe and the second highest among all OECD countries. There are a number of reasons for the very high use of statins in the UK, which include the emphasis on evidence based medicine in the training of UK doctors; the 2004 GP contract, which introduced financial incentives for the management of long term conditions such as coronary heart disease and diabetes; and the NHS Health Check programme, which aims (among its objectives) to increase the use of statins for the primary prevention of cardiovascular disease (CVD) in England in people with a 20% or more 10 year risk of CVD.
The National Institute for Health & Care Excellence (NICE) is now proposing to reduce the threshold for starting statins for the primary prevention of CVD from its current threshold of a 20% 10 year CVD risk to a 10% 10 year CVD risk. Although this could have major benefits for population health by substantially increasing the number of people who would be eligible for statins for the primary prevention of CVD, there are three key issues that need to be addressed if we are to implement this policy successfully.
Firstly, general practices—the main route for assessing CVD risk and prescribing long term statins— are currently under considerable workload and financial pressures. Both the BMA and the RCGP have launched public campaigns to make people aware of these pressures, and to try to increase the resources going to primary care (in recent years, the BMA reports that the proportion of the NHS budget spend on primary care has declined from around 10% to 8%). In its draft guidance, NICE did not attempt to assess the workload implications of its proposed 10% 10 year CVD risk threshold or how this additional work would be funded.
Furthermore, despite already being overstretched and underfunded, general practices will have other substantial new areas of work to take on: such as hospital admission avoidance schemes, improved care of older patients, longer opening hours, and faster access for people with acute medical problems. General practices may not be able cope with all these additional areas of work, and at the same time expand access to statins even further, unless the government increases the funding that general practices receive.
Secondly, patients need to be convinced to take statins, particularly those with lower levels of CVD risk who may perceive themselves as being healthy and therefore not be keen to take long term medication. Early results from local evaluations of the NHS Health Check Programme are not encouraging. Only a minority of patients attended their NHS Health Check after they received an invitation and a substantial proportion of patients who did attend, and who were found to have a high 10 year CVD risk, did not subsequently start treatment with statins.
Clearly, there is a lot of work to do by general practices, local authorities (who are now responsible for commissioning the NHS Health Check Programme), and Public Health England to convince people who think they are healthy to start long term treatment with statins. Convincing people to take statins may be even more difficult in those with a 10 to 20% 10 year CVD risk if the proposed NICE guidelines are adopted into clinical practice and 10% becomes the threshold risk level for starting treatment.
Finally, what is the true level of side effects from statins? Millions of people are taking statins in the UK without suffering any notable problems. But there are differences in the risk of side effects between clinical trials and in data derived from electronic medical records, with the latter generally reporting higher rates of adverse events in people taking statins than has been reported in clinical trials. This discordance between the evidence from clinical trials and from clinical practice needs to be addressed so that doctors and patients are given accurate information about the risks and benefits of long term statin therapy.
Azeem Majeed is a professor of primary care and head of the Department of Primary Care and Public Health at Imperial College London. He is also a GP principal at the practice of Dr Curran & Partners in Clapham, London. He can be followed on Twitter (@Azeem_Majeed).
Conflict of Interest: I am a GP principal at the practice of Dr Curran & Partners in Clapham, London.