Dr Ivan Benett has been a GP in Central Manchester for 30years. He has held various educational posts, served on the LMC Executive, has been PCG chair and chair of the PCT professional executive until 2005. Following this he gained a PG diploma in Cardiology & became a GPwSI in cardiology. He has been on the NICE guideline groups for CKD, Post-MI care, chest Pain, Parkinson's & AAA, and expert group for Quality Standards in Heart Failure and CKD care. He is a Fellow of the RCGP & RCP and standing member of a NICE Quality Standards Advisory Committee. He was the Clinical Director Central Manchester CCG until December 2015. Currently he sits on the GM Clinical Senate and is a Non-Executive Director at the Central Manchester University NHS Foundation Trust with an interest in Patient Experience and is 'Freedom to speak out" guardian
This is no different to any risk assessment based on population studies. In other words there are always confidence intervals that always need to be applied to an individual. If you’re using risk estimates this should be part of the explanation. The key sentence is that the risk model performs well for populations. This is not surprising since they are based on population studies. An individual's risk is X +\- Y. More importantly is the discussion about what they can do to reduce their risk
Well written, but really? Another moan about incidental findings. Get over it. They are an inevitable consequence of investigations looking for pathology. Generally the more sensitive a test the lower the specificity. Until we get a newer test with better Sensitivity and Specificity. Rather than constant grumbling by populists wanting to endear themselves to a cynical readership, why not embrace the new reality? Teach how to deal with it. Start by learning about how to convey the limitation of testing to patients. We manage uncertainty all the time.
Doc | GP Partner/Principal24 Jul 2019 8:36pm
Ivan Benett- though what u add is correct- “ health” doesn’t address this.... see Black report etc...... social changes do!!!!
I agree (mostly). I don't say GPs should do it all, of course not.
Most of the 'investment' should be through public health measures which include societal changes.
But GPs should do our bit. Our main influence is in secondary prevention. Unfortunately the rule of halves still exists, we don't manage long term conditions optimally.
My point though, was to say that diseases are preventable. I wasn't saying who should prevent them.
Let common sense prevail | GP Partner/Principal24 Jul 2019 8:55am: 'No amount of investment will ever prevent people from developing disease'.
This just isn't true.
There are many examples. Most notably vaccination, indeed HPV vaccine seems to prevent Cervical Cancer. It is likely that moderating weight gain and being more active will prevent type 2 diabetes and coronary disease. Statins in high risk people can prevent coronary disease. Smoking cessation prevents lung cancer and COPD, as well and CHD. Diseases from blood born viruses can be stopped. Moderation alcohol intake can prevent liver disease. There are others I'm sure.
All of these require investment which, although may not be cost saving, will improve the health of the Nation. Let common sense indeed prevail. Investing in health care to prevent disease is not only an expectation, it will also lead to benefits.
We will always over do it sometimes and under do it at others. It's the nature of medicine. The sensitivity and specificity of our tools (mostly history and examination) are not 100%. Our thresholds for intervention change according to a whole load of factors including public demand, personal preference, new evidence, peer review and others. There's no point getting wound up about it.
We should do our best to get it right, recognising that sometimes we wont. That's medicine. That's life.
Since we work in a probabilistic discipline we will always risk missing some diagnoses, and over diagnosing sometimes. Its the nature of medicine, especially for low prevalence conditions.
Our responsibility is to enable access, use investigations wisely, safety net and take people seriously when they keep coming back with the same problem.
All of these are harder to do in an under resourced service. This is why better resourced services tend to do better at early diagnosis than we do. We should also undertake Significant Event Analyses on every misdiagnosis, or cancer that presents in ED, to see if there was anything that could have been done better.
Don't beat yourself up, but see if there is anything in our control that could improve earlier pickup.
I don’t necessarily agree with all of this, but I do agree with the point about electing the President. It would give her, or him, more authority as her (or his) views are after taken to represent the profession. I agree also that past Presidents have sometimes used this position to further their own agendas. Having a democratic mandate and clear register of interests can only be a positive advance.
PS there are many things we could check for opportunistically
This finding is hardly a surprise since it perfectly exemplifies the rule of halves that exists for all long term conditions. Although there are patient factors, there are also doctor factors that all combine to lowering the effectiveness of these interventions. Cynicism and adverse press are also factors well demonstrated in these columns
The independent contractor status (and the partnership model) has never been fit for purpose. It was never part of the NHS. It effectively died when Ken Clark introduced a contract that specified what the government should expect from their contract with GPs. So since then the intransigence of the profession to adapt to change, to become more responsive while retaining continuity has mean that the ‘Contract’ has become increasingly explicit and detailed. The less willing the profession has been to become patient responsive rather than doctor orientated, the more the contract has tried to enforce it. The consequence has been that in order to cope with rising demand (for same day as well as long term demand) practices are having to be forced to work collaboratively and to make the most of the seven day working week.
It is simply not good enough that patients have to wait 3 weeks for an appointment.
While continuity is the key to the doctor-patient relationship it is also not possible when most GPs do on average that 5-6 surgeries a week.
It is of course inaccurate to say that consultation rates are rising exponentially, but they are rising. This is mainly due to increasing age of the population and complexity of co-morbidities.
The way to respond is to argue for more resources and better workforce numbers and skill mix. It also means smaller list sizes, and managing today’s work today. This would allow better access to your own GP and for same day demand to be managed on that day.
Because partnerships have been managed for the benefit of the partners (with notable exceptions) the government has had to curtail their insular outlook for the benefit of comprehensive and timely service.
The end of professional partnerships ended with the demise of professionalism as Marshall Marinker pointed out in the 1980s. While we remain Contractors, we will do what the contract tells us to do. And we cannot wind back the clock
In terms of prevention the evidence has been put together in the NICE guideline - Cardiovascular disease: risk assessment and reduction, including lipid modification
Clinical guideline [CG181] Published date: July 2014 Last updated: September 2016. Recommendations include risk assessment, lifestyle changes, risk factor modification and statins where indicated. As this article points out CVD can be prevented if we give sufficient focus, energy and resources.
Indeed. NICE chest pain guidline 1June 2017 update (which I sat on) explicitly says that we should treat women and ethnic minirities in the same way.
Notably NICE now recommends that all patients with new onset chest pain with atypical or typical anginal features, as well as those with non-cardiac chest pain and an abnormal resting ECG, should first be investigated with CTCA using a 64-slice (or above) CT scanner. Sadly, this recommendation seems to have been poorly taken up. We should be pressing commissioners for this to be made available
Northwestdoc | Locum GP17 Mar 2019 7:53pm - Quality Statement 3
NICE - Cardiovascular risk assessment and lipid modification
Quality Standard Published: 4 September 2015
List of quality statements
Statement 1. Adults under 85 years with an estimated increased risk of cardiovascular disease (CVD) are offered a full formal risk assessment using the QRISK2 tool.
Statement 2. Adults with a 10-year risk of CVD of 10% or more are assessed for secondary causes before any offer of statin therapy.
Statement 3. Adults with a 10-year risk of CVD of 10% or more receive advice on lifestyle changes before any offer of statin therapy.
Statement 4. Adults with a 10-year risk of CVD of 10% or more for whom lifestyle changes are ineffective or inappropriate, discuss the risks and benefits of starting statin therapy with their healthcare professional.
Statement 5. Adults choosing statin therapy for the primary prevention of CVD are offered atorvastatin 20 mg.
Statement 6. Adults with newly diagnosed CVD are offered atorvastatin 80 mg.
Statement 7. Adults on a high-intensity statin who have side effects are offered a lower dose or an
Statement 8. Adults on a high-intensity statin have a repeat measurement of lipids and liver transaminases after 3 months of treatment.
Northwestdoc | Locum GP17 Mar 2019 7:53pm - I agree with you. Lifestyle adjustments is the first line of management. Just as NICE recommends.
Initially statin trials were against usual treatment which includes lifestyle changes and drugs for hypertension, diabetes etc. As the evidence has become so overwhelming for statins in secondary prevention the issue became how high a dose/ strength of statin should be - as assessed by how low LDL should go.
The classic Primary prevention trial was WOSCOPS where the placebo arm were 'seen at three-month intervals, and dietary advice was reinforced on each occasion'.
The conclusion was that treatment with pravastatin significantly reduced the incidence of myocardial infarction and death from cardiovascular causes without adversely affecting the risk of death from non-cardiovascular causes in men with moderate hypercholesterolaemia (non-fasting plasma cholesterol level 6.5 mmol/l) but who had no history of myocardial infarction.
Prevention of Coronary Heart Disease with Pravastatin in Men with Hypercholesterolemia N Engl J Med 1995; 333:1301-1308
I agree. QOF is the best way to address the ‘rule of halves’ for Chronic Diseases listed. Some places have suggested scrapping and using the money for other things. I disagree. We should be continuing with QoF AND resourcing things like work force expansion, extended Primary care and same day access for same day problems. The issue is overall under resourcing, bad long term planning and failure to match capacity with demand.
Stopping QOF will be a retrograde step
NNT for those without know heart disease taking statin for 5 years 1:104 heart attack prevented and 1:154 strokes. No mention of prior risk, dose of statin, age or co-morbidities.
My point is patients should be informed and we should listen to NICE advice
The benefits of Statins in Primary Prevention for high and moderate risk (of CHD) outweighs any anecdotal side effects, which are in any case mostly reversible.
May I present a couple of studies to support this contention and maybe the benefits and risks in the elderly. The only deniers are those who deny patients the opportunity to improve their risk of CVD by withholding statins. Yes I know there are non-physical risks like medicalisation, labelling and dependancy, but they are part of the risk assessment when balancing with benefits.
Cholesterol Treatment Trialists’ Collaboration. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trialsLancet 2019; 393: 407–15. 186 854 participants in the 28 trials. Overall, statin therapy or a more intensive statin regimen produced a 21% (RR 0·79, 95% CI 0·77–0·81) proportional reduction in major vascular events per 1·0 mmol/L reduction in LDL cholesterol.
The proportional reduction in major vascular events was similar, irrespective of age, among patients with pre-existing vascular disease (ptrend=0·2), but appeared smaller among older than among younger individuals not known to have vascular disease (ptrend=0·05). They found a 12% (RR 0·88, 95% CI 0·85–0·91) proportional reduction in vascular mortality per 1·0 mmol/L reduction in LDL cholesterol, with a trend towards smaller proportional reductions with older age (ptrend=0·004), but this trend did not persist after exclusion of the heart failure or dialysis trials (ptrend=0·2). Statin therapy had no effect at any age on non-vascular mortality, cancer death, or cancer incidence.
Ramos R et al., Statins for primary prevention of cardiovascular events and mortality in old and very old adults with and without type 2 diabetes: retrospective cohort study BMJ 2018;362:k3359 Statins were significantly related to a reduction in incidence of atherosclerotic CVD and in all-cause mortality in people with type 2 diabetes mellitus; this effect was substantially reduced after the age of 85 and disappeared in nonagenarians These results do not support the widespread use of statins in old and very old populations, but they do support treatment in those with diabetes who are younger than 85 years.
The American Heart Association has issued a “Scientific Statement” titled “Statin Safety and Associated Adverse Events,” which is a comprehensive overview based on data from both randomised and observational studies. The authors focus considerable attention on muscle symptoms: They estimate that myopathy — if defined as muscle symptoms plus creatine kinase (CK) levels at least 10 times the upper limit of normal — occurs in fewer than 1 per 1000 patients who are receiving maximally recommended doses of statins; they also estimate that severe myopathy (rhabdomyolysis) occurs in about 1 per 10,000 patients. The incidence of less-severe muscle symptoms (myalgias with or without mild increases in CK level) is difficult to estimate, given that myalgias are so common in the general population.
Moderate-intensity and high-intensity statins increase relative risk for diagnosed diabetes by about 10% and 20%, respectively, affecting roughly 1 per 100 statin users during 5 years. Whether the diabetogenic effect is reversible is unclear.
Severe liver toxicity is rare, occurring in roughly 1 per 100,000 people. The incidence of asymptomatic mild transaminase elevations (which often are transient) is ≈1%. The FDA recommends against routine monitoring of transaminase levels in statin users.
Conclusions about other postulated adverse effects of statins are as follows:
• Haemorrhagic stroke: Possible small excess incidence in patients with histories of cerebrovascular disease, offset by fewer ischemic strokes
• Cognitive function: No definitive evidence of benefit or harm
• Peripheral neuropathy: An association was noted in observational studies but was not reported in randomised trials
• Erectile dysfunction: No association
• Cataracts: Evidence is mixed, but the “preponderance of evidence” suggests no excess risk
• Renal function: No evidence of any effect (except for the rare rhabdomyolysis)
• Tendonitis or tendon rupture: No association
• Cancer: No association
The evidence is increasing about the benefit of statins in Primary Prevention. Meanwhile, I would suggest sticking to NICE guidance, until it is further updated.
David Young | GP Partner/Principal08 Mar 2019 6:09pm - in fact my income doesn’t depend on QOF since I am a salaried employee. Nevertheless I take your point. We should strive to give impartial advice to patients. It was the ‘snouts in the trough’ comment that got my goat. Most hypotension drugs are generic anyway and none of the NICE guideline group would gain financially from the outcome of their deliberations
"Angus Podgorny | GP Partner/Principal08 Mar 2019 3:41pm @carfenatyl Spot on. NICE = snouts in the trough.
Shameful thing is that we are the minions mooted to do the dirty work for them". -
Actually NICE have very strict conflict of interest policies, perhaps you would like to ask them before making such outrageous slurs. ..There are 3 BP studies of relevance. SPRINT, ACCORD, and SPS3 are similar in many respects with regard to trial methodology. All used currently accepted antihypertensive medications as they are used inclinical practice. None had a placebo arm. ACCORD and SPRINT were conducted in the United States. SPS3 was conducted predominantly in the United States (65%), with lesser fractions in South American (23%) and Spain (12%).
It is likely that the results of these 3 trials had a major impact on NICE guidelines groups thinking. They each had slightly different populations, ACCORD including people with diabetes and SPS3 people after stroke. Otherwise there were also other differences in population such as ethnicity and age. Intensive treatment for all 3 studies was highly effective for achieving a substantial reduction in systolic pressure for low goal cohorts compared to the usual goal groups. However, better outcomes only reached statistical difference in SPRINT.
The NICE guideline group will have had the opportunity to evaluate the differences, without pharmaceutical industry influence or any other financial inducements (as suggested by the snout comment), and will ave been able to come up with a fair, dispassionate and evidence based conclusion. That is their role.
We really can't have it both ways, claiming to wish to practice evidence based medicine and then rejecting conclusions we don't like.
I do think the resource argument is a reasonable one, as is the danger of over medicalisation and the consequent harms both to the individual and society. Lets discuss the absolute as well as relative benefits with individuals for sure. But please let's not dismiss with comments like 'snouts in the trough'.
PS I was not on this guideline and do not have any conflicts of interest, involvement with pharma or axe to grind.
Oh and please lets not forget lifestyle, weight and exercise as major interventions too.
Ha ha indeed. We do need more affective care. I’m afraid spell check takes it upon itself to improve my words