GPs hit by guidelines muddle
Chasms open between advice from NSF, NICE, hypertension experts and the contract – Rob Finch reports
The national service framework for CHD is out of date and GPs should ignore it in favour of more recent guidelines, says the eminent Government adviser who wrote the document.
Professor Sir George Alberti told Pulse the framework should have been updated annually in line with emerging evidence but the Government had failed to do so.
He urged GPs to ignore the framework recommendation to limit statin use to patients with a 10-year CHD risk over 30 per cent.
GPs should instead follow the new national guidelines from the British Hypertension Society and prescribe the drugs to anyone with a 10-year CHD risk over 15 per cent, said Sir George, the Government's emergency care tsar and former president of the Royal College of Physicians. 'We have to move with the times and get as many people as we can on statins.'
But the new society guidelines – published in the Journal of Human Hypertension this month – have raised fears of a massive rise in prescribing bills. The second Wanless report on NHS spending – presented to Chancellor Gordon Brown last month – predicted the cost of statins would spiral to £2.1 billion per year by 2010 if GPs lower their prescribing threshold to a 10-year CHD risk of 15 per cent.
A meta-analysis has cast doubt on the validity of the newly updated British Hypertension Society guidelines, after it found little evidence for tailoring
antihypertensive drug choice according to a patient's ethnic group.
The findings would appear to bolster a provisional conclusion reached by the National Institute for Clinical Excellence that there is no evidence to back the ABCD approach to selecting antihypertensives.
The ABCD rules – controversially endorsed by the society in its new
hypertension guidelines – recommend
an ACE inhibitor, A2A blocker or
ß-blocker firstline in non-black patients under 55. A calcium channel blocker or diuretic is the firstline choice in non-black over-55s and black patients of any age.
The meta-analysis, published this month in Hypertension, concludes that ethnic group should not influence the choice of drug.
It adds: 'Clinical decisions to use a specific drug should be based on other considerations such as efficacy in individual patients, compelling indications, and cost.'
But Dr Mark Davies, a GP involved in writing the society's guidelines, insisted: 'The current thinking is that black patients respond less well to drugs that inhibit the renin system.'
The NICE guidelines were still in draft form and could change, added Dr Davies, secretary of the Primary Care Cardiovascular Society and a GP in Leeds.
The quality and outcomes framework has already been overtaken by new evidence, admits one of the two GP academics who signed it off for the Government as evidence-based.
Professor Martin Roland said he would have no objection if the Department of Health decided to amend the framework before its launch next month to bring the section on COPD in line with more up-to-date guidance from the National Institute for Clinical Excellence.
'The framework was developed in 2003 and we would expect new guidance from time to time which moves the evidence along,' said Professor Roland, director of the National Primary Care Research and Development Centre in Manchester.
Under the framework, GPs must confirm a COPD diagnosis with spirometry and reversibility testing to earn maximum points.
But Professor Roland said NICE had taken account of more recent evidence to reach its conclusion that reversibility testing is pointless and can mislead.
He added: 'GPs don't want changes to the framework on a day-to-day basis, but they will accept changes when and where appropriate.'
The department is still considering whether to amend the framework before its April 1 launch.