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Perverse incentives

From Dr Bern Bedford, Southampton

You seem surprised that drug use has changed towards ACE inhibitors from diuretics (News, 22 February).


a) diuretics are off-patent so nobody advertises them – hence ASCOT was advertised massively more than ALLHAT. Diuretics are fading just as many other useful drugs do when they become generic and also because of the small perceived risk of diabetes, which is still argued over.

We need a counterbalance

to the hype of newer


b) how strange that ACE inhibitor use has risen so much this last year in comparison. I think it's attributable to 'ill-thought-through QOF syndrome'.

Patients with hypertension need regular renal blood checks. At least half the population I test seems to

have eGFRs less than 60 – chronic kidney disease

stage 3. Patients with CKD3 need ACE inhibitors or

there's no recognition under QOF.

Irrespective of what NICE says about hypertensive patients aged over 55 being prescribed calcium antagonists or diuretics first line, they are very likely to

get an ACE as a priority as

they mostly have this new 'disease'.

This is an example of how special interest groups, perverse incentives and the pharmaceutical industry

play their parts in skewing standard cost-effective treatment at considerable

NHS cost.

Perhaps I wouldn't mind so much if it were an accurate test, but eGFR results show considerable random variation.

Is there any chance someone up there in the Ivory Towers penthouse suite will come up with some joined-up thinking before the next round of QOF chaos?

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