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Gold, incentives and meh

NICE recommends introduction of 10% statin threshold into QOF despite GP opposition

NICE has given the green light to a new QOF indicator rewarding practices for how many patients they treat with statins at the 10% primary prevention threshold, despite unease among GP members on the independent advisory panel.

The introduction of the 10% threshold for prescribing statins to patients newly diagnosed diabetes and hypertension was discussed this afternoon at the first meeting of the newly convened QOF committee.

The indicator will now be put forward for GPC and NHS Employers to negotiate its introduction into the contract for 2015/16.

It comes after the RCGP, the GPC and the former chair of the QOF advisory panel all strongly spoke out against the introduction of the indicator.

Several GP members of the panel voiced concerns about the proposed indicator rewarding practices only for treatment with statins and not lifestyle advice - which they said goes against the NICE lipid modification guidelines which emphasise lifestyle advice should be offered before statin therapy.

They argued for the indicator to be reworded to reward offering lifestyle advice and other interventions as appropriate, including statins, to allow GPs room to discuss the option of statins with patients. They also proposed the term ‘offer’ a statin be used rather than ‘treated with’ a statin to allow more room for GPs to give patients the option of a statin rather than be paid only if the patient ended up with a prescription.

However, other committee members, including one GP, argued that NICE guidelines were clear that GPs should be prescribing statins at the 10% threshold, and that GPs would be able to exception report patients who chose not to take the drug option.

The panel agreed instead to introduce a new indicator incentivising lifestyle advice in these groups, as well as a new indicator incentivising statin treatment at the 10% threshold - and to introduce new business codes to allow for the exception reporting.

NICE QOF Committee chair Professor Danny Keenan said patients in these risk groups at the 10% risk threshold ‘should be on a statin’.

He added: ‘We have very clear guidelines, they couldn’t be clearer - and we’ve been over and over this. We’ve introduced the lifestyle indicator and allowed for exception reporting and we should go ahead with this.’

Dr Andrew Green, chair of the GPC prescribing committee, said it was ‘obviously disappointing that NICE have chosen to ignore the views of both the body that represents GPs as well as our royal college’.

However, he added, ‘whether this eventually becomes part of QOF remains subject to negotiation’.

Dr Green said: ‘I have no doubt the proposed indicator 11a [the proposal to measure the prescription of statins] will be a measure of prescribing activity but not of the quality of patient care, which depends on many more factors than a simple tablet-count. As general practice becomes more complex it is vital that measures of performance are sophisticated enough maintain validity, and have the confidence of GPs; this proposal meets neither of these requirements.’

Pulse revealed today, the former chair of the committee - Dr Colin Hunter, a GP in Westhill, Aberdeenshire - said that NICE had ‘lost the plot’ to consider introducing the new indicators.

He said: ‘I personally am completely against the 10%. I don’t think there is enough evidence to support it and I think it’s a societal question.

‘I think it is where NICE has lost the plot – when you end up with the majority of people over 65 needing a statin because the economics tell you that. The economics are far from a good science.’

Dr Hunter’s intervention followed those of the RCGP and the GPC, who both strongly opposed the proposals in their consultation responses.

The GPC said that it was ‘vital for the credibility of QOF’ that indicators have a robust evidence base, make significant difference to patients and are backed for the profession, adding that these proposals ‘fail on all these counts’.

The RCGP warned that the proposals risked ‘the loss of professional confidence in the healthcare targets they are being asked to meet’.

Proposed wording of new indicators

  • IND-11: % of patients aged 25-84, with a new diagnosis of hypertension or type 2 diabetes* who have a recorded cardiovascular risk assessment score of 10% or greater who have been given lifestyle advice;
  • IND-11a: % of patients aged 25-84, with a new diagnosis of hypertension or diabetes* who have a recorded cardiovascular risk assessment score of 10% or greater who are currently treated with statins.

* this may include ‘three months either side of diagnosis’


Readers' comments (44)

  • I'm struggling with Tony Copperfields lets me positive

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  • Crazy. Why not just add atorvastatin to the water supply and be done with it.

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  • Please note the American guidelines are to start statins at 7.5% risk, although they have to pay for privilege of being Statinised!
    Theoretically NICE are correct, however given the lack of adequate funding for healthcare even for many mainstream diseases, this would be in the bottom of my list.
    NICE maybe be clever but certainly not wise!
    Interestingly I look forward to 75% exception reporting!

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  • Sorry but is there any evidence for 7.5%? or is it big pharma speaking again?? Should we care what the Americans are doing?

    Prof Keenan says 'should', but if we don't, we don't get paid or we get sued by the patient's family or whoever....... right........

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  • Ivan Benett

    Anon 3.48pm - I really don't think this is appropriate language. You should knw better.
    As for the headline, I this it's rather inflamatory, since NICE isn't forcing anyone to take anything. QOF is using this quality standard to incentivise prescribing of statins, which rightly should b after discussion of lifestyle and other risk factor modification.
    As 3.54pm says, the Americans have an even lower threshold.
    My own view is that we should adopt an holistic approach to the issue of prescribing drugs in this and any other situation. Discuss pros and cons dispationately with patients and share decision making. Not the foul mouthed approach of 3.48pm who frankly should have his comment withdrawn

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  • Hi Dr Benett - the headline was changed to reflect this.

  • Ivan Benett

    Anon3.58, the American College of Cardiology and the American Heart Assocition have joint guideline, ebvidence based, and published in NEJM to support their decision. Obviously the lower the threshold the great the impact on outcomes, but higher costs and side effects. It is nothing to do with Pharma who do not benefit from these gudelines.
    Should we care what the Americans say, well yes we should since they are leaders in Health Care whether we agree with them or not - doesn't mean we have to do what they say, but we should listen, and often learn.

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  • Well Ivan, I think 3.48 is just venting, and yes its not forcing, but incentivising is pretty much almost the same thing. How was it foul anyways, there was no bad language. I also think we all know on here you're a pro-govt, pro-workload GP from manchester and nobody takes you seriously. Pharma might not benefit from the guidelines, but they do benefit from increased prescribing eh. How do you determine leading in healthcare? strength of evidence? or biggest influence by big pharma?

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  • Silence the computer alerts with "patient declined" after you have persuaded them that there is more to life than a risk calculator and HmG-CoA reductase inhibitors. Next problem please.

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  • I really don't think this is appropriate language. You should know better.

    Hardly - many people are genuinely concerned about the effects of medicalizing so many people with this trendy 'pre-disease' and the risks of over-treatment. It's fairly obvious that this threshold has been lowered as a proxy pay-cut to GPs as the target will be damn near impossible to achieve.

    As for the headline, I this it's rather inflammatory, since NICE isn't forcing anyone to take anything.

    Again, not true. NICE have once again rode rough-shod over the medical profession's advice which is why this magazine wrote an article about NICE becoming a 'laughing stock'. Furthermore as we know, QOF has a tenancy towards mission creep tightening up target definitions year on year.

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  • Whilst I think that we would all agree that we should adopt a holistic approach this certainly is not it.
    The indicator as approved says that you must prescribe statins. You can exception report but it is quite clear that many comissioners reporting exception reporting as a form of cheating. Also if you don't persuade anyone to take the things (perhaps put off but 100,000 tablets it will take to prevent one event) you will get no points at all.

    The other indicator is fairly bizarre as well as it suggests that if you have a risk of less than ten percent, even with a new diagnosis of hypertension or diabetes, you don't need lifestyle advice.

    This is NICE as its most paternalistic and least holistic.

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  • NICE holistic? with no GP on its QOF advisory committee? don't make me laugh. You wouldn't expect a rock to taste nice would you

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  • Let's hand all QoF to protocol droids that just dish out whatever the algorithm states.
    For me the unmeasurable / unQoFable stuff is far more important to patients.
    I'm afraid this is just another nail that is tacked and ready to be driven in to general practice's coffin.
    Can anyone come up with QoF for TATT?
    Question one We're or are you a GP?
    Indicator 1: Counsel them to retire. We have a computer waiting for their job.

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  • Patient centered holistic individualised care?
    Utter nonsense hipocrits! Target driven harmful generic care. NICE and their lab based professors and clinical advisors. The real world is more wild than they could handle.

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  • What would be very useful is NICE publishing NNTs which we can use as the basis for providing standard information to allow the patient to make an informed consent.

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  • Dear Ivan,
    I am not sure if anon at 3.48 p.m means that if the threshold is low enough it maybe worthwhile offering it to everyone over a certain age, rather than an individualized plan which although ideal may not be feasible to deliver with the lack of appointments for acute illness leave alone preventive medicine ( however statistically better it maybe on paper).
    Also adding same to water supply is not necessarily a flippant remark-rather sarcastic reference to an BMJ article in 2003- as the concept of a "polypill" -Atenolol, statins, aspirin and ACEI- have been bandied about for more than a decade and the exact term "we are not suggesting adding it to the water supply" was an editorial interview with guardian.
    Link provided.
    I who wrote about the 7.5% risk threshold at 3.54 pm-so aware of many of the latest guidelines.

    I think you need to look up the difference between Knowledge and wisdom!

    Alternatively you can see all those with CVD risk >10% and < 20% in the extended hour clinics and have leisurely chat as it seems most pilots are shutting down on Sundays due to lack of demand!

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  • wish i had been quicker off the mark to read the 3;48 comment! by far the most intriguing bit in this entire article!

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  • I am 3.48 lol, I said, in more direct terms, that I wish I will be the one to force statins to Prof Keenan, WHEN, not IF, his risk hits 10%.

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  • Dr Bennett

    You should not be "disciplining" your colleagues! While I did not read the deleted comment, in general, I believe in free speech and unless violence or clearly libellous comments are made you MUST tolerate views other than yours-in fact it is YOUR DUTY to tolerate such views-this site cannot tolerate suppression of such views.

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  • Vinci Ho

    No surprise from the authority
    No surprise from the usual suspects
    'True gold fears no fire.' Chinese saying .
    The truth remains the truth despite the judgement of time and history.
    Who is the genius ? Who is the fool?
    There will be an answer , let it be at the mean time......

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