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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)

  • Be aware that failure to follow NICE "guidance" is actionable - defence union "expert independent" GP opinion regards failure to adhere to such "guidance" as a breach of duty of care and you can/ will be sued if you fail to tow the line - trust me I know to my cost!!!!

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  • 18.18 Pretty much sums up everything that is wrong with the NHS these days...

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  • Another Bennett, no relation, but I do think that I trained at Manchester about the same time as Ivan.
    I don't intend to comment about the research evidence for offering statins at 10%, 15% or whatever, but prefer to reflect on the day to day consequences of this type of target.
    Having recently lost the argument with my colleagues about adding an HbA1c to the list of blood tests we already do in relation to our longterm condition patients I now finding that I am receiving more and more slightly abnormal test results which take time to action, require repeating or a letter/ telephone appointment with the patient concerned.
    My practice age profile is already heavy with the workload arising from an elderly population, many in care homes, perhaps some who have been enabled to live long enough to suffer from dementia which wouldn't have been the case in previous generations.
    Has anybody looked at the long term comsequences of prescribing statins and whether or not there is a downside healthwise in other directions?
    Lastly having been a partner in my practice for 30 years I find that we are now finding it difficult to attract new doctors, as are other practices in Stoke on Trent. Does a newly qualified GP really want to spend all his/ her time filing/ actioning results of blood tests, discussing statins endlessly with (mostly) sceptical patients?
    I am retiring at the end of July, but will continue to work as a locum after that, hopefully freed from the strait jacket of the worst aspects of NICE, QOF etc.

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  • I'm sorry but there is no evidence that Statins actually reduce mortality ... Yes, they may reduce cardiovascular events in men but not mortaility!

    Furthermore , even this slight reduction in cardiovascular events does not seem to manifest in women, it's completely pointless to put women on statins...but alas The Ivan bennetts who like kowtowing to current trends will unsurprisingly disagree!!

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  • Knowledge is Porridge

    10.04pm. cochrane review says they do reduce mortality...
    Hate being told what to do by "the man", but statins are not a bad thing for me to offer.

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  • This is not clinical guidance, it is governance

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  • @ 11:23 -- I suggest you read the Cochrane review carefully , they have highlighted serious concerns about the true benefits of statins in large trials claiming that they reduce mortality

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  • As most people will be aware none of the individual trials in primary prevention have shown a reduction in all cause mortality - even (almost) all of the meta-analysis has shown the same thing. The only analysis that has shown a significant reduction in all cause mortality is that done by Prof Collins at the CTSU - an organisation funded by the industry and one which refuses to allow anyone else to analyse the data. Somehow, Collins magically came up with beautiful reductions in ACM even though none of the trials themselves showed this. Yes, you can argue that its only seen when we have bigger numbers, but he won't let us see the data to confirm. This is covered in a new documentary film:
    http://www.statinnation.net/ctsu

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  • Dr Bennett is hardly one to talk - forcing his "Manchester standards" on his colleagues.

    I guess some people simply like to lord it over others. Some people just like boxticking beaurucracy.

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  • The NNTs are available for the 10% cut-off and as soon as you explain them to patients they lose interest in being on a statin. So are we supposed to just mention the 10% risk and use it as a sword of Damocles to frighten people into starting a statin or have a rationale discussion about the benefits / risks even if this means they decide they do not want to go onto them..... Oh well, as long as we can exception report the majority who decline our kind offer....

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