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NICE advisers to consult on introducing 10% CVD risk threshold to QOF

NICE advisers will consult on introducing the newly recommended 10% risk threshold for cardiovascular prevention into the QOF, having deferred a decision over concerns about the impact on GPs and patients.

NICE’s QOF advisory committee decided today it would not recommend lowering the threshold for statin use from 20% to 10% in the indicator CVD-PP001 – which incentivises statin therapy in patients newly diagnosed with hypertension – despite this risk level being considered the new standard for primary prevention in updated NICE lipid modification guidelines.

The chair of the committee said it would be ‘premature’ to make the recommendation, but added that they would consult on the issue and that NICE should put more research into incentivising lifestyle advice before prescribing statins.

The QOF panel also decided it would not yet recommend NICE develops an indicator on offering a statin to all people with chronic kidney disease (CKD) – as now recommended in NICE guidelines – at its meeting in Manchester today.

NICE earlier this year lowered the risk threshold for primary prevention of cardiovascular disease (CVD) – including statin treatment – to a 10-year QRISK2 score of 10%, despite widespread opposition, including from the GPC.

A recent survey by Pulse found two-thirds of GPs were not following the new recommendation.

Some QOF committee members argued the change to the CVD-PP001 indicator should be implemented – and suggested GPs would be more accepting of the 10% threshold in patients newly identified as having hypertension because these patients have an established condition rather than being completely ‘healthy’.

However, owing to widespread uncertainty about the impact of changing the indicator, the panel eventually agreed NICE should do more research and consult on potential indicators, including looking at incentivising lifestyle advice prior to offering a statin in those at the 10%-20% risk level.

The panel also put forward ideas on ‘extrapolating’ the CVD-PP001 indicator to patients with newly diagnosed type 2 diabetes – as statins are recommended in this group – and creating a ‘high risk’ register of patients with QRISK2 10-year risk scores of 10% or higher, in order to prioritise primary prevention efforts in these patients.

The committee agreed to put out suggestions for consultation in January, and the earliest any would be introduced in the NICE menu of QOF indicators is 2016/17, NICE confirmed to Pulse.

However, the QOF committee decided not to recommend an indicator to incentivise statin use in patients with CKD – in line with the new guidelines – for further development, because it would be ‘too controversial’ and ‘unacceptable to GPs’ without clarifying the subgroup of patients this would apply to.

Summing up discussions, NICE QOF advisory chair Dr Colin Hunter said there had been such disquiet about the new 10% threshold advice that the panel had to acknowledge the uncertainty in the profession.

Dr Hunter said: ‘The general feeling is the wider societal and ethical implications of the [10% threshold] have not been duly appraised by NICE. For us to be putting this in as an incentive… seems premature.’

He added: ‘In this case it is not straightforward. NICE has recommended [the lower threshold] based on economic analyses, but guidelines are not gospel.

‘Whereas most guidelines have generally strong support, this guidance has had a lot of “pushback” from the profession.’

Dr Andrew Green, chair of the GPC clinical and prescribing subcommittee, said he was pleased the panel had taken on board the profession’s concerns about the new threshold.

Dr Green said: ‘I think that their caution is justified and I am pleased that they are recognising the controversy surrounding these thresholds. We will, of course, respond to the consultation next year. ‘

He added that the ‘evidence bar’ for QOF indicators ‘should be very high indeed’.

‘It damages the credibility of the entire system if indicators are put in one year only to be removed the next when the problems become apparent,’ he said.

However, he questioned whether GPs would be happy with a lower risk threshold for intervention in patients with hypertension or diabetes because they would regard them as ‘sick’.

Dr Green said: ‘I would reject any suggestion that those with essential hypertension have established disease or are unhealthy; they should be regarded as having a risk factor for other diseases.

‘Taking medication may or may not be of benefit to them, and so might form part of their management, but there cannot be an “in for a penny in for a pound” attitude to polypharmacy.’

This story was updated on 18 December to remove the assertion that the decisions taken were a change to normal procedure, and that NICE advisors had ‘blocked’ the recommendation on statin use in CKD from being put into an indicator