The Pharmaceutical Journal
Vol 268 No 7180 p35
5/12 January 2002

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United Kingdom drug utilisation research group

NSF for Coronary Heart Disease has promoted the use of statins

The National Service Framework for Coronary Heart Disease has promoted the use of statins to reduce the risk of CHD mortality, said Keith Farrar, chief pharmacist, Wirral hospital. From 1998 to 1999 spending on lipid-regulating drugs in England increased by £66m (35 per cent). However, "we may not be getting the health gain we require from the investment we are making," he said.

A review of statin prescribing in general practice in England from January 1993 to December 1998, using data for 14,329 patients from the Doctors Independent Network, showed that prescribing is not consistent with evidence from major outcome studies such as the West of Scotland Coronary Prevention Study. GPs tended to prescribe the lowest possible dose and the doses prescribed were lower than that used in such studies, Mr Farrar said. The patterns of prescribing for each year were similar for each statin analysed. The results are supported by local prescribing analysis and cost data for Wirral Health Authority.

In Central and South Knowsley Primary Care Group, Merseyside, a study has been carried out to ascertain how GPs are responding to the NSF for CHD. Maria Allinson, senior primary care pharmacist, Central and South Knowsley PCG, said that nearly half of the 20 GPs interviewed believe that they could improve the way they managed CHD and view the NSF for CHD as a worthwhile document, although awareness of the contents is low. All the GPs interviewed agree with the NSF for CHD in theory, but many thought that the targets set are impractical, she said. Time constraints and staff shortages are the main barriers for implementation.

Professor Stephen Chapman, department of medicines management, Keele University, described setting up an outcomes guarantee project for patients with established CHD who were most likely to benefit from statin therapy. He said that an outcomes guarantee project is a novel way of approaching audit whereby a manufacturer underwrites the effectiveness of its product. If the product does not perform under an agreed set of circumstances as claimed by the manufacturer, the manufacturer refunds resources spent on the drug within a period of time. The effects seen to date, in an area of high cardiovascular morbidity, include a rapid increase in the use of lipid-lowering drugs and the use of aspirin after a myocardial infarction.

Sudesh Basra, pharmaceutical adviser, Hillingdon Primary Care Trust, West London, said that pharmacists and nurses have been employed by the PCT to help GPs with patient care and to implement NSFs. She gave an example of a GP surgery with a CHD register of 900 patients, where 300 patients were identified as not having a recent recording of their cholesterol or having a cholesterol level that was above recommended levels. Of these patients, 100 were asked to attend a clinic because, in addition, they were either not receiving a statin or had been prescribed a statin but their cholesterol levels were still high, or they were not receiving aspirin. She said: "You can see how the NSF quickly becomes quite practical and you can actually pull in patients to improve their treatment."

NSF for Older People

The National Service Framework for Older People requires that, by April 2002, all people aged over 75 years should normally have their medicines reviewed at least annually, and those taking four or more medicines should have a review every six months. Jenny Harding, PCG pharmacist, Rowley Regis and Tipton PCG, West Midlands, said that in Tipton there are seven GP practices with a total of 2,724 patients aged over 75 years. Of these, 57 per cent are taking four or more regular medicines, which is higher than the NSF estimate of 36 per cent.

In Tipton, as part of an ongoing medicines management project in the community, over 50 patients, most of whom are aged over 75 years, have had their medication reviewed regularly and interventions made. Among the problems identified was inefficient repeat prescribing systems. Since the initial review, the average number of repeat drugs has decreased from 9.4 to 7.9, Mrs Harding said. By putting the NSF for Older People into practice the number of patients prescribed aspirin or warfarin for preventing stroke had increased from nine out of 21 patients in December 2000, to 21 out of 25 patients in May 2001.

Mrs Harding said that the NSF for Older People says that lower doses of diuretics are generally more appropriate for older people and that treatment can often be stopped providing progress is monitored. It was found that 10 out of 21 patients reviewed were receiving higher doses of diuretics than considered appropriate and four had had a fall, possibly as a result. Looking at linking the NSF for Older People with the NSF for CHD, it was identified that 19 out of 31 patients had heart failure, only seven of whom had been prescribed angiotensin-converting enzyme inhibitors, of whom only three were prescribed an appropriate dose.

Speaking about National Institute for Clinical Excellence guidance and multiple sclerosis, Charles Dobson, special project adviser, Department of Health, said that at present NICE cannot recommend any disease modifying therapies for MS. He explained that the data available from randomised trials were only for the first two or three years of treatment of the disease and that assessment of cost-effectiveness data for 20 years of treatment was needed, which would be closer to that of the progression of the disease. The Department of Health and the National Assembly for Wales are looking at addressing the main areas of uncertainty over the cost-effectiveness described by NICE.

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