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Thursday, 29 January 2015

GPs to be incentivised to prescribe statins at 10% risk threshold under NICE proposals

GP practices could be rewarded for prescribing statins to patients newly diagnosed with hypertension or diabetes at the new 10% 10-year risk cardiovascular risk threshold from next year, under NICE plans unveiled today.

The proposals - outlined in a consultation on a raft of new QOF measures - include three potential new indicators on cardiovascular prevention that would introduce the 10% threshold, as recommended by NICE since last summer.

But GP leaders have warned that such a move undermines the credibility of QOF and will encourage GPs to prescribe statins without discussion around whether patients should be taking them - something that will ‘jeopardise patient choice’.

The proposals come after NICE updated its lipid modification guidelines to recommend lowering the 10-year cardiovascular risk threshold at which GPs prescribe interventions, including statin therapy, from 20% to 10% - despite opposition from GP leaders and other leading clinicians who raised concerns the proposals would lead to ‘over-medicalisation’ of healthy people and divert GPs’ time and resources away from their unwell patients.

The QOF advisory committee subsequently agreed at their December meeting not to simply update the existing indicator on statin prescribing in line with the new guidelines, but instead use the upcoming consultation period to obtain feedback on potential new indicators.

The consultation, released today, sets out a number of proposals that would introduce the 10% risk threshold into QOF. They are:

  • The introduction of QOF IND 10 - which updates the existing CVD-PP001 indicator - which rewards practices for prescribing statins in patients with newly diagnosed hypertension at the lower 10% level instead of the previous 20% risk threshold;
  • The introduction of an entirely new indicator, QOF IND 11, which would incentivise statin use at the 10% risk threshold in patients with either newly diagnosed hypertension or diabetes;
  • A third, QOF IND 12, would reward practices simply for setting up and maintaining a register of their patients with a 10-year QRISK2 score of 10% or higher.  
GP advisors on the QOF advisory board, including then-chair Dr Colin Hunter, had expressed concerns about how the lower 10% threshold could be implemented given the strength of opposition from GPs.

Some also warned that simply rewarding GPs for prescribing a statin at the 10% threshold would not allow them scope to encourage patients try lifestyle modifications first, although it was agreed that restricting this to groups with hypertension and diabetes could be acceptable as these represent ‘high-risk’ groups.

NICE is inviting feedback from all stakeholders on the proposed indicators by 23 Feburary, with a view to introducing them in the menu for negotiations for the 2016/17 GP contract.

However, GPs have warned that this could undermine the whole credibility of QOF.

Dr Andrew Green, chair of the GPC prescribing subcommittee, said: ‘There is insufficient evidence of benefit for individual patients, and too much controversy about the NICE guidance, for these indicators to be included in QOF. If QOF is to maintain its credibility then there has to be widespread agreement throughout the profession that it measures good practice, that agreement about this is a very long way off.

‘Let me illustrate with an example, one practice simply issues statin prescriptions to anyone with a 10% 10 year risk. Another sees those patients, offers lifestyle advise, then goes through with them the chances of statins producing benefit or harm, perhaps using a decision aid; having done that, it respects patients’ choices. Which practice will have higher statin prescribing, but which one is offering higher quality care?’

Dr Martin Brunet, a GP in Godalming, Surrey, said: ‘The NICE guidance says that patients should be offered stains if their risk is >10%, not that they should be treated. If this indicator is included at all it should be on the basis that the doctor has had an informed discussion about the benefits and harms of statins, rather than whether or not the patient chooses to take them. This indicator will jeopardise patient choice in its current form.’

Other potential new indicators include ones on cardiovascular risk assessment in patients with serious mental illness, BMI recordings in patients with long-term conditions and referral of patients newly diagnosed with anxiety or depression for psychological treatments.

They were released alongside a range of proposed new outcomes indicators for CCG performance management – the CCG outcomes indicator set – which has now been brought together under one committee.

Professor Gillian Leng, health and social care director at NICE, said: ‘This consultation on potential new indicators is an integral part of NICE’s process for QOF and CCG OIS. It provides the opportunity for everyone with an interest to contribute to the development of the 2016/17 indicators. We value this input highly and all feedback will help the new Indicator Advisory Committee decide which indicators will be put forward for publication on the NICE menu for the QOF and CCG OIS.’

Could be a NICE little earner for some of the panel members 

MPs probe claims of NHS drugs conflicts of interests

They warned that eight out of the 12 members of the Nice panel which produced the guidelines had “direct financial ties” to firms which manufacture statins.


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