In previous posts I’ve expressed a distinct lack of enthusiasm for cholesterol-reducing statin drugs. These medicaments are very much in vogue as a result of their much-touted ability to reduce the risk of ‘cardiovascular’ conditions such as heart disease and stroke. However, a better measure of the effectiveness of a ‘preventive’ treatment such as statin drugs is ‘overall mortality’ (basically, funeral rates). Research shows that in individuals with no prior history of cardiovascular disease (who represent the great majority of those taking statins), funeral rates are NOT reduced by taking statins.
This fact reared its ugly head again in an ‘analysis’ piece in today’s British Medical Journal [1]. Three General Practitioners, one based in New Zealand and two others from the UK have questioned the use of statin drugs in the elderly. The paper is based on the findings of what is known as the PROSPER study, which assessed the effects of the statin pravastatin in a group of more than 500 individuals aged 70-82 years.
In this population, heart attacks and death due to heart attack was reduced. However, risk of being diagnosed with cancer was 25 per cent higher in those taking the drug. Crucially, overall mortality rates were not reduced by taking the pravastatin. The authors of this paper suggest that the taking of statins by the elderly is likely to give with one hand and take with the other: cardiovascular risk goes down while risk of cancer goes up. The authors state: By providing treatments designed to prevent particular diseases, we may be selecting for another cause of death unknowingly, and certainly without the patient’s informed consent. This is fundamentally unethical and undermines the principle of respect for autonomy. They go on to add that: Prevention has side effects other than the hazards of the treatment”in particular, the shadow cast over a currently healthy life by the threat of disease, which might be magnified in elderly people for whom mortality looms closer.
These all seem like very good points to me. Furthermore, they make another good point in their observation that the problem here is not that we have inadequate data, but how that data is interpreted and communicated to doctors and their patients.
One reason for why statin treatment is so entrenched in medical care in the UK relates to the fact that general practitioners are remunerated by the Government for this practice. As the authors point out, offering doctors financial incentives may coerce doctors into persuading patients to accept such preventive treatments. There is evidence that this sort of remuneration actually changes health care practice [2]. As the authors of this paper state, whether this improves actual health care is not always so clear.
References:
1. Mangin D, et al. Preventive health care in elderly people needs rethinking
BMJ 2007;335:285-287
2. Petersen LA, et al. Does pay-for-performance improve the quality of health care? Ann Intern Med 2006;145:265-72
