BMJ  2003;327:933 (18 October), doi:10.1136/bmj.327.7420.933-b

Letter

Might money spent on statins be better spent?

EDITOR—As Abbasi argues in his Editor's choice, the benefits of publishing negative findings should be obvious.¹

As a general practitioner I wonder how many million pounds sterling the NHS could save if the Medical Research Council, the British Heart Foundation, and the Lancet shared this view. An example is in the prescribing of statins. They are a major cost in my practice, as I am sure they are to many practitioners.

Even in general practice I recognised the Scandinavian simvastatin survival study as a seminal paper on the benefits of statins,² and as we used to be taught to evaluate evidence (as opposed to stick to protocols) I read it. I was surprised to learn that more women died in the treated group than in the control group. On discussion with cardiology colleagues I was assured that as the numbers were small it was a statistical anomaly, resolvable by larger studies.

Imagine my delight when I heard of the large heart protection study showing clear benefits in the use of statins for women.³ On reading this study I was therefore disappointed to find the total mortality data for women missing. I now understand that the total mortality benefit for women did not reach significance and therefore was not published (Louise Bowman, personal communication, 2002).

I do not understand why the censors of this paper do not realise two things.

Firstly, any meta analyses based on this study are likely to be skewed.

Secondly, in such long term studies total mortality, not improvement in the condition, should be the gold standard for evaluation (euthanasia, for example, provides 100% cure of headache but should be ruled out on the mortality data).

I have yet to find a paper showing a significant reduction in mortality in women for groups treated with statins. It therefore seems that any benefit, if found, will be minimal. Yet we are almost compelled by protocols such as the national service framework for coronary heart disease⁴ and local prescribing incentives to prescribe for this subgroup. Also the supporting documentation to the new general medical services contract⁵ indicates that such statin prescribing may become a quality indicator.⁴

I wonder whether the money could be better spent or if we should abandon the little evidence based medicine we currently have?

Colne Road Surgery, Burnley BB10 1LG AJ_Jenkins{at}compuserve.com

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Competing interests: None declared.

References

1. Abbasi K. Editor's choice. The positive in negatives. BMJ 2003; 327. (2 August.)
2. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4,444 patients with coronary heart disease: the Scandinavian simvastatin survival study (4S). Lancet 1994;344: 1383-9.[CrossRef][ISI][Medline]
3. Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360: 7-22.[CrossRef][ISI][Medline]
4. Department of Health. National service framework for coronary heart disease. London: DoH, 2000. (Chapter 2:5; chapter 8:1). www.doh.gov.uk/pdfs/chdchapter2.pdf (accessed 6 Oct 2003).
5. Department of Health. Supporting documentation to the new general medical services contract. London: DoH, 2003. www.doh.gov.uk/gmscontract/supportingdocs.htm (accessed 6 Oct 2003).

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