- Email: [email protected]
Statins audit: wrong question, wrong conclusions
Correspondence
Royal London Hospital Total patients P1 and P2 P3
King Edward VII Memorial Hospital
194
76
[email protected]
27
31
167
45
Seth G S Medical College and King Edward VII Memorial Hospital,Parel, Mumbai 400012, India 1
Time between incident and first priority patient reaching hospital
75 min
30 min
Surge rate* in first hour
18
69
Time to reaching resuscitation room capacity
15 min
30 min
Plain radiographs
58
240 (49 abnormal)
Ultrasonographs
2 8
45 (14 abnormal)
CT scans
30
42 (27 abnormal)
Total surgical procedures
58 (17 patients)
18 (17 patients)
Number of laparotomies Critical mortality rate Blood units used Blood donors
5 15% (3/20) 264 10 000 calls
0 25% (2/8)
3
4
175 1165 donors
*Critically injured patients per hour. P1=critical requiring resuscitation. P2=critical but stable. P3=requiring observation.
Table: Comparative figures from the Royal London Hospital, London, UK, and King Edward VII Memorial Hospital, Mumbai, India, in managing blast victims in 2005 and 2006, respectively
department decongested in 4 h. 16 of 18 surgical procedures were completed within 18 h of the event. Our hospital’s Disaster Management Plan (DMP), although having existed for many years, was revised in May, 2006, after the monsoon disaster of July, 2005.5 Having a DMP drill only a month previously helped in the implementation of the plan on July 11, 2007. The success of the plan was entirely due to the commitment of the people involved and political will. Shortcomings in the DMP were noted, particularly in the form of an unexpected excess of enthusiastic manpower for whom roles were not defined, and a difficulty in coping with increasing demands for information from relatives, media, and others. An open-ended questionnaire was sent to 50 heads of clinical, paraclinical, non-clinical, administrative, and engineering sections of the hospital. Feedback is being used in modifying the DMP. We acknowledge the active support of our entire staff, with special thanks to J V Hordikar and Atul Goel. We declare that we have no conflict of interest.
640
*Aparna A Deshpande, Sanjay Mehta, Nilima A Kshirsagar
5
Aylwin CJ, Konig TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resources use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219–25. Turégano-Fuentes F, Perez-Diaz D. Medical response to the 2005 terrorist bombings in London. Lancet 2006; 368: 2188–89. Goenka AH, Jethwani KS. KEM hospital’s response to serial bomb blasts in the Mumbai suburban trains on 11th July 2006: student’s perspective. J Postgrad Med 2006; 52: 330. Deshpande AA. When disaster strikes…Our experience at KEM hospital, tertiary referral centre in Mumbai (Bombay) after the serial bomb blasts. J Postgrad Med 2006; 52: 331. Kshirsagar NA, Shinde RR, Mehta S. Floods in Mumbai: Impact of public health service by hospital staff and medical students. J Postgrad Med 2006; 52: 312–14.
Statins audit: wrong question, wrong conclusions The audit reported by Rob Butler and James Wainwright (Jan 6, p 27)1 confuses two separate issues. Schemes promoted in the UK for switching statins focus on discontinuation of high-cost branded statins at low to intermediate doses (mainly atorvastatin 10 mg or 20 mg) and substitution with the therapeutically equivalent simvastatin 40 mg.2 At the time of Butler and Wainwright’s audit, among the ten primary-care trusts (PCTs) within the Staffordshire and Shropshire cardiac network, the annual spend on atorvastatin 10 mg or 20 mg was £8·9 million per annum, £7 million of which would be saved by switching patients to simvastatin 40 mg. Substantial progress has been made,3 with some of the savings allowing provision of statins to more patients—3000 in Stoke-on-Trent PCT alone last year. Butler and Wainwright confuse this with another important issue: the possible but unproven benefit of atorvastatin 80 mg over simvastatin
40 mg or 80 mg for high-risk patients. The evidence has been reviewed elsewhere.4 However, simvastatin 40 mg was shown to be more potent than the low-dose statin used in all four high-dose statin trials. If highdose statins are thought appropriate, generic simvastatin 80 mg is the most cost-effective choice. The incremental cost-effectiveness of high-dose versus low-dose statins is currently under independent assessment by Birmingham University and the National Institute for Health and Clinical Excellence (NICE). We urge Butler and Wainwright to support rational prescribing by withdrawing atorvastatin 10 mg or 20 mg from their hospital formulary in accordance with their local guidelines, substituting simvastatin 40 mg.5 For high-risk patients, allow the physicians the freedom to prescribe simvastatin or atorvastatin at 40 mg or 80 mg, while awaiting new data and the reviews of the evidence. JCM has received management training from Pfizer. RGB has received lecturer honoraria from AstraZeneca and Pfizer and grants from Roche. RM has attended advisory boards and received honoraria for speaking at educational meetings from AstraZeneca, MSD, Novartis, and Pfizer. He is also a participant in the NICE guideline development.
James C Moon, *Richard G Bogle, Rubin Minas [email protected] University College London NHS Trust, London, UK (JCM); Imperial College London, Hammersmith Hospital, London, UK (RGB); and Medway PCT, Gillingham, UK (RM) 1
2
3
4
5
Butler R, Wainright J. Cholesterol lowering in patients with CHD and metabolic syndrome. Lancet 2007; 369: 27. National Prescribing Centre campaign to increase low-cost statin prescribing. http://www. npc.co.uk/statins.htm (accessed Jan 17, 2007). NHS better care, better value indicators for the West Midlands. http://www.productivity.nhs. uk/Form_PCT_4.1_Statin.aspx?period=2006Q2&report=p41&orgCode=5CN&email= (accessed Jan 17, 2007). Brown BG. Direct comparison of the A to Z and PROVE IT trials: a second chance to gain a first impression. Circulation 2006; 113: 1382–84. University College London Hospitals. Guidelines on statin prescribing in the prevention of cardiovascular disease. http://www.uclh.nhs.uk/ NR/rdonlyres/0A09D988-0CAB-4CFC-BB58BEC5212F6D19/34496/statinprescribingguidel ines1.pdf (accessed Jan 17, 2007).
www.thelancet.com Vol 369 February 24, 2007
Royal London Hospital Total patients P1 and P2 P3
King Edward VII Memorial Hospital
194
76
[email protected]
27
31
167
45
Seth G S Medical College and King Edward VII Memorial Hospital,Parel, Mumbai 400012, India 1
Time between incident and first priority patient reaching hospital
75 min
30 min
Surge rate* in first hour
18
69
Time to reaching resuscitation room capacity
15 min
30 min
Plain radiographs
58
240 (49 abnormal)
Ultrasonographs
2 8
45 (14 abnormal)
CT scans
30
42 (27 abnormal)
Total surgical procedures
58 (17 patients)
18 (17 patients)
Number of laparotomies Critical mortality rate Blood units used Blood donors
5 15% (3/20) 264 10 000 calls
0 25% (2/8)
3
4
175 1165 donors
*Critically injured patients per hour. P1=critical requiring resuscitation. P2=critical but stable. P3=requiring observation.
Table: Comparative figures from the Royal London Hospital, London, UK, and King Edward VII Memorial Hospital, Mumbai, India, in managing blast victims in 2005 and 2006, respectively
department decongested in 4 h. 16 of 18 surgical procedures were completed within 18 h of the event. Our hospital’s Disaster Management Plan (DMP), although having existed for many years, was revised in May, 2006, after the monsoon disaster of July, 2005.5 Having a DMP drill only a month previously helped in the implementation of the plan on July 11, 2007. The success of the plan was entirely due to the commitment of the people involved and political will. Shortcomings in the DMP were noted, particularly in the form of an unexpected excess of enthusiastic manpower for whom roles were not defined, and a difficulty in coping with increasing demands for information from relatives, media, and others. An open-ended questionnaire was sent to 50 heads of clinical, paraclinical, non-clinical, administrative, and engineering sections of the hospital. Feedback is being used in modifying the DMP. We acknowledge the active support of our entire staff, with special thanks to J V Hordikar and Atul Goel. We declare that we have no conflict of interest.
640
*Aparna A Deshpande, Sanjay Mehta, Nilima A Kshirsagar
5
Aylwin CJ, Konig TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resources use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219–25. Turégano-Fuentes F, Perez-Diaz D. Medical response to the 2005 terrorist bombings in London. Lancet 2006; 368: 2188–89. Goenka AH, Jethwani KS. KEM hospital’s response to serial bomb blasts in the Mumbai suburban trains on 11th July 2006: student’s perspective. J Postgrad Med 2006; 52: 330. Deshpande AA. When disaster strikes…Our experience at KEM hospital, tertiary referral centre in Mumbai (Bombay) after the serial bomb blasts. J Postgrad Med 2006; 52: 331. Kshirsagar NA, Shinde RR, Mehta S. Floods in Mumbai: Impact of public health service by hospital staff and medical students. J Postgrad Med 2006; 52: 312–14.
Statins audit: wrong question, wrong conclusions The audit reported by Rob Butler and James Wainwright (Jan 6, p 27)1 confuses two separate issues. Schemes promoted in the UK for switching statins focus on discontinuation of high-cost branded statins at low to intermediate doses (mainly atorvastatin 10 mg or 20 mg) and substitution with the therapeutically equivalent simvastatin 40 mg.2 At the time of Butler and Wainwright’s audit, among the ten primary-care trusts (PCTs) within the Staffordshire and Shropshire cardiac network, the annual spend on atorvastatin 10 mg or 20 mg was £8·9 million per annum, £7 million of which would be saved by switching patients to simvastatin 40 mg. Substantial progress has been made,3 with some of the savings allowing provision of statins to more patients—3000 in Stoke-on-Trent PCT alone last year. Butler and Wainwright confuse this with another important issue: the possible but unproven benefit of atorvastatin 80 mg over simvastatin
40 mg or 80 mg for high-risk patients. The evidence has been reviewed elsewhere.4 However, simvastatin 40 mg was shown to be more potent than the low-dose statin used in all four high-dose statin trials. If highdose statins are thought appropriate, generic simvastatin 80 mg is the most cost-effective choice. The incremental cost-effectiveness of high-dose versus low-dose statins is currently under independent assessment by Birmingham University and the National Institute for Health and Clinical Excellence (NICE). We urge Butler and Wainwright to support rational prescribing by withdrawing atorvastatin 10 mg or 20 mg from their hospital formulary in accordance with their local guidelines, substituting simvastatin 40 mg.5 For high-risk patients, allow the physicians the freedom to prescribe simvastatin or atorvastatin at 40 mg or 80 mg, while awaiting new data and the reviews of the evidence. JCM has received management training from Pfizer. RGB has received lecturer honoraria from AstraZeneca and Pfizer and grants from Roche. RM has attended advisory boards and received honoraria for speaking at educational meetings from AstraZeneca, MSD, Novartis, and Pfizer. He is also a participant in the NICE guideline development.
James C Moon, *Richard G Bogle, Rubin Minas [email protected] University College London NHS Trust, London, UK (JCM); Imperial College London, Hammersmith Hospital, London, UK (RGB); and Medway PCT, Gillingham, UK (RM) 1
2
3
4
5
Butler R, Wainright J. Cholesterol lowering in patients with CHD and metabolic syndrome. Lancet 2007; 369: 27. National Prescribing Centre campaign to increase low-cost statin prescribing. http://www. npc.co.uk/statins.htm (accessed Jan 17, 2007). NHS better care, better value indicators for the West Midlands. http://www.productivity.nhs. uk/Form_PCT_4.1_Statin.aspx?period=2006Q2&report=p41&orgCode=5CN&email= (accessed Jan 17, 2007). Brown BG. Direct comparison of the A to Z and PROVE IT trials: a second chance to gain a first impression. Circulation 2006; 113: 1382–84. University College London Hospitals. Guidelines on statin prescribing in the prevention of cardiovascular disease. http://www.uclh.nhs.uk/ NR/rdonlyres/0A09D988-0CAB-4CFC-BB58BEC5212F6D19/34496/statinprescribingguidel ines1.pdf (accessed Jan 17, 2007).
www.thelancet.com Vol 369 February 24, 2007