Dr Chris Ellis and Professor Russell Scott have recently summarised the clinical evidence supporting increased access to statins for patients at high risk of cardiovascular outcomes.1 They note that increasing the number of people using lipid-modifying agents should improve patient outcomes for cardiovascular disease in New Zealand. They also refer to how recent changes to statin access, coupled with impending updated guidelines, should allow most high-risk patients to be more effectively treated.

PHARMAC has looked at statin Special Authority approvals data and dispensing claims data compiled by Health Benefits Ltd (HBL, now HealthPAC) and compared these with epidemiological estimates of statin eligibility. Time trend analyses for the ten-year period July 1991 to June 2001 indicate a significant non uptake of statins amongst eligible patients. For instance, by April 2001 there were an estimated 175 500 patients eligible for statins under the old Special Authority criteria, but the equivalent of 67 000 people being dispensed them – less than 40% of those eligible (Figure 1) [click here to view a larger version of Figure 1].

Similarly, preliminary analysis of direct age-standardised rates of statin dispensings for the calendar year 2000 suggest very wide inter-regional variations of statin prescribing within New Zealand. The statin dispensing rate from pharmacies serving the Northland District Health Board (DHB) population (11.3 person-year equivalent (pye) dispensings per 1000 (95% CI 10.7–11.8)) was 61% of that for Otago DHB after adjusting for age and gender (18.6 pyes per 1000 (18.0–19.2)). By territorial local authority (TLA), dispensings for the Ruapehu District population were 29% of that of the Papakura District. The degree of variation can be seen in Tables 1 and 2, and in Figure 2 [click here to view Tables 1 and 2].

Such wide differences are not readily explained by variations in demography (already partly accounted for by age/sex standardisation) or by the prevalence of cardiovascular disease. We will more fully describe these and other analyses in forthcoming publications.

Professor Rory Collins of the Heart Protection Study has described statins as the ‘new aspirin’.2 This description is in terms of statins’ effects on heart attacks and strokes and their potential ubiquity. Others have ascribed further meaning to the term ‘new aspirin’ – that statins likewise protect against coronary heart disease by reducing blood coagulability, and the optimal cardioprotective dose may be lower than originally suspected.3 In New Zealand, there is a yet another meaning. Like aspirin, not only are the statins highly effective at reducing cardiovascular events, but also they are now inexpensive. In short, most statin drugs available in New Zealand are now affordable and cost effective.4

We suggest that Dr Ellis’ and Professor Scott’s summary1 could be enhanced by noting that statins have not always been so favourably priced. This was the main contributor to the “delays” in widening access criteria to statins.

Although effective, statins were priced so high that to treat everyone advocated by the 1996 NHF dyslipidaemia guidelines would have cost some $198.7 million each year* [click here to view endnotes]. This would have amounted to nearly 40% of all community pharmaceutical spending ($523.3 million for 1996/97) at that time.† From 1993–97, 137 300 patients met the NHF guideline recommendations for treatment, but not PHARMAC’s Special Authority criteria. Treating these extra patients at that stage (137 300 patients at $146.9 million per year‡) would have meant not treating the 35 055 plus patients benefiting from all significant new investments PHARMAC has made in other (non-statin) areas ($73 million actual spending since 1996). Such investments have included atypical anti-psychotics (for treatment-resistant schizophrenia), cyclosporin A and tacrolimus, newer anti-epilepsy agents (treatment-resistant epilepsy), aldendronate (Paget’s disease and severe osteoporosis), and treatments for refractory glaucoma, to name a few (Table 3) [click here to view Table 3]. The remaining $73.9 million would have funded 4560 extra coronary bypass operations.§

Yet many patients at highest need (as defined by the Special Authority criteria) would still not have accessed statins for reasons beyond funding criteria, as seen in the above non uptake by eligible patients.

PHARMAC recognised that statins were effective in reducing coronary events by around one third (ie relative risk reduction). However, their effects overall are modified by the baseline degree of absolute cardiovascular risk,5 and hence absolute risk reduction. What might be cost effective in one group will be less so in another with lower baseline absolute risk.6,7,8 Both price and the range baseline cardiovascular risk have an impact on cost effectiveness.9 Examples of the range of possible cost effectiveness can be seen in PHARMAC’s cost-effectiveness analyses prior to widening access in 1997 and since, available on-line at PHARMAC’s website.10,11,12 Estimates take into account relevant clinical trial data.

In short, statins were effective but too expensive. However, the new lower prices mean such concerns have gone. As Drs Ellis and Scott state, all doctors have a responsibility to use this clinical resource efficiently and wisely.1 ‘Wisely’ includes identifying people with high cardiovascular risk, implementing lifestyle modifications, and making sure that the remaining people who would get the most benefit from statins do get them.

Author information: Scott Metcalfe, Public Health Physician, Wellington; Peter Moodie, Medical Director, Pharmaceutical Management Agency (PHARMAC), Wellington

Acknowledgments: Jason Arnold (Analyst, PHARMAC) extracted the HBL statin Special Authority data and undertook age standardisation and mapping of regional dispensing rates for statins.

Conflicts of interest: Scott Metcalfe is externally contracted to work with PHARMAC for public health advice. PHARMAC will be launching a campaign to increase awareness of cardiovascular risk and increase the number of eligible patients taking statins.

Correspondence: Dr Scott Metcalfe, C/o PHARMAC, PO Box 10-254, Wellington. Fax: (04) 460 4995; email: scott.metcalfe@pharmac.govt.nz