Medicalisation in Ireland - A mixed methods analysis using the case of statins for primary prevention of cardiovascular disease
Byrne, Paula
Byrne, Paula
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2019-05-29
Type
Thesis
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Abstract
Statins are a class of drugs that lower blood cholesterol levels and were originally used to prevent further recurrences in those with a history of cardiovascular disease (CVD). Over time, their use has been extended to those with no prior history but who may be at risk of CVD in the future, referred to as primary prevention. The increase in the proportion of people taking statins for primary prevention has raised concern about the medicating of asymptomatic people, a process described as medicalisation. The aim of this thesis is to explore the increased use of statins within the context of primary prevention of CVD and to consider whether or not this constitutes an appropriate use of this medicine both from the perspective of the individual patient and of society. In order to establish the proportion of statin users and reasons for statin use, an analysis of data from The Irish LongituDinal Study on Ageing (TILDA) was undertaken. Almost one third of over-50s were using statins and, of those, almost two-thirds were doing so for primary prevention of CVD. However, while just over a half of men who took statins did so for primary prevention, almost three quarters of women did likewise. This analysis of TILDA data also suggests that there may be an overemphasis on high cholesterol as a reason to prescribe, rather than prescribing based on a person’s overall risk assessment. Given the common use of statins for primary prevention, an overview of systematic reviews of exclusively primary prevention data regarding the effectiveness of statins for prevention of CVD was then conducted, finding mixed and limited evidence on the effectiveness of statins in primary prevention populations, particularly in women. Changes in the recommendations of clinical guidelines have been identified as a driver of the medicalisation process in general, and changes in the clinical guidelines for CVD prevention since 1987 have resulted in almost 62% of over-50s becoming eligible for stain therapy by 2016. This has significant implications for State spending on statins and also implies that many low-risk people have become eligible for statin therapy. As a result, many statin users may not achieve risk reductions needed to justify taking a daily medicine. Another driver of medicalisation is how people themselves, both doctors and patients, subscribe to particular ways of understanding primary prevention of CVD. By exploring these issues through analyses of semi-structured interviews, it was found that rather than high cholesterol being seen as one of several risk factors that may contribute to heart disease, it tended to be reified and evaluated as a current problem. Statins were represented as a necessary medicine that many patients, and doctors, felt they did not have a choice about taking or prescribing. Taking statins for life is a common biomedically sanctioned experience in Ireland, indicating that this has been a site of medicalisation. The fundamental question that motivated the analyses in this thesis is whether the benefits of statins outweigh the costs, opportunity costs, or harms to society and to the individual patient? Low-value care has been defined as healthcare that offers little clinical benefit but has the potential to cause harm and I argue that for many patients in primary prevention, and for the State reimbursing those patients, statin use may be an example of low-value care and, in some cases, represent a waste of healthcare resources. However, the boundaries between appropriate use, overuse and low-value care are difficult to delineate. Therefore, to conclude, Abstract Statins are a class of drugs that lower blood cholesterol levels and were originally used to prevent further recurrences in those with a history of cardiovascular disease (CVD). Over time, their use has been extended to those with no prior history but who may be at risk of CVD in the future, referred to as primary prevention. The increase in the proportion of people taking statins for primary prevention has raised concern about the medicating of asymptomatic people, a process described as medicalisation. The aim of this thesis is to explore the increased use of statins within the context of primary prevention of CVD and to consider whether or not this constitutes an appropriate use of this medicine both from the perspective of the individual patient and of society. In order to establish the proportion of statin users and reasons for statin use, an analysis of data from The Irish LongituDinal Study on Ageing (TILDA) was undertaken. Almost one third of over-50s were using statins and, of those, almost two-thirds were doing so for primary prevention of CVD. However, while just over a half of men who took statins did so for primary prevention, almost three quarters of women did likewise. This analysis of TILDA data also suggests that there may be an overemphasis on high cholesterol as a reason to prescribe, rather than prescribing based on a person’s overall risk assessment. Given the common use of statins for primary prevention, an overview of systematic reviews of exclusively primary prevention data regarding the effectiveness of statins for prevention of CVD was then conducted, finding mixed and limited evidence on the effectiveness of statins in primary prevention populations, particularly in women. Changes in the recommendations of clinical guidelines have been identified as a driver of the medicalisation process in general, and changes in the clinical guidelines for CVD prevention since 1987 have resulted in almost 62% of over-50s becoming eligible for stain therapy by 2016. This has significant implications for State spending on statins and also implies that many low-risk people have become eligible for statin therapy. As a result, many statin users may not achieve risk reductions needed to justify taking a daily medicine. Another driver of medicalisation is how people themselves, both doctors and patients, subscribe to particular ways of understanding primary prevention of CVD. By exploring these issues through analyses of semi-structured interviews, it was found that rather than high cholesterol being seen as one of several risk factors that may contribute to heart disease, it tended to be reified and evaluated as a current problem. Statins were represented as a necessary medicine that many patients, and doctors, felt they did not have a choice about taking or prescribing. Taking statins for life is a common biomedically sanctioned experience in Ireland, indicating that this has been a site of medicalisation. The fundamental question that motivated the analyses in this thesis is whether the benefits of statins outweigh the costs, opportunity costs, or harms to society and to the individual patient? Low-value care has been defined as healthcare that offers little clinical benefit but has the potential to cause harm and I argue that for many patients in primary prevention, and for the State reimbursing those patients, statin use may be an example of low-value care and, in some cases, represent a waste of healthcare resources. However, the boundaries between appropriate use, overuse and low-value care are difficult to delineate. Therefore, to conclude, I argue that the prescription, use and reimbursement of statins in primary prevention warrants more careful consideration incorporating patient preferences and numbers-needed-to-treat, and that the concept of overuse and low-value care should become integral to policy making.
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NUI Galway
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Attribution-NonCommercial-NoDerivs 3.0 Ireland