Reimbursement systems influence achievement of cholesterol targets

Dr Gitt said: "There are wide variations between European countries in the achievement of LDL-cholesterol (LDL-C) targets. However the effect of different reimbursement systems on meeting the targets was unknown."

Between June 2008 and February 2009 DYSIS assessed the prevalence and types of persistent lipid abnormalities in patients receiving statins. Eligible patients were at high risk of a cardiovascular event, aged >45 years, and had been on chronic statin treatment for at least three months. A total of 22,063 patients were enrolled from 2,954 sites across 11 European countries and Canada.

The current subanalysis examined the possible impact of reimbursement systems on the achievement of LDL-C targets in 4,260 German patients and 540 UK patients. Germany operates a "restrictive" system in which chronic medical treatment is restricted by budget constraints. In the UK's incentive system, reimbursement of general practitioners (GPs) is linked to achieving cholesterol targets.

Dr Gitt said: "The bottom line is that German doctors fear a punitive system where they could be fined if they don't stay within budget while UK doctors get rewarded for achieving targets."

The study found that just 42% of German patients achieved the target of LDL-C <100mg/dl compared to 79.8% of UK patients (p<0.001). Dr Gitt said: "Twice as many UK patients achieve cholesterol target levels as German patients. By definition of the study protocol all patients had been on statin treatment. As there are no differences in the availability of lipid lowering drugs between both countries, the different health care systems might have an impact on the way patients are treated."

Atorvastatin (a potent statin) was used in 3.9% of German patients (mean dose 24.0 mg) compared to 24.8% of UK patients (mean dose 34.2 mg) (p<0.01). Simvastatin (a weaker statin) was used in 83.9% of Germans (mean dose 27.2 mg) compared to 67.6% of UK patients (mean dose 36.6 mg) (p<0.01). Daily dosages were significantly lower in Germany than in the UK, independent of the statin used.

Dr Gitt said: "We found that UK patients are treated with more potent statins and higher doses. UK doctors are treating patients aggressively with statins in response to a financial incentive to reach cholesterol targets. German doctors treat more conservatively, less often using potent statins and high doses which are more expensive."

He added: "The quality control feedback system in the UK may also impact on the achievement of cholesterol targets. GPs have to measure cholesterol levels and this identifies which patients need more aggressive treatment to reach the target."

Dr Gitt concluded: "Our study showed that healthcare reimbursement systems appear to impact on the achievement of cholesterol lowering targets. The German system was put in place to control costs but it remains to be seen whether it will achieve this in the long term. The UK system has higher short term costs, with more GP visits, use of potent statins and high doses, but it may ultimately be more cost effective because of fewer complications."