Questioning the benefits of statins

The recently published controversy on the 2003 Canadian dyslipidemia guidelines1^,2^,3 should be cause for some reflection on the utility of guidelines. The back-and-forth dialogue was reminiscent of what does, or should, occur daily in the offices of Canada's family physicians.

Family doctors see patients with various values, resources, education levels, motivations, fears, preferences, degrees of risk aversion and levels of understanding. Their task is to define treatment goals consistent with all these patient attributes and then base management decisions on those goals. Guidelines, where available, should contribute to the discussion but should rarely be the sole determinant of a patient's treatment goals. Just as from a population health perspective we must weigh benefit with cost and lost opportunity, so must we do with each individual. Guidelines must inform us but should not necessarily compel us.

Unfortunately, as our primary care system comes under more and more stress, the family physician's ability to discuss individual treatment goals, as opposed to simply applying guidelines, is diminished. It is easier to titrate a drug to a guideline or laboratory end point. Furthermore, achievement of such end points is often easily measured and therefore this goal is attractive to administrators. This may not, however, be best for patients when evaluated in the context of treatment goals, population outcomes and system costs.