A systematic review and economic analysis of drug‐eluting coronary stents available in Australia

Abstract

Objectives: To compare the safety, effectiveness and cost‐effectiveness of drug‐eluting coronary stents used in Australia with bare‐metal stents and determine whether the benefits are greater for high‐risk subgroups. Data sources: MEDLINE, Pre‐Medline, EMBASE, Current Contents, CINAHL and the Cochrane Library database were searched to identify eligible randomised controlled trials and systematic reviews published in English between January 1966 and June 2004. Study selection: Seven randomised controlled trials that assessed polymer‐based paclitaxel‐ or sirolimus‐eluting stents versus bare‐metal stents in patients with coronary atherosclerosis and reported on stent thrombosis, mortality, myocardial infarction, coronary artery bypass grafting or target lesion revascularisation. Data extraction: Two independent reviewers appraised eligible studies and extracted data. Relative risks (RRs) were calculated for each outcome and pooled using the Mantel–Haenszel method. Data synthesis: Rates of stent thrombosis, mortality, myocardial infarction and bypass grafts did not differ by stent type. Drug‐eluting stents (DESs) resulted in a 71%–80% lower risk of revascularisation at 12 months (RR 0.29 [95% CI, 0.20–0.43] for paclitaxel‐eluting stents [n = 1593 patients]; RR 0.20 [95% CI, 0.13–0.29] for sirolimus‐eluting stents [n = 1296 patients]). Similar benefits were seen in several high‐risk subgroups of patients: those with diabetes, lesion length > 20 mm and target‐vessel diameter ≤ 2.5 mm. The benefits of DESs in these high‐risk groups over lower‐risk groups were inconclusive because of low numbers. The cost per revascularisation avoided by using DESs was A$3750–$6100, with an estimated cost per quality‐adjusted‐life‐year (QALY) gained of A$46 829–$76 467. In sensitivity analyses, estimates varied from DESs being cost‐saving to costing an additional $314 385 per QALY gained. Conclusions: DESs are effective in reducing revascularisation. Estimates of cost‐effectiveness are very sensitive to changes in estimates of their true effects in clinical practice, market price and the number of stents used per patient. Decisions to limit DESs to only patients at the highest risk of restenosis may improve their cost‐effectiveness but will need to be reassessed when evidence is available to compare absolute benefits between patient groups.

Use of drug‐eluting stents in Victorian public hospitals

“…Marginal improvement in outcomes from DES use in these low‐risk patients is unlikely to be cost‐effective, thus providing the economic basis for current Victorian guidelines. A recent Australian study showed that limiting DES use to patients at the highest risk of restenosis might improve the cost‐effectiveness of DESs in an Australian model based on randomised trial results 29 …”

Use of Drug-eluting Stents Versus Bare-metal Stents in Korea: A Cost-minimization Analysis Using Population Data

“…Several economic analyses have been conducted to examine the implications of the use of DES compared with the use of BMS in each country's healthcare system, including Canada, the United Kingdom, the United States of America, Italy, Switzerland, the Netherlands, Australia, and Belgium [3,9-11]. Few studies have concluded that the use of DES is cost-effective when compared with BMS, and most studies concluded that the use of DES is not cost-effective for all patients or lower risk groups, but is (or might be) cost-effective in some high-risk population such as patients with diabetes, small vessels, or long lesions.…”

Exploring the Likely Effect of the Introduction of Drug Eluting Stents on Requirements for Coronary Artery Revascularisation Procedures in Western Australia: A Use of the CHD/CARP Markov Simulation Model

“…This is the basis for altering these same event risks following introduction of DES. The evidence from several meta-analyses of randomized controlled trials that compare DES to ordinary stents is that the use of DES will reduce the risk of restenosis and CABG by about 40% [4][5][6] while another meta-analysis has shown DESs to reduce the risk of repeat PCI by about 79 percent and CABG by 69 percent [7]. In our simulation we have used a risk reduction for repeat CARP (when the first CARP is PCI) of 50%.…”

“…Meta-analyses of randomized controlled trials [2] and population based observational studies [3] have already shown that ordinary stents have contributed to a decline in the risk of a repeat CARP. More recent meta-analyses of randomized controlled trials comparing drug-eluting to ordinary stents [4][5][6][7] suggest even greater effectiveness. Moreover, a population based modeling approach has suggested that DES will lead to a further reduction in the need for revision procedures [3].…”

“…First, it reduced the risk of a repeat CARP following a primary PCI and second, it initiated a shift towards doing less CABGs and more PCIs. Randomised control trial evidence indicates that the introduction of DES will reduce the risk of a repeat CARP following primary PCI even further [6,7] but it is unclear if it will initiate a further shift from CABG to PCI overall.…”