Clinical and Economic Outcomes of Liberal Versus Selective Drug-Eluting Stent Use

Abstract

Background-Although the benefits of drug-eluting stents (DES) for reducing restenosis after percutaneous coronary intervention are well established, the impact of alternative rates of DES use on population-level outcomes is unknown. One-year rates of death or myocardial infarction were similar in both eras. Over this time period, the incidence of target lesion revascularization increased from 4.1% to 5.1%, an absolute increase of 1.0% (95% confidence interval, 0.1 to 1.9; Pϭ0.03), whereas total cardiovascular costs per patient decreased by $401 (95% confidence interval, 131 to 671; Pϭ0.004). The risk-adjusted incremental cost-effectiveness ratio for the liberal versus selective DES era was $16 000 per target lesion revascularization event avoided, $27 000 per repeat revascularization avoided, and $433 000 per quality-adjusted life-year gained. Conclusions-In this prospective registry, a temporal reduction in DES use was associated with a small increase in target lesion revascularization and a modest reduction in total cardiovascular costs. These findings suggest that although clinical outcomes are marginally better with unrestricted DES use, this approach represents a relatively inefficient use of healthcare resources relative to several common benchmarks for cost-effective care.

Survival Benefit With Drug-Eluting Stents in Observational Studies

“…An IV is an observable factor that is associated with a specific treatment pattern but is otherwise unrelated to underlying patient characteristics and does not directly affect the outcome of interest. Based on our previous work in the EVENT registry, 25 , whereas most other patient and treatment characteristics were similar over time. In this study, we used Cox proportional hazards models to validate the assumption that the enrollment year was not associated with differences in either mortality or TLR, independent of DES use.…”

Drug-Eluting Coronary-Artery Stents

“…68,69 Reducing the use of drug-eluting stents among patients at low risk for restenosis may result in cost savings with a small effect on the rate of repeat revascularization. 69,70 However, reimbursement systems vary widely, rendering cost-effectiveness analyses rarely applicable to different health care systems. In the United States, a reduction in the use of drug-eluting stents in 2007, as compared with a more liberal use of such stents in the period from 2004 through 2006 (in 68% and 92% of procedures, respectively), was associated with a small increase in the risk of repeat revascularization (4.1 to 5.1%) and a modest reduction in costs ($400 per patient) over a period of 1 year.…”

Letter by Saad et al Regarding Article, “Outcomes With Intravascular Ultrasound-Guided Stent Implantation: A Meta-Analysis of Randomized Trials in the Era of Drug-Eluting Stents”

“…2 A subanalysis on the multicenter Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry concluded that the selective use of DES is a better cost-effective approach compared with unrestricted DES use. 3 Furthermore, it might be more reasonable to use BMS in patients with questionable compliance or concern on prolonged dual antiplatelet therapy, such as patients who might require noncardiac surgeries in the future.…”