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DES use: Less may be more
Venkitachalam L. Circulation. 2011;124:1028-1037.
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Although reducing use of drug-eluting stents led to a small but significant increase in target lesion revascularization, this was associated with a substantial reduction in CV costs that may tip the balance in favor of the more judicious strategy, according to a study published in Circulation.
The study featured pooled data from 10,144 patients of the EVENT registry who underwent percutaneous coronary intervention in the United States from 2004 through 2007. CV-specific costs and clinical outcomes were prospectively determined during a 1-year follow-up.
Overall, rates of drug-eluting stents (DES) use decreased from 92% between 2004 and 2006 to 68% in 2007. Although rates of MI and death were similar for both periods, target lesion revascularization incidence rose 1% in 2007 (from 4.1% to 5.1%; P=.03). Total 1-year CV costs per patient, however, fell substantially by $401 per patient during the same time period (P=.004).
When the investigators compared the strategy of liberal vs. selective DES use, the risk-adjusted incremental cost-effectiveness ratio for the more liberal approach was $16,000 per target lesion revascularization event avoided, $27,000 per repeat revascularization avoided and $433,000 per quality-adjusted life-year gained — values that generally exceed what society is willing to pay for such advantages, David J. Cohen, MD, senior study researcher and director of cardiovascular research, Saint-Luke’s Mid America Heart Institute, Kansas City, Mo., told Cardiology Today Intervention.
“There was a very small clinical price to be paid, but the economic advantages were quite substantial by virtue of using fewer DES and less dual antiplatelet therapy to maintain the patency of the stents,” Cohen said. “We project that these changes in practice saved the health care system about $400 for every patient who was treated during the later time period, and when one considers that we do about 700,000 PCIs a year in the United States that works out to about a $300 to $400 million a year savings.”
Disclosure: Dr. Cohen has received research grants from Boston Scientific, Abbott Vascular, Edwards Lifesciences, Eli Lilly/Daiichi-Sankyo and Merck/Schering Plough, and has consulted for Cordis, Medtronic, Eli Lilly, Merck/Schering Plough and The Medicines Company.